1. A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following:
Blood group: A Rhesus negative
What is the most appropriate management regarding her rhesus status?ia
A.A Give first dose of anti-D at 28 weeksia
B.A No action required unless antenatal vaginal blood lossia
C.A Give first dose of anti-D as soon as possibleia
D.A Give anti-D just prior to deliveryia
E.A No action requiredia
Rhesus negative woman - anti-D at 28 + 34 weeks
NICE recommend giving rhesus negative woman anti-D at 28 weeks followed by a second dose at 34 weeks
Antenatal care: timetable
NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. They recommend:
• 10 antenatal visits in the first pregnancy if uncomplicated
• 7 antenatal visits in subsequent pregnancies if uncomplicated
• women do not need to be seen by a consultant if the pregnancy is uncomplicated
Gestation Purpose of visit
8 - 12 weeks (ideally < 10 weeks) Booking visit
• general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
• BP, urine dipstick, check BMI
Booking bloods/urine
• FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
• hepatitis B, syphilis, rubella
• HIV test is offered to all women
• urine culture to detect asymptomatic bacteriuria
10 - 13 weeks Early scan to confirm dates, exclude multiple pregnancy
11 - 13+6 weeks Down's syndrome screening including nuchal scan
16 weeks Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
18 - 20+6 weeks Anomaly scan
25 weeks (only if primip) Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
28 weeks Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 11 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip) Routine care as above
34 weeks Routine care as above
Second dose of anti-D prophylaxis to rhesus negative women
Information on labour and birth plan
36 weeks Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, 'baby-blues'
38 weeks Routine care as above
40 weeks (only if primip) Routine care as above
Discussion about options for prolonged pregnancy
41 weeks Routine care as above
Discuss labour plans and possibility of induction
2. A 21-year-old female is seen in the first seizure clinic in the outpatient department. A decision is made not to start her on anti-epileptic medication. What restrictions on driving should she be informed about?ia
A.A No restrictions but inform DVLAia
B.A No restrictions, no need to inform DVLA if not on medicationia
C.A Cannot drive for 1 month from date of seizureia
D.A Cannot drive for 6 months from date of seizureia
E.A Cannot drive for 1 year from date of seizureia
Patients cannot drive for 1 year following a seizure
DVLA: neurological disorders
The guidelines below relate to car/motorcycle use unless specifically stated. For obvious reasons, the rules relating to drivers of heavy goods vehicles tend to be much stricter
Specific rules
• first seizure - 1 year off driving
• stroke or TIA - 1 month off driving
• multiple TIAs over short period of times - 3 months off driving
• craniotomy - 1 year off driving*
• narcolepsy/cataplexy: cease driving on diagnosis, can restart once 'satisfactory control of symptoms'
Syncope
• simple faint: no restriction
• unexplained, low risk of recurrence: 4 weeks off
• explained and treated: 4 weeks off
• unexplained: 6 months off
*if the tumour is a benign meningioma and there is no seizure history, licence can be reconsidered 6 months after surgery if remains seizure free
3. A 54-year-old male with no past medical history is found to be in atrial fibrillation during a consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. After discussing treatment options he elects not to be cardioverted. If the patient remains in chronic atrial fibrillation what is the most suitable treatment to offer?ia
A.A Aspirinia
B.A Warfarin, target INR 2-3ia
C.A No anticoagulationia
D.A Warfarin, target INR 3-4ia
E.A Warfarin, target INR 2-3 for six months then aspirinia
Young AF, no TIA or risk factors, just give aspirin
Atrial fibrillation: anticoagulation
The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006
The guidelines suggest a stroke risk stratification approach when determining how to anticoagulate a patient, as detailed below:
Low risk - annual risk of stroke = 1%
• age < 65 years with no moderate or high risk factors
• use aspirin
Moderate risk - annual risk of stroke = 4%
• age > 65 years with no high risk factors, or:
• age < 75 years with diabetes, hypertension or vascular disease (ischaemic heart disease or peripheral arterial disease)
• use aspirin or warfarin depending on individual circumstances
High risk - annual risk of stroke = 8-12%
• age > 75 years with diabetes, hypertension or vascular disease (ischaemic heart disease or peripheral arterial disease)
• previous TIA, ischaemic stroke or thromboembolic event
• valve disease, heart failure or impaired left ventricular function
• use warfarin
4. An 18-year-old female presents to her GP as she has missed one of her Microgynon 30 pills yesterday morning. She has taken Microgynon for the past 2 years and is currently 4 days into a packet of pills. She had sexual intercourse last night and is unsure what to do. What is the correct management?ia
A.A Advise condom use for next 7 daysia
B.A Perform a pregnancy testia
C.A Omit pill break at end of packia
D.A No action neededia
E.A Emergency contraception should be offeredia
For further information please consult the link to the FFPRHC guidelines
Combined oral contraceptive pill: missed pill
The advice from the Faculty of Family Planning and Reproductive Health Care has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 or 2 pills missed (at any time in the cycle)
• take a pill as soon as possible and then continue taking pills daily, one each day
• no additional contraceptive protection needed
If 3 or more pills missed
• take a pill as soon as possible and then continue taking pills daily, one each day
• the women should use condoms or abstain from sex until she has taken pills for 7 days in a row
• if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
• if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
• if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
5. Which one of the following products is 'blacklisted' under Part XVIIIA of the Drug Tariff and hence cannot be dispensed on the NHS?ia
A.A Juvela gluten-free breadia
B.A Clozapineia
C.A Farley's Soya Formulaia
D.A EpiPenia
E.A Topical minoxidilia
Part XVIIIA of the Drug Tariff - The Blacklist
Theoretically any food, drug, toiletry or cosmetic may be prescribed on an NHS prescription unless the product is listed in Part XVIIIA of the Drug Tariff ('the blacklist’).
Medical devices (appliances) can only be prescribed on NHS prescriptions if the product is listed in Part IX of the Drug Tariff.
If a proprietary product is listed in ‘the blacklist’, it cannot be dispensed on the NHS. The only exception to this is if the prescription is issued using a generic name and the generic name is not itself included in the blacklist.
Some examples of 'blacklisted' products:
• Propecia (finasteride for male-pattern alopecia)
• Regaine (topical minoxidil for male-pattern alopecia)
• Calpol (see above, paracetamol suspension may be prescribed)
The Selected List
Part XVIIIB of the Drug Tariff lists items that may only be prescribed for the patient groups and for the purpose listed in the Drug Tariff. Prescribers must endorse prescriptions for these products ‘SLS’. This section covers the prescription of phosphodiesterase type-5 inhibitors.
For example:
• Niferex Elixir 30ml Paediatric Dropper Bottle - infants born prematurely - prophylaxis in treatment of iron deficiency
• sildenafil - only if treated prior to September 1998 or if has one of the following conditions: diabetes mellitus, Parkinson's disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, spinal cord injury, renal failure treated with dialysis or transplant, prostatectomy or radical pelvic surgery
6. A 62-year-old man presents with insomnia and lethargy. He has no other systemic symptoms of note. Routine clinical examination reveals a palpable mass in the right lower quadrant of the abdomen, which doesn't move with respiration and is non-pulsatile. What is the most appropriate management?ia
A.A Blood screen including LFTs, U&Esia
B.A Urgent referral to local urological serviceia
C.A Ultrasound abdomenia
D.A Urgent referral to local colorectal serviceia
E.A Routine referral to general surgical clinicia
Colorectal cancer: referral guidelines
NICE recommend the following patients are referred urgently (i.e. within 2 weeks) to colorectal services for investigation:
• patients > 40 years old, reporting rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more
• patients > 60 years old, with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms
• patients > 60 years old, with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding
• any patient presenting with a right lower abdominal mass consistent with involvement of the large bowel
• any patient with a palpable rectal mass
• unexplained iron deficiency anaemia in men or non-menstruating women (Hb < 11 g/dl in men, < 10 g/dl in women)
8. A 57-year-old female presents due to problems with urine leakage over the past six months. She describes frequent voiding and not always being able to get to the toilet in time. She denies losing urine when coughing or sneezing. What is the most appropriate initial treatment?ia
A.A Trial of oxybutyninia
B.A Bladder retrainingia
C.A Regular toiletingia
D.A Pelvic floor muscle trainingia
E.A Topical oestrogen creamia
Urinary incontinence - first-line treatment:
• urge incontinence: bladder retraining
• stress incontinence: pelvic floor muscle training
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the UK population. It is more common in elderly females. NICE released guidance on the management of UI in 2006
Causes
• overactive bladder (OAB)/urge incontinence: due to detrusor over activity
• stress incontinence: leaking small amounts when coughing or laughing
• mixed incontinence: both urge and stress
• overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigation
• bladder diaries should be completed for a minimum of 3 days
• urine dipstick and culture
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
• bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
• bladder stabilising drugs: immediate release oxybutynin is first-line
• surgical management: e.g. sacral nerve stimulation
If stress incontinence is predominant:
• pelvic floor muscle training (for a minimum of 3 months)
• surgical procedures: e.g. retropubic mid-urethral tape procedures
9. A 55-year-old man is admitted following an anterior myocardial infarction. Which of the following drugs is least likely to reduce mortality in the long-term?ia
A.A Atorvastatinia
B.A Atenololia
C.A Ramiprilia
D.A Aspirinia
E.A Isosorbide mononitrateia
Isosorbide mononitrate may be important in managing symptoms yet it has no proven mortality benefit following a myocardial infarction
Myocardial infarction: secondary prevention
NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2007. Some key points are listed below
All patients should be offered the following drugs:
• ACE inhibitor
• beta-blocker
• aspirin
• statin
Clopidogrel
• after an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks
• after a non-ST segment elevation myocardial infarction clopidogrel should be given for the first 12 months
Aldosterone antagonists
• patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3–14 days of the MI, preferably after ACE inhibitor therapy
10. A 54-year-old man presents with a variety of physical symptoms that have been present for the past 9 years. Numerous investigations and review by a variety of specialties have indicated no organic basis for his symptoms. This is an example of:ia
A.A Munchausen's syndromeia
B.A Hypochondrial disorderia
C.A Dissociative disorderia
D.A Somatisation disorderia
E.A Conversion disorderia
Unexplained symptoms
• Somatisation = Symptoms
• hypoChondria = Cancer
Somatisation disorder is the correct answer as the patient is concerned about persistent, unexplained symptoms rather than an underlying diagnosis such as cancer (hypochondrial disorder). Munchausen's syndrome describes the intentional production of symptoms, for example self poisoning
Unexplained symptoms
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Somatisation disorder
• multiple physical SYMPTOMS present for at least 2 years
• patient refuses to accept reassurance or negative test results
Hypochondrial disorder
• persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
• patient again refuses to accept reassurance or negative test results
Conversion disorder
• typically involve loss of motor or sensory function
• some patients may experience secondary gain from loss of function
• patients may be indifferent to their apparent disorder
Dissociative disorder
• dissociation is a process of 'separating off' certain memories from normal consciousness
• in contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor
• dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Munchausen's syndrome
• also known as factitious disorder
• the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other
11. A 2-month-old boy is brought to the afternoon surgery by his mother. Since the morning he has been taking reduced feeds and has been 'not his usual self'. On examination the baby appears well but has a low-grade temperature of 38.1ºC. What is the most appropriate management?ia
A.A Advise regarding antipyretics, to see if not settlingia
B.A IM benzylpenicillinia
C.A Advise regarding antipyretics, booked appointment for next dayia
D.A Admit to hospitalia
E.A Empirical amoxicillin for 7 daysia
Any child less than 3 months old with a temperature > 38ºC is regarded as a 'red' feature in the new NICE guidelines, warranting urgent referral to a paediatrician. Although many experienced GPs may choose not to strictly follow such advice it is important to be aware of recent guidelines for the AKT exam
Feverish illness in children
The 2007 Feverish illness in children guidelines by NICE introduced a 'traffic light' for risk stratification of children under the age of 5 years presenting with a fever. It should be noted that these guidelines only apply 'until a clinical diagnosis of the underlying condition has been made'. A link to the guidelines is provided but some key points are listed below.
Assessment
The following should be recorded in all febrile children:
• temperature
• heart rate
• respiratory rate
• capillary refill time
Signs of dehydration (reduced skin turgor, cool extremities etc) should also be looked for
Measuring temperature should be done with an electronic thermometer in the axilla if the child is < 4 weeks or with an electronic/chemical dot thermometer
in the axilla or an infra-red tympanic thermometer.
Risk stratification
Please see the link for the complete table, below is a modified version
Green – low risk Amber – intermediate risk Red – high risk
• Normal colour
• Responds normally to social cues
• Normal cry
• Not dehydrated
• No amber or red signs • Pallor reported by parent/carer
• Not responding normally to social cues
• Wakes only with prolonged stimulation
• Decreased activity
• Not smiling
• Nasal flaring
• Tachypnoea:
- RR > 50 breaths/minute age 6–12 months
- RR > 40 breaths/minute age > 12 months
• Oxygen saturation = 95% in air
• Crackles
• Dry mucous membrane
• Poor feeding in infants
• CRT = 3 seconds
• Reduced urine output
• Fever for = 5 days
• Swelling of a limb or joint
• Non-weight bearing/not using an extremity
• A new lump > 2 cm • Pale/mottled/ashen/blue
• No response to social cues
• Appears ill to a healthcare professional
• Unable to rouse
• Weak, high-pitched or continuous cry
• Grunting
• Tachypnoea:
- RR > 60 breaths/minute
• Moderate or severe
chest indrawing
• Reduced skin turgor
• Age 0–3 months, temperature > 38°C
• Age 3–6 months, temperature > 39°C
• Non-blanching rash
• Bulging fontanelle
• Neck stiffness
• Status epilepticus
• Focal neurological signs
• Focal seizures
• Bile-stained vomiting
Management
If green:
• Child can be managed at home with appropriate care advice, including when to seek further help
If amber:
• provide parents with a safety net or refer to a paediatric specialist for further assessment
• a safety net includes verbal or written information on warning symptoms and how
further healthcare can be accessed, a follow-up appointment, liaison with other healthcare professionals, e.g. out-of-hours providers, for further follow-up
If red:
• refer child urgently to a paediatric specialist
Other key points include
• oral antibiotics should not be prescribed to children with fever without apparent source
• if a pneumonia is suspected but the child is not going to be referred to hospital then a chest x-ray does not need to be routinely performed.
12. A 67-year-old man with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he be prescribed for breakthrough pain?ia
A.A 5 mgia
B.A 10 mgia
C.A 15 mgia
D.A 20 mgia
E.A 30 mgia
Breakthrough dose = 1/6th of daily morphine dose
The total daily morphine dose is 30 * 2 = 60 mg, therefore the breakthrough dose should be one-sixth of this, 10 mg
Palliative care prescribing: pain
SIGN issued guidance on the control of pain in adults with cancer in 2008
Selected points
• the breakthrough dose of morphine is one-sixth the daily dose of morphine
• all patients who receive opioids should be prescribed a laxative
• opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
• metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
Conversion between opioids
From To
Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 5
From To
Oral morphine Oral oxycodone Divide by 2
The BNF states that oral morphine sulphate 80-90mg over 24 hours is approximately equivalent to one '25 mcg/hour' patch, therefore product literature should be consulted
From To
Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5
13. What are funnel plots primarily used for?ia
A.A Demonstrate the heterogeneity of a meta-analysisia
B.A Demonstrate the existence of publication bias in meta-analysesia
C.A Provide a graphical representation of the relative risk results in a case-control studyia
D.A Provide a graphical representation of the relative risk results in a cohort studyia
E.A Provide a graphical representation of the probability of a patient experiencing a particular adverse effectia
Funnel plots - show publication bias in meta-analyses
Funnel plot
A funnel plot is primarily used to demonstrate the existence of publication bias in meta-analyses. Funnel plots are usually drawn with treatment effects on the horizontal axis and study size on the vertical axis.
Interpretation
• a symmetrical, inverted funnel shape indicates that publication bias is unlikely
• conversely, an asymmetrical funnel indicates a relationship between treatment effect and study size. This indicates either publication bias or a systematic difference between smaller and larger studies (‘small study effects’)
14. A 19-year-old male with a history of asthma presents to the surgery due to shortness of breath. On examination his peak expiratory flow is 270 l/min (usual 600 l/min). Pulse is 96 bpm and the respiratory rate is 24 / min. Examination of the chest reveals a bilateral expiratory wheeze but is otherwise unremarkable. What is the most appropriate management?ia
A.A Oxygen + nebulised salbutamol + prednisolone arrange immediate admission to A&E via ambulanceia
B.A Nebulised salbutamol + advise to double inhaled steroids + allow home if settles with follow-up reviewia
C.A Oxygen + nebulised salbutamol + prednisolone arrange immediate admission to medical team via ambulanceia
D.A Oxygen + nebulised salbutamol + prednisolone and review following treatmentia
E.A Nebulised salbutamol + prednisolone + allow home if settles with follow-up reviewia
Whilst his respiratory rate is consistent with a 'moderate' exacerbation his peak flow, less than 50% of usual, means he should be treated as for a 'severe' exacerbation. The British Thoracic Society give specific recommendations on dealing with acute asthma in primary care - please see the link
Asthma: assessment and management in primary care
Patients with acute severe asthma are stratified into moderate, severe or life-threatening
Moderate Severe Life-threatening
• PEFR > 50% best or predicted
• Speech normal
• RR < 25 / min
• Pulse < 110 bpm • PEFR 33 - 50% best or predicted
• Can't complete sentences
• RR > 25/min
• Pulse > 110 bpm • PEFR < 33% best or predicted
• Oxygen sats < 92%
• Silent chest, cyanosis or feeble respiratory effort
• Bradycardia, dysrhythmia or hypotension
• Exhaustion, confusion or coma
Management of moderate asthma
• beta 2 agonists such as salbutamol, either nebulised or via a spacer (4-6 puffs, given one at a time and inhaled separately, repeated at intervals of 10-20 minutes)
• if PEFR between 50-75% then prednisolone 40-50mg
Management of severe asthma
• consider admission
• oxygen 40-60%
• beta 2 agonists such as salbutamol, either nebulised or via a spacer (4-6 puffs, given one at a time and inhaled separately, repeated at intervals of 10-20 minutes)
• prednisolone 40-50mg
• if no response then admit
Management of life-threatening asthma
• arrange immediate admission (999 call)
• oxygen 40-60%
• nebulised beta 2 agonists such as salbutamol, and ipratropium
• prednisolone 40-50mg or IV hydrocortisone 100mg
15. A 17-year-old female presents with recurrent attacks of collapse. These episodes typically occur without warning and have occurred whilst she was running for a bus. There is no significant past medical history and the only family history of note is that her father died suddenly when he was 38-years-old. What is the likely cause?ia
A.A Vaso-vagal attacksia
B.A Anxietyia
C.A Epilepsyia
D.A Cardiac syncopeia
E.A Malingeringia
Sudden death, unusual collapse in young person - ? HOCM
This is a rather vague question. However, a family history of sudden death should make you think of conditions such as hypertrophic obstructive cardiomyopathy
HOCM: features
Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins
Features
• dyspnoea, angina, syncope
• sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure
• jerky pulse, large 'a' waves, double apex beat
• ejection systolic murmur: increases with Valsalva manoeuvre and decreases on squatting
Associations
• Friedreich's ataxia
• WPW
Echo
• systolic anterior motion (SAM) of the anterior mitral valve leaflet
• asymmetric hypertrophy (ASH)
• mitral regurgitation
ECG
• LVH
• progressive T wave inversion
• deep Q waves
16. A 72-year-old woman presents with polyuria and polydipsia. Investigations reveal the following:
Fasting glucose 4.5 mmol/l
Calcium 2.88 mmol/l
Phosphate 0.75 mmol/l
Parathyroid hormone 6 pmol/L (normal range = 0.8 - 8.5)
What is the most likely underlying diagnosis?ia
A.A Myelomaia
B.A Sarcoidosisia
C.A Primary hyperparathyroidismia
D.A Vitamin D excessia
E.A Osteomalaciaia
The PTH level in primary hyperparathyroidism may be normal
Despite a raised calcium level the parathyroid hormone level is inappropriately normal. This points towards a diagnosis of primary hyperparathyroidism and the other causes would lead to a suppression of parathyroid hormone
Primary hyperparathyroidism
In postgraduate exams primary hyperparathyroidism is stereotypically seen in elderly females with an unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is most commonly due to a solitary adenoma
Causes of primary hyperparathyroidism
• 80%: solitary adenoma
• 15%: hyperplasia
• 4%: multiple adenoma
• 1%: carcinoma
Features - 'bones, stones, abdominal groans and psychic moans'
• polydipsia, polyuria
• peptic ulceration/constipation/pancreatitis
• bone pain/fracture
• renal stones
• depression
• hypertension
Associations
• hypertension
• multiple endocrine neoplasia: MEN I and II
Investigations
• raised calcium, low phosphate
• PTH may be raised or normal
• technetium-MIBI subtraction scan
Treatment
• total parathyroidectomy
17. A 58-year-old man with no past medical history of note is admitted to hospital with crushing central chest pain. ECG on arrival shows anterior ST elevation and he is subsequently thrombolysed with a good resolution of symptoms and ECG changes. Two months following discharge from hospital, which combination of drugs should he be taking?ia
A.A ACE inhibitor + beta-blocker + statin + aspirinia
B.A Spironolactone + beta-blocker + statin + aspirinia
C.A ACE inhibitor + beta-blocker + statin + aspirin + clopidogrelia
D.A ACE inhibitor + statin + aspirin + clopidogrelia
E.A Beta-blocker + statin + aspirin + clopidogrelia
The current guidance is to continue clopidogrel for 4 weeks following a ST-elevation myocardial infarction
Myocardial infarction: secondary prevention
NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2007. Some key points are listed below
All patients should be offered the following drugs:
• ACE inhibitor
• beta-blocker
• aspirin
• statin
Clopidogrel
• after an ST-segment-elevation MI, patients treated with a combination of aspirin and clopidogrel during the first 24 hours after the MI should continue this treatment for at least 4 weeks
• after a non-ST segment elevation myocardial infarction clopidogrel should be given for the first 12 months
Aldosterone antagonists
• patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment should be initiated within 3–14 days of the MI, preferably after ACE inhibitor therapy
18. A 19-year-old man presents with a compound fracture of his leg following a fall from scaffolding. Examination reveals soiling of the wound with mud. He is sure he has had five previous tetanus vaccinations. What is the most appropriate course of action to prevent the development of tetanus?ia
A.A Clean wound + intramuscular human tetanus immunoglobulinia
B.A Clean wound + tetanus vaccineia
C.A Clean wound + tetanus vaccine + intramuscular human tetanus immunoglobulinia
D.A Clean wound + tetanus vaccine + benzylpenicillinia
E.A Clean woundia
A soiled, compound fracture is regarded as high-risk for tetanus and intramuscular human tetanus immunoglobulin should be given
Tetanus: vaccination
The tetanus vaccine is a cell-free purified toxin that is given as part of a combined vaccine (e.g. combined with diphtheria and inactivated polio vaccine)
Tetanus vaccine is currently given in the UK as part of the routine immunisation schedule at:
• 2 months
• 3 months
• 4 months
• 3-5 years
• 13-18 years
This therefore provides 5 doses of tetanus-containing vaccine. Five doses is now considered to provide adequate long-term protection against tetanus.
Intramuscular human tetanus immunoglobulin should be given to patients with high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue) irrespective of whether 5 doses of tetanus vaccine have previously been given
If vaccination history is incomplete or unknown then a dose of tetanus vaccine should be given combined with intramuscular human tetanus immunoglobulin for high-risk wounds
.com - Terms and Conditions
19. A 56-year-old man is reviewed in the Cardiology outpatient clinic following a myocardial infarction one year previously. During his admission he was found to be hypertensive and diabetic. He complains that he has put on 5kg in weight in the past 6 months. Which of his medications may be contributing to his weight gain?ia
A.A Metforminia
B.A Losartania
C.A Clopidogrelia
D.A Gliclazideia
E.A Simvastatinia
Sulfonylureas
Sulfonylureas are oral hypoglycaemic drugs used in the management of type 2 diabetes mellitus. They work by increasing pancreatic insulin secretion and hence are only effective if functional B-cells are present.
Common adverse effects
• hypoglycaemic episodes (more common with long acting preparations such as chlorpropamide)
• increased appetite and weight gain
Rarer adverse effects
• syndrome of inappropriate ADH secretion
• bone marrow suppression
• liver damage (cholestatic)
• photosensitivity
• peripheral neuropathy
Sulfonylureas should be avoided in breast feeding and pregnancy
20. A mother whose 14-year-old daughter had a history of glue ear when younger asks the practice manager for a copy of her medical records. Which one of the following statements governing access to medical records is incorrect?ia
A.A Doctors should withhold information they may feel is damaging to the patients physical or mental healthia
B.A Access to records should be given within 40 daysia
C.A Parents may request access to their children's recordsia
D.A Competent children may seek access to their recordsia
E.A Should be done without a feeia
A fee is normally charged for access to medical records
Access to medical records
A patients right to view their own medical records is governed by the 1998 Data Protection Act and the 1990 Access to Health Records Act
Key principles
• patients have a right to see what is written in their medical record
• competent children may seek access to their records
• parents may request access to their children's (< 16 years) records
• doctors should not release information they feel may damage a patients emotional or physical health
• access to information recorded during the previous 40 days must be given within 21 days, or in any other case 40 days
• a fee may be charged
21. A 56-year-old man with metastatic prostate cancer comes for review. He is known to have spinal metastases but until now has not had any significant problems with pain control. Unfortunately he is now getting regular back pain despite taking paracetamol 1g qds. Neurological examination is unremarkable. What is the most appropriate next step?ia
A.A Switch to co-codamol 30/500ia
B.A Refer for radiotherapyia
C.A Add oral bisphosphonateia
D.A Add diclofenacia
E.A Add dexamethasoneia
Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
Bone pain often responds well to NSAIDs. Both radiotherapy and bisphosphonates have a role in managing bony pain but these are not first-line treatments
Palliative care prescribing: pain
SIGN issued guidance on the control of pain in adults with cancer in 2008
Selected points
• the breakthrough dose of morphine is one-sixth the daily dose of morphine
• all patients who receive opioids should be prescribed a laxative
• opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
• metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
Conversion between opioids
From To
Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 5
From To
Oral morphine Oral oxycodone Divide by 2
The BNF states that oral morphine sulphate 80-90mg over 24 hours is approximately equivalent to one '25 mcg/hour' patch, therefore product literature should be consulted
From To
Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5
22. Theme: Theme: Consultation modelsia
A. Heron
B. Byrne and Long
C. Berne
D. Fraser
E. Neighbour
F. Balint
G. Stott and Davis
H. Helman's folk model
I. Pendleton
For each of the following tasks select the consultation model most associated with itia
1. Safety netting
The correct answer is Neighbour
2. Handing over
The correct answer is Neighbour
3. Considering other problems
The correct answer is Pendleton
Consultation models
Calgary-Cambridge observation guide- Kurtz and Silverman - 1996
• initiating the session
• gathering information
• building the relationship
• giving information, explaining and planning
• closing the session
Stewart - patient-centred clinical method - 1995. 2003
• exploring both the disease and the illness experience
• understanding the whole person
• finding common ground
• incorporating prevention and health promotion
• enhancing the doctor-patient relationship
• being realistic (with time and resources)
Pendleton - The Consultation: an Approach to Learning and Teaching - 1984, 2003
• define the reason for the patient's attendance (ideas, concerns and expectations)
• consider other problems
• with the patient, choose an appropriate action for each problem
• achieve a shared understanding of the problems with the patient
• involve the patient in the management and encourage him/her to accept appropriate responsibility
• use time and resources appropriately
• establish or maintain a relationship with the patient which helps to achieve the other tasks
Fraser - Areas of competence - 1992
• interviewing and history-taking
• physical examination
• diagnosis and problem-solving
• patient management
• relating to patients
• anticipatory care
• record keeping
Neighbour - The Inner Consultation - five checkpoint model - 1987
• connecting
• summarising
• handing over
• safety netting
• housekeeping
Tuckett - meeting of two experts - 1985
• the consultation is a meeting between two experts
• doctors are experts in medicine
• patients are experts in their own illnesses
• shared understanding is the aim
• doctors should seek to understand the patient's beliefs
• doctors should address explanations in terms of the patient's belief system
Stott and Davis - Exceptional potential of the consultation - 1979
• management of presenting problems
• management of continuing problems
• modification of help-seeking behaviour
• opportunistic health promotion
23. A 23-year-old man presents as he is concerned about recent hair loss. Examination reveals the following:ia
What is the most likely diagnosis?
A.A Telogen effluviumia
B.A Alopecia areataia
C.A Tinea capitisia
D.A Male-pattern baldnessia
E.A Discoid lupus erythematousia
Alopecia areata
Alopecia areata is a presumed autoimmune condition causing localised, well demarcated patches of hair loss. At the edge of the hair loss, there may be small, broken 'exclamation mark' hairs
Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually. Careful explanation is therefore sufficient in many patients. Other treatment options include:
• topical or intralesional corticosteroids
• topical minoxidil
• phototherapy
• dithranol
• contact immunotherapy
24. Which one of the following is the most common ocular manifestation of rheumatoid arthritis?ia
A.A Scleritisia
B.A Episcleritisia
C.A Keratoconjunctivitis siccaia
D.A Corneal ulcerationia
E.A Keratitisia
Keratoconjunctivitis sicca is characterised by dry, burning and gritty eyes caused by decreased tear production
Rheumatoid arthritis: ocular manifestations
Ocular manifestations of rheumatoid arthritis are common, with 25% of patients having eye problems
Ocular manifestations
• keratoconjunctivitis sicca (most common)
• episcleritis (erythema)
• scleritis (erythema and pain)
• corneal ulceration
• keratitis
Iatrogenic
• steroid-induced cataracts
• chloroquine retinopathy
25. A 78-year-old women is discharged following a fractured neck of femur. On review she is making good progress but consideration is given to secondary prevention of further fractures. What is the most suitable management?ia
A.A Arrange DEXA scan + start strontium ranelate if T-score < -2.5 SDia
B.A Start oral bisphosphonateia
C.A Arrange DEXA scan + start oral bisphosphonate if T-score < -1.0 SDia
D.A Arrange DEXA scan + start hormone replacement therapy if T-score < -2.5 SDia
E.A Arrange DEXA scan + start oral bisphosphonate if T-score < -1.5 SDia
NICE guidelines support starting a bisphosphonate without waiting for a DEXA scan in such scenarios
Osteoporosis: secondary prevention
NICE guidelines were updated in 2008 on the secondary prevention of osteoporotic fractures in postmenopausal women.
Key points include
• treatment is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of – 2.5 SD or below). In women aged 75 years or older, a DEXA scan may not be required 'if the responsible clinician considers it to be clinically inappropriate or unfeasible'
• vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
• alendronate is first-line
• around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate (see treatment criteria below)
• strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates (see treatment criteria below)
Treatment criteria for patients not taking alendronate
Unfortunately, a number of complicated treatment cut-off tables have been produced in the latest guidelines for patients who do not tolerate alendronate
Risk factors (for use in the tables below)
• parental history of hip fracture
• alcohol intake of 4 or more units
• rheumatoid arthritis
T-scores (SD) at (or below) which risedronate or etidronate is recommended when alendronate cannot be taken
Age (years) No risk factors 1 risk factor 2 risk factors
50–54 Not indicated – 3.0 – 2.5
55–59 – 3.0 – 3.0 – 2.5
60–64 – 3.0 – 3.0 – 2.5
65–69 – 3.0 – 2.5 – 2.5
70 or older – 2.5 – 2.5 – 2.5
T-scores (SD) at (or below) which strontium ranelate or raloxifene is recommended when alendronate and either risedronate or etidronate cannot be taken
Age (years) No risk factors 1 risk factor 2 risk factors
50–54 Not indicated – 3.5 – 3.5
55–59 – 4.0 – 3.5 – 3.5
60–64 – 4.0 – 3.5 – 3.5
65–69 – 4.0 – 3.5 – 3.0
70–74 – 3.0 – 3.0 – 2.5
75 or older – 3.0 – 2.5 – 2.5
Supplementary notes on treatment
Bisphosphonates
• alendronate, risedronate and etidronate are all licensed for the prevention and treatment of post-menopausal and glucocorticoid-induced osteoporosis
• all three have been shown to reduce the risk of both vertebral and non-vertebral fractures although alendronate, risedronate may be superior to etidronate in preventing hip fractures
• ibandronate is a once-monthly oral bisphosphonate
Vitamin D and calcium
• poor evidence base to suggest reduced fracture rates in the general population at risk of osteoporotic fractures - may reduce rates in frail, housebound patients
Raloxifene - selective oestrogen receptor modulator (SERM)
• has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been shown to reduce the risk of non-vertebral fractures
• has been shown to increase bone density in the spine and proximal femur
• may worsen menopausal symptoms
• increased risk of thromboembolic events
• may decrease risk of breast cancer
Strontium ranelate
• 'dual action bone agent' - increases deposition of new bone by osteoblasts and reduces the resorption of bone by osteoclasts
• strong evidence base, may be second-line treatment in near future
• increased risk of thromboembolic events
Teriparatide
• recombinant form of parathyroid hormone
• very effective at increasing bone mineral density but role in the management of osteoporosis yet to be clearly defined
Hormone replacement therapy
• has been shown to reduce the incidence of vertebral fracture and non-vertebral fractures
• due to concerns about increased rates of cardiovascular disease and breast cancer it is no longer recommended for primary or secondary prevention of osteoporosis unless the woman is suffering from vasomotor symptoms
Hip protectors
• evidence to suggest significantly reduce hip fractures in nursing home patients
• compliance is a problem
Falls risk assessment
• no evidence to suggest reduced fracture rates
• however, do reduce rate of falls and should be considered in management of high risk patients
26. A 34-year-old man confides in you that he experienced childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?ia
A.A Hyperarousalia
B.A Emotional numbingia
C.A Nightmaresia
D.A Loss of inhibitionsia
E.A Avoidanceia
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example a major disaster or childhood sexual abuse. It encompasses what became known as 'shell shock' following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month
Features
• re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
• avoidance: avoiding people, situations or circumstances resembling or associated with the event
• hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
• emotional numbing – lack of ability to experience feelings, feeling detached
from other people
• depression
• drug or alcohol misuse
• anger
• unexplained physical symptoms
Management
• following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
• watchful waiting may be used for mild symptoms lasting less than 4 weeks
• trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
• drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended
27. A 7-year-old girl is brought to surgery due to a sore throat. She has a temperature of 39.2ºC and is not eating due to the pain, although she is tolerating fluids. The tonsils are covered in exudate bilaterally. Examination of the ears is unremarkable. Other than supportive treatment, what is the most appropriate management?ia
A.A Erythromycin for 10 daysia
B.A Amoxicillin for 7 daysia
C.A Antibiotics are not indicatedia
D.A Phenoxymethylpenicillin for 10 daysia
E.A Phenoxymethylpenicillin for 5 daysia
This girl has marked systemic upset and should be treated with antibiotics. A 7 or 10 day course of antibiotics is appropriate to ensure eradication of possible Streptococcus infection. Phenoxymethylpenicillin is the first-line antibiotic choice in the BNF
Sore throat
Sore throat encompasses pharyngitis, tonsillitis, laryngitis
Clinical Knowledge Summaries recommend:
• throat swabs and rapid antigen tests should not be carried out routinely in patients with a sore throat
Management
• paracetamol or ibuprofen for pain relief
• antibiotics are not routinely indicated
NICE indications for antibiotics
• features of marked systemic upset secondary to the acute sore throat
• unilateral peritonsillitis
• a history of rheumatic fever
• an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
If antibiotics are indicated then either phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic) should be given. Either a 7 or 10 day course should be given
28. In accordance with recent NICE guidelines on urinary tract infection in children, which one of the following patients would not require a urine sample to be obtained?ia
A.A 4-year-old with a 5 day history of urinary frequencyia
B.A 2-year-old who has a persistent pyrexia after 48 hours of antibiotic treatment for otitis mediaia
C.A 16-month-old complaining of abdominal painia
D.A 2-month-old who is feeding poorly and vomitingia
E.A 3-year-old with a temperature of 37.7ºC who is well and has no obvious focus of infectionia
The 3-year-old most probably has a non-specific viral infection. There is no indication at the current time to check for a urinary tract infection
Urinary tract infection in children: features, diagnosis and management
Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood
Presentation in childhood depends on age:
• infants: poor feeding, vomiting, irritability
• younger children: abdominal pain, fever, dysuria
• older children: dysuria, frequency, haematuria
• features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness
NICE guidelines for checking urine sample in a child
• if there are any symptoms or signs suggestive or a UTI
• with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
• with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)
Urine collection method
• clean catch is preferable
• if not possible then urine collection pads should be used
• cotton wool balls, gauze and sanitary towels are not suitable
• invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible
Management
• infants less than 3 months old should be referred immediately to a paediatrician
• children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
• children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
• antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
29. A 31-year-old woman presents as she has noted an offensive, fishy vaginal discharge. She describes a grey, watery discharge. What is the most likely diagnosis?ia
A.A Trichomonas vaginalisia
B.A Candidaia
C.A Chlamydiaia
D.A Bacterial vaginosisia
E.A Physiological dischargeia
Vaginal discharge
Vaginal discharge is a common presenting symptom and is not always pathological
Common causes
• physiological
• Candida
• Trichomonas vaginalis
• bacterial vaginosis
Less common causes
• whilst cervical infections such as Chlamydia and Gonorrhoea can cause a vaginal discharge this is rarely the presenting symptoms
• ectropion
• foreign body
• cervical cancer
Key features of the common causes are listed below
Condition Key features
Candida 'Cottage cheese' discharge
Vulvitis
Itch
Trichomonas vaginalis Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
Bacterial vaginosis Offensive, thin, white/grey, 'fishy' discharge
30. A 52-year-old woman with a history of hypothyroidism presents with lethargy and a sore tongue. Blood tests are reported as follows:
Hb 10.7 g/dl
MCV 121 fl
Plt 177 * 109/l
WBC 5.4 * 109/l
Further tests are ordered:
Vitamin B12 64 ng/l (200-900 ng/l)
Folic acid 7.2 nmol/l (> 3.0 nmol/l)
Antibodies to intrinsic factor are also found. What is the most appropriate management?ia
A.A 1 mg of IM hydroxocobalamin once every 3 monthsia
B.A 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 monthsia
C.A 1 mg of IM hydroxocobalamin once every 2 months + folic acid 5mg odia
D.A Give folic acid 5mg od one week then recheck bloodsia
E.A 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months + folic acid 5mg odia
Vitamin B12 deficiency
sqweqwesf erwrewfsdfs adasd dhe
Vitamin B12 is mainly used in the body for red blood cell development and also maintenance of the nervous system. It is absorbed after binding to intrinsic factor (secreted from parietal cells in the stomach) and is actively absorbed in the terminal ileum. A small of vitamin B12 is passively absorbed without being bound to intrinsic factor.
Causes of vitamin B12 deficiency
• pernicious anaemia
• post gastrectomy
• poor diet
• disorders of terminal ileum (site of absorption): Crohn's, blind-loop etc
Features of vitamin B12 deficiency
• macrocytic anaemia
• sore tongue and mouth
• neurological symptoms: e.g. Ataxia
• neuropsychiatric symptoms: e.g. Mood disturbances
Management
• if no neurological involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months
• if a patient is also deficient in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord
31. Which one of the following statements regarding appraisal is incorrect?ia
A.A The appraiser may be a non-principalia
B.A Formal training is required to become an appraiseria
C.A It is compulsoryia
D.A The average time commitment for appraisal is a minimum of 4.5 to 6.5 hoursia
E.A Practices are responsible for funding locum coveria
Primary care trusts are responsible for funding locum cover to compensate for time lost to appraisals
Appraisal
sqweqwesf erwrewfsdfs adasd dhe
Appraisal has been a requirement for GPs since 2002. It is meant to be a formative process identifying development needs rather than performance management.
Appraisal will eventually provide a regular, structured system for recording progress
towards revalidation and identifying development needs
The appraiser should be another GP (principal or non-principal), who will
have been properly trained in appraisal. Typically the average time commitment for appraisal is a minimum of 4.5 to 6.5 hours. This includes between 2 and 4 hours for preparation. Primary Care Trusts should provide funds for locum cover to compensate for this time
The content of appraisal is based on the core headings set out in the GMC’s
Good Medical Practice document:
• good clinical care
• maintaining good medical practice
• relationships with patients
• working with colleagues
• teaching and training
• probity
• health
32. A 24-year-old woman who is 14 weeks pregnant presents with a severe migraine. She has a long history of migraine and stopped propranolol prophylaxis when she found out she was pregnant. Unfortunately the headache has not responded to paracetamol 1g. What is the most appropriate next step?ia
A.A Ergotamineia
B.A Nasal zolmitriptania
C.A Ibuprofen 400mgia
D.A Almotriptan 12.5mgia
E.A Codeine 30mgia
Migraine: pregnancy, contraception and other hormonal factors
sqweqwesf erwrewfsdfs adasd dhe
SIGN produced guidelines in 2008 on the management of migraine, the following is selected highlights:
Migraine during pregnancy
• paracetamol 1g is first-line
• aspirin 300mg or ibuprofen 400mg can be used second-line in the first and second trimester
Migraine and the combined oral contraceptive (COC) pill
• if patients have migraine with aura then the COC is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72)
Migraine and hormone replacement therapy (HRT)
• safe to prescribe HRT for patients with a history of migraine but it may make migraines worse
33. A 64-year-old man with a history of Parkinson's disease is reviewed in clinic and a decision has been made to start him on cabergoline. Which one of the following adverse effects is most strongly associated with this drug?ia
A.A Optic neuritisia
B.A Transient rise in liver function testsia
C.A Pulmonary fibrosisia
D.A Renal failureia
E.A Thrombocytopeniaia
Parkinson's disease: management
sqweqwesf erwrewfsdfs adasd dhe
Currently accepted practice in the management of patients with Parkinson's disease (PD) is to delay treatment until the onset of disabling symptoms and then to introduce a dopamine receptor agonist. If the patient is elderly, levodopa is sometimes used as an initial treatment
Dopamine receptor agonists
• e.g. bromocriptine, ropinirole, cabergoline, apomorphine
• ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide*) have been associated with pulmonary, retroperitoneal and cardiac fibrosis. The Committee on Safety of Medicines advice that an ESR, creatinine and chest x-ray should be obtained prior to treatment and patients should be closely monitored
Levodopa
• usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of levodopa to dopamine
• reduced effectiveness with time (usually by 2 years)
• unwanted effects: dyskinesia, 'on-off' effect
• no use in neuroleptic induced parkinsonism
MAO-B (Monoamine Oxidase-B) inhibitors
• e.g. selegiline
• inhibits the breakdown of dopamine secreted by the dopaminergic neurons
Amantadine
• mechanism is not fully understood, probably increases dopamine release and inhibits its uptake at dopaminergic synapses
COMT (Catechol-O-Methyl Transferase) inhibitors
• e.g. entacapone
• COMT is an enzyme involved in the breakdown of dopamine, and hence may be used as an adjunct to levodopa therapy
• used in established PD
Antimuscarinics
• block cholinergic receptors
• now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson's disease
• help tremor and rigidity
• e.g. procyclidine, benzotropine, trihexyphenidyl (benzhexol)
*pergolide was withdrawn from the US market in March 2007 due to concern regarding increased incidence of valvular dysfunction
35. A 24-year-old woman who is 18 weeks pregnant presents to surgery. Earlier on in the morning she came into contact with a child who has chickenpox. She is unsure if she had the condition herself as a child. What is the most appropriate action?ia
A.A Advise her to present within 24 hours of the rash developing for consideration of IV acicloviria
B.A Reassure her that there is no risk of fetal complications at this point in pregnancyia
C.A Give varicella immunoglobulinia
D.A Check varicella antibodiesia
E.A Prescribe oral acicloviria
Chickenpox exposure in pregnancy - first step is to check antibodies
If there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies
Chickenpox exposure in pregnancy
sqweqwesf erwrewfsdfs adasd dhe
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
Fetal varicella syndrome (FVS)
• risk of FVS following maternal varicella exposure is around 1-2% if occurs before 20 weeks gestation
• studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks. The risk in the first trimester is thought to be less (around 0.5-1%)
• features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Management of chickenpox exposure
• if there is any doubt about the mother previously having chickenpox maternal blood should be checked for varicella antibodies
• if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
• consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash
36. A 41-year-old woman is investigated for hot flushes and night sweats. Bloods show a significantly raised FSH level and her symptoms are attributed to the menopause. Following discussions with the patient she elects to have hormone replacement treatment. What is the most significant risk of failing to prescribe a combined oestrogen-progestogen preparation rather than an oestrogen-only preparation?ia
A.A Increased risk of venous thromboembolismia
B.A Increased risk of ovarian canceria
C.A Increased risk of endometrial canceria
D.A Increased risk of breast canceria
E.A Increased risk of colorectal canceria
HRT: unopposed oestrogen increases risk of endometrial cancer
Hormone replacement therapy: adverse effects
sqweqwesf erwrewfsdfs adasd dhe
Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
Side-effects
• nausea
• breast tenderness
• fluid retention and weight gain
Potential complications
• increased risk of breast cancer: increased by the addition of a progestogen
• increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely
• increased risk of venous thromboembolism: increased by the addition of a progestogen
Breast cancer
• in the Women's Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
• the increased risk relates to duration of use
• breast cancer incidence is higher in women using combined preparations compared to oestrogen-only preparations
• the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
37. A 54-year-old man with a history of type 2 diabetes mellitus and benign prostatic hyperplasia is referred to dermatology due to a number of lesions over his shin. On examination symmetrical, erythematous, tender, nodules are found. The lesions have started to heal without scarring. What is the most likely diagnosis?ia
A.A Necrobiosis lipoidica diabeticorumia
B.A Erythema nodosumia
C.A Pyoderma gangrenosumia
D.A Syphilisia
E.A Pretibial myxoedemaia
Shin lesions
sqweqwesf erwrewfsdfs adasd dhe
The differential diagnosis of shin lesions includes the following conditions:
• erythema nodosum
• pretibial myxoedema
• pyoderma gangrenosum
• necrobiosis lipoidica diabeticorum
Below are the characteristic features:
Erythema nodosum
• symmetrical, erythematous, tender, nodules which heal without scarring
• most common causes are streptococcal infections, sarcoidosis, inflammatory bowel disease and drugs (penicillins, sulphonamides, oral contraceptive pill)
Pretibial myxoedema
• symmetrical, erythematous lesions seen in Graves' disease
• shiny, orange peel skin
Pyoderma gangrenosum
• initially small red papule
• later deep, red, necrotic ulcers with a violaceous border
• idiopathic in 50%, may also be seen in inflammatory bowel disease, connective tissue disorders and myeloproliferative disorders
Necrobiosis lipoidica diabeticorum
• shiny, painless areas of yellow/red skin typically on the shin of diabetics
• often associated with telangiectasia
38. A 22-year-old woman who is an immigrant from Malawi presents for review as she thinks she is pregnant. This is confirmed with a positive pregnancy test. She is known to be HIV positive. Which one of the following should not be part of the management plan to ensure an optimal outcome?ia
A.A Oral zidovudine for the newborn until 6 weeks of ageia
B.A Maternal antiretroviral therapyia
C.A Encourage breast feedingia
D.A Intrapartum zidovudine infusionia
E.A Elective caesarean sectionia
The 2008 BHIVA guidelines suggest vaginal delivery may be an option for women on HAART who have an undetectable viral load but whether this will translate into clinical practice remains to be seen
HIV and pregnancy
sqweqwesf erwrewfsdfs adasd dhe
With the increased incidence of HIV infection amongst the heterosexual population there is an increasing number of HIV positive women giving birth in the UK. In London the incidence may be as high as 0.4% of pregnant women. The aim of treating HIV positive women during pregnancy is to minimise harm to both the mother and fetus, and to reduce the chance of vertical transmission.
Factors which reduce vertical transmission (from 25-30% to 2%)
• maternal antiretroviral therapy
• mode of delivery (caesarean section)
• neonatal antiretroviral therapy
• infant feeding (bottle feeding)
Screening
• NICE guidelines recommend offering HIV screening to all pregnant women
Antiretroviral therapy
• all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously
• if women are not currently taking antiretroviral therapy it is usually commenced between 28 and 32 weeks of gestation and should be continued intrapartum
Mode of delivery
• elective caesarean section*
• a zidovudine infusion should be started four hours before beginning the caesarean section
Neonatal antiretroviral therapy
• zidovudine is usually administered orally to the neonate for four to six weeks
Infant feeding
• in the UK all women should be advised not to breast feed
*the 2008 BHIVA guidelines suggest vaginal delivery may be an option for women on HAART who have an undetectable viral load but whether this will translate into clinical practice remains to be seen
39. Which one of the following statements regarding the link between intrauterine devices (IUDs) and ectopic pregnancies is correct?ia
A.A The percentage of pregnancies that are ectopic is increased and the absolute number is increasedia
B.A The percentage of pregnancies that are ectopic is increased but the absolute number is decreasedia
C.A Having an intrauterine device has no effect on the rate of ectopic pregnanciesia
D.A The percentage of pregnancies that are ectopic is decreased and the absolute number is decreasedia
E.A The percentage of pregnancies that are ectopic is decreased but the absolute number is increasedia
IUCD - the percentage of pregnancies that are ectopic is increased but the absolute number is decreased
Intrauterine contraceptive devices
sqweqwesf erwrewfsdfs adasd dhe
Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirena). The IUS is also used in the management of menorrhagia
Effectiveness
• both the IUD and IUS are more than 99% effective
Mode of action
• IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
• IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening
Counselling
• IUD is effective immediately following insertion
• IUS can be relied upon after 7 days
Potential problems
• IUDs make periods heavier, longer and more painful
• the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
• uterine perforation during insertion: less than 1 in 1,000 risk
• the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
• infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
• expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
40. At what age would the average child acquire the ability to crawl?ia
A.A 6 monthsia
B.A 9 monthsia
C.A 12 monthsia
D.A 18 monthsia
E.A 2 yearsia
Developmental milestones: gross motor
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The table below summarises the major gross motor developmental milestones
Age Milestone
3 months Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve
6 months Lying on abdomen, arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back
9 months Sits without support (Refer at 12 months)
Pulls to standing
Crawls
12 months Cruises
Walks with one hand held
15 months Walks unsupported (Refer at 18 months)
18 months Squats to pick up a toy
2 years Runs
Walks upstairs and downstairs holding on to rail
3 years Rides a tricycle using pedals
Walks up stairs without holding on to rail
4 years Hops on one leg
Notes
• the majority of children crawl on all fours before walking but some children 'bottom-shuffle'. This is a normal variant and runs in families
41. An 8-year-old boy is reviewed in clinic due to nocturnal enuresis. Of the following options, what is the most appropriate initial management strategy?ia
A.A Enuresis alarmia
B.A Trial of oral desmopressinia
C.A Trial of imipramineia
D.A Trial of intranasal desmopressinia
E.A Restrict fluids in the eveningia
A reward based system may also be used as a first line treatment in enuresis. Restricting fluids is not recommended advice - Clinical Knowledge Summaries suggest: 'Do not restrict fluids. The child should have about eight drinks a day, spaced out throughout the day, the last one about 1 hour before bed.'
Nocturnal enuresis
sqweqwesf erwrewfsdfs adasd dhe
The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the 'involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract'
Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)
Management
• dip urine for protein and sugar, send for culture (helps exclude diabetes mellitus and UTI)
• explanation, reassurance and education (e.g. avoid punitive measures)
• star charts are useful (the child earns a star for a dry night)
• if star charts fail then alarms which awake the child following a wetting episode may be tried
42. With reference to the Quality and Outcomes Framework (QOF), which component is responsible for the second highest number of points?ia
A.A Child health surveillanceia
B.A Clinical indicatorsia
C.A Organisationalia
D.A Additional servicesia
E.A Patient experienceia
Quality and Outcomes Framework
sqweqwesf erwrewfsdfs adasd dhe
The Quality and Outcomes Framework (QOF) is the annual reward and incentive programme detailing GP practice achievement results. It was introduced as part of the new General Medical Services (GMS) to incentivise not only the management of chronic disease such as diabetes but also to improve the organisation of the practice and patient experience
Other points
• for clinical indicators the value of a point is determined by the prevalence of that condition in the practice
• participation in the QOF is voluntary
• 5% of practices should be visited at random to help prevent fraud. The PCT visiting team will normally consist of a PCT management representative, a GP and a patient representative
The table below shows the four key areas on which the QOF is based
Clinical indicators 655 points Standards linked to the care of patients suffering from chronic diseases
Organisational 181 points Standards relating to records and information, communicating with patients, education and training, medicines management and clinical and practice management
Additional services 36 points Covering cervical screening, child health surveillance, maternity services and contraceptive services
Patient experience 108 points Based on patient surveys and length of consultations
20 points are also awarded for holistic care. The calculation is complicated but is basically awarded on the basis of overall achievement in the clinical domain
Patients may be 'exception reported' in the following situations:
• patients who have been recorded as refusing to attend review who have been invited on at least three occasions during the preceding 12 months
• patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances e.g. terminal illness, extreme frailty
• patients newly diagnosed within the practice or who have recently registered with the practice, who should have measurements made within 3 months and delivery of clinical standards within 9 months e.g. blood pressure or cholesterol measurements within target levels
• patients who are on maximum tolerated doses of medication whose treatment remain sub-optimal
• patients for whom prescribing a medication is not clinically appropriate e.g. those who have an allergy, another contraindication or have experienced an adverse reaction
• where a patient has not tolerated medication
• where a patient does not agree to investigation or treatment (informed dissent), and this has been recorded in their medical records
• where the patient has a supervening condition which makes treatment of their condition inappropriate e.g. cholesterol reduction where the patient has liver disease
• where an investigative service or secondary care service is unavailable
43. A home visit is requested by the husband of a 71-year-old woman who is 'off her legs'. On arriving the patient states that since mid-morning her left arm has felt weak and a degree of facial asymmetry is noted when she smiles. She is normally fit and well other than a past history of hypertension for which she takes ramipril. What is the most appropriate action?ia
A.A Arrange same-day medical admissionia
B.A Dial 999 for emergency admissionia
C.A Arrange review at rapid access TIA clinicia
D.A Arrange review at rapid access TIA clinic + give aspirin 300 mgia
E.A Dial 999 for emergency admission + give aspirin 300 mgia
This lady is most likely having a stroke, nowadays rightly recognised as a medical emergency. Aspirin should only be given once a haemorrhagic stroke has been excluded
Stroke: management
sqweqwesf erwrewfsdfs adasd dhe
The Royal College of Physicians (RCP) published guidelines on the diagnosis and management of patients following a stroke in 2004
Selected points relating to the management of acute stroke include:
• blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
• blood pressure should not be lowered in the acute phase unless there are complications e.g. hypertensive encephalopathy
• aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
• with regards to atrial fibrillation, the RCP state: 'anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke'
• if the cholesterol is > 3.5 mmol/l patients should be commence on a statin
Thrombolysis
Thrombolysis should only be given if:
• it is administered within 3 hours of onset of stroke symptoms (unless as part of a clinical trial)
• haemorrhage has been definitively excluded (i.e. imaging has been performed)
Alteplase is currently recommended by NICE
44. A meta-analysis is performed examining whether giving patients who've recently had a myocardial infarction a new dietary supplement prevents a further attack. The meta-analysis consists of four randomised controlled trials and is summarised below:ia
What is the most appropriate interpretation of the data?
A.A There is publication bias in studies looking into this questionia
B.A There is a non-significant trend that taking the supplement reduces the chance of a further myocardial infarctionsia
C.A There is a non-significant trend towards no benefit from taking the supplement in terms of reducing further myocardial infarctionsia
D.A Taking the supplement reduces the chance of a further myocardial infarctionsia
E.A Taking the supplement increases the chance of a further myocardial infarctionia
The meta-analysis of the results, represented by the diamond, is clear from the no effect line (odds ratio of 1) and shows a signficant increase in the chance of a further myocardial infarction.
Forest plots
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Forest plots are usually found in meta-analyses and provide a graphical representation of the strength of evidence of the constituent trials.
The name of the trials is listed down the left hand side, usually in chronological order. On the right side the results of the studies are shown as squares centred on the point estimate of the result of each trial. The size of the square is proportional to the size of the trial. The line running through the line shows the confidence interval, usually at 95%. Beneath the individual trials is the summary result (i.e. The result of the meta-analysis) represented by a diamond.
Saturday 1 May 2010
Thursday 22 April 2010
haematuria
1. A 53-year-old man attends as a new patient to your practice. He has no previous past medical history and is not taking any regular medication. As part of his new patient check, the following results are obtained:
Urinalysis Blood++
Mid-stream urine (MSU) Negative
Blood pressure 112/68 mmHg
Urea and electrolytes Normal
Which ONE of the following options is the most appropriate INITIAL management for this patient? Select ONE option only.
A. Check prostate-specific antigen (PSA)
B. Re-check urinalysis in 2 weeks
C. Referral for renal ultrasound scan
D. Routine referral to renal physician
E. Urgent referral to urological surgeon
answer: E
Regarding the management of suspected urological cancer:
•Male or female adult patients of any age who present with painless macroscopic haematuria should be referred urgently.
•In male or female patients with symptoms suggestive of a urinary infection who also present with macroscopic haematuria, investigations should be undertaken to diagnose and treat the infection before consideration of referral. If infection is not confirmed the patient should be referred urgently.
•In all adult patients 40 years of age and older who present with recurrent or persistent urinary tract infection associated with haematuria, an urgent referral should be made.
•In patients under 50 years of age with microscopic haematuria, the urine should be tested for proteinuria and serum creatinine levels measured. Those with proteinuria or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non-urgent referral to a urologist should be made.
•In patients 50 years of age and older who are found to have unexplained microscopic haematuria, an urgent referral should be made.
Any patient with an abdominal mass identified clinically or on imaging that is thought to be arising from the urinary tract should be referred urgently.
Urgent referral to urological surgeon
Urinalysis Blood++
Mid-stream urine (MSU) Negative
Blood pressure 112/68 mmHg
Urea and electrolytes Normal
Which ONE of the following options is the most appropriate INITIAL management for this patient? Select ONE option only.
A. Check prostate-specific antigen (PSA)
B. Re-check urinalysis in 2 weeks
C. Referral for renal ultrasound scan
D. Routine referral to renal physician
E. Urgent referral to urological surgeon
answer: E
Regarding the management of suspected urological cancer:
•Male or female adult patients of any age who present with painless macroscopic haematuria should be referred urgently.
•In male or female patients with symptoms suggestive of a urinary infection who also present with macroscopic haematuria, investigations should be undertaken to diagnose and treat the infection before consideration of referral. If infection is not confirmed the patient should be referred urgently.
•In all adult patients 40 years of age and older who present with recurrent or persistent urinary tract infection associated with haematuria, an urgent referral should be made.
•In patients under 50 years of age with microscopic haematuria, the urine should be tested for proteinuria and serum creatinine levels measured. Those with proteinuria or raised serum creatinine should be referred to a renal physician. If there is no proteinuria and serum creatinine is normal, a non-urgent referral to a urologist should be made.
•In patients 50 years of age and older who are found to have unexplained microscopic haematuria, an urgent referral should be made.
Any patient with an abdominal mass identified clinically or on imaging that is thought to be arising from the urinary tract should be referred urgently.
Urgent referral to urological surgeon
Friday 19 March 2010
AKT revision: Knee problems
1. Which one of the following statements below makes a meniscal tear more likely than alternative diagnoses?
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.
2.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?
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.
3. 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?
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.
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.
2.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?
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.
3. 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?
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.
AKT revision: Ovarian cysts and cancer
1.Which one of the following statements is true about CA125?
A serum level greater than 100U/ml (NR <35 U/ml) makes a germ cell tumour the most likely diagnosis.
It is only raised if an epithelial ovarian tumour is present
It is an important parameter in the ovarian risk of malignancy index
The level is reduced if the patient has glycosuria
Women over 50 are screened with a serum CA125 every five years
Answer: C
The RMI combines Ultrasound findings, CA125 and menopausal status. CA125 is a non specific test and the most likely association is with epithelial tumours and not germ cell. Other tumours may cause it to be raised as may diabetes, CCF and liver disease
*The options below relate to referral patterns in women with issues relating to potential ovarian pathology. Each option may be used once, more than once or not at all. Indicate the single most appropriate answer for each patient.
2.A 56 year old woman complaining of bloating and a walnut sized adnexal swelling
A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission
Answer: C
3. A 30 year old asymptomatic Irish woman whose sister has breast cancer aged 35
A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission
Answer: B
for genetic counselling / testing.
4. A 3.5cm right sided cyst found on pelvic ultrasound in a 28 year old non pregnant woman
A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission
Answer: A
referral will however be necessary if this is still present on a repeat scan in 2-3 months.
5. A 40 year old asymptomatic Jewish woman whose aunt died from ovarian cancer
A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission
Answer: B
for genetic counselling / testing since there is a higher incidence of BRCA1 and BRCA2 mutations in this population.
A serum level greater than 100U/ml (NR <35 U/ml) makes a germ cell tumour the most likely diagnosis.
It is only raised if an epithelial ovarian tumour is present
It is an important parameter in the ovarian risk of malignancy index
The level is reduced if the patient has glycosuria
Women over 50 are screened with a serum CA125 every five years
Answer: C
The RMI combines Ultrasound findings, CA125 and menopausal status. CA125 is a non specific test and the most likely association is with epithelial tumours and not germ cell. Other tumours may cause it to be raised as may diabetes, CCF and liver disease
*The options below relate to referral patterns in women with issues relating to potential ovarian pathology. Each option may be used once, more than once or not at all. Indicate the single most appropriate answer for each patient.
2.A 56 year old woman complaining of bloating and a walnut sized adnexal swelling
A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission
Answer: C
3. A 30 year old asymptomatic Irish woman whose sister has breast cancer aged 35
A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission
Answer: B
for genetic counselling / testing.
4. A 3.5cm right sided cyst found on pelvic ultrasound in a 28 year old non pregnant woman
A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission
Answer: A
referral will however be necessary if this is still present on a repeat scan in 2-3 months.
5. A 40 year old asymptomatic Jewish woman whose aunt died from ovarian cancer
A. Initial management in primary care
B. Routine referral
C. Two week referral
D. Urgent admission
Answer: B
for genetic counselling / testing since there is a higher incidence of BRCA1 and BRCA2 mutations in this population.
AKT revision: breast conditions
1.A 28 year old develops a tender red quadrant on her right breast 10 days following the birth of her first child. Her temperature is 37.5 degrees, there is no fluctuance and she is breast feeding. Which one of the options below represents the single most appropriate management plan?
A. Avoid antibiotics since she is breast feeding
B. Co-amoxiclav and temporary cessation of breast feeding
C. Co-amoxiclav and continue breast feeding
D. Doxycycline temporary cessation of breast feeding
E. Doxycycline and continue breast feeding
Answer: C
Co-amoxiclav and continue feeding. Tetracyclines should generally be avoided if breast feeding (and in any case are unlikely to be helpful) and it is important that breast feeding continues.
2. Which one of the following female patients with a three day history requires urgent referral? They are all on day 24 of their menstrual cycles
A. A non pregnant 35 year old with tender lumpy breasts who presents with worsening tenderness on the right side.
B. A 28 year old woman with a non tender 2cm mobile lump. She is on the combined oral contraceptive pill and her grandmother developed breast cancer aged 60
C. A 30 year old with an eczematous eruption on both breasts
D. A non pregnant 35 year old with nodularity in her right breast. Her left breast is normal
E. A nulliparous 30 year old with bilateral serous discharge from both nipples.
Answer: D
Solitary asymmetrical nodularity should be triple assessed. All the other options require careful discussion with the patient and review - Option 1 probably has Benign Fibrocystic Change but should be reviewed after menstruation. Option 2 is most likely to have a fibroadenoma and although most GPs would refer her there is no clinical urgency unless there are additional risk factors (e.g. strong family history). Options 3 and 5 are unlikely to have serious pathology. It is however important not to mistake a unilateral eczematous eruption (which does not respond to topical treatment) for eczema since it may be a marker for an underlying carcinoma.
3. Which one of the following variables is the most important determinant of prognosis in Invasive ductal breast cancer?
A. Age of patient
B. Axillary lymph node positivity
C. Oestrogen receptor status
D. Site of tumour
E. Size of tumour
Answer: B
A. Avoid antibiotics since she is breast feeding
B. Co-amoxiclav and temporary cessation of breast feeding
C. Co-amoxiclav and continue breast feeding
D. Doxycycline temporary cessation of breast feeding
E. Doxycycline and continue breast feeding
Answer: C
Co-amoxiclav and continue feeding. Tetracyclines should generally be avoided if breast feeding (and in any case are unlikely to be helpful) and it is important that breast feeding continues.
2. Which one of the following female patients with a three day history requires urgent referral? They are all on day 24 of their menstrual cycles
A. A non pregnant 35 year old with tender lumpy breasts who presents with worsening tenderness on the right side.
B. A 28 year old woman with a non tender 2cm mobile lump. She is on the combined oral contraceptive pill and her grandmother developed breast cancer aged 60
C. A 30 year old with an eczematous eruption on both breasts
D. A non pregnant 35 year old with nodularity in her right breast. Her left breast is normal
E. A nulliparous 30 year old with bilateral serous discharge from both nipples.
Answer: D
Solitary asymmetrical nodularity should be triple assessed. All the other options require careful discussion with the patient and review - Option 1 probably has Benign Fibrocystic Change but should be reviewed after menstruation. Option 2 is most likely to have a fibroadenoma and although most GPs would refer her there is no clinical urgency unless there are additional risk factors (e.g. strong family history). Options 3 and 5 are unlikely to have serious pathology. It is however important not to mistake a unilateral eczematous eruption (which does not respond to topical treatment) for eczema since it may be a marker for an underlying carcinoma.
3. Which one of the following variables is the most important determinant of prognosis in Invasive ductal breast cancer?
A. Age of patient
B. Axillary lymph node positivity
C. Oestrogen receptor status
D. Site of tumour
E. Size of tumour
Answer: B
AKT revision: menopause and HRT
1.In a non hysterectomised woman, for which one of the following perimenopausal conditions is systemic HRT likely to be recommended?
A. Poor concentration
B. Depression
C. Flushes
D. Incontinence
E. Vaginal dryness
Answer: C
Although many experts would recommend HRT for vaginal dryness this can generally be achieved with topical preparations.
2. Which one of the following lifestyle interventions is most likely to be of help in a patient of 50 with troublesome vasomotor symptoms?
A. Coffee
B. Occasional Exercise
C. Red wine in moderation
D. Weight loss
Answer: D
3.When counselling a 48 year old perimenopausal woman regarding the menopause which one of the following statements regarding combined HRT is correct?
A. Continuous combined preparations are the treatment of choice at this age
B. It is the treatment of choice for established osteoporosis
C. Her risk of arterial disease is unlikely to be significantly increased
D. Persistent bleeding problems are usual
E. Treatment usually continues for up to ten years
Answer: C
Studies suggest a minor increase heart disease risk in women 10 yrs post menopause, and no increased stroke risk detectable in the first year of HRT use. At this age therefore (assuming a duration of treatment of 1-2 years) problems are unlikely.
Generally speaking continuous combined preparations would be given to women who have finished menstruating. Whilst HRT is useful in preventing osteoporosis in those at high risk it has no place in managing the condition. Although bleeding problems can occur initially they should settle after three months. The duration of treatment is for the shortest time possible (as a rule of thumb around 1-2 years).
A. Poor concentration
B. Depression
C. Flushes
D. Incontinence
E. Vaginal dryness
Answer: C
Although many experts would recommend HRT for vaginal dryness this can generally be achieved with topical preparations.
2. Which one of the following lifestyle interventions is most likely to be of help in a patient of 50 with troublesome vasomotor symptoms?
A. Coffee
B. Occasional Exercise
C. Red wine in moderation
D. Weight loss
Answer: D
3.When counselling a 48 year old perimenopausal woman regarding the menopause which one of the following statements regarding combined HRT is correct?
A. Continuous combined preparations are the treatment of choice at this age
B. It is the treatment of choice for established osteoporosis
C. Her risk of arterial disease is unlikely to be significantly increased
D. Persistent bleeding problems are usual
E. Treatment usually continues for up to ten years
Answer: C
Studies suggest a minor increase heart disease risk in women 10 yrs post menopause, and no increased stroke risk detectable in the first year of HRT use. At this age therefore (assuming a duration of treatment of 1-2 years) problems are unlikely.
Generally speaking continuous combined preparations would be given to women who have finished menstruating. Whilst HRT is useful in preventing osteoporosis in those at high risk it has no place in managing the condition. Although bleeding problems can occur initially they should settle after three months. The duration of treatment is for the shortest time possible (as a rule of thumb around 1-2 years).
Thursday 18 March 2010
AKT revision - hepatitis
1.You receive a clinic letter regarding a 57 year old man whom you had referred to the local hepatologist for further investigation of abnormal liver function tests. The consultant describes a diagnosis of chronic hepatitis in his clinic letter.
Which ONE of the following viruses is MOST LIKELY to be the cause of chronic hepatitis in this patient? Select ONE option only.
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
Answer: C
Hepatitis A and E viruses cause an acute hepatitis and do not have a chronic infection state.
Approximately 2-5% of patients infected with hepatitis B virus (HBV) will develop a chronic hepatitis; however, almost 75% of patients infected with hepatitis C virus (HCV) will develop a chronic hepatitis.
Hepatitis D virus (HDV) requires the presence of HBV to replicate; therefore, HDV infection develops only in patients who are positive for hepatitis B surface antigen. The rate of progression to chronic hepatitis is approximately 70-80%. HDV is less common than HCV and therefore HCV would be the most likely cause of chronic hepatitis in this patient.
2.A 36 year old man was seen by your colleague last week with a 10 day history of abdominal pain following a recent family holiday in Africa. He is otherwise well in himself. You are the on-call GP in your surgery today and receive the following results:
Bilirubin 17 µmol/l (3-17 µmol/l)
Alanine aminotransferase 58 IU/l (0-35 IU/l)
Alkaline phosphatase 266 IU/l (30-300 IU/l)
Gamma glutamyl transpeptidase 32 IU/l (11-50 IU/l)
Hepatitis A IgM antibodies POSITIVE
Hepatitis A IgG antibodies NEGATIVE
What is the SINGLE MOST appropriate INITIAL management option for this patient? Select ONE option only.
A. Advice and reassurance
B. Arrange sexual contact tracing
C. Refer for abdominal ultrasound scan
D. Repeat hepatitis serology in three months
E. Routine referral to gastroenterology
Answer: A
The presence of hepatitis A IgM antibodies here indicates acute hepatitis A infection.
If hepatitis A IgG antibodies were present, this would indicate previous hepatitis A infection and these antibodies would be detectable lifelong.
Hepatitis A virus is transmitted faeco-orally through contacts or travel to an endemic area. It has an incubation period of 2-6 weeks and is usually a self-limiting illness. The risk of acute liver failure is very low (less than 0.1%) although this increases with age and in those with pre-existing liver disease. There is no chronic infection state and recovery from an acute infection induces lifelong immunity.
3. A 30 year old lady attends the surgery for preconception advice. She is newly married and is originally from China. She last had sexual intercourse with her husband 14 days ago and he has been abroad on a business trip since that time. He is due to return home today. You elucidate that her husband has chronic hepatitis B. She requests a blood test to determine her Hepatitis B status.
In order to reduce the immediate risk of transmission of disease, which ONE of the following is the most appropriate INITIAL management for this patient? Select ONE option only.
A. Advise the patient about 'safe sex', or to refrain from sexual intercourse
B. Arrange an 'accelerated schedule' preexposure immunisation
C. Arrange for passive immunisation with hepatitis B immunoglobulin (HBIG)
D. Arrange for routine pre-exposure immunisation
E. Arrange serological testing to confirm the patient's hepatitis B status
Answer: A
Ideally, the patient needs to undergo serological testing to ascertain her hepatitis B status.
In the interim, she either needs to practice 'safe sex' or refrain completely.
Both the vaccine and passive immunization with HBIG should be given as soon as possible-preferably within 12 hours, ideally within 24 hours, although it should be considered up to 1 week after exposure.
DoH: The Green Book
www.dh.gov.uk
www.britishlivertrust.org.uk
www.bnf.org
4.A 48 year old man attends the surgery for advice regarding travel vaccinations. After assessing his risks including specific travel destinations, you advise him to receive a hepatitis A vaccination.
Which ONE of the following statements regarding Hepatitis A vaccination is correct? Select ONE option only.
A. A booster dose given between 6 and 12 months after the initial dose provides immunity for up to 10 years
B. A single dose of hepatitis A vaccine confers immunity for up to 2 years
C. A single dose of hepatitis A vaccine confers immunity for up to 3 years
D. Hepatitis A is a live vaccine
E. Hepatitis A vaccine is administered subcutaneously
Answer: A
A booster dose given between 6 and 12 months after the initial dose provides immunity for up to 10 years. A single dose of hepatitis A vaccine confers immunity for up to 1 year. It is an inactivated vaccine and is administered intramuscularly.
www.bnf.org.uk
www.fitfortravel.nhs.uk
5. Which ONE of the following diseases is notifiable under the Public Health (Infectious Diseases) Regulations 1988? Select ONE option only.
A. Creutzfeldt-Jakob disease
B. Hepatitis A
C. HIV
D. Infectious mononucleosis
E. Syphilis
Answerr: B
Which ONE of the following viruses is MOST LIKELY to be the cause of chronic hepatitis in this patient? Select ONE option only.
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D
E. Hepatitis E
Answer: C
Hepatitis A and E viruses cause an acute hepatitis and do not have a chronic infection state.
Approximately 2-5% of patients infected with hepatitis B virus (HBV) will develop a chronic hepatitis; however, almost 75% of patients infected with hepatitis C virus (HCV) will develop a chronic hepatitis.
Hepatitis D virus (HDV) requires the presence of HBV to replicate; therefore, HDV infection develops only in patients who are positive for hepatitis B surface antigen. The rate of progression to chronic hepatitis is approximately 70-80%. HDV is less common than HCV and therefore HCV would be the most likely cause of chronic hepatitis in this patient.
2.A 36 year old man was seen by your colleague last week with a 10 day history of abdominal pain following a recent family holiday in Africa. He is otherwise well in himself. You are the on-call GP in your surgery today and receive the following results:
Bilirubin 17 µmol/l (3-17 µmol/l)
Alanine aminotransferase 58 IU/l (0-35 IU/l)
Alkaline phosphatase 266 IU/l (30-300 IU/l)
Gamma glutamyl transpeptidase 32 IU/l (11-50 IU/l)
Hepatitis A IgM antibodies POSITIVE
Hepatitis A IgG antibodies NEGATIVE
What is the SINGLE MOST appropriate INITIAL management option for this patient? Select ONE option only.
A. Advice and reassurance
B. Arrange sexual contact tracing
C. Refer for abdominal ultrasound scan
D. Repeat hepatitis serology in three months
E. Routine referral to gastroenterology
Answer: A
The presence of hepatitis A IgM antibodies here indicates acute hepatitis A infection.
If hepatitis A IgG antibodies were present, this would indicate previous hepatitis A infection and these antibodies would be detectable lifelong.
Hepatitis A virus is transmitted faeco-orally through contacts or travel to an endemic area. It has an incubation period of 2-6 weeks and is usually a self-limiting illness. The risk of acute liver failure is very low (less than 0.1%) although this increases with age and in those with pre-existing liver disease. There is no chronic infection state and recovery from an acute infection induces lifelong immunity.
3. A 30 year old lady attends the surgery for preconception advice. She is newly married and is originally from China. She last had sexual intercourse with her husband 14 days ago and he has been abroad on a business trip since that time. He is due to return home today. You elucidate that her husband has chronic hepatitis B. She requests a blood test to determine her Hepatitis B status.
In order to reduce the immediate risk of transmission of disease, which ONE of the following is the most appropriate INITIAL management for this patient? Select ONE option only.
A. Advise the patient about 'safe sex', or to refrain from sexual intercourse
B. Arrange an 'accelerated schedule' preexposure immunisation
C. Arrange for passive immunisation with hepatitis B immunoglobulin (HBIG)
D. Arrange for routine pre-exposure immunisation
E. Arrange serological testing to confirm the patient's hepatitis B status
Answer: A
Ideally, the patient needs to undergo serological testing to ascertain her hepatitis B status.
In the interim, she either needs to practice 'safe sex' or refrain completely.
Both the vaccine and passive immunization with HBIG should be given as soon as possible-preferably within 12 hours, ideally within 24 hours, although it should be considered up to 1 week after exposure.
DoH: The Green Book
www.dh.gov.uk
www.britishlivertrust.org.uk
www.bnf.org
4.A 48 year old man attends the surgery for advice regarding travel vaccinations. After assessing his risks including specific travel destinations, you advise him to receive a hepatitis A vaccination.
Which ONE of the following statements regarding Hepatitis A vaccination is correct? Select ONE option only.
A. A booster dose given between 6 and 12 months after the initial dose provides immunity for up to 10 years
B. A single dose of hepatitis A vaccine confers immunity for up to 2 years
C. A single dose of hepatitis A vaccine confers immunity for up to 3 years
D. Hepatitis A is a live vaccine
E. Hepatitis A vaccine is administered subcutaneously
Answer: A
A booster dose given between 6 and 12 months after the initial dose provides immunity for up to 10 years. A single dose of hepatitis A vaccine confers immunity for up to 1 year. It is an inactivated vaccine and is administered intramuscularly.
www.bnf.org.uk
www.fitfortravel.nhs.uk
5. Which ONE of the following diseases is notifiable under the Public Health (Infectious Diseases) Regulations 1988? Select ONE option only.
A. Creutzfeldt-Jakob disease
B. Hepatitis A
C. HIV
D. Infectious mononucleosis
E. Syphilis
Answerr: B
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