AKT

1. You are teaching a group of medical students basic clinical skills. Which one of the following statements is true?

A. Extrapyramidal syndromes characteristically produce an upper motor neurone pattern
B. Fasciculation of the tongue is an upper motor neurone feature of motor neurone disease
C. Lesions of peripheral nerves are usually upper motor neurone in type
D. Lower motor neurone lesions cause ankle clonus
E. Upgoing plantar responses and absent ankle jerks imply both upper and lower motor neurone lesions

Answer: E

This seemingly incompatible combination seen in conditions in which both upper and lower motor neurone lesions are present. These include advanced B12 deficiency and perhaps most commonly combined lumbar spondylosis and cervical myelopathy. While MND could, at least in theory, produce this pattern, it would not be characteristic. Remember that upper motor neurone lesions (that is lesions above the dorsal column cell or cranial nerve nucleus involve the pyramidal (corticospinal) tracts and produce spastic tone, increased reflexes, a characteristic pattern of weakness and sometimes ankle clonus. Plantar responses will be extensor. In contrast lower motor neurone lesions produce a flaccid tone, reduced reflexes and sometimes muscle fasciculation.

2. A right-handed male actor aged 66 presents with gradual deterioration of clarity in his speech. He has no problems with his teeth, pains in his mouth or associated neurological problems. Which is the single most likely site of his problem?

A. Bilateral upper motor neurone lesion of cranial nerves 1X and X
B. Left hemisphere

C. Lower motor neurone lesion of cranial nerves 1X and X
D. Midbrain
E. Right hemisphere

Answer: C

Motor neurone disease features high on the differential diagnosis here and careful assessment should be made of this patient’s swallowing and respiratory function. Dominant hemispheric lesions would be expected to produce dysphasia (not as in this case a dysarthria) and since the 1X and X nerve nuclei are below the level of the midbrain, a lesion at this site would not produce a LMN weakness. A bilateral corticospinal lesion, however, will produce (so called) ‘Pseudobulbar palsy’—the commonest causes of which are motor neurone disease and cerebrovascular disease. These are almost inevitably associated with other neuropsychiatric signs such as bilateral spasticity and emotional lability.

3. A 66-year-old man, known to have motor neurone disease presents with the gradual onset of breathlessness. Which is the single most helpful measure of respiratory function? [Show

A. Forced expiratory volume in 1 second (FEV1)
B. Forced vital capacity (FVC)
C. Forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC)
D. Oxygen saturation
E. Peak flow rate

Answer: B

Patients with MND may have weakness of the intercostal muscles and the diaphragm. Symptoms may vary from breathlessness to orthopnoea (the latter especially if there is diaphragmatic involvement). More non-specific symptoms include daytime drowsiness due to changes in sleep pattern caused by hypercapnia—this, as in other causes of hypercapnia, may produce a morning headache.FEV1 is an important measure but is of most use in obstructive airways disease. While the FEV1/FVC would probably show a restrictive pattern in MND, the information gained from the combination is of less use than the FVC alone. The FVC (or more correctly the VC) not only indicates severity but is also easy to measure serially. Oxygen saturation alone, while relevant, may be expected to be fairly normal even in relatively advanced disease due to the shape of the oxygen dissociation curve. Peak flow is not relevant in this context.

4. A man with motor neurone disease is prescribed riluzole for motor neurone disease. You see the patient regularly and have a ‘shared care’ arrangement for monitoring the therapy. Which one of the following blood tests requires regular monitoring? [Show Discussion]

A. Fasting glucose
B. Full blood count
C. Liver function
D. Renal function
E. Thyroid function

Answer: C

Assuming normal baseline hepatic function, LFTs should be checked every month for 3 months, every 3 months for a further 9 months and every year thereafter.

5. A male patient has type 2 respiratory failure secondary to advanced motor neurone disease. When discussing options with him which is the single most appropriate initial way of delivering respiratory support should he wish to stay at home? [Show Discussion]

A. Endotracheal tube
B. Iron lung
C. Mask
D. Non-invasive ventilation
E. Tracheostomy

Answer: D

These portable devices are available via specialized respiratory units and prolong life. Further details of these (and other palliative measures) from the motor neurone disease association. http://www.mndassociation.org/

6. Which one of the following statements is true when considering a peripheral neuropathy

A. Examination should include testing from distally to proximally in the legs
B. Feet and hands are usually equally affected
C. Hyper-reflexia is characteristic
D. Hypertension is among the common causes
E. Joint position sense is usually absent if there is disturbance of pinprick sensation

Answer: A

There are many causes of peripheral neuropathy (alcohol and diabetes being two of the most common). Testing is best done for a given modality by first comparing the feet with (say) the upper leg which is likely to be normal. If there is a reproducible difference, it is then helpful to go from distal to proximal to see where sensation changes. The legs are usually affected before the hands and if anything hyporeflexia would be the norm. Hypertension is not a recognized cause and joint position sense loss would characteristically be a dorsal column problem.

7. The photograph below illustrates a previously fit middle-aged man who is recovering from a problem which started acutely 3 weeks before. Which one of the statements below is true? (See Figure 1)

A. He has a left-sided lower motor neurone weakness
B. He has a right-sided lower motor neurone weakness
C. He has a left-sided upper motor neurone weakness
D. He has a right-sided upper motor neurone weakness

Answer: A

This is most likely to be due to a Bell’s palsy. If this were an upper motor neurone weakness, the eye would not have been so obviously affected due to bilateral innervations. He does not require imaging or for that matter neurological referral unless atypical. If the weakness is prolonged (or recovery incomplete), the patient may benefit from assessment in a specialist facial nerve clinic.

AKT

1. A 59 year-old woman with rheumatoid arthritis requires antibiotic prophylaxis for recurrent urinary tract infections. She is currently taking methotrexate on a weekly basis.Which is the SINGLE LEAST appropriate antibiotic to prescribe for this patient? Select ONE option only.

A. Cefalexin
B. Ciprofloxacin
C. Co-amoxiclav
D. Nitrofurantoin
E. Trimethoprim

Answer: E

The BNF states that the excretion of methotrexate is possibly reduced by ciprofloxacin, which increases the risk of methotrexate toxicity. However, this is not as significant as the methotrexate-trimethoprim interaction.There is a risk of cholestatic jaundice with co-amoxiclav, and it would therefore be less suitable for prolonged use in any patient with a history of liver disease.The most serious complication of methotrexate therapy is bone marrow suppression, and hence the need for regular blood monitoring with a full blood count. The concomitant use of an anti-folate drug (e.g. trimethoprim) increases the risk of bone marrow suppression, and should therefore be avoided, especially for prolonged treatment courses.

2. A 30 year-old man presents with an eight month history of low back pain and stiffness which is worse in the mornings. He has a long history of bilateral heel pain.Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only. [Show Discussion]

A. Ankylosing spondylitis
B. Osteoarthritis
C. Psoriatic arthritis
D. Reactive arthritis
E. Rheumatoid arthritis

Answer: A

The history of stiffness suggests an inflammatory condition in this patient. Ankylosing spondylitis is more common in young men. There may be a positive family history, and there is a strong association with HLA B27. Extra-articular manifestations include Anterior uveitis, Apical lung fibrosis, AV heart block, Aortic regurgitation and aortitis, Amyloidosis, Achilles tendonitis and plantar fasciitis.This would be the main differential diagnosis here, as psoriatic arthritis can present with a spondyloarthropathy or sacroiliitis.It would be unusual for symptoms to continue for eight months with a reactive arthritis, and there would be usually be a preceding history of (typically) a gastrointestinal infection.

3. A 15 year-old boy presents with a two month history of fever and a painful, red swelling just above his left knee. There is no history of trauma.Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Ewing’s sarcoma
B. Juvenile idiopathic arthritis
C. Osgood-Schlatter’s disease
D. Osteomyelitis
E. Reactive arthritis

Answer: A

This is a rare but important diagnosis not to miss. It accounts for 2% of all childhood cancers. It is more common in males and typically presents in children and young adults aged 5-20 years. It may mimic an infective process, but red flag symptoms of fever, persistent pain (including nocturnal and rest pain) and persistent localised swelling should prompt an urgent referral to exclude a malignant lesion.Juvenile idiopathic arthritis refers to the onset of arthritis in a patient under the age of 16, which lasts for more than three months. If there are associated systemic features (e.g. fever, rash, lymphadenopathy), then it is referred to as Still’s disease.Osgood-Schlatter’s disease is an overuse condition which presents with pain (often bilateral) and tenderness over the tibial tuberosity, usually around the time of the pubertal growth spurt. Symptoms improve with rest. There should be no red flag symptoms present.Osteomyelitis would be unlikely in the absence of trauma, although can occur (e.g. from haematogenous spread).

4. A 38 year-old man presents having recently joined your practice. He is currently taking bendroflumethiazide for hypertension. He complains of recurrent episodic swelling and pain in his right ankle over the last three years. The practice nurse elicited the following clinical information at a new patient check yesterday:BMI 34.6BP 144/90Smoking status Ex-smokerAlcohol intake 40 units per weekUrinalysis Protein 1+Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only. [Show Discussion]

A. Gout
B. Osteoarthritis
C. Psoriatic arthritis
D. Reiter’s syndrome
E. Rheumatoid arthritis

Answer: A

The combination of alcohol excess and use of bendroflumethiazide make gout the most likely diagnosis here. Most cases of gout are idiopathic, but identifiable causes include: increased purine levels (e.g. diet and alcohol), decreased urate excretion (e.g. renal failure) and drugs (e.g. thiazide and loop diuretics). Common sites of involvement include the metatarsophalangeal joint (MTPJ) of the big toe, the ankle joint and the finger joints. Factors precipitating acute attacks of gout include dehydration, alcohol, trauma and infection.Osteoarthritis would be unlikely in a 38 year-old patient.The asymmetrical oligoarthropathy subtype of psoriatic arthritis would be the main differential diagnosis here. However, this is less common than gout, and therefore less likely.Reiter’s syndrome is a triad of urethritis, conjunctivitis and seronegative arthritis. There is an association with HLA B27 and it usually occurs following a genital or gastrointestinal infection (e.g. chlamydia, gonorrhoea, shigella or campylobacter).Rheumatoid arthritis typically presents as a symmetrical polyarthropathy with morning stiffness affecting the small joints of the hands and feet. It affects women more commonly than men.

5. A 22 year-old woman presents to an out of hours GP after slipping on a wet pavement. She complains of pain in her right ankle.According to the Ottawa ankle rules, which SINGLE clinical finding indicates the need for an ankle x-ray? Select ONE option only. [Show Discussion]

A. Bony tenderness over the anterior tip of the medial malleolus
B. Bony tenderness over the posterior tip of the lateral malleolus
C. Inability to dorsiflex the ankle
D. Inability to plantarflex the ankle
E. Swelling over the lateral malleolus

Answer: B

The Ottawa rules clearly state the indications for a plain film x-ray of the ankle, foot and knee.An ankle x-ray is required only if there is pain in the malleolar area, associated with any of the following:
• Pain on palpation over the posterior tip/edge of the lateral malleolus
• Pain on palpation over the posterior tip/edge of the medial malleolus
• Inability to weight bear
The Ottawa rules can be found at www.gp-training.net

6. A 56 year-old woman presents complaining of thoracic back pain. A plain film x-ray of her thoracic spine confirms a vertebral wedge fracture at T10. Her GP requests a DEXA scan to assess bone mineral density.Which SINGLE result would confirm a diagnosis of osteoporosis in this patient? Select ONE option only. [Show Discussion]

A. T score of -2.6
B. T score of -2.1
C. T score of +1.7
D. Z score of -1.3
E. Z score of +2.2

Answer: A

Bone mineral density (BMD) is usually expressed as the number of standard deviations (SD) from the young adult mean. This is known as the T score. Normal bone density is within 1 SD of the young adult mean (i.e. T score > -1). Osteopenia is defined by a T score between -1 and -2.5. Osteoporosis is defined as a T score < -2.5. BMD can also be expressed as the number of standard deviations from the age-related mean. This is the Z score, which enables a patient's risk to be compared to other patients of the same age

7. A 67 year-old man complains of aches and pains in his lower back and pelvis. The pain is constant and worse at night. Investigations including blood tests and a lumbar spine x-ray are requested. The lumbar spine x-ray reveals characteristic changes of Paget’s disease.Which is the SINGLE MOST likely bone profile result to be expected in Paget’s disease? Select ONE option only. [Show Discussion]

A. Low serum calcium, normal alkaline phosphatase
B. Normal serum calcium, normal alkaline phosphatase
C. Normal serum calcium, raised alkaline phosphatase
D. Raised serum calcium, normal alkaline phosphatase
E. Raised serum calcium, raised alkaline phosphatase

Answer: C

In Paget’s disease, the classical biochemical finding is an elevated alkaline phosphatase with a normal serum calcium. This reflects an increase in osteoclastic activity and bone turnover. Mild hypercalcaemia can occasionally be found if the patient has been immobile for a prolonged period.

AKT

1. A 34 year-old woman complains of tingling and numbness in her right hand for the past three weeks which is keeping her awake at night. The numbness is worst in the thumb, with some radiation to the right elbow.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Cervical spondylosis
B. De Quervain’s tenosynovitis
C. Median nerve entrapment
D. Multiple sclerosis
E. Ulnar nerve entrapment

Answer: C

This is a typical history of carpal tunnel syndrome which is due to median nerve entrapment in the carpal tunnel at the wrist. Symptoms are worst at night, and pain and parasthesia can extend proximally in to the elbow and shoulder in some cases which may cause some confusion or difficulty with diagnosis. Tinel’s and Phalen’s tests are useful examination tools to help confirm the diagnosis, although they can often be negative in the presence of otherwise classical symptoms. In Tinel’s test, tapping over the carpal tunnel causes tingling in the distribution of the median nerve (thumb and radial two and a half fingers). In Phalen’s test, symptoms are elicited by forcible palmar flexion of the wrist causes venous engorgement of the carpal tunnel.Cervical spondylosis is common in the elderly, but would be unlikely in a 34 year-old patient.De Quervain’s tenosynovitis is an overuse condition. It is characterised by localised tenderness over the extensor and abductor tendon sheaths of the thumb.The most common site of ulnar nerve entrapment is at the elbow, and this typically causes parasthesia and/or weakness in the ring and little fingers.

2. A 62 year-old woman presents with pain and stiffness in both shoulders for the last four weeks. Her symptoms are worse in the mornings, and she also admits to low mood and recent-onset headaches.

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: H

The history of morning stiffness points towards this being an inflammatory condition, and in this age group polymyalgia rheumatica is common. It may be associated with other systemic and non-specific features such as malaise, anorexia, low-grade fever, weight loss and depression. The history of headaches raises the possibility of associated temporal arteritis, and this requires urgent further assessment.

3. A 56 year-old man presents with bilateral shoulder pain and weakness for the last three months. He has noticed increasing difficulty in lifting himself out of his armchair at home. Investigations reveal a raised C reactive protein and creatine kinase. [Show Discussion]

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: I

The history of objective weakness here suggests a possible muscular problem. In polymyositis the limb girdle or proximal muscles are most severely affected, but typically their bulk is preserved beyond that expected from their weakness. Raised C reactive protein and creatine kinase levels reflect the acute and chronic inflammation of skeletal muscle which occur in this condition.

4. A 44 year-old woman presents with pain in all of her joints for the last four months. Her symptoms are worse in the shoulders and hips. On examination she has multiple sites of tenderness including over both trapezius muscles. [Show Discussion]

A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis

Answer: B

Fibromyalgia is characterised by chronic widespread pain (for more than three months) and the presence of at least 11 out of 18 specified ‘tender points’.

AKT

1. A 52 year-old woman presents with an itchy rash on both wrists for the last three months. (See Figure 1) What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.

A. Contact dermatitis
B. Lichen planus
C. Pityriasis rosea
D. Psoriasis
E. Tinea corporis

Answer: B

This picture demonstrates the typical appearance of shiny, flat-topped, violaceous (purple/mauve colour) polygonal papules on the flexural aspects of the wrists which occur in lichen planus. There may be a fine white lace-like pattern on the surface which are called Wickham’s striae. Mucosal membranes including the genitalia may be affected, and treatment usually involves potent topical steroids. The aetiology is thought to be auto-immune.Pityriasis rosea typically presents with a scaly rash that is normally flat or only slightly raised. It is more common in children and young adults and usually affects the trunk predominantly. Human herpes viruses 6 and 7 may be implicated in the aetiology.Chronic extensor plaque psoriasis typically affects the elbow, knees, umbilicus, scalp and natal cleft. Other less common variants of psoriasis can occur, including a flexural type.Tinea corporis has typically a more scaly and annular appearance would be expected with a fungal infection.

AKT questions, nMRCGP exam

1. Your practice nurse asks for your advice about a 66-year-old woman with a venous ulcer. Her ankle brachial pressure index (ABPI) is normal. Which one of the following interventions has been shown to increase healing of her ulcer? [Show Discussion]

A. Antibiotics
B. Exposure to air
C. Four-layer compression bandaging
D. Larvae
E. Non-occlusive dressings

Answer: C

four-layer compression bandaging (DOI: 10.1136/bmj.b1344) is a systematic review and meta-analysis of two forms of compression bandages (four-layer bandage and short-stretch bandage) in the treatment of venous leg ulcers. It concludes that the four-layer bandage significantly reduced the time to healing (hazard ratio = 1.31, 95% confidence interval = 1.09 to 1.58). Short-stretch bandages are useful in patients who are mobile and should be replaced daily. Although the four-layer bandage system is effective, its bulkiness may lead to non-adherence in some patients. It is designed to be left in place for several days, so its use is limited in highly exuding ulcers because dressings may need to be changed more often. Therefore, although four-layer bandages may improve healing overall, the choice of compression bandage should reflect the patient’s specific needs and circumstances. Of the other alternatives, antibiotics are of limited value unless there is cellulitis. Dressings are normally occlusive as ulcers heal better in a moist environment. Larvae have been shown to improve debridement (which is possibly an important component of healing) but not healing itself.

2. Your health care assistant asks for your advice on carrying out an ABPI on a patient with leg ulceration. Which one of the following pieces of advice below is appropriate?

A. The ABPI represents the highest recorded systolic pressure recorded in the two arms over the highest recorded systolic pressure in the affected leg
B. The ABPI represents the highest recorded systolic pressure recorded in the affected leg over the systolic pressure in the ipsilateral arm
C. The ABPI represents the highest recorded systolic pressure recorded in the affected leg over the highest recorded systolic pressure in either arm
D. The ABPI represents the highest recorded systolic pressure recorded in the ipsilateral arm over the systolic pressure in the affected leg

Answer: C

ABPI1 = P1/Pa—where ABPI1 represents the ABPI for a leg, P1 represents the highest pressure obtained from the ankle vessels in that leg and Pa is the highest brachial pressure in the two arms

3. Your practice nurse asks for your advice about a female patient of 67 years with severe, weeping varicose eczema that appears to be infected. Along with antibiotics and emollients, which is the single most appropriate management plan? [Show Discussion]

A. Emollients alone
B. Potassium permanganate (1 : 10 000)
C. Topical steroid (weak)
D. Topical steroid (potent)
E. Topical steroid (potent) + potassium permanganate (1 : 10 000)
F. Topical steroid (weak) + potassium permanganate (1 : 10 000)

Answer: E

potent topical steroids are likely to be needed for up to a month before stepping down. Potassium permanganate (1 : 10 000) is useful in moist weeping eczema and in usually prescribed as 'tablets' to be diluted in water (e.g. 'Permitabs'). It is particularly important to be aware that some of these patients have a contact sensitivity to the treatment itself ('MIMS' has a useful table of potential sensitizers in various preparations). Furthermore, these patients will usually require long-term emollients once the acute flare has settled.

4. At a patient group meeting in your practice, there is interest in screening for abdominal aortic aneurysm (AAA) following the tragic demise of the chairman from a ruptured aneurysm. Which one of the following statements is correct?

A. AAA is as common in women as in men
B. Computerized tomography is the screening method of choice
C. The usual threshold for intervention is 7 cm
D. Four percent of men older than 65 years will have an AAA
E. Women are to be screened from 2009 by the NHS

Answer: D

4% of men will have this condition. The NHS screening programme (which is being gradually implemented) is for men older than 65 years in whom the condition is much more common.

5. An 18 month old girl is brought to the surgery by her mother who is concerned regarding her development. On examination, she is able to crawl but is unable to stand unaided. She can hold a book and turn several pages but is not yet able to turn the pages singly. She has a vocabulary of 25 words but is unable to use two or three word phrases.Which is the SINGLE best description of this patient’s development? Select ONE option only.
A. Fine motor delay
B. Global developmental delay
C. Gross motor delay
D. Isolated speech delay
E. Normal development

Answer: C

At 18 months, a child with normal gross motor development will be able to walk well carrying a toy, and be able to walk up and down stairs with help. Building a tower of three cubes or turning pages of a book, two or three at a time would demonstrate normal fine motor development at this age. A child with normal speech development at 18 months will chatter continuously during play and use between six and twenty recognizsable words.Signs of abnormal development at 18 months include inability to stand or walk, no pincer grip, no spontaneous vocalizsation, and inability to recogniszee simple commands.

6. A 6 year old boy attends the community paediatric clinic with his parents. They are concerned that he is currently struggling academically at school. He is reading and writing at a level below that of his 4 year old brother. Cognitive testing reveals an intelligence quotient (IQ) of 54.Which SINGLE description best describes this patient’s intellectual ability? Select ONE option only.

A. Normal intelligence
B. Mild learning disability
C. Moderate learning disability
D. Severe learning disability
E. Profound learning disability

Answer: B

An IQ of 54 is consistent with a mild learning disability (LD).
Normal, >70
Mild LD, 50-–69
Moderate LD, 35-–49
Severe LD, 20-–34
Profound LD, < 20

IQ testing does not assess functional ability and may be affected by communication difficulties. Children with mild LD are often identified after starting school, whilst while those with moderate LD will require significant support at school. Patients with severe LD will often develop simple speech only, and those with profound LD may not develop speech at all

7. An 18 month old girl is brought to the surgery by her parents who are worried that her development has regressed over the last 2 months. She had normal developmental milestones up until the age of 15 months. However, she is now unable to walk and can only crawl. Her first words have become unrecognisable and she is now only able to babble. She has had two seizures in the last month.

A. Asperger’s syndrome
B. Cerebral palsy
C. Conduct disorder
D. Down’s syndrome
E. Dyslexia
F. Fetal alcohol syndrome
G. Fragile X syndrome
H. Gilles de la Tourette syndrome
I. Obsessive compulsive disorder
J. Rett syndrome

Answer: J

Rett syndrome is a sporadic neurodevelopmental syndrome seen almost exclusively in girls aged 17-–18 months. It is characterizsed by developmental regression following a period of normal childhood development. There is a subsequent rapid deterioration in symptoms including seizures and dementia.

8. A 14 year old boy is reviewed in the community paediatric clinic. He has a moderate learning disability. On examination, it is noted that he has a prominent forehead, large ears and large testes. His height and weight are both on the 50th centile for his age.

A. Asperger’s syndrome
B. Cerebral palsy
C. Conduct disorder
D. Down’s syndrome
E. Dyslexia
F. Fetal alcohol syndrome
G. Fragile X syndrome
H. Gilles de la Tourette syndrome
I. Obsessive compulsive disorder
J. Rett syndrome

Answer: G

Fragile X syndrome is characterizsed by developmental delay, mild to moderate learning disability and phenotypical features including long face, prominent forehead, large ears and large jaw. Post-pubertal boys typically have macro-orchidism.

AKT questions, nMRCGP exam

1. Which one of the following statements is true when assessing a teenager who has self harmed?

A. Assessing how the patient feels about the consequences of his / her actions is essential
B. A doctor centred approach is preferable
C. Questioning on suicidal ideation makes it more likely that a future attempt at self harm will occur
D. The severity of a self harming episode is approximately proportional to the suicidal intent
E. The presence of a suicide note is reassuring

Answer: A

The consultation should be patient centred and it is essential to enquire about thoughts of future self harm. It does not make matters worse for the future. The presence of plans prior to the attempt or a suicide note are concerning

2. Which one of the following statements regarding treatment of young people is true?

A. A 15 year old girl wishing to commence the oral contraceptive should always have parental consent
B. Gillick / Fraser competence only applies to contraceptive issues
C. Once a child is deemed to be Gillick / Fraser competent this competence applies to all future forms of medical treatment.
D. If a 15 year old is deemed Gillick / Fraser competent this judgement confers to them the right to accept treatment
E. The parents of a 17 year old girl with severe anorexia nervosa have the right to over-ride her decision to refuse feeding even though she is deemed competent

Answer: D

Gillick / Fraser competence confers the right of a 15 year old to accept treatment but not necessarily the right to refuse (except in Scotland where competent minors have an independent right to consent to or refuse treatment under the age of legal capacity). Answers 1-3 are clearly false. Regarding answer 5: - GMC Guidance – Young People refusing consent: In England, Wales and Northern Ireland, the law on parents overriding young people’s competent refusal is complex.You should seek legal advice if you think treatment is in the best interests of a competent young person who refuses.

AKT questions, nMRCGP exam

1. Assuming Fraser competence (where applicable) which one of the following situations is generally regarded as acceptable in law?

A. A 17 year old girl appearing in a pornographic film
B. Sexual intercourse between a 20 year old male and 15 year old female
C. Sexual intercourse between a 20 year old female and 15 year old male
D. Sexual intercourse between a 15 year old boy and 14 year old girl
E. Sexual intercourse between a 15 year old girl and 12 year old boy

Answer: D

There is specific protection in law for young people under the age of 18 regarding pornographic activity. Whilst sex under the age of 16 is regarded as criminal activity by the Crown Prosecution Service action is unlikely if both parties are of a similar age.

2. A healthy 16 year old girl consults you regarding the sequelae of chlamydial infection. Which one of the following statemtents is true? [Show Discussion]

A. It is a common cause of ectopic pregnancy
B. It is a common cause of pneumonia
C. 90% of infected females will develop pelvic inflammatory disease if untreated
D. 50% of patients with pelvic inflammatory disease due to Chlamydia will develop infertility
E. The risk of pelvic inflammatory disease is greatest after the first chlamydial infection

Answer: A

43% ectopic pregnancies are due to Chlamydia. It is a rare cause of pneumonia. If untreated up to 40% of women develop PID. Of which 20% have fertility problems. The risk of PID increases with subsequent infections

3. A healthy 16 year old girl consults you regarding the sequelae of chlamydial infection. Which one of the following statemtents is true?

A. A 19 year old nurse with vaginal discharge who thinks she has Chlamydia
B. A 15 year old student who is on the COC
C. A 17 year old girl with severe learning difficulties
D. A 20 year old homeless person with no contact details
E. A 26 year old girl who’s boyfriend has recently found out he has chlamydia

Answer: B

This patient is eligible if competent.

4. Jenny is 19 and has to come to you asking for you to fill in her health insurance form for work. She was screened for chlamydia two months ago but the test was negative. Which of the following is the correct advice about the information that you can give her insurance company?

A. You can disclose that she has had the test but not the result
B. You can disclose the test and the result
C. You can always disclose the result if it was positive
D. You can disclose the result if it was negative
E. You should not disclose that the test has been done despite the result being negative

Answer: E

BMA guidance states that information should not be revealed about whether an applicant for insurance has undertaken tests for STIs – not should any negative results be disclosed. In addition doctors should not reveal information about an isolated incident of an STI that has no long term health implications or even multiple episodes of non serious STIs.

5. Sasha comes to see you after having been told that her Chlamydia screening test was positive and asks about the potential complications. Which one of the following options is the least likely complication?

A. Fitz Hugh Curtis Syndrome
B. Chronic Pelvic Pain
C. Ectopic pregnancy
D. Tubal infertility
E. Bartholinitis

Answer: E

This is rare

6. The parents of a 14 year old boy consult you regarding their son’s behaviour. Which one of the options below is most likely to indicate an underlying psychiatric illness?

A. Aggressive behaviour accompanied by mood swings
B. Covert alcohol consumption
C. Feeling irritable for several weeks
D. A diet consisting solely of junk food
E. School truancy

Answer: C

7. A 17 year old boy presents alone with anxiety and agitation. On examination he appears dishevelled and appears to be distracted. His answers are monosyllabic and he feels that he is being persecuted by the media. He denies illicit drug taking. The single most likely diagnosis is:

A. Anxiety
B. Bipolar disorder
C. Depression
D. Personality disorder
E. Schizophrenia

Answer: E

Schizophrenia. There is evidence of psychosis in this patient and he needs urgent assessment by CAMHS. Bipolar disorder could produce a psychosis but is less common in this age group as could illicit drug abuse

8. Which one of the options below makes school refusal more likely than school truancy in a 16 year old boy?

A. Hiding school absence from parents
B. Nonchalance despite poor academic achievements
C. Somatic symptoms
D. Staying away from home during truancy
E. Stealing

Answer: C

School refusers tend to be sensitive , sometimes bullied children who may have a background of unhappiness. Somatic symptoms (eg abdominal pain) would be common associations. School truants on the other hand are more likely to come from poor, sometimes dysfunctional backgrounds and to have anti social tendencies.

9. A 14 year old boy presents with features of mild depression. Pending an opinion from the Child and Adolescent Mental Health Services (CAHMS) which one of the following courses of action would be most appropriate? [Show Discussion]

A. Amitriptylene
B. Fluoxetine
C. Imipramine
D. No prescription
E. Zopiclone

Answer: D

Because of the tendency to do more harm than good anti-depressants should not be used first line in adolescents with mild depression. Zopiclone (which is not an anti-depressant) would be inappropriate in this age group.

10. You are consulted by the parents of a four year old boy. He appears to be hyperactive, impulsive and he is unable to focus his attention but his parents say that this is relatively mild and only in certain situations. They are concerned that he might have ADHD. Assuming that you will review the patient which is the single most appropriate initial course of action?

A. Prescribe methylphenidate
B. Prescribe atomoxine
C. Refer to child psychiatrist
D. Refer to health visitor
E. Refer to paediatrician

Answer: D

Bearing in mind that the symptoms are mild either this or possibly referral to a parent-training / education programme (if available). Do not initiate methylphenidate or atomoxine in primary care although they may be prescribed under shared agreements with secondary care