1. A 52 year old woman presents with unpleasant tingling in the right thumb, forefinger and middle finger. The sensation wakens her at night. She finds that shaking her wrist gives some relief. On examination, there is thenar eminence wasting. Her symptoms are reproduced by tapping on the volar aspect of her wrist. Which single treatment is likely to be beneficial?
a ) Oral loop diuretic
b ) Oral non steroidal anti-inflammatory
c ) Steroid injection into the wrist
d ) Topical non steroidal anti-inflammatory
e ) Oral pyridoxine
Answer: C
Clinical Evidence" reports that, for carpal tunnel syndrome, steroid injection and systemic corticosteroid therapy are likely to be beneficial. Non-steroidal anti-inflammatories and pyridoxine are of unknown effectiveness and diuretics are unlikely to be beneficial.
2. A 25 year old man attends with a history of constant itch and mild discomfort in his left ear. Examination reveals an erythematous rash of the ear canal. He also has a large, chronic tympanic membrane perforation. Which single treatment should be avoided in this case?
a ) Clotrimazole ear drops
b ) Flumetasone and clioquinol ear drops
c ) Hydrocortisone and gentamicin ear drops
d ) Aluminium acetate ear drops
e ) Prednisolone ear drops
Answer: C
Otitis externa causes itch and discomfort. A precipitant should be sought, e.g. swimming, skin conditions etc. Treatment of the inflammation is by topical corticosteroids. If bacterial infection is suspected, corticosteroid drops containing antibiotics may be used. However, those containing aminoglycosides are contraindicated in chronic tympanic perforation (due to risk of absorption and ototoxicity) unless initiated by a specialist.
3. A 36 year-old female hairdresser attends complaining of an intensely itchy rash affecting her wrists and hands. This has developed over the last seven days. On examination, there is a symmetrical eruption of small (less than 5mm), discrete, flat-topped, violet-coloured papules affecting the palmar surface of both wrists. There are also some small translucent papules on the palms themselves. Closer inspection of the surface of the lesions on the wrists reveals some whitish lines. On direct questioning, she admits that she has felt some discomfort in her mouth when eating for the last couple of days. On inspection of the buccal mucosa, you notice some faint, lacy, white lines and a few shallow erosions. Which is the single most likely diagnosis?
a ) Atopic eczema
b ) Hand, Foot and Mouth Disease
c ) Irritant Contact Dermatitis
d ) Lichen Planus
e ) Pompholyx
Answer: D
Lichen planus (LP) is an intensely itchy eruption of essentially unknown aetiology which is commonest between the ages of 20-50 years. The white lines are known as Wickham's Striae, and although not always seen, are good indicators of LP. If palms and soles are involved, the classic 'violaceous' colour is lost, and the lesions are translucent. Most cases resolve spontaneously within 12 months. Treatment is with high potency steroids, or occasionally oral steroids.
Thursday, 2 October 2008
AKT Questions
1. A 60 year old Caucasian woman, not normally prone to headaches, describes the gradual onset of worsening pain over the left side of her head, during the last five days. It is jabbing in nature and is aggravated by combing her hair. She has also noticed pain in the jaw when eating or talking. She has no rash. What is the single most likely diagnosis?
a ) Acute closed-angle glaucoma
b ) Migraine
c ) Retinal artery occlusion
d ) Temporal arteritis
e ) Trigeminal neuralgia
Answer: D
Temporal arteritis is 4-6 times more common in women than in men. It affects mainly those over the age of 50 – increasing with age. Jaw claudication occurs in approximately 65% of patients with temporal arteritis. Prompt treatment with oral steroids is required as more than 50% of untreated patients will get visual loss.
2. A patient presents to you in the surgery with several articles about his condition which he has taken from the internet. He wishes your opinion about the scientific robustness of these studies. You agree to read them in your spare time and report back to him. Which one of the following methods would you weight most highly in basing your opinion?
a ) Case control study
b ) Cohort study
c ) Expert opinion
d ) Meta-analysis
e ) Randomised control study
Answer: D
Meta-analysis is the systematic review of Randomised Control Trials. This is the highest level of evidence.
Levels of Evidence
Level
1++
High quality meta analysis, systemic review of RCTs, or RCTs with a very low risk of bias
1+
Well conducted meta analysis, systemic review of RCTs, or RCTs with a low risk of bias
1-
Meta analysis, systemic reviews of RCTs, or RCTs with a high risk of bias
2++
High quality systemic reviews of case-control or cohort studies.
High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is casual.
2+
Well conducted case control or cohort study with a low risk of confounding, bias, or chance and a moderate probability that the relationship is casual.
2-
Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not casual.
3
Non-analytical studies, e.g. case report, case series
4
Expert opinion
Grades Of Recommendation
Grade
A
At least one meta analysis, systemic review, or RCT rated as 1++, and directly applicable to the target population: or
A systemic review of RCTs or a body of evidence consisting principally of studies rated as 1+ , directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence including studies rated as 2++, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or
Extrapolation of evidence from studies rated as 2+
3. OPTIONS:
a ) Adrenal Carcinoma
b ) Colonic Carcinoma
c ) Gastric Carcinoma
d ) Hodgkin’s Lymphoma
e ) Pancreatic Carcinoma
f ) Prostatic Carcinoma
g ) TesticularTeratoma
INSTRUCTION: For each of the patients below, choose the most likely underlying diagnosis from the list above. All are malignant diseases which may metastasise. Each option may be used once, more than once or not at all.
1 . A 72 year old man presents with fatigue and weight loss. There is no dysphagia nor post prandial fullness. His appetite has been poorer and bowel motions have become more frequent and loose. Abdominal examination reveals no masses. There is some tenderness in his RIF. Hb. is 9.2g/l and serum ferritin 15. Faecal Occult Blood test is positive.
The Correct answer is b.
2 . A 66 year old man presents with reduced appetite and weight loss over a three month period. He has felt nauseated with a feeling of epigastric fullness .There is no dysphagia. He has had no abdominal pain. He has noticed that his urine is dark and bowel motions are pale. On examination, he appears icteric. His abdomen reveals no masses; there is slight discomfort in the epigasrium.
The Correct answer is e.
3 . A 47 year old man relates that for the last two months he has experienced right sided abdominal and back pain. He is eating normally and has noted no weight loss. His bowels may be a little looser. He feels profoundly weak. He sweats a lot. On examination, there are no abdominal masses; there is tenderness in the right flank. He has quite marked acne vulgaris. BP 170/106. Urinalysis is negative. Hb is 14.2g/l. U & Es show hypokalaemia and hypernatraemia.
The Correct answer is a.
The symptoms of cancer of the colon differ according to the part of the colon affected and the type of tumour, but pain is common to all types. Unexplained weakness and anaemia are characteristic of right colonic carcinoma whilst a change in bowel habit feature in left colonic carcinoma. In Pancreatic carcinoma the classic symptoms are - weight loss, abdominal pain, loss of appetite, jaundice, nausea and vomiting, weakness, fatigue, diarrheoa, indigestion, back pain, clay-colored stools. Adrenocortical carcinomas are typically bulky, greater that 1.5 cm in diameter and invade locally with early spread to the liver, regional lymph nodes and the lungs. Half the tumours are physiologically active with hypercortisolism and/or excessive androgen production.
4. A 37 year old man presents thinking he may have caught Chlamydia through sexual contact with his partner. You agree to test him for infection. Which is the single most appropriate sample to send to the laboratory?
a ) A first void urine sample
b ) A midstream urine sample
c ) An early morning urine sample
d ) A semen sample
e ) A twenty four hour urine sample
Answer: A
SIGN no.42 on Management of Genital Chlamydia trachomatis infection states that the sample of choice for men or women is first void urine. The main alternative in women is an endocervical swab. A urethral swab in men is no more sensitive than first void urine and causes discomfort. The recommended test is a nucleic acid amplification test in which a ligase chain reaction or polymerase chain reaction amplifies the DNA. This test has almost 100% sensitivity, compared with 60-80% for antigen detection.
5. OPTIONS:
a ) Cardiac arrhythmia
b ) Parkinson’s disease
c ) Epilepsy
d ) Intermittent delirium
e ) Myopathy
f ) Meniere’s disease
g ) Transient ischaemic attack
INSTRUCTION: Each of the following patients has had an unwitnessed fall in the past week. Choose the single most likely cause from the above list. Each option can be used once, more than once or not at all.
1 . An 83 year old woman, on long term treatment for temporal arteritis, says she got no warning of the fall and just collapsed. She did not lose consciousness. When seen, her HR was 80/min and regular. BP 150/90 sitting and 148/88 standing. Her limbs showed poor musculature and strength -especially her thighs.
The Correct answer is e.
2 . An 80 year old man has suffered from hypertension for many years. He takes Aspirin. Perindopril and Atorvastatin. He says he felt slightly dizzy at the time of the fall. He also says that recently he has been walking much more slowly and has tripped on a number of occasions. He did not lose consciousness. On examination, his HR was 68/min. BP 120/78 sitting and 100/60 standing. His limbs showed no weakness but appeared very rigid.
The Correct answer is b.
3 . An 85 year-old woman has had hypertension for 20 years. She takes Enalapril and Simvastatin. Her husband thought she seemed confused immediately after the fall but her speech was difficult to make out. She was back to normal within an hour. On examination, HR 88/m and regular. BP160/100 sitting and 160/96 standing. Her limbs showed normal power.
The Correct answer is g.
Falls are usually multifactorial, and are caused by a combination of environmental factors and factors intrinsic to the patient. Long – term steroids can cause significant muscle wasting. Previously undiagnosed Parkinson’s Disease should be kept in line as a cause of an unexplained falls.
a ) Acute closed-angle glaucoma
b ) Migraine
c ) Retinal artery occlusion
d ) Temporal arteritis
e ) Trigeminal neuralgia
Answer: D
Temporal arteritis is 4-6 times more common in women than in men. It affects mainly those over the age of 50 – increasing with age. Jaw claudication occurs in approximately 65% of patients with temporal arteritis. Prompt treatment with oral steroids is required as more than 50% of untreated patients will get visual loss.
2. A patient presents to you in the surgery with several articles about his condition which he has taken from the internet. He wishes your opinion about the scientific robustness of these studies. You agree to read them in your spare time and report back to him. Which one of the following methods would you weight most highly in basing your opinion?
a ) Case control study
b ) Cohort study
c ) Expert opinion
d ) Meta-analysis
e ) Randomised control study
Answer: D
Meta-analysis is the systematic review of Randomised Control Trials. This is the highest level of evidence.
Levels of Evidence
Level
1++
High quality meta analysis, systemic review of RCTs, or RCTs with a very low risk of bias
1+
Well conducted meta analysis, systemic review of RCTs, or RCTs with a low risk of bias
1-
Meta analysis, systemic reviews of RCTs, or RCTs with a high risk of bias
2++
High quality systemic reviews of case-control or cohort studies.
High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is casual.
2+
Well conducted case control or cohort study with a low risk of confounding, bias, or chance and a moderate probability that the relationship is casual.
2-
Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not casual.
3
Non-analytical studies, e.g. case report, case series
4
Expert opinion
Grades Of Recommendation
Grade
A
At least one meta analysis, systemic review, or RCT rated as 1++, and directly applicable to the target population: or
A systemic review of RCTs or a body of evidence consisting principally of studies rated as 1+ , directly applicable to the target population, and demonstrating overall consistency of results
B
A body of evidence including studies rated as 2++, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or
Extrapolation of evidence from studies rated as 2+
3. OPTIONS:
a ) Adrenal Carcinoma
b ) Colonic Carcinoma
c ) Gastric Carcinoma
d ) Hodgkin’s Lymphoma
e ) Pancreatic Carcinoma
f ) Prostatic Carcinoma
g ) TesticularTeratoma
INSTRUCTION: For each of the patients below, choose the most likely underlying diagnosis from the list above. All are malignant diseases which may metastasise. Each option may be used once, more than once or not at all.
1 . A 72 year old man presents with fatigue and weight loss. There is no dysphagia nor post prandial fullness. His appetite has been poorer and bowel motions have become more frequent and loose. Abdominal examination reveals no masses. There is some tenderness in his RIF. Hb. is 9.2g/l and serum ferritin 15. Faecal Occult Blood test is positive.
The Correct answer is b.
2 . A 66 year old man presents with reduced appetite and weight loss over a three month period. He has felt nauseated with a feeling of epigastric fullness .There is no dysphagia. He has had no abdominal pain. He has noticed that his urine is dark and bowel motions are pale. On examination, he appears icteric. His abdomen reveals no masses; there is slight discomfort in the epigasrium.
The Correct answer is e.
3 . A 47 year old man relates that for the last two months he has experienced right sided abdominal and back pain. He is eating normally and has noted no weight loss. His bowels may be a little looser. He feels profoundly weak. He sweats a lot. On examination, there are no abdominal masses; there is tenderness in the right flank. He has quite marked acne vulgaris. BP 170/106. Urinalysis is negative. Hb is 14.2g/l. U & Es show hypokalaemia and hypernatraemia.
The Correct answer is a.
The symptoms of cancer of the colon differ according to the part of the colon affected and the type of tumour, but pain is common to all types. Unexplained weakness and anaemia are characteristic of right colonic carcinoma whilst a change in bowel habit feature in left colonic carcinoma. In Pancreatic carcinoma the classic symptoms are - weight loss, abdominal pain, loss of appetite, jaundice, nausea and vomiting, weakness, fatigue, diarrheoa, indigestion, back pain, clay-colored stools. Adrenocortical carcinomas are typically bulky, greater that 1.5 cm in diameter and invade locally with early spread to the liver, regional lymph nodes and the lungs. Half the tumours are physiologically active with hypercortisolism and/or excessive androgen production.
4. A 37 year old man presents thinking he may have caught Chlamydia through sexual contact with his partner. You agree to test him for infection. Which is the single most appropriate sample to send to the laboratory?
a ) A first void urine sample
b ) A midstream urine sample
c ) An early morning urine sample
d ) A semen sample
e ) A twenty four hour urine sample
Answer: A
SIGN no.42 on Management of Genital Chlamydia trachomatis infection states that the sample of choice for men or women is first void urine. The main alternative in women is an endocervical swab. A urethral swab in men is no more sensitive than first void urine and causes discomfort. The recommended test is a nucleic acid amplification test in which a ligase chain reaction or polymerase chain reaction amplifies the DNA. This test has almost 100% sensitivity, compared with 60-80% for antigen detection.
5. OPTIONS:
a ) Cardiac arrhythmia
b ) Parkinson’s disease
c ) Epilepsy
d ) Intermittent delirium
e ) Myopathy
f ) Meniere’s disease
g ) Transient ischaemic attack
INSTRUCTION: Each of the following patients has had an unwitnessed fall in the past week. Choose the single most likely cause from the above list. Each option can be used once, more than once or not at all.
1 . An 83 year old woman, on long term treatment for temporal arteritis, says she got no warning of the fall and just collapsed. She did not lose consciousness. When seen, her HR was 80/min and regular. BP 150/90 sitting and 148/88 standing. Her limbs showed poor musculature and strength -especially her thighs.
The Correct answer is e.
2 . An 80 year old man has suffered from hypertension for many years. He takes Aspirin. Perindopril and Atorvastatin. He says he felt slightly dizzy at the time of the fall. He also says that recently he has been walking much more slowly and has tripped on a number of occasions. He did not lose consciousness. On examination, his HR was 68/min. BP 120/78 sitting and 100/60 standing. His limbs showed no weakness but appeared very rigid.
The Correct answer is b.
3 . An 85 year-old woman has had hypertension for 20 years. She takes Enalapril and Simvastatin. Her husband thought she seemed confused immediately after the fall but her speech was difficult to make out. She was back to normal within an hour. On examination, HR 88/m and regular. BP160/100 sitting and 160/96 standing. Her limbs showed normal power.
The Correct answer is g.
Falls are usually multifactorial, and are caused by a combination of environmental factors and factors intrinsic to the patient. Long – term steroids can cause significant muscle wasting. Previously undiagnosed Parkinson’s Disease should be kept in line as a cause of an unexplained falls.
AKT Questions
1. You are visiting a 73 year old woman who has been living with her son for the last three months, following frequent falls in her own home and then a subsequent diagnosis of vascular dementia. He is worried as he thinks his mum has been getting more forgetful, irritable and argumentative especially over the last 6-8 weeks. He asks if medication might help settle her. He says she forgets to change her clothes some days and says she has eaten when she hasn't. When asked about this, she becomes abusive, agitated and shouts at her son. She states that she wishes to return home as she misses her privacy and her friends, before breaking down in tears. She has no additional relevant past medical history or medication. Which one of the following drugs would treat this patient most appropriately?
a ) Amitriptyline
b ) Diazepam
c ) Donepezil
d ) Citalopram
e ) Risperidone
Answer: D
Vascular dementia is the second commonest dementia affecting older people. It is important to remember that those with dementia may also develop depression. Depression in older people can often cause forgetfulness along with a change in mood –and should be considered in this case. Adapting to life changes and having to accept a loss of independence because of ill health can be triggers for depression. An SSRI is preferred to a tricyclic due to the latter's increased side effect profile. Benzodiazepines should be avoided when possible in the elderly due to the risk of ataxia and falls. Donepezil is indicated for use in Alzheimer's disease but not vascular dementia. Risperidone should be avoided in the elderly due to the increased risk of cerebrovascular disease.
2. Baby Josh was born at 32 weeks gestation and has made good progress. He is now six months old and presents with a 24 hour history of clear nasal discharge and a wheezy cough. On examination, his temperature is 37oC. He is grunting with nasal flaring. Auscultation of his chest reveals bilateral fine inspiratory crackles. Which single management option is most appropriate?
a ) High flow rate oxygen
b ) Nebulised budesonide
c ) Nebulised ipratropium
d ) Nebulised ribavirin
e ) Nebulised salbutamol
Answer: A
Expert consensus suggests that nasal flaring and grunting is one of several indications for acute paediatric referral of babies with bronchiolitis. The need for high flow oxygen implies that admission is required. There is evidence that prematurity is a risk factor for severe disease.
3. You are asked to visit a 36 yr old man who lives in residential care and is significantly learning disabled. Over the last four days, the staff reported that he has gradually been getting more agitated and restless. He has been shouting out and hasn't been eating as much as usual. The staff are not sure when his bowels last moved but his pads have been wet as usual and there is no foul smell from his urine. He is totally unable to give a history himself. Examination is difficult as he is shouting and won't remain still. He is apyrexial, his chest is clear and, although his abdomen is soft, you think he might be tender there. He has cerebral palsy but no other significant history. His medication history is not significant. Which of the following would be the single best treatment to prescribe?
a ) Amoxicillin
b ) Diazepam
c ) Haloperidol
d ) Mebeverine
e ) Movicol
Answer: E
Common conditions, like constipation, can present atypically, often with a change in behaviour, in patients with learning disabilities due to difficulties with communication. One should avoid rushing in with psychotropic medication.
4. You receive a chest x-ray report for a 62 year old woman who has had a recent chest infection. Although there is no abnormality of the cardio-respiratory system, the film is reported as showing "severe osteopenia of the thoracic spine". The woman became menopausal at age 48, smoked until her early 60's and has a body mass index of 27. There is no other past medical or family history of relevance. In confirming or excluding a diagnosis of osteoporosis, what is the single most appropriate investigation?
a ) Dual-Energy X-ray Absorptiometry (DEXA) scan of AP spine and hip
b ) Plain x-ray of lateral spine and proximal femur
c ) Quantitative ultrasound (QUS)of heel
d ) Quantitative computed tomography(QCT) of spine
e ) Markers of bone turnover (calcium, phosphate , alkaline phosphatase)
Answer: A
Assessment of bone density from plain radiographs is not accurate, and, although severe osteopenia on plain films correlates reasonably with low bone mineral density (BMD) measured by DEXA, there is a wide overlap. There is evidence that QUS of the heel can predict fractures of the hip and spine independently of BMD. However, QUS results are difficult to extrapolate from one instrument to another. QCT has been reliably used to measure BMD, especially of the spine. It does, however, deliver high doses of radiation and the scanners are costly. Biochemical markers of bone turnover have no role in the diagnosis of osteoporosis, or in the selection of patients for BMD measurement. Treatment should not be instituted on the basis of plain film findings alone. When plain films are interpreted as ''severe osteopenia'' it is appropriate to suggest referral for DEXA. BMD should normally be measured by DEXA scanning performed on two sites, preferably anteroposterior spine and hip.
5. OPTIONS:
a ) Acute asthma
b ) Epiglottitis
c ) Laryngomalacia
d ) Pertussis
e ) Post viral wheeze
f ) RSV bronchiolitis
g ) Viral laryngotracheobronchitis (croup)
INSTRUCTION: For each child below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . An 18 month-old boy who has been coryzal, with mild pyrexia on and off for the preceding 36 hours, is brought to the emergency morning surgery. Overnight he has developed noisy inspiration and hoarseness, both of which are most dramatic when crying, but which settle easily at rest. You note a barking, 'sea lion' cough. Chest examination reveals only transmitted upper airways sounds.
The Correct answer is g.
2 . A five month-old boy has been coryzal and sneezy for a day or two. He now has a dry cough and increasing breathlessness which is limiting his feeding. On examination, he is tachycardic and tachypnoeic, with nasal flaring. Chest examination reveals intercostal recession and widespread wheeze, but no focal signs or crepitations.
The Correct answer is f.
3 . A 10 year-old girl has had a persistent, spasmodic cough since developing a 'cold' four weeks earlier. She has vigorous bouts of violent coughing which are worse at night, and which make her face 'go blue', or in some cases, makes her vomit. Her breathing seems normal in between bouts of coughing. Chest examination is essentially normal.
The Correct answer is d.
The peak incidence of croup is in the second year of life, and most cases are safely managed at home. The harsh stridor and barking cough are typical features. Respiratory syncitial virus (RSV) bronchiolitis is the most common lower respiratory tract infection of infancy. Those under six months are most at risk of respiratory failure. The child in this scenario should be admitted for supportive treatment. Immunisation reduces the risk of, but does not fully prevent, pertussis (whooping cough) in all cases. Not all cases have the classic inspiratory "whoop", and symptoms can persist for a number of months after the initial coryzal illness.
6. A 55 year old man has problems with impotence. In the treatment of erectile dysfunction, which one of the following has clear evidence of effectiveness?
a ) Ginseng
b ) Papaverine
c ) Tadalafil
d ) Vacuum devices
e ) Yohimbine
Answer: C
ED has many causes and all of the above options have been used in its treatment. However, of the options presented, only PDEIs such as tadalafil have clear evidence of effectiveness for the treatment of ED.
7. A 45 year old woman had her last cervical smear ten years ago. Her recent cervical smear, taken two weeks ago, has been reported as showing moderate dyskaryosis consistent with CIN 2. Which is the single most appropriate course of action?
a ) Repeat smear immediately
b ) Arrange routine colposcopy
c ) Repeat smear in three years
d ) Repeat smear in six months
e ) Arrange urgent colposcopy
Answer: B
Moderate dyskaryosis is abnormal and equivalent to CIN 2. HPV changes are also present in <1%. Routine referral to a colposcopy clinic is appropriate for excision/biopsy of the lesion.
8. A 35 year old former Accountant, who remains a daily Crack Cocaine user, has agreed to attend you every 3-4 months for support and health check monitoring. He has never injected and is HIV negative. Which two of the following should be included in your examination?
a ) Checking his FBC
b ) Taking his BP
c ) Checking for proteinuria
d ) Monitoring his peak flow rate
e ) Checking for glycosuria
f ) Carrying out fundoscopy
Answer: B & D
Chronic cocaine use commonly results in cardiovascular disease, raised BP, stroke, seizures, and lung disease.
9. A 17 year old man presents in a morning surgery with several hours of acute left testicular pain. He is unsure if there are urinary symptoms, but there is no history of injury. On examination, the left testicle is very tender. Clinical examination is otherwise unhelpful. Which is the single best course of action?
a ) Arrange an outpatient department ultrasound of the testes
b ) Arrange to review at the end of the evening surgery
c ) Arrange for admission via urology
d ) Check bloods for levels of AFP and ßhCG
e ) Prescribe ciprofloxacin
answer: C
Acute testicular pain can be difficult to manage in primary care. In this case, the differential is between epididymo-orchitis and testicular torsion. Diagnostic signs are not sufficiently sensitive. Torsion is commoner in adolescents and orchitis in those who are older/sexually active. The treatment of torsion is time-sensitive and requires urgent Doppler ultrasound assessment. The only safe course of action is to admit as an emergency via urology.
10. OPTIONS:
a ) Anorexia nervosa
b ) Anxiety
c ) Binge eating disorder
d ) Bulimia nervosa
e ) Depression
f ) Munchaushen syndrome
g ) Personality disorder
INSTRUCTION: For each of the patients below, choose the most likely mental health diagnosis above? Each option may be used once, more than once or not at all.
1 . A 26 year old woman, with a BMI of 25, is a frequent attender at the surgery. Her last period was three weeks ago. She is a vegan and is obsessed with what she eats. She has been like this since her early teens. She tends to isolate herself from others. She has made several suicide attempts. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is g.
2 . A 36 year old woman, with a BMI of 21, had her last period three weeks ago. She makes frequent visits to her dentist because of caries. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is d.
3 . A 17 year old woman, with a BMI of 14, had her last period a year ago. She attends the gym for four hours a day. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is a.
It is obviously important to distinguish between different eating disorders and other mental health problems that may present in a similar way. It is also important to be aware that a request for laxatives is not as straightforward as it may at first appear. Bulimics manage to maintain a normal BMI. Vomiting may show itself in dental caries due to the gastric acid's attack on dental enamel. Diarrhoea may be common in bulimic patients. Even though Anorexics may have similar behaviour patterns, they always have a low BMI and are often amenorrhoeic. Patients with a binge eating disorder eat vast quantities of food and are often obese as they do not compensate for their eating by inducing vomiting.
11. A 60 year old smoker, who is on treatment for hypertension and ischaemic heart disease, presents with a cough for the last six weeks. In considering a management plan for him, which one of the following statements, about cough, would you feel is most valid?
a ) ACE-inhibitor related cough is dose related
b ) Chronic cough related to smoking is not dose related
c ) GORD-associated cough may occur in the absence of GI symptoms
d ) Viral-induced cough responds to over-the-counter remedies
e ) Rhinosinusitis is rarely associated with
Answer: C
ACE-inhibitor cough is not dose related and onset can be more than a year after starting treatment. One of the commonest causes of persistent cough is smoking, which appears to be dose-related. Although patients may report subjective benefit from OTC cough remedies, there is no evidence for their efficacy. Rhinosinusitis is a common cause of cough. Spirometry is mandatory in the investigation of chronic cough.
12. OPTIONS:
a ) Erythema migrans
b ) Granuloma annulare
c ) Impetigo
d ) Palmoplantar pustulosis
e ) Pitted keratolysis
f ) Tinea pedis
g ) Varicella zoster
INSTRUCTION: For each of the following patients, select the single most appropriate diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A three year-old girl is brought from nursery school by her mother. Over the last 24 hours, she has developed a cluster of small pustules on her right face. Some of these have evolved into fragile blisters which are easily burst, leaving a golden crusted appearance. She is otherwise well. The Correct answer is c.
2 . A 42 year-old male Scout leader attends because he has noticed a gradually enlarging, pink, annular lesion on his left buttock. He thinks he may have been bitten by something during a camping expedition in rural Wales three weeks ago. It has not responded to topical Clotrimazole cream as suggested by his pharmacist
The Correct answer is a.
3 . A 25 year-old male fitness instructor consults with a complaint of excessive and embarrassing foot odour over the last year or so. On removing his training shoes and socks, you note a pungent odour and a thickening and whitening of the skin on the plantar aspect of his heels and forefoot. Multiple punched out erosions are noted on the affected skin.
The Correct answer is e.
Case 1, Impetigo, pages 517-523 Click here Case 2, Erythema Migrans, pages 267-272 Click here Case 3, Pitted Keratolysis, page 416 Click here
13. A man is 58 years old. One year ago, he began to have some difficulty swallowing and developed fasciculation of his tongue. His voice has become progressively weaker and he is now only able to communicate by writing. Which is the single most likely diagnosis?
a ) Dystrophia Myotonica
b ) Motor Neurone Disease
c ) Multiple Sclerosis
d ) Myaethenia Gravis
e ) Paraneoplastic Syndrome
Answer: B
The man has a bulbar palsy causing dysphonia, dysarthria and dysphagia. Each of the conditions listed may be associated with these; however only in Motor Neurone Disease is there fasciculation. He has loss of function of the lower motor neurones of the brainstem motor nuclei resulting in weakness of the tongue, facial muscles and the muscles involved in chewing and swallowing.
14. A 36 year old man presents with a short history of lethargy, weight loss, thirst and passing copious amounts of urine. Your provisional diagnosis would best be confirmed by which one of the following results?
a ) Glycosuria of 3+
b ) Random blood glucose of >10mmol/l
c ) HbA1c =6%
d ) Fasting blood glucose of >7mmol/l
e ) Post prandial blood glucose of >9mmol/l
Answer: D
15. OPTIONS:
a ) Absence seizure
b ) Febrile seizure
c ) Infantile spasms (West's syndrome)
d ) Myoclonic epilepsy
e ) Pseudoseizure
f ) Breath-holding
INSTRUCTION: For each patient below, choose the single most likely diagnosis above. Each option may be used once, more than once or not at all.
1 . A four month old baby develops tonic spasms, especially flexionally, that occur in runs every 5–10 seconds. The child is otherwise well.
The Correct answer is c.
2 . A two year old child is noted by his mother to be having staring spells, with fluttering of his eyelids, lasting a few seconds at a time.
The Correct answer is a.
3 . A five year old child develops sudden involuntary spasm of a group of muscles with symmetrical repetitive jerking. There is no loss of consciousness.
The Correct answer is d.
West's syndrome starts in first year of life. Runs of tonic spasms occur every 5-10 seconds. It is associated with loss of vision and social interaction. Most commonly one gets flexion spasms ("salaam" spasms). Myoclonic epilepsy is the sudden involuntary spasm of a muscle or a group of muscles. Lennox-Gastaut is a severe form (starts age 2-6y) with intractable seizures.
16. A 24 year old man with Down's syndrome visits you with his mum. He states that he is well but his mum has noticed a change in him. For the last few months, he has been much more lethargic than usual, is participating less at his day centre and wants to spend longer in bed sleeping. She has also noticed he has gained more weight and clothes he wore about four months ago no longer fit. Which one of the following is the most likely cause of his symptoms?
a ) Addison's disease
b ) Cushing's syndrome
c ) Hypercalcaemia
d ) Hypothyroidism
e ) Type 2 diabetes mellitus
Answer: D
Down's syndrome is a common cause of learning disability, with the average GP having 1 in 1000 patients with this syndrome. Hypothyroidism is often not routinely screened for in Down's syndrome; but is much more common than in the general population. There is an increased incidence of type 1 diabetes which presents in early childhood; but there is no increased incidence of type 2 diabetes associated with Down's syndrome. Down's syndrome is also associated with congenital heart disease, congenital GIT abnormalities, atlanto-axial instability, Alzheimer's disease, leukaemia, deafness, and cataracts.
a ) Amitriptyline
b ) Diazepam
c ) Donepezil
d ) Citalopram
e ) Risperidone
Answer: D
Vascular dementia is the second commonest dementia affecting older people. It is important to remember that those with dementia may also develop depression. Depression in older people can often cause forgetfulness along with a change in mood –and should be considered in this case. Adapting to life changes and having to accept a loss of independence because of ill health can be triggers for depression. An SSRI is preferred to a tricyclic due to the latter's increased side effect profile. Benzodiazepines should be avoided when possible in the elderly due to the risk of ataxia and falls. Donepezil is indicated for use in Alzheimer's disease but not vascular dementia. Risperidone should be avoided in the elderly due to the increased risk of cerebrovascular disease.
2. Baby Josh was born at 32 weeks gestation and has made good progress. He is now six months old and presents with a 24 hour history of clear nasal discharge and a wheezy cough. On examination, his temperature is 37oC. He is grunting with nasal flaring. Auscultation of his chest reveals bilateral fine inspiratory crackles. Which single management option is most appropriate?
a ) High flow rate oxygen
b ) Nebulised budesonide
c ) Nebulised ipratropium
d ) Nebulised ribavirin
e ) Nebulised salbutamol
Answer: A
Expert consensus suggests that nasal flaring and grunting is one of several indications for acute paediatric referral of babies with bronchiolitis. The need for high flow oxygen implies that admission is required. There is evidence that prematurity is a risk factor for severe disease.
3. You are asked to visit a 36 yr old man who lives in residential care and is significantly learning disabled. Over the last four days, the staff reported that he has gradually been getting more agitated and restless. He has been shouting out and hasn't been eating as much as usual. The staff are not sure when his bowels last moved but his pads have been wet as usual and there is no foul smell from his urine. He is totally unable to give a history himself. Examination is difficult as he is shouting and won't remain still. He is apyrexial, his chest is clear and, although his abdomen is soft, you think he might be tender there. He has cerebral palsy but no other significant history. His medication history is not significant. Which of the following would be the single best treatment to prescribe?
a ) Amoxicillin
b ) Diazepam
c ) Haloperidol
d ) Mebeverine
e ) Movicol
Answer: E
Common conditions, like constipation, can present atypically, often with a change in behaviour, in patients with learning disabilities due to difficulties with communication. One should avoid rushing in with psychotropic medication.
4. You receive a chest x-ray report for a 62 year old woman who has had a recent chest infection. Although there is no abnormality of the cardio-respiratory system, the film is reported as showing "severe osteopenia of the thoracic spine". The woman became menopausal at age 48, smoked until her early 60's and has a body mass index of 27. There is no other past medical or family history of relevance. In confirming or excluding a diagnosis of osteoporosis, what is the single most appropriate investigation?
a ) Dual-Energy X-ray Absorptiometry (DEXA) scan of AP spine and hip
b ) Plain x-ray of lateral spine and proximal femur
c ) Quantitative ultrasound (QUS)of heel
d ) Quantitative computed tomography(QCT) of spine
e ) Markers of bone turnover (calcium, phosphate , alkaline phosphatase)
Answer: A
Assessment of bone density from plain radiographs is not accurate, and, although severe osteopenia on plain films correlates reasonably with low bone mineral density (BMD) measured by DEXA, there is a wide overlap. There is evidence that QUS of the heel can predict fractures of the hip and spine independently of BMD. However, QUS results are difficult to extrapolate from one instrument to another. QCT has been reliably used to measure BMD, especially of the spine. It does, however, deliver high doses of radiation and the scanners are costly. Biochemical markers of bone turnover have no role in the diagnosis of osteoporosis, or in the selection of patients for BMD measurement. Treatment should not be instituted on the basis of plain film findings alone. When plain films are interpreted as ''severe osteopenia'' it is appropriate to suggest referral for DEXA. BMD should normally be measured by DEXA scanning performed on two sites, preferably anteroposterior spine and hip.
5. OPTIONS:
a ) Acute asthma
b ) Epiglottitis
c ) Laryngomalacia
d ) Pertussis
e ) Post viral wheeze
f ) RSV bronchiolitis
g ) Viral laryngotracheobronchitis (croup)
INSTRUCTION: For each child below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . An 18 month-old boy who has been coryzal, with mild pyrexia on and off for the preceding 36 hours, is brought to the emergency morning surgery. Overnight he has developed noisy inspiration and hoarseness, both of which are most dramatic when crying, but which settle easily at rest. You note a barking, 'sea lion' cough. Chest examination reveals only transmitted upper airways sounds.
The Correct answer is g.
2 . A five month-old boy has been coryzal and sneezy for a day or two. He now has a dry cough and increasing breathlessness which is limiting his feeding. On examination, he is tachycardic and tachypnoeic, with nasal flaring. Chest examination reveals intercostal recession and widespread wheeze, but no focal signs or crepitations.
The Correct answer is f.
3 . A 10 year-old girl has had a persistent, spasmodic cough since developing a 'cold' four weeks earlier. She has vigorous bouts of violent coughing which are worse at night, and which make her face 'go blue', or in some cases, makes her vomit. Her breathing seems normal in between bouts of coughing. Chest examination is essentially normal.
The Correct answer is d.
The peak incidence of croup is in the second year of life, and most cases are safely managed at home. The harsh stridor and barking cough are typical features. Respiratory syncitial virus (RSV) bronchiolitis is the most common lower respiratory tract infection of infancy. Those under six months are most at risk of respiratory failure. The child in this scenario should be admitted for supportive treatment. Immunisation reduces the risk of, but does not fully prevent, pertussis (whooping cough) in all cases. Not all cases have the classic inspiratory "whoop", and symptoms can persist for a number of months after the initial coryzal illness.
6. A 55 year old man has problems with impotence. In the treatment of erectile dysfunction, which one of the following has clear evidence of effectiveness?
a ) Ginseng
b ) Papaverine
c ) Tadalafil
d ) Vacuum devices
e ) Yohimbine
Answer: C
ED has many causes and all of the above options have been used in its treatment. However, of the options presented, only PDEIs such as tadalafil have clear evidence of effectiveness for the treatment of ED.
7. A 45 year old woman had her last cervical smear ten years ago. Her recent cervical smear, taken two weeks ago, has been reported as showing moderate dyskaryosis consistent with CIN 2. Which is the single most appropriate course of action?
a ) Repeat smear immediately
b ) Arrange routine colposcopy
c ) Repeat smear in three years
d ) Repeat smear in six months
e ) Arrange urgent colposcopy
Answer: B
Moderate dyskaryosis is abnormal and equivalent to CIN 2. HPV changes are also present in <1%. Routine referral to a colposcopy clinic is appropriate for excision/biopsy of the lesion.
8. A 35 year old former Accountant, who remains a daily Crack Cocaine user, has agreed to attend you every 3-4 months for support and health check monitoring. He has never injected and is HIV negative. Which two of the following should be included in your examination?
a ) Checking his FBC
b ) Taking his BP
c ) Checking for proteinuria
d ) Monitoring his peak flow rate
e ) Checking for glycosuria
f ) Carrying out fundoscopy
Answer: B & D
Chronic cocaine use commonly results in cardiovascular disease, raised BP, stroke, seizures, and lung disease.
9. A 17 year old man presents in a morning surgery with several hours of acute left testicular pain. He is unsure if there are urinary symptoms, but there is no history of injury. On examination, the left testicle is very tender. Clinical examination is otherwise unhelpful. Which is the single best course of action?
a ) Arrange an outpatient department ultrasound of the testes
b ) Arrange to review at the end of the evening surgery
c ) Arrange for admission via urology
d ) Check bloods for levels of AFP and ßhCG
e ) Prescribe ciprofloxacin
answer: C
Acute testicular pain can be difficult to manage in primary care. In this case, the differential is between epididymo-orchitis and testicular torsion. Diagnostic signs are not sufficiently sensitive. Torsion is commoner in adolescents and orchitis in those who are older/sexually active. The treatment of torsion is time-sensitive and requires urgent Doppler ultrasound assessment. The only safe course of action is to admit as an emergency via urology.
10. OPTIONS:
a ) Anorexia nervosa
b ) Anxiety
c ) Binge eating disorder
d ) Bulimia nervosa
e ) Depression
f ) Munchaushen syndrome
g ) Personality disorder
INSTRUCTION: For each of the patients below, choose the most likely mental health diagnosis above? Each option may be used once, more than once or not at all.
1 . A 26 year old woman, with a BMI of 25, is a frequent attender at the surgery. Her last period was three weeks ago. She is a vegan and is obsessed with what she eats. She has been like this since her early teens. She tends to isolate herself from others. She has made several suicide attempts. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is g.
2 . A 36 year old woman, with a BMI of 21, had her last period three weeks ago. She makes frequent visits to her dentist because of caries. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is d.
3 . A 17 year old woman, with a BMI of 14, had her last period a year ago. She attends the gym for four hours a day. She tells you that she is constipated and wants you to prescribe laxatives.
The Correct answer is a.
It is obviously important to distinguish between different eating disorders and other mental health problems that may present in a similar way. It is also important to be aware that a request for laxatives is not as straightforward as it may at first appear. Bulimics manage to maintain a normal BMI. Vomiting may show itself in dental caries due to the gastric acid's attack on dental enamel. Diarrhoea may be common in bulimic patients. Even though Anorexics may have similar behaviour patterns, they always have a low BMI and are often amenorrhoeic. Patients with a binge eating disorder eat vast quantities of food and are often obese as they do not compensate for their eating by inducing vomiting.
11. A 60 year old smoker, who is on treatment for hypertension and ischaemic heart disease, presents with a cough for the last six weeks. In considering a management plan for him, which one of the following statements, about cough, would you feel is most valid?
a ) ACE-inhibitor related cough is dose related
b ) Chronic cough related to smoking is not dose related
c ) GORD-associated cough may occur in the absence of GI symptoms
d ) Viral-induced cough responds to over-the-counter remedies
e ) Rhinosinusitis is rarely associated with
Answer: C
ACE-inhibitor cough is not dose related and onset can be more than a year after starting treatment. One of the commonest causes of persistent cough is smoking, which appears to be dose-related. Although patients may report subjective benefit from OTC cough remedies, there is no evidence for their efficacy. Rhinosinusitis is a common cause of cough. Spirometry is mandatory in the investigation of chronic cough.
12. OPTIONS:
a ) Erythema migrans
b ) Granuloma annulare
c ) Impetigo
d ) Palmoplantar pustulosis
e ) Pitted keratolysis
f ) Tinea pedis
g ) Varicella zoster
INSTRUCTION: For each of the following patients, select the single most appropriate diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A three year-old girl is brought from nursery school by her mother. Over the last 24 hours, she has developed a cluster of small pustules on her right face. Some of these have evolved into fragile blisters which are easily burst, leaving a golden crusted appearance. She is otherwise well. The Correct answer is c.
2 . A 42 year-old male Scout leader attends because he has noticed a gradually enlarging, pink, annular lesion on his left buttock. He thinks he may have been bitten by something during a camping expedition in rural Wales three weeks ago. It has not responded to topical Clotrimazole cream as suggested by his pharmacist
The Correct answer is a.
3 . A 25 year-old male fitness instructor consults with a complaint of excessive and embarrassing foot odour over the last year or so. On removing his training shoes and socks, you note a pungent odour and a thickening and whitening of the skin on the plantar aspect of his heels and forefoot. Multiple punched out erosions are noted on the affected skin.
The Correct answer is e.
Case 1, Impetigo, pages 517-523 Click here Case 2, Erythema Migrans, pages 267-272 Click here Case 3, Pitted Keratolysis, page 416 Click here
13. A man is 58 years old. One year ago, he began to have some difficulty swallowing and developed fasciculation of his tongue. His voice has become progressively weaker and he is now only able to communicate by writing. Which is the single most likely diagnosis?
a ) Dystrophia Myotonica
b ) Motor Neurone Disease
c ) Multiple Sclerosis
d ) Myaethenia Gravis
e ) Paraneoplastic Syndrome
Answer: B
The man has a bulbar palsy causing dysphonia, dysarthria and dysphagia. Each of the conditions listed may be associated with these; however only in Motor Neurone Disease is there fasciculation. He has loss of function of the lower motor neurones of the brainstem motor nuclei resulting in weakness of the tongue, facial muscles and the muscles involved in chewing and swallowing.
14. A 36 year old man presents with a short history of lethargy, weight loss, thirst and passing copious amounts of urine. Your provisional diagnosis would best be confirmed by which one of the following results?
a ) Glycosuria of 3+
b ) Random blood glucose of >10mmol/l
c ) HbA1c =6%
d ) Fasting blood glucose of >7mmol/l
e ) Post prandial blood glucose of >9mmol/l
Answer: D
15. OPTIONS:
a ) Absence seizure
b ) Febrile seizure
c ) Infantile spasms (West's syndrome)
d ) Myoclonic epilepsy
e ) Pseudoseizure
f ) Breath-holding
INSTRUCTION: For each patient below, choose the single most likely diagnosis above. Each option may be used once, more than once or not at all.
1 . A four month old baby develops tonic spasms, especially flexionally, that occur in runs every 5–10 seconds. The child is otherwise well.
The Correct answer is c.
2 . A two year old child is noted by his mother to be having staring spells, with fluttering of his eyelids, lasting a few seconds at a time.
The Correct answer is a.
3 . A five year old child develops sudden involuntary spasm of a group of muscles with symmetrical repetitive jerking. There is no loss of consciousness.
The Correct answer is d.
West's syndrome starts in first year of life. Runs of tonic spasms occur every 5-10 seconds. It is associated with loss of vision and social interaction. Most commonly one gets flexion spasms ("salaam" spasms). Myoclonic epilepsy is the sudden involuntary spasm of a muscle or a group of muscles. Lennox-Gastaut is a severe form (starts age 2-6y) with intractable seizures.
16. A 24 year old man with Down's syndrome visits you with his mum. He states that he is well but his mum has noticed a change in him. For the last few months, he has been much more lethargic than usual, is participating less at his day centre and wants to spend longer in bed sleeping. She has also noticed he has gained more weight and clothes he wore about four months ago no longer fit. Which one of the following is the most likely cause of his symptoms?
a ) Addison's disease
b ) Cushing's syndrome
c ) Hypercalcaemia
d ) Hypothyroidism
e ) Type 2 diabetes mellitus
Answer: D
Down's syndrome is a common cause of learning disability, with the average GP having 1 in 1000 patients with this syndrome. Hypothyroidism is often not routinely screened for in Down's syndrome; but is much more common than in the general population. There is an increased incidence of type 1 diabetes which presents in early childhood; but there is no increased incidence of type 2 diabetes associated with Down's syndrome. Down's syndrome is also associated with congenital heart disease, congenital GIT abnormalities, atlanto-axial instability, Alzheimer's disease, leukaemia, deafness, and cataracts.
Wednesday, 24 September 2008
AKT Questions
1. A 30 year old woman presents complaining of infrequent, scanty periods, weight gain, acne and excessive hair growth. You arrange some biochemical tests. In confirming your provisional diagnosis, which is the single most useful test?
a ) Fasting glucose
b ) Fasting lipid profile
c ) Free testosterone
d ) LH/FSH ratio
e ) Prolactin
Answer: C
An international consensus definition of PCOS has been published, which defines PCOS as having at least two of the following criteria: reduced or no ovulation; clinical and/or biochemical signs of excessive secretion of androgens; and/or polycystic ovaries (the presence of at least 12 follicles measuring 2–9 mm in diameter, an ovarian volume in excess of 10 ml, or both). Although the other tests can be useful, raised androgen levels are the most useful blood test in primary causes of Polycystic Ovarian Syndrome.
2. OPTIONS:
a ) Bacterial vaginosis
b ) Chlamydia trachomatis
c ) Gonorrhoea
d ) Herpes genitalis
e ) Syphilis
f ) Trichomonas vaginalis
g ) Vulvovaginal candidiasis
INSTRUCTION:
Choose the single most likely underlying gynaecological diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A sexually active 30 year old woman presents with a frothy vaginal discharge, abnormal vaginal odour, dyspareunia, and mild vulval itching. Vaginal examination reveals a ‘strawberry cervix’. A swab and smear test showed flagellated protozoa on microscopy.
The Correct answer is f.
2 . A 22 year old woman attends for a routine cervical smear test. She has no symptoms. On examination the nurse notes some mild mucopurulent discharge at the cervix and takes a swab. The swab shows gram negative diplococci.
The Correct answer is c.
3 . A sexually active 48 year old woman presents with symptoms of polyuria, polydipsia and recent weight loss. She has a BMI of 31. She has noticed a vaginal itch and some whitish discharge. Examination reveals a very red vulva and confirms a copious white discharge.
The Correct answer is g.
Trichomonas vaginalis is often an incidental finding, perhaps on a cervical cytology report. It may be carried by women for months or even years. It is almost exclusively a sexually transmissible infection. Refer to Genito-urinary Medicine if you find / suspect it. Be aware of the possibility of co-existing infections. Trichomonas vaginalis is a flagellated protozoan which lives in the vagina, urethra, foreskin and the paraurethral glands. Gonococci are Gram negative intra-cellular diplococci. They are spread by direct innoculation of secretions from one mucous membrane to another (urethra, endocervix, rectum, pharynx, and conjunctiva). Non-sexual transmission is exceptional – there is no evidence that it is caught from toilet seats. Vulvovaginal candidiasis - 80% are Candida albicans Non albicans species (e.g. C glabrata) account for the rest. 10 to 20% of women harbour candida species without symptoms (and no treatment may be needed if found).Typical symptoms are vulval or vaginal itch/soreness, external dysuria, dyspareunia and vaginal discharge. The pH of the discharge is 4 to 4.5 i.e. normal. (If higher, think of Bacterial vaginosis or Trichomonas vaginalis)
3. You see a 77 year old man who has been attending for review of his blood pressure. You have checked his blood pressure on two occasions over the previous two months and again today. The readings have been 170/80, 174/76 and today 180/78. His only medication is allopurinol which he has been taking for years for gout. He is an otherwise well man who has a healthy lifestyle and after giving him advice relating to this you would like to offer him treatment. According to current evidence, which is the most appropriate drug to initiate treatment?
a ) Amlodipine
b ) Bendroflumethiazide
c ) Doxazosin
d ) Losartan
e ) Ramipril
Answer: A
Isolated systolic hypertension is a sustained systolic pressure =140mmHg and a diastolic <90mmhg.>140 and/or diastolic >90) and those with isolated systolic hypertension should be treated as they will benefit from the reduction in risk of cardiovascular disease just as much, or more than, younger people. Current recommendations are that in patients more than 55 years a thiazide or a calcium channel blocker should be the first choice with an ACE inhibitor being added to the initial choice if needed. In this case, a thiazide is contraindicated in gout.
4. A 75 year old widow who has previously been well, and who has been commenced on Bendroflumethiazide for essential hypertension. Which one of the following biochemical abnormalities is she most at risk of developing?
a ) Hypoalbuminaemia
b ) Hypocalcaemia
c ) Hypogammaglobulinaemia
d ) Hypokalaemia
e ) Hypouricaemia
Answer: D
Other side effects of Bendroflumethazide include hypomagnesaemia, hyponatraemia, hypochloraemic alkalosis, hyperuricaemia, gout and hyperglycaemia. The likelihood of adverse effects in the elderly is increased by polypharmacy.
5. A 60 year old woman seeks your advice two weeks after coronary artery bypass grafting. She is an ex- smoker and her BMI is 30. Her husband died of a myocardial infarction several years previously and she is anxious to avoid a similar fate. For which one of the following interventions is there evidence to suggest that her all-cause mortality could be reduced by about a third?
a ) Avoidance of heavy lifting
b ) Cognitive behavioural therapy.
c ) Exercise
d ) Limitation of alcohol to 14 units per week.
e ) Weight reduction to a BMI of 24.
Answer: C
There is good evidence that exercise training should be a core element of cardiac rehabilitation programmes, and there is increasing recognition that it reduces morbidity as well as mortality in men and women of all ages with previous MI, revascularisation or angina. Exercise-only rehabilitation reduces mortality by 27%.
6. A patient has depression. He is employed as an accountant and he has been off work for 14 weeks. After how many weeks of sickness absence is he entitled to claim incapacity benefit?
a ) 4 weeks
b ) 13 weeks
c ) 20 weeks
d ) 28 weeks
e ) 52 weeks
Answer: D
The most common causes of sick note requests are back pain, depression and work place stress. If the patient is employed, they are entitled to statutory sick pay which lasts for a maximum of 28 weeks. At 28 weeks, incapacity benefit can then be claimed.
7. OPTIONS:
a ) Agitated depression
b ) Alzheimer’s disease
c ) Frontal lobe dementia
d ) Lewy body dementia
e ) Parkinson’s Disease
f ) Toxic confusional state
g ) Vascular dementia
INSTRUCTION: For each of the following patients with mental disturbance, select the single most likely above diagnosis. Each option can be used once, more than once or not at all.
1 . A 70 year old woman with a six month history of fluctuating cognitive impairment associated with visual hallucinations and a tremor.
. The Correct answer is d.
2 . A 79 year old woman with a six day history of fluctuating consciousness level, impaired memory and visual hallucinations -all of acute onset
The Correct answer is f.
3 . An 86 year old woman with a six month history of sexual disinhibition, cognitive impairment and a change of personality.
The Correct answer is C
As management and prognosis of these states differs in many respects, it is obviously important to make an accurate diagnosis and not assume that all problems presenting with confusion represent dementia.
a ) Fasting glucose
b ) Fasting lipid profile
c ) Free testosterone
d ) LH/FSH ratio
e ) Prolactin
Answer: C
An international consensus definition of PCOS has been published, which defines PCOS as having at least two of the following criteria: reduced or no ovulation; clinical and/or biochemical signs of excessive secretion of androgens; and/or polycystic ovaries (the presence of at least 12 follicles measuring 2–9 mm in diameter, an ovarian volume in excess of 10 ml, or both). Although the other tests can be useful, raised androgen levels are the most useful blood test in primary causes of Polycystic Ovarian Syndrome.
2. OPTIONS:
a ) Bacterial vaginosis
b ) Chlamydia trachomatis
c ) Gonorrhoea
d ) Herpes genitalis
e ) Syphilis
f ) Trichomonas vaginalis
g ) Vulvovaginal candidiasis
INSTRUCTION:
Choose the single most likely underlying gynaecological diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A sexually active 30 year old woman presents with a frothy vaginal discharge, abnormal vaginal odour, dyspareunia, and mild vulval itching. Vaginal examination reveals a ‘strawberry cervix’. A swab and smear test showed flagellated protozoa on microscopy.
The Correct answer is f.
2 . A 22 year old woman attends for a routine cervical smear test. She has no symptoms. On examination the nurse notes some mild mucopurulent discharge at the cervix and takes a swab. The swab shows gram negative diplococci.
The Correct answer is c.
3 . A sexually active 48 year old woman presents with symptoms of polyuria, polydipsia and recent weight loss. She has a BMI of 31. She has noticed a vaginal itch and some whitish discharge. Examination reveals a very red vulva and confirms a copious white discharge.
The Correct answer is g.
Trichomonas vaginalis is often an incidental finding, perhaps on a cervical cytology report. It may be carried by women for months or even years. It is almost exclusively a sexually transmissible infection. Refer to Genito-urinary Medicine if you find / suspect it. Be aware of the possibility of co-existing infections. Trichomonas vaginalis is a flagellated protozoan which lives in the vagina, urethra, foreskin and the paraurethral glands. Gonococci are Gram negative intra-cellular diplococci. They are spread by direct innoculation of secretions from one mucous membrane to another (urethra, endocervix, rectum, pharynx, and conjunctiva). Non-sexual transmission is exceptional – there is no evidence that it is caught from toilet seats. Vulvovaginal candidiasis - 80% are Candida albicans Non albicans species (e.g. C glabrata) account for the rest. 10 to 20% of women harbour candida species without symptoms (and no treatment may be needed if found).Typical symptoms are vulval or vaginal itch/soreness, external dysuria, dyspareunia and vaginal discharge. The pH of the discharge is 4 to 4.5 i.e. normal. (If higher, think of Bacterial vaginosis or Trichomonas vaginalis)
3. You see a 77 year old man who has been attending for review of his blood pressure. You have checked his blood pressure on two occasions over the previous two months and again today. The readings have been 170/80, 174/76 and today 180/78. His only medication is allopurinol which he has been taking for years for gout. He is an otherwise well man who has a healthy lifestyle and after giving him advice relating to this you would like to offer him treatment. According to current evidence, which is the most appropriate drug to initiate treatment?
a ) Amlodipine
b ) Bendroflumethiazide
c ) Doxazosin
d ) Losartan
e ) Ramipril
Answer: A
Isolated systolic hypertension is a sustained systolic pressure =140mmHg and a diastolic <90mmhg.>140 and/or diastolic >90) and those with isolated systolic hypertension should be treated as they will benefit from the reduction in risk of cardiovascular disease just as much, or more than, younger people. Current recommendations are that in patients more than 55 years a thiazide or a calcium channel blocker should be the first choice with an ACE inhibitor being added to the initial choice if needed. In this case, a thiazide is contraindicated in gout.
4. A 75 year old widow who has previously been well, and who has been commenced on Bendroflumethiazide for essential hypertension. Which one of the following biochemical abnormalities is she most at risk of developing?
a ) Hypoalbuminaemia
b ) Hypocalcaemia
c ) Hypogammaglobulinaemia
d ) Hypokalaemia
e ) Hypouricaemia
Answer: D
Other side effects of Bendroflumethazide include hypomagnesaemia, hyponatraemia, hypochloraemic alkalosis, hyperuricaemia, gout and hyperglycaemia. The likelihood of adverse effects in the elderly is increased by polypharmacy.
5. A 60 year old woman seeks your advice two weeks after coronary artery bypass grafting. She is an ex- smoker and her BMI is 30. Her husband died of a myocardial infarction several years previously and she is anxious to avoid a similar fate. For which one of the following interventions is there evidence to suggest that her all-cause mortality could be reduced by about a third?
a ) Avoidance of heavy lifting
b ) Cognitive behavioural therapy.
c ) Exercise
d ) Limitation of alcohol to 14 units per week.
e ) Weight reduction to a BMI of 24.
Answer: C
There is good evidence that exercise training should be a core element of cardiac rehabilitation programmes, and there is increasing recognition that it reduces morbidity as well as mortality in men and women of all ages with previous MI, revascularisation or angina. Exercise-only rehabilitation reduces mortality by 27%.
6. A patient has depression. He is employed as an accountant and he has been off work for 14 weeks. After how many weeks of sickness absence is he entitled to claim incapacity benefit?
a ) 4 weeks
b ) 13 weeks
c ) 20 weeks
d ) 28 weeks
e ) 52 weeks
Answer: D
The most common causes of sick note requests are back pain, depression and work place stress. If the patient is employed, they are entitled to statutory sick pay which lasts for a maximum of 28 weeks. At 28 weeks, incapacity benefit can then be claimed.
7. OPTIONS:
a ) Agitated depression
b ) Alzheimer’s disease
c ) Frontal lobe dementia
d ) Lewy body dementia
e ) Parkinson’s Disease
f ) Toxic confusional state
g ) Vascular dementia
INSTRUCTION: For each of the following patients with mental disturbance, select the single most likely above diagnosis. Each option can be used once, more than once or not at all.
1 . A 70 year old woman with a six month history of fluctuating cognitive impairment associated with visual hallucinations and a tremor.
. The Correct answer is d.
2 . A 79 year old woman with a six day history of fluctuating consciousness level, impaired memory and visual hallucinations -all of acute onset
The Correct answer is f.
3 . An 86 year old woman with a six month history of sexual disinhibition, cognitive impairment and a change of personality.
The Correct answer is C
As management and prognosis of these states differs in many respects, it is obviously important to make an accurate diagnosis and not assume that all problems presenting with confusion represent dementia.
AKT Questions
1. 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?
A. 4-year-old with a 5 day history of urinary frequency
B. 2-year-old who has a persistent pyrexia after 48 hours of antibiotic treatment for otitis media
C. 16-month-old complaining of abdominal pain
D. 2-month-old who is feeding poorly and vomiting
E. 3-year-old with a temperature of 37.7ºC who is well and has no obvious focus of infection
Answer: E
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
2. 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?
A. Enuresis alarm
B. Trial of oral desmopressin
C. Trial of imipramine
D. Trial of intranasal desmopressin
E. Discourage fluids at night
Answer: A
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
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
3. At what age would the average child acquire the ability to crawl?
A. 6 months
B. 9 months
C. 12 months
D. 18 months
E. 2 years
Answer: B
The table below summarises the major gross motor developmental milestones
Age - Milestone
3 months
Little or no head lag on being pulled to sitLying on abdomen, good head controlHeld sitting, lumbar curve
6 months
Lying on abdomen, arms extendedLying on back, lifts and grasps feetPulls self to sittingHeld sitting, back straightRolls front to back
9 months
Sits without support (Refer at 12 months)Pulls to standingCrawls
12 months
CruisesWalks with one hand held
15 months
Walks unsupported (Refer at 18 months)
18 months
Squats to pick up a toy
2 years
RunsWalks upstairs and downstairs holding on to rail
3 years
Rides a tricycle using pedalsWalks 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
4. A 9-year-old boy is brought to surgery as his asthma has been getting worse over the past 2 days. His mother is concerned that his breathing is getting worse and not responding to inhaled salbutamol as normal. Which one of the following is consistent with a life-threatening asthma attack?
A. Quiet breath sounds on auscultation
B. SpO2 of 94%
C. Heart rate of 120 bpm
D. Respiratory rate of 30 / minute
E. Peak flow 40% of predicted
Answer: A
Quiet breath sounds in a child with asthma is a worrying feature. Children with asthma normally have an obvious bilateral wheeze - the absence of this may suggest a life-threatening asthma attack
Asthma in children: assessment of acute attacks
The table below summarises the grading of asthma attacks in children between 2 and 5 years of age
Moderate attack
SpO2 > 92%No clinical features of severe asthma
Severe attack
SpO2 <> 130/minRespiratory rate > 50/minUse of accessory neck muscles
Life-threatening attack
SpO2 <92%Silent chestPoor respiratory effortAgitationAltered consciousnessCyanosis
The table below summarises the grading of asthma attacks in children greater than 5 years of age
Moderate attack
SpO2 > 92%PEF > 50% best or predictedNo clinical features ofsevere asthma
Severe attack
SpO2 <> 120/minRespiratory rate > 30/minUse of accessory neck muscles
Life-threatening attack
SpO2 < 92%PEF < 33% best or predictedSilent chestPoor respiratory effortAltered consciousnessCyanosis
A. 4-year-old with a 5 day history of urinary frequency
B. 2-year-old who has a persistent pyrexia after 48 hours of antibiotic treatment for otitis media
C. 16-month-old complaining of abdominal pain
D. 2-month-old who is feeding poorly and vomiting
E. 3-year-old with a temperature of 37.7ºC who is well and has no obvious focus of infection
Answer: E
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
2. 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?
A. Enuresis alarm
B. Trial of oral desmopressin
C. Trial of imipramine
D. Trial of intranasal desmopressin
E. Discourage fluids at night
Answer: A
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
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
3. At what age would the average child acquire the ability to crawl?
A. 6 months
B. 9 months
C. 12 months
D. 18 months
E. 2 years
Answer: B
The table below summarises the major gross motor developmental milestones
Age - Milestone
3 months
Little or no head lag on being pulled to sitLying on abdomen, good head controlHeld sitting, lumbar curve
6 months
Lying on abdomen, arms extendedLying on back, lifts and grasps feetPulls self to sittingHeld sitting, back straightRolls front to back
9 months
Sits without support (Refer at 12 months)Pulls to standingCrawls
12 months
CruisesWalks with one hand held
15 months
Walks unsupported (Refer at 18 months)
18 months
Squats to pick up a toy
2 years
RunsWalks upstairs and downstairs holding on to rail
3 years
Rides a tricycle using pedalsWalks 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
4. A 9-year-old boy is brought to surgery as his asthma has been getting worse over the past 2 days. His mother is concerned that his breathing is getting worse and not responding to inhaled salbutamol as normal. Which one of the following is consistent with a life-threatening asthma attack?
A. Quiet breath sounds on auscultation
B. SpO2 of 94%
C. Heart rate of 120 bpm
D. Respiratory rate of 30 / minute
E. Peak flow 40% of predicted
Answer: A
Quiet breath sounds in a child with asthma is a worrying feature. Children with asthma normally have an obvious bilateral wheeze - the absence of this may suggest a life-threatening asthma attack
Asthma in children: assessment of acute attacks
The table below summarises the grading of asthma attacks in children between 2 and 5 years of age
Moderate attack
SpO2 > 92%No clinical features of severe asthma
Severe attack
SpO2 <> 130/minRespiratory rate > 50/minUse of accessory neck muscles
Life-threatening attack
SpO2 <92%Silent chestPoor respiratory effortAgitationAltered consciousnessCyanosis
The table below summarises the grading of asthma attacks in children greater than 5 years of age
Moderate attack
SpO2 > 92%PEF > 50% best or predictedNo clinical features ofsevere asthma
Severe attack
SpO2 <> 120/minRespiratory rate > 30/minUse of accessory neck muscles
Life-threatening attack
SpO2 < 92%PEF < 33% best or predictedSilent chestPoor respiratory effortAltered consciousnessCyanosis
Tuesday, 23 September 2008
more AKT Questions
1. A Theatre nurse in the local hospital presented to you several weeks ago stating that he fell into an at-risk category for HIV infection. After counselling, you arrange a test. This has now come back positive. You discuss with him the physical and social implications of the condition and how it will be managed. He states very clearly that he does not wish his employer to know. You explain the difficulties this may place on your professional obligation to maintain patient confidentiality. In this regard, what is the single, most appropriate action to take?
a ) You ask him to inform the Occupational Health Dept.
b ) You inform, anonymously, the Occupational Health Dept.
c ) You agree to review the issue after an interval.
d ) You inform, openly, the Occupational Health Dept.
e ) You agree to disclose the issue to no-one.
Answer: D
If you know, or have good reason to believe, that a medical colleague or a health care worker who has, or may have, a serious communicable disease, is practising, or has practised, in a way which places patients at risk, you must inform an appropriate person in the health care worker's employing authority, for example an occupational health physician, or where appropriate, the relevant regulatory body.
2. OPTIONS:
a ) Autistic spectrum disorder
b ) Cerebral palsy
c ) Developmental dyspraxia
d ) Dyscalculia
e ) Dysgraphia
f ) Dyslexia
g ) Fragile X syndrome
INSTRUCTIONFor each of the patients below, select the single most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A father consults you with his 8 year old son. He says that the boy has trouble putting thoughts on paper and writes with inappropriately sized and spaced letters. He has spelling difficulties although he seems to know verbally how to spell the words. He seems to have no difficulty reading. He is interested in sports and has lots of friends.
a . The Correct answer is e.
2 . A young couple attend the surgery to discuss their 6 year old son. They are clearly distressed and are finding their son difficult to cope with. He plays on his own and does not interact well with his peer group. He is not interested in stories and has a habit of repeating what is said.
a . The Correct answer is a.
3 . A young single mother brings her 9 year old son to your surgery. She has noticed that he is poor at games and is getting a hard time at school. He knocks into things and has difficulty with buttons when dressing. He has some difficulty with sounding words and has poor handwriting.
answer C
a ) You ask him to inform the Occupational Health Dept.
b ) You inform, anonymously, the Occupational Health Dept.
c ) You agree to review the issue after an interval.
d ) You inform, openly, the Occupational Health Dept.
e ) You agree to disclose the issue to no-one.
Answer: D
If you know, or have good reason to believe, that a medical colleague or a health care worker who has, or may have, a serious communicable disease, is practising, or has practised, in a way which places patients at risk, you must inform an appropriate person in the health care worker's employing authority, for example an occupational health physician, or where appropriate, the relevant regulatory body.
2. OPTIONS:
a ) Autistic spectrum disorder
b ) Cerebral palsy
c ) Developmental dyspraxia
d ) Dyscalculia
e ) Dysgraphia
f ) Dyslexia
g ) Fragile X syndrome
INSTRUCTIONFor each of the patients below, select the single most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A father consults you with his 8 year old son. He says that the boy has trouble putting thoughts on paper and writes with inappropriately sized and spaced letters. He has spelling difficulties although he seems to know verbally how to spell the words. He seems to have no difficulty reading. He is interested in sports and has lots of friends.
a . The Correct answer is e.
2 . A young couple attend the surgery to discuss their 6 year old son. They are clearly distressed and are finding their son difficult to cope with. He plays on his own and does not interact well with his peer group. He is not interested in stories and has a habit of repeating what is said.
a . The Correct answer is a.
3 . A young single mother brings her 9 year old son to your surgery. She has noticed that he is poor at games and is getting a hard time at school. He knocks into things and has difficulty with buttons when dressing. He has some difficulty with sounding words and has poor handwriting.
answer C
Sunday, 7 September 2008
AKT questions
1. A young woman, who normally wears contact lenses, consults you wearing her glasses. The day before, she was clearing out a cupboard when she felt she had got dust into her left eye, and it became suddenly painful. It has not improved. You do a visual acuity test and it is 6/6 in both eyes with glasses. You stain her left cornea with Fluorescein and can clearly identify a tiny foreign body. There is no corneal staining otherwise. You decide to remove the foreign body (FB) with a cotton wool bud, after first inserting anaesthetic drops. The FB comes away very easily. You set out a management plan for her. Which two of the following should be included in that plan?
a ) Ask her to wear an eye pad for 24hours.
b ) Prescribe Chloramphenicol eye drops for five days
c ) Arrange a follow-up in 24 hours
d ) Prescribe Diclofenac eye drops as a first line painkiller
e ) Tell her she can reinsert her contact lenses in 24 hours time
f ) Arrange for her to see an ophthalmologist
Answer: B & C
Local anaesthetic eye drops act for about 15 minutes, so an eye pad to prevent injury is not required. Oral Paracetamol or Ibuprofen are the first line painkillers. She should not replace the contact lenses until 24 hours after the antibiotic course has been completed. Referral to an ophthalmologist is only indicated if your follow up reveals a problem
2. An obese 45 year old man, with hypertension and peptic ulcer disease, presents with difficulty walking. Examination reveals an acutely swollen, erythematous and tender metatarsophalangeal joint of the right big toe. What is the single best treatment option for him?
a ) Aspirin
b ) Colchicine
c ) Co-codamol
d ) Ibuprofen
e ) Allopurinol
Answer: B
Acute attacks of gout are usually treated with high doses of anti-inflammatory NSAIDs such as ibuprofen, diclofenac or naproxen unless contraindicated e.g. with peptic ulcer. Caution should be exercised in hypertension. Colchicine is probably as effective as NSAIDs and can be used if NSAIDs are contra-indicated. It can only be used as a very short course and up to a total of 6mg has been reached. The course should not be repeated within 3 days. Its use can be limited by the development of toxicity at higher doses. In renal failure, use of NSAIDs and colchicine can be problematic. Aspirin is not recommended in gout. Co-codamol does not confer the anti-inflammatory effect required. COX2s’ share the side effects of conventional NSAIDS and are not licensed for the treatment of gout. Allopurinol treatment is used in the long term treatment of gout but should not be used until three weeks after an acute attack.
3. A 20 year old woman, who has suffered from well controlled epilepsy for the last 10 years, tells you that she is contemplating a pregnancy. She takes Carbamazepine 1.2g daily. She has given up smoking and restricts herself to two units of alcohol per week. She has heard that there are vitamin supplements she can take. She wishes your advice on these. Which one of the following would you advise her to take?
a ) Calcium Folinate 15mg preconceptually and for the first trimester at least
b ) Folic Acid 5mg preconceptually and for the first trimester at least
c ) Ferrograd-Folic 105/350 preconceptually and for the first trimester at least
d ) Folic acid 400mcg preconceptually and for the first trimester at least
e ) Pyridoxine 50mg preconceptually and for the first trimester at least
Answer: B
There is an increased risk of neural tube defects with, in particular, Carbamazepine, Lamotrigine, Oxcarbazepine, Phenytoin and Valproate. A dose of Folic Acid 5mg is required along with individual counselling by a doctor. Combined preparations are not appropriate
4. A young woman, on Methadone maintenance, delivers a 3,500g baby and discharges herself from hospital after 24 hours. She is breastfeeding. On the third day postnatally, she phones and tells you the baby seems very irritable, has a high pitched cry and is breathing very rapidly. You visit them. Which one of the following actions is most appropriate?
a ) Ask the mother to stop breast feeding
b ) Admit the baby and mother to hospital
c ) Ask the Health Visitor to monitor and review
d ) Ask the mother to reduce the Methadone over the next four weeks
e ) Admit the baby to hospital
Answer: B
The baby is likely to be suffering from Neonatal Abstinence Syndrome due to Methadone withdrawal and would most safely be cared for in a paediatric unit. Mother should be encouraged to continue to take her usual dose of Methadone. She should also continue to breastfeed as the small amounts of drug in her breast milk will help the gradual reduction of Methadone levels in the baby’s blood. The mother is likely to have high levels of guilt and discussing these with a Counsellor or Health Visitor, at a later point, would be therapeutic.
5. OPTIONS:
a ) Aspirin
b ) Bendroflumethiazide
c ) Enalapril
d ) Gliclazide
e ) Metformin
f ) Nifedipine
g ) Simvastatin
INSTRUCTION: A 67 year old type 2 diabetic man is on the drugs listed above. At different stages, he develops various additional problems described below. Choose the single drug above most likely to be the cause of the problem. Each option can be used once, more than once or not at all.
1 . He develops an intractable dry cough without wheeze.
The Correct answer is c.
2 . He develops an inflamed joint which you think might be gout?
The Correct answer is b.
3 . He develops severe muscle pain.
The Correct answer is g.
6. A 25 year old woman is 28 weeks pregnant. She has a feeling of fullness in one breast and is fearful of breast cancer, from which an aunt suffered. Which single characteristic would warrant her referral to a breast clinic?
a ) Bilateral breast pain
b ) Bilateral breast nodularity
c ) Breast pain with fever
d ) Localised breast erythema
e ) Discrete breast mass
Answer: E
Women who should be referred include those with any new discrete lump, those with a new lump in a pre-existing area of nodularity those with a non-lactational abscess that does not settle after one course of antibiotics, those with a refilling or recurrent cyst and those with a unilateral axillary lymph node lump.
7. A 40 year old patient develops left sided facial weakness. On examination the paralysis is of lower motor neurone type. He asks what may be the cause. Apart from herpes virus infection, which one of the following is a common cause?
a ) Alcohol excess
b ) Dental caries
c ) Horner’s syndrome
d ) Middle ear disease
e ) Syphilis
Answer: D
This patient has Bell’s Palsy – a condition described 100 years ago by Sir Charles Bell. It is the most common cause of facial paralysis world wide. Its aetiology is usually unclear. There can be vascular, infectious, genetic and immunological causes.
8. OPTIONS:
a ) Carcinoma of colon
b ) Campylobacter
c ) Crohn’s disease
d ) Giardiasis
e ) Irritable bowel syndrome
f ) Laxative abuse
g ) Pseudomembranous colitis
INSTRUCTION: For each of the patients below, choose the most likely underlying diagnosis from the list above. Each answer can be used once, more than once or not at all.
1 . An 18 year old girl has been amenorrhoeic for six months. She has lost 5kgs and has developed loose stools, without bleeding, at least four times a day.
The Correct answer is f.
2 . A 22 year old student has returned from Russia with episodic loose stools and passing offensive wind.
The Correct answer is d.
3 . A 36 year old businessman has completed a two week course of cephalexin. He has now developed a fever, diarrhoea and cramping abdominal pain.
The Correct answer is g.
Laxative abuse is found to be the cause of chronic diarrhoea, after comprehensive investigations,in about 20% of patients. This may commonly occur with a history of an eating disorder. Giardiasis infection is suggested by watery stool with flatus++ (explosive diarrhoea). It is estimated that 95% of travellers to St Petersburg contract the disease. The treatment is metronidazole 2g for three days. Rapid response is diagnostic. Pseudomembranous colitis is due to an overgrowth in the colon of Clostridium difficile. There is a history of antibiotic usage.
9. OPTIONS:
a ) Body Temperature
b ) Full Blood Count
c ) Liver Function Tests
d ) Plasma Glucose
e ) Serum electrolytes
f ) Throat Swab
g ) Thyroid Function Tests
INSTRUCTION: For each patient below, with a potential psychotropic medication side effect, select the single most important confirmatory investigation, or examination, from the list above. Each option can be used once, more than once or not at all.
1 . A 72 year-old woman, in the local nursing home, who was started on Citalopram four weeks ago following a diagnosis of depression, has become increasingly confused over the last week. Today she seems drowsy, and a reliable staff member reports what appeared to be a short-lived seizure that morning.
The Correct answer is e.
2 . A 25 year-old man with resistant schizophrenia has been well controlled on Clozapine 400mg daily for 15 months. Over the last six weeks, he has been living with various family and friends after eviction from his flat. His attendance for reviews at the psychiatric clinic has been erratic. He presents with general malaise, a sore throat, and thinks he has “the 'flu”.
The Correct answer is b.
3 . A 19 year-old male schizophrenic, who lives with his parents, is being visited urgently at home. He has been well controlled since starting Flupentixol (Depixol) depot injections three months ago. On arrival, you find him to have a fluctuating level of consciousness, muscular rigidity, tachycardia and labile blood pressure.
The Correct answer is a.
10. A 26 year-old keen sportsman attends after being advised to do so by a local pharmacist. He has been told he has a fungal toenail infection, and has been using over-the-counter amorolfine lacquer for three months, with no change in the appearance of the nail. He has subungual hyperkeratosis and onycholysis of his right great toenail. Which single statement best reflects the advice you would give him?
a ) Fungal nail infection is trivial requiring no treatment
b ) Treatment can be commenced without confirmation of fungal infection
c ) First-line treatment should be oral
d ) All cases of nail dystrophy are fungal in origin
e ) First line treatment should be topical
Answer: C
Only around 50% of all cases of nail dystrophy are due to fungal infection, so treatment should not be commenced before mycological confirmation has been made. Tinea infection of the nail is almost always treated systemically. Topical applications such as amorolfine and ticonazole may be effective in treating very early onycomycosis. Fungal nail infection is not universally trivial: in the elderly the disease can give rise to complications such as cellulitis, and therefore further compromise the limb in those with diabetes or peripheral vascular disease. Complications can therefore be serious in some clinical situations.
a ) Ask her to wear an eye pad for 24hours.
b ) Prescribe Chloramphenicol eye drops for five days
c ) Arrange a follow-up in 24 hours
d ) Prescribe Diclofenac eye drops as a first line painkiller
e ) Tell her she can reinsert her contact lenses in 24 hours time
f ) Arrange for her to see an ophthalmologist
Answer: B & C
Local anaesthetic eye drops act for about 15 minutes, so an eye pad to prevent injury is not required. Oral Paracetamol or Ibuprofen are the first line painkillers. She should not replace the contact lenses until 24 hours after the antibiotic course has been completed. Referral to an ophthalmologist is only indicated if your follow up reveals a problem
2. An obese 45 year old man, with hypertension and peptic ulcer disease, presents with difficulty walking. Examination reveals an acutely swollen, erythematous and tender metatarsophalangeal joint of the right big toe. What is the single best treatment option for him?
a ) Aspirin
b ) Colchicine
c ) Co-codamol
d ) Ibuprofen
e ) Allopurinol
Answer: B
Acute attacks of gout are usually treated with high doses of anti-inflammatory NSAIDs such as ibuprofen, diclofenac or naproxen unless contraindicated e.g. with peptic ulcer. Caution should be exercised in hypertension. Colchicine is probably as effective as NSAIDs and can be used if NSAIDs are contra-indicated. It can only be used as a very short course and up to a total of 6mg has been reached. The course should not be repeated within 3 days. Its use can be limited by the development of toxicity at higher doses. In renal failure, use of NSAIDs and colchicine can be problematic. Aspirin is not recommended in gout. Co-codamol does not confer the anti-inflammatory effect required. COX2s’ share the side effects of conventional NSAIDS and are not licensed for the treatment of gout. Allopurinol treatment is used in the long term treatment of gout but should not be used until three weeks after an acute attack.
3. A 20 year old woman, who has suffered from well controlled epilepsy for the last 10 years, tells you that she is contemplating a pregnancy. She takes Carbamazepine 1.2g daily. She has given up smoking and restricts herself to two units of alcohol per week. She has heard that there are vitamin supplements she can take. She wishes your advice on these. Which one of the following would you advise her to take?
a ) Calcium Folinate 15mg preconceptually and for the first trimester at least
b ) Folic Acid 5mg preconceptually and for the first trimester at least
c ) Ferrograd-Folic 105/350 preconceptually and for the first trimester at least
d ) Folic acid 400mcg preconceptually and for the first trimester at least
e ) Pyridoxine 50mg preconceptually and for the first trimester at least
Answer: B
There is an increased risk of neural tube defects with, in particular, Carbamazepine, Lamotrigine, Oxcarbazepine, Phenytoin and Valproate. A dose of Folic Acid 5mg is required along with individual counselling by a doctor. Combined preparations are not appropriate
4. A young woman, on Methadone maintenance, delivers a 3,500g baby and discharges herself from hospital after 24 hours. She is breastfeeding. On the third day postnatally, she phones and tells you the baby seems very irritable, has a high pitched cry and is breathing very rapidly. You visit them. Which one of the following actions is most appropriate?
a ) Ask the mother to stop breast feeding
b ) Admit the baby and mother to hospital
c ) Ask the Health Visitor to monitor and review
d ) Ask the mother to reduce the Methadone over the next four weeks
e ) Admit the baby to hospital
Answer: B
The baby is likely to be suffering from Neonatal Abstinence Syndrome due to Methadone withdrawal and would most safely be cared for in a paediatric unit. Mother should be encouraged to continue to take her usual dose of Methadone. She should also continue to breastfeed as the small amounts of drug in her breast milk will help the gradual reduction of Methadone levels in the baby’s blood. The mother is likely to have high levels of guilt and discussing these with a Counsellor or Health Visitor, at a later point, would be therapeutic.
5. OPTIONS:
a ) Aspirin
b ) Bendroflumethiazide
c ) Enalapril
d ) Gliclazide
e ) Metformin
f ) Nifedipine
g ) Simvastatin
INSTRUCTION: A 67 year old type 2 diabetic man is on the drugs listed above. At different stages, he develops various additional problems described below. Choose the single drug above most likely to be the cause of the problem. Each option can be used once, more than once or not at all.
1 . He develops an intractable dry cough without wheeze.
The Correct answer is c.
2 . He develops an inflamed joint which you think might be gout?
The Correct answer is b.
3 . He develops severe muscle pain.
The Correct answer is g.
6. A 25 year old woman is 28 weeks pregnant. She has a feeling of fullness in one breast and is fearful of breast cancer, from which an aunt suffered. Which single characteristic would warrant her referral to a breast clinic?
a ) Bilateral breast pain
b ) Bilateral breast nodularity
c ) Breast pain with fever
d ) Localised breast erythema
e ) Discrete breast mass
Answer: E
Women who should be referred include those with any new discrete lump, those with a new lump in a pre-existing area of nodularity those with a non-lactational abscess that does not settle after one course of antibiotics, those with a refilling or recurrent cyst and those with a unilateral axillary lymph node lump.
7. A 40 year old patient develops left sided facial weakness. On examination the paralysis is of lower motor neurone type. He asks what may be the cause. Apart from herpes virus infection, which one of the following is a common cause?
a ) Alcohol excess
b ) Dental caries
c ) Horner’s syndrome
d ) Middle ear disease
e ) Syphilis
Answer: D
This patient has Bell’s Palsy – a condition described 100 years ago by Sir Charles Bell. It is the most common cause of facial paralysis world wide. Its aetiology is usually unclear. There can be vascular, infectious, genetic and immunological causes.
8. OPTIONS:
a ) Carcinoma of colon
b ) Campylobacter
c ) Crohn’s disease
d ) Giardiasis
e ) Irritable bowel syndrome
f ) Laxative abuse
g ) Pseudomembranous colitis
INSTRUCTION: For each of the patients below, choose the most likely underlying diagnosis from the list above. Each answer can be used once, more than once or not at all.
1 . An 18 year old girl has been amenorrhoeic for six months. She has lost 5kgs and has developed loose stools, without bleeding, at least four times a day.
The Correct answer is f.
2 . A 22 year old student has returned from Russia with episodic loose stools and passing offensive wind.
The Correct answer is d.
3 . A 36 year old businessman has completed a two week course of cephalexin. He has now developed a fever, diarrhoea and cramping abdominal pain.
The Correct answer is g.
Laxative abuse is found to be the cause of chronic diarrhoea, after comprehensive investigations,in about 20% of patients. This may commonly occur with a history of an eating disorder. Giardiasis infection is suggested by watery stool with flatus++ (explosive diarrhoea). It is estimated that 95% of travellers to St Petersburg contract the disease. The treatment is metronidazole 2g for three days. Rapid response is diagnostic. Pseudomembranous colitis is due to an overgrowth in the colon of Clostridium difficile. There is a history of antibiotic usage.
9. OPTIONS:
a ) Body Temperature
b ) Full Blood Count
c ) Liver Function Tests
d ) Plasma Glucose
e ) Serum electrolytes
f ) Throat Swab
g ) Thyroid Function Tests
INSTRUCTION: For each patient below, with a potential psychotropic medication side effect, select the single most important confirmatory investigation, or examination, from the list above. Each option can be used once, more than once or not at all.
1 . A 72 year-old woman, in the local nursing home, who was started on Citalopram four weeks ago following a diagnosis of depression, has become increasingly confused over the last week. Today she seems drowsy, and a reliable staff member reports what appeared to be a short-lived seizure that morning.
The Correct answer is e.
2 . A 25 year-old man with resistant schizophrenia has been well controlled on Clozapine 400mg daily for 15 months. Over the last six weeks, he has been living with various family and friends after eviction from his flat. His attendance for reviews at the psychiatric clinic has been erratic. He presents with general malaise, a sore throat, and thinks he has “the 'flu”.
The Correct answer is b.
3 . A 19 year-old male schizophrenic, who lives with his parents, is being visited urgently at home. He has been well controlled since starting Flupentixol (Depixol) depot injections three months ago. On arrival, you find him to have a fluctuating level of consciousness, muscular rigidity, tachycardia and labile blood pressure.
The Correct answer is a.
10. A 26 year-old keen sportsman attends after being advised to do so by a local pharmacist. He has been told he has a fungal toenail infection, and has been using over-the-counter amorolfine lacquer for three months, with no change in the appearance of the nail. He has subungual hyperkeratosis and onycholysis of his right great toenail. Which single statement best reflects the advice you would give him?
a ) Fungal nail infection is trivial requiring no treatment
b ) Treatment can be commenced without confirmation of fungal infection
c ) First-line treatment should be oral
d ) All cases of nail dystrophy are fungal in origin
e ) First line treatment should be topical
Answer: C
Only around 50% of all cases of nail dystrophy are due to fungal infection, so treatment should not be commenced before mycological confirmation has been made. Tinea infection of the nail is almost always treated systemically. Topical applications such as amorolfine and ticonazole may be effective in treating very early onycomycosis. Fungal nail infection is not universally trivial: in the elderly the disease can give rise to complications such as cellulitis, and therefore further compromise the limb in those with diabetes or peripheral vascular disease. Complications can therefore be serious in some clinical situations.
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