Thursday 28 January 2010

AKT questions



1. A 19-year-old man attends complaining of a rash on his penis for the last 3 months. (See Figure 1) What is the SINGLE most appropriate intervention for this patient? Select ONE option only.

A. Cryotherapy
B. Prescribe oral aciclovir
C. Prescribe topical podophyllotoxin (Warticon)
D. Reassure
E. Refer to genitourinary medicine clinic
Answer: D
This picture shows the typical appearance of pearly penile papules. They are common, occurring in up to 20% of men and present as flesh-coloured, smooth, rounded papules predominantly around the coronal margin of the glans. They are often arranged in parallel rows or concentric rings. They are not sexually -transmitted.Pearly penile papules may be mistaken for warts by both patients and clinicians.No treatment is necessary, although if cosmesis is a problem for the patient, then cryotherapy may be tried.Aciclovir is the treatment of choice for genital herpes which typically presents acutely with very painful ulcers.Cryotherapy and topical podophyllotoxin are both treatment options for genital warts. Podophyllotoxin cannot be used in pregnant or breastfeeding women.
2. Which ONE of the following is NOT associated with an increased risk of developing penile intraepithelial neoplasia? Select ONE option only. [Show Discussion]

A. Atopic dermatitis
B. Chronic infection with human papilloma virus (HPV)
C. Lichen sclerosus
D. Smoking
E. Uncircumcised males
Answer: A
Penile intraepithelial neoplasia (PIN) is associated with:
• Chronic infection with human papilloma virus (HPV)
• Chronic skin disease, especially lichen sclerosus and lichen planus
• Smoking
• ImmunosuppressionIf untreated,
PIN is associated with the development of invasive squamous cell carcinoma.www.dermnet.nz
3. In which ONE of the following situations can phosphodiesterase type-5 inhibitors such as sildenafil (Viagra) be prescribed on an National Health Service (NHS) prescription rather than on a private prescription? Select ONE option only.

A. In men aged 60 years or over
B. In men with chronic kidney disease stage 3 (CKD 3)
C. In men with hypogonadism
D. In men with hypothyroidism
E. In men with Parkinson’s disease
Answer: E
Phosphodiesterase type-5 inhibitors are not prescribable under the NHS, except to treat erectile dysfunction in men who:
• Have diabetes, multiple sclerosis, Parkinson’s disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, or spinal cord injury
• Are receiving dialysis for renal failure
• Have had radical pelvic surgery, prostatectomy (including transurethral resection of the prostate), or kidney transplant
• Were receiving Caverject®, Erecnos®, MUSE®, Viagra® or Viridal® for erectile dysfunction, at the expense of the NHS, on 14 September 1998
• Are suffering severe distress as a result of impotence (prescribed in specialist centres only)www.bnf.org.uk
4. A 23-year-old man attends complaining of difficulty getting an erection since starting a new relationship 4 months ago. He has already tried sildenafil (Viagra) which he had bought on the internet, but this has not helped. On examination, he has bilateral gynaecomastia, small testes and scanty axillary and pubic hair. His recent blood tests reveal the following:Testosterone 6 nmol/l (11–36 nmol/l)Luteinising hormone (LH) 27 IU/l (0.5–9 IU/l)Follicle stimulating hormone (FSH) 19 IU/l (1–8 IU/l)Which is the single MOST appropriate initial intervention for this patient? Select ONE option only. [Show Discussion]

A. Refer to clinical geneticist
B. Refer to endocrinologist
C. Refer to neurologist
D. Refer to psychosexual counsellor
E. Refer to urological surgeon
Answer: A
This scenario describes the typical phenotypical appearance of a patient with Klinefelter’s syndrome (47 XXY). It is the most common cause of male hypogonadism and infertility, affecting approximately 1 in 600 to 1 in 800 live births.It is characterizsed by hypergonadotrophic hypogonadism (raised gonadotrophins and low testosterone) and usually remains undiagnosed until adulthood.Referral to an endocrinologist would be required for advice regarding hormonal treatment;, however, the most appropriate initial referral would be to a clinical geneticist for genetic counselling and testing to confirm the diagnosis. They would be able to advise him regarding longer-term implications, including fertility issues (azoospermia) and risk of male breast cancer.
5. A 56-year-old man attends the surgery complaining of inability to maintain an erection during intercourse for the last 3 months. He describes normal early morning erections. On examination, his blood pressure is 150/84 mmHg and his body mass index (BMI) is 32. Physical examination is otherwise unremarkable.What is the SINGLE most likely underlying diagnosis in this patient? Select ONE option only.

A. Depression
B. Hypertension
C. Parkinson’s disease
D. Spinal cord injury
E. Type 2 diabetes
Answer: A
A good quality early morning erection makes an organic cause of erectile dysfunction unlikely
6. Which ONE of the following drugs does NOT cause erectile dysfunction? Select ONE option only.

A. Bendroflumethiazide
B. Chlorpromazine
C. Nifedipine
D. Sildenafil
E. spironolactone
Answer: D
Sildenafil is the generic name for Viagra, a phosphodiesterase-5 inhibitor which is used to treat erectile dysfunction. All of the other drugs listed can cause erectile dysfunction.Other commonly used classes of drugs which may cause erectile dysfunction include:• Anti-cholinergics• Anti-depressants• Anti-histamines• Anti-hypertensives• Anti-psychotics• Tranquilisers
7. A 58-year-old man attends complaining of inability to get an adequate erection for the last 5 months. He asks whether you would be able to prescribe him Viagra (sildenafil).Which ONE of the following would be a CONTRAINDICATION to the use of a phosphodiesterase type-5 inhibitor such as Viagra in this patient? Select ONE option only. [Show Discussion]

A. Current blood pressure of 178/96 mmHg
B. Current diagnosis of angina pectoris
C. Currently taking bisoprolol
D. Currently taking isosorbide mononitrate
E. Currently taking warfarin
Answer: D
Phosphodiesterase type-5 inhibitors are contra-indicated in patients receiving nitrates, in patients in whom vasodilation or sexual activity are inadvisable, or in patients with a previous history of non-arteritic anterior ischaemic optic neuropathy.In the absence of information, manufacturers contra-indicate these drugs in hypotension (avoid if systolic blood pressure below 90 mmHg), recent stroke, unstable angina, and myocardial infarction.www.bnf.org.uk

AKT questions/ nMRCGP questions

1. A 56-year-old man is seen in the urgent care centre with vomiting and severe left-sided loin pain radiating to his left groin. On examination, his temperature is 37.6°C and he has left-sided loin tenderness. Urinalysis reveals blood+++ and protein++. A diagnosis of renal colic is suspected.In addition to an anti-emetic, which is the single MOST appropriate intervention for this patient? Select ONE option only.

A. Intramuscular codeine phosphate
B. Intramuscular diamorphine
C. Intramuscular diclofenac
D. Intramuscular pethidine
E. Rectal diclofenac

Answer: C

Intramuscular diclofenac 75 mg is the treatment of choice in acute renal colic. An opioid (e.g. pethidine or diamorphine) should be considered if diclofenac is contraindicated or is insufficient to control the pain.An anti-emetic should be administered for nausea and vomiting, particularly if an injectable opioid is given.


2. A 7-year-old boy is brought to the surgery by his father with a 2 week history of headache, rash and intermittent abdominal and joint pains. Urinalysis reveals blood++++ and protein+.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Acute leukaemia
B. Henoch–Schönlein purpura
C. Idiopathic thrombocytopenia
D. Post-streptococcal glomerulonephritis
E. Urinary tract infection

Answer: B

Henoch–-Schönlein purpura (HSP) is a vasculitis which most typically affects young children aged 3 to –8 years old. It is more common in boys. There is usually a preceding infective trigger such as a respiratory tract infection.There may be gastro-intestinal, joint and renal manifestations. There is haematuria and proteinuria in 70%, although this is often asymptomatic. More serious complications are rare. HSP is usually self-limiting and does no’t normally require any specific treatment.There is usually a preceding history of sore throat in post-streptococcal glomerulonephritis, and a rash would not normally be expected.

3. 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) NegativeBlood pressure 112/68 mmHgUrea and electrolytes NormalWhich ONE of the following options is the most appropriate INITIAL management for this patient? Select ONE option only. [Show Discussion]

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.

Wednesday 27 January 2010

1. Doctors must notify the Proper Office of the local authority (which is usually the consultant in communicable disease control) when attending a patient suspected of suffering from certain diseases.Which ONE of the following conditions is NOT a notifiable disease? Select ONE option only.

A. Cholera
B. Human Immunodeficiency Virus (HIV)
C. Mumps
D. Tuberculosis
E. Whooping cough

Answer: B

The statutory requirement for the notification of certain infectious diseases came into being towards the end of the 19th century. The list of diseases has been increased over the decades and now stands at about 30.The prime purpose of the notifications system is speed in detecting possible outbreaks and epidemics. Accuracy of diagnosis is secondary, and since 1968 clinical suspicion of a notifiable infection is all that is required.The full list of notifiable diseases can be found on the Health Protection Agency website at www.hpa.org.uk

2. A 54 year-old woman attends complaining of intermittent blurred vision in her left eye for the last two weeks. She is currently taking treatment for pulmonary tuberculosis. On examination the visual acuity is 6/9 in the right eye and 6/18 in the left eye.Which SINGLE drug is the most likely cause of this patient’s symptoms? Select ONE option only. [Show Discussion]

A. Ethambutol
B. Isoniazid
C. Pyrazinamide
D. Rifampicin
E. Streptomycin

Answer: A

Visual acuity should always be tested before ethambutol is used, since its side-effects are largely confined to visual disturbances in the form of loss of acuity, colour blindness and restriction of visual fields.These toxic effects are more common where excessive dosage is used or if the patient’s renal function is impaired.The earliest features of ocular toxicity are subjective and patients should be advised to discontinue therapy immediately if they develop deterioration in vision and promptly seek further advice.Early discontinuation of the drug is almost always followed by recovery of eyesight.www.bnf.org.ukIsoniazid, rifampicin and pyrazinamide are associated with liver toxicity, and therefore hepatic function should be checked before treatment with these drugs. Those with pre-existing liver disease or alcohol dependence should have frequent checks particularly in the first two months.Streptomycin is now rarely used in the UK except for resistant organisms.

3. Which ONE of the following statements represents the standard regime for treatment of tuberculosis in the UK? Select ONE option only. [Show Discussion]

A. 4 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 1 month
B. 4 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 2 months
C. 6 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 1 month
D. 4 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 2 months
E. 6 months of isoniazid and rifampicin, plus pyrazinamide and ethambutol for the first 3 months

Answer: E

Initial phase treatment should be continued for two months, whilst continuous phase treatment is continued for a further four months.Longer treatment is necessary if there are complications of meningitis or spinal cord involvement, and for resistant organisms which may also require modification of the regimen.

4. In which ONE of the following situations should a BCG vaccination be offered to a newborn baby? Select ONE option only.
A. Born in an area with tuberculosis (TB) notification rate greater than 20 per 100,000 population
B. Born in an area with TB notification rate greater than 40 per 100,000 population
C. Family history of TB in previous 5 years
D. Family history of TB in previous 10 years
E. Family history of TB in previous 15 years

Answer: B

Primary care organisations with a high incidence of TB should consider vaccinating all neonates.www.nice.org.uk

AKT questions

1. The Centor criteria are used to predict the likelihood of Group A beta-haemolytic streptococcal infection in patients presenting with acute sore throat. It may therefore be a useful tool in helping to determine whether or not such patients require an antibiotic prescription.Which ONE of the following is NOT one of the Centor criteria? Select ONE option only.

A. Absence of cough
B. Cough
C. Fever
D. Tender anterior cervical lymphadenopathy
E. Tonsillar exudate

Answer: B

The Centor criteria are:• Absence of cough• Fever• Tender anterior cervical lymphadenopathy• Tonsillar exudate. The presence of all four criteria has only a 40% positive predictive value for Group A beta-haemolytic streptococcal sore throat. However, the absence of all four criteria has an 80% negative predictive value.NICE have published guidelines incorporating the Centor criteria to guide antibiotic prescribing in patients presenting with acute sore throat.

2. An 82 year-old man presents with a three day history of sore throat and cough. He has type 2 diabetes. On examination he is apyrexial with no tonsillar exudate or cervical lymphadenopathy. His chest is clear on auscultation.Which is the SINGLE most appropriate intervention for this patient? Select ONE option only.

A. Delayed antibiotic prescription
B. Immediate antibiotic prescription
C. Admit to the acute medical unit
D. Prescribe simple analgesia
E. Reassure

Answer: B

Current NICE guidance recommends that an immediate prescription of antibiotics is appropriate for any patient aged over 80 years old with an acute cough and one of:
• Hospitalisation in the previous year
• Diabetes
• History of congestive heart failure
• Current use of oral steroids

Other patients should be offered an immediate antibiotic prescription if they:
• Are systemically unwell
• Have signs or symptoms of serious underlying infection
• Have co-morbidity increasing the risk of complications (e.g. significant heart, lung, renal, liver or neuromuscular disease, immunosuppression
• Are young children who were born prematurely

3. A 6 year-old boy attends the surgery with his mother. He complains of a runny nose, persistent sneezing and a sore throat, which all started yesterday. He is otherwise well with no other past medical history. You diagnose acute rhinosinusitis and decide not to prescribe an antibiotic.Approximately how long would you expect this patient’s illness to last? Select ONE option only.

A. 5 days
B. 7 days
C. 10 days
D. 14 days
E. 18 days

Answer: E

The average length of illness in acute rhinosinusitis is 2½ weeks. For all antibiotic prescribing strategies it is recommended that patients receive information about the natural course of the illness including the average duration of symptoms to expect.
Average duration of illness:
• Acute otitis media – 4 days
• Acute sore throat (including pharyngitis and tonsillitis) – 1 week
• Common cold – 1½ weeks
• Acute rhinosinusitis – 2½ weeks
• Acute cough (including bronchitis) – 3 weeks

4. A 21 year-old man presents with a ten day history of headache, malaise, myalgia, fever and dry cough. On examination his temperature is 38.7°C and his respiratory rate is 28/min. On auscultation of his chest there is reduced air entry and crackles and wheeze at the left base. Which SINGLE organism is the most likely cause of this patient’s symptoms? Select ONE option only.

A. Haemophilus influenzae
B. Legionella pneumophilia
C. Mycoplasma pneumoniae
D. Staphylococcus aureus
E. Streptococcus pneumoniae

Answer: C

Mycoplasma pneumoniae:is implicated in approximately 6% of pneumonias in the UK. It primarily affects children and young adults. It often presents with atypical symptoms and signs. It is characterised by an influenza-like respiratory illness of gradual onset with headache, malaise, fever and cough. Doxycycline, alone or combined with amoxicillin is the treatment of choice.
Haemophilus influenzae :is a common cause of pneumonia in children and is frequently found in the phlegm of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).
Legionella pneumophilia: presents as an atypical pneumonia, however it is less common than Mycoplasma pneumoniae. Three epidemiological patterns are recognised:• In previously fit individuals living in an institution in which, for example, the shower or cooling system are contaminated• In immunocompromised and elderly male smokers• Sporadic. Erythromycin is the treatment of choice.
Staphylococcus aureus: is a rare cause of community-acquired pneumonia, but may occur as a secondary infection following a viral illness. It should therefore be considered during influenza epidemics or if the patient presents with a history suggesting recent pneumonia.
Streptococcus pneumoniae: is the commonest cause of community acquired pneumonia, accounting for approximately one third of all pneumonias in which an organism is identifiable. Typically it presents acutely over two to three days with dirty brown sputum. Amoxicillin is the treatment of choice.

5. A 16 month old baby boy is brought to the urgent care centre late at night by his parents. They describe a three day history of fever, runny nose and cough. Over the last 12 hours his cough has become much louder and his voice has become hoarse. On examination his temperature is 38.9°C and his respiratory rate is 30/min. There is no intercostal recession.What is the SINGLE most appropriate immediate management for this patient? Select ONE option only.

A. Oral amoxicillin
B. Oral dexametasone
C. Oxygen
D. Nebulised adrenaline
E. Nebulised salbutamol

Answer: B

This scenario describes a typical case of croup. Parainfluenza viruses account for the majority of cases. Single doses of dexametasone or budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Steam inhalation is no longer routinely recommended to parents due to the potential risk of steam burn injuries.The British National Formulary (BNF) has a useful section on the back few pages regarding ‘Medical Emergencies in the Community’ which outlines management of specific conditions including drug dosages. The dosage of dexametasone syrup is calculated by age and weight.Nebulised adrenaline may be useful in severe croup where there are marked signs of respiratory distress. The child should be transferred to hospital immediately if signs of respiratory distress are present.

6. This is the threshold criterion for confusion.

A. Less than 70 mmHg
B. Less than 80 mmHg
C. Less than 90 mm Hg
D. Less than 100 mmHg
E. 20/min or more
F. 25/min or more
G. 30/min or more
H. Mental test score of 7 or less
I. Mental test score of 8 or less
J. Mental test score of 9 or less

Answer: I

7. This is the threshold criterion for systolic blood pressure.

A. Less than 70 mmHg
B. Less than 80 mmHg
C. Less than 90 mm Hg
D. Less than 100 mmHg
E. 20/min or more
F. 25/min or more
G. 30/min or more
H. Mental test score of 7 or less
I. Mental test score of 8 or less
J. Mental test score of 9 or less

Answer: C

8. This is the threshold criterion for respiratory rate.

A. Less than 70 mmHg
B. Less than 80 mmHg
C. Less than 90 mm Hg
D. Less than 100 mmHg
E. 20/min or more
F. 25/min or more
G. 30/min or more
H. Mental test score of 7 or less
I. Mental test score of 8 or less
J. Mental test score of 9 or less

Answer: I

Monday 25 January 2010


1. A 26-year-old man presents with a rash over his right arm and elbow for the past 4 months. It is not itchy. What is the SINGLE MOST likely underlying cause for this patient’s rash? Select ONE option only.

A. Alcohol excess
B. Coeliac disease
C. Human immunodeficiency virus (HIV) infection
D. Hyperthyroidism
E. Hypogonadism

Answer: A

This picture shows eruptive xanthomata which characteristically arise on the buttocks, elbows and knees. They typically occur in hypertriglyceridaemia and uncontrolled diabetes mellitus. Alcohol excess is a common cause of hypertriglyceridaemia.Coeliac disease may be associated with dermatitis herpetiformis – —a blistering rash which tends to affect extensor surfaces. It is typically very itchy.HIV infection per se would not cause this rash, but some anti-retroviral drugs used in the management of HIV infection can cause dyslipidaemia as a side- effect. This rash may be mistaken for molluscum contagiosum which can occur in HIV and acquired immune deficiency syndrome (AIDS).

2. In the assessment of cardiovascular disease risk, if the patient is a man of South Indian origin, by what factor is his risk increased?

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: B

3. In the assessment of cardiovascular disease risk, if the patient has ONE first-degree relative with a history of premature coronary heart disease, by what factor is their risk increased?

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: C

4. In the assessment of cardiovascular disease risk, if the patient has TWO OR MORE first-degree relatives with a history of premature coronary heart disease, by what factor is their risk increased?

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: D

NICE clinical guideline 67 (May 2008) Lipid Modification gives full details of how to assess and calculate cardiovascular disease risk.

5. In the treatment of hyperlipidaemia, statin therapy should be discontinued if serum transaminases are raised by more than what factor above the upper limit of normal?

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: F

6.
In the treatment of hyperlipidaemia, statin therapy should be discontinued if myopathy is suspected and creatine kinase is elevated by more than what factor above the upper limit of normal? [Show Discussion]

A. ×1.2
B. ×1.4
C. ×1.5
D. ×2
E. ×2.5
F. ×3
G. ×3.5
H. ×4
I. ×4.5
J. ×5

Answer: J

The BNF has an excellent section on lipid-regulating drugs, including the use of statins (HMG CoA reductase inhibitors), their cautions and side-effects.Caution should be exercised when prescribing statins to those with liver disease and/or a history of alcohol excess.Hypothyroidism should be adequately treated before assessing the need for lipid-regulating treatment. Treating hypothyroidism can potentially correct the dyslipidaemia. In addition, hypothyroidism increases the risk of myositis with concomitant lipid-regulating therapy.
1. According to current National Institute of Clinical Excellence (NICE) guidance, metformin should be stopped (due to lactic acidosis) when the estimated glomerular filtration rate falls below what level? Select ONE option only

A. 25 ml/min/1.73 m2
B. 30 ml/min/1.73 m2
C. 40 ml/min/1.73 m2
D. 45 ml/min/1.73 m2
E. 50 ml/min/1.73 m2

Answer:: B

See NICE guideline 66 (May 2008) Type 2 Ddiabetes: the management of type 2 diabetes.

2. A 49-year-old man attends for a repeat prescription of insulin, which has recently been started by his consultant diabetologist. His latest HbA1c is 10.2%. He currently works as a taxi driver.What is the SINGLE MOST appropriate advice to give to this patient regarding his work?

A. He can continue driving without any restrictions
B. He should inform the Driver and Vehicle Licensing Agency (DVLA) and can then continue driving without any restrictions
C. He should inform the DVLA and await further assessment from one of their medical advisors
D. He should inform the DVLA and can continue driving once his insulin dose is stable
E. He should inform the DVLA and must stop driving immediately

Answer: E

The DVLA recognizses two groups of licence holder – —Group 1 (for car and motorcycle drivers) and Group 2 (for taxi, lorry and bus drivers).Patients with insulin-treated diabetes and a Group 1 licence must be able to recognizse the warning symptoms of hypoglycaemia before being granted either a one1, two 2 or three 3 year licence.Patients with insulin-treated diabetes and a Group 2 licence are barred by law from driving.www.dft.gov.uk/dvla/medical.

3. A 74-year-old woman with type 2 diabetes presents with a swelling on her left thigh for the last 3 months. She was started on insulin 6 months ago and always uses her left thigh as an insulin injection site. On examination, a small soft mass is felt underneath the skin. There is no overlying erythema.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Acanthosis nigricans
B. Cellulitis
C. Insulinoma
D. Lipid hypertrophy
E. Necrobiosis lipoidica

Answer: D

The most likely diagnosis is lipid hypertrophy. The history that this patient has not been rotating injection sites. All patients starting insulin are advised to vary the site of injection to reduce the risk of this complication.Cellulitis is more common in those with diabetes, although there are no features to suggest it as a diagnosis here.An insulinoma is an insulin-secreting pancreatic tumour.Acanthosis nigricans is a rare skin condition which can be associated with insulin resistance and diabetes. It causes papillomatous hyperplasia of the dermis with hyperpigmentation – —commonly in the axilla, groin and neck creases.Necrobiosis lipoidica is a skin condition closely associated with diabetes. Initially, there are dusky red nodules on the shin which later become flat, irregular and yellow–-brown. Small-vessel damage in the dermis is thought to be implicated in its aetiology. It is more common in young and middle-aged women.

Sunday 24 January 2010

AKT Questions

1. A 41-year-old man has recently attended the surgery for fasting blood tests, including an oral glucose tolerance test, as part of his annual hypertension review. The following results are received:Fasting plasma glucose 5.9 mmol/l2 hour plasma glucose 9.6 mmol/lSerum total cholesterol 5.6 mmol/l (3.0–5.3 mmol/l)Serum triglycerides 2.2 mmol/l (0.5–2.0 mmol/l)Whati is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.


A. Diabetes mellitus
B. Impaired fasting glycaemia
C. Impaired glucose tolerance
D. Metabolic syndrome
E. Normal glycaemic control

Answer: C

Diabetes mellitus is defined by:• Fasting glucose greater than or equal to 7.0 mmol/lL and• 2 hour glucose greater than or equal to11.1 mmol/lL
Impaired fasting glycaemia is defined by:• Fasting glucose greater than or equal to6.1 and less than < 7.0 mmol/lL and• 2 hour glucose < less than 7.8 mmol/lL
Impaired glucose tolerance is defined by:• Fasting glucose < less than 7.0 mmol/Ll and• 2 hour glucose greater than or equal to7.8 and < less than 11.1 mmol/lLThe
metabolic syndrome is a condition characterizsed by at least three of the following clinical features:• Central obesity• Elevated triglyceride• Low HDL cholesterol• Raised blood pressure• Raised fasting plasma glucoseNormal glycaemic control is defined by:• Fasting glucose less than or equal to 6.0 mmol/lL and• 2 hour glucose < less than 7.8 mmol/lL