1. A 15 year old boy is brought in by his father. The father describes witnessing his son collapsing and becoming briefly unconscious during a game of football two days earlier. Which one of the following would be the most appropriate management in the surgery?
a ) FBC
b ) 12 lead ECG
c ) Reassurance
d ) Spirometry
e ) Urinalysis
Answer: B
Sudden death in the young during exertion can commonly be due to Long QT syndrome and may present with syncope and or palpitation prior to sudden death at a later date. It is increasingly recognised that non-competitive physical activity or even emotional upsets can be associated with arrhythmias and sudden death. A history such as this should, therefore, always prompt further cardiac investigation.
2. A 45 year old man (lifelong UK resident) presents with a three month history of cough, sweats, tiredness and weight loss. Despite these symptoms, he is managing all activities of daily living. He has recently moved into a flat with his new partner and her seven year old son having previously been homeless and living in hostels. He has no significant past medical or drug history. He had a chest X-ray carried out which suggested a diagnosis of active pulmonary TB. Risk assessment suggests that this is unlikely to be a multiple drug resistant strain. In infection control, which one of the following is the most appropriate statement?
a ) Wear a face mask when seeing him during the early weeks of treatment
b ) Screen close contacts only if they become symptomatic
c ) Admit him for commencement of treatment in isolation
d ) His BCG vaccinated partner should be screened
e ) The asymptomatic son should receive BCG vaccination immediately
Answer: D
Generally a face mask is unnecessary unless the patient has multiple drug resistant TB (MDR TB) in which case it is advisable until the patient is no longer infectious. All close contacts should be assessed and screened for asymptomatic disease. Once disease has been excluded BCG vaccination can be considered. Unless the patient is clinically unwell, hospital admission for tests or treatment should be avoided. Previous BCG vaccination cannot be assumed to give immunity for a close contact, particularly so if they could be HIV positive. All patients should have a risk assessment carried out for HIV and MDR Tuberculosis.
3. OPTIONS:
a ) Abdominal ultrasound
b ) Ankle brachial pressure index
c ) Exercise tolerance ECG
d ) Echocardiography
e ) 12 lead resting ECG
f ) 24 hour ambulatory blood pressure monitoring
g ) 24 hour ambulatory ECG monitoring
INSTRUCTION: From the above list, select the investigations most likely to confirm the clinical diagnosis for each of the following patients. Each option can be used once, more than once or not at all.
A . A 45 year-old woman presents with a three month history of feelings of thumping in the chest, associated with breathlessness. She is a non-smoker and drinks 30 units of alcohol weekly. Examination reveals a regular pulse, and a BP of 150/90.
The Correct answer is g.
B . A 50 year-old man has experienced a tight sensation in his chest for three weeks when walking uphill on the golf course, and after meals. He smokes 10 cigarettes daily. Examination is normal.
The Correct answer is c.
C. A 70 year-old man presents with two weeks’ vague lumbar backache. His past history is unremarkable apart from controlled hypertension, and he stopped smoking 20 years ago. His father died suddenly in his 60s, of an unknown cause. Examination reveals no abnormality except obesity.
The Correct answer is a.
Resting ECGs should be performed in patients with palpitations or chest pain, but a normal ECG does not exclude coronary artery disease. It also rarely picks up episodic arrhythmias. Abdominal aortic aneurysm should be considered as a cause of vague abdominal or back pain in the elderly.
4. A young woman, for whom you have been prescribing daily supervised Methadone 40mgs, tells you she is approximately 10 weeks pregnant. She relates that, about 20 minutes after taking her Methadone, she vomits it up. She then feels sweaty and agitated for the rest of the day. She asks if she could be given more Methadone to take later in the day. What is the single most appropriate action?
a ) Reduce her daily dose of Methadone
b ) Prescribe additional Methadone for a few weeks
c ) Report her to Social Services
d ) Arrange additional drug counselling
e ) Stop her Methadone
Answer: B
The main objective is to maintain drug taking stability during pregnancy as this is associated with a better outcome.
5. You examine a five year old child who has had a cough and runny nose for 48 hours. He has a temperature of 38oC. There are no significant focal signs. He is very active around your room, showing no signs of being unwell or distressed. With regard to his temperature, which one of the following is the best intervention?
a ) Tepid sponging
b ) Paracetamol
c ) No treatment
d ) Paracetamol with Ibuprofen
e ) Ibuprofen
Answer: C
Antipyretic therapy should not be used routinely with the sole aim of reducing body temperature in children with a fever who are otherwise well and not distressed. Discussion with the parent is clearly an important part of the management plan
6. A 25 year old woman with a diagnosis of chronic fatigue syndrome asks your opinion on various interventions which she has read about on the internet. Based on a systematic review of randomised controlled trials, which one of the following interventions has been shown to improve measures of fatigue and physical functioning?
a ) Antidepressants
b ) Hypnotherapy
c ) Galantamine
d ) Graded exercise
e ) Immunotherapy
Answer: D
7. OPTIONS:
a ) Bacterial vaginitis
b ) Breakthrough bleeding
c ) Cervical carcinoma
d ) Dysfunctional uterine bleeding
e ) Ectopic pregnancy
f ) Pelvic inflammatory disease
g ) Threatened abortion
INSTRUCTION: For each patient with vaginal bleeding or discharge, select the most likely single diagnosis. Each option can be used once, more than once or not at all.
A . A 26 year old woman attends complaining of recent onset of painful vaginal bleeding. Her period is two weeks late although she puts this down to a recent illness. On vaginal examination, she has some cervical excitation and on abdominal examination there is guarding and rebound tenderness in the left iliac fossa.
The Correct answer is e.
B. A 20 year old non-pregnant woman presents with a fever of 38C, bilateral lower abdominal pain and increased vaginal discharge. Abdominal examination reveals generalised tenderness with no rebound. Vaginal examination reveals cervical excitation with adnexal tenderness.
The Correct answer is f.
C . A 40 year old woman, with a previous regular period pattern, presents with a three month history of painless inter menstrual and post coital bleeding. She is a current smoker and has a past history of HPV. A pregnancy test is negative.
The Correct answer is c.
Always think of ectopic pregnancy in a sexually active woman with abdominal pain and bleeding. There is usually amenorrhoea but an ectopic may be present before a period is missed. Tubal colic causes abdominal pain which may precede vaginal bleeding. Blood loss may be dark (prune juice) or fresh. Symptoms may range from mild to severe (shock if rupture occurs). Early diagnosis is vital, immediate referral for assessment is required. Early diagnosis and treatment of pelvic infection is essential to minimise immediate and future complications (e.g. sepsis, pain, menorrhagia, dysmenorrhoea, infertility and ectopic pregnancy). Risk factors for cervical carcinoma include smoking and the Human Papilloma Virus. Overt carcinoma is rarely detected on a smear. Non menstrual bleeding (intermenstrual, postcoital) is the classic symptom and should always be investigated.
8. A 41 year old overweight type 2 diabetic with three children presents for review of contraception. She has a history of dysmenorrhoea and menorrhagia with iron deficiency anaemia. She is troubled by migraine with aura. Her mother suffered a fractured neck of femur and died from breast carcinoma. She does not wish sterilisation. Which one of the following methods would you recommend?
a ) Combined oral contraceptive (COC)
b ) Depomedroxyprogesterone acetate (DMPA)
c ) Intrauterine device (IUD)
d ) Intrauterine system (IUS)
e ) Norethisterone enantate
Answer: D
Migraine contraindicates the use of COC. The IUD can exacerbate menorrhagia. DMPA is associated with a small loss in bone mineral density, which is largely recovered after discontinuation, and it is recommended that it should be used with care in the over 40s. There is no evidence that an IUS causes weight gain, whereas DMPA use can be associated with a weight gain of up to 2-3kg in one year.
Thursday, 8 January 2009
Wednesday, 7 January 2009
AKT Questions
1. Which of the following statements about encompresis is true?
A. it cannot be diagnosed before the age of four.
B. it involves the voluntary passage of faeces.
C. it I particularly a common problem in lower socioeconomic groups.
D. it is best managed with a coercive approach to potty training.
E. it is more common in females.
Answer: A
Encompresis is the involuntary passage of fully formed faeces and is not a diagnosis that can be made before the age of four. It is an uncommon disorder but much more common in boys. Coercive potty training is likely to worsen the condition. Organic disorders such as Hirschprung's disease must be excluded before psychiatric management is considered. The treatment of choice includes behavioural management, such as the use of a start chart, along with parental counselling or family therapy to help modify hostile attitudes.
2. A 34-year-old man presents to his GP with a 6-month Hx of back pain with no recent Hx of trauma. There are no red flag symptoms. He works long hours as an IT technician. You see from the notes that he has presented in the past with intermittent episodes of back stiffness and occasional neck ache. He is otherwise fit and well, though he was treated with a steroid injection for plantar fascitis last year. On examination, he has no neurological signs but does have reduced range of movement in his cervical spine, particularly for extension. Which one of the following options is the most likely diagnosis?
A. ankylosing spondylitis
B. mechanical back pain
C. osteoarthritis
D. rheumatoid arthritis
E. wedge fracture
Answer: A
AS has prevalence of approximately 1 in 2200 and affects men twice as frequently as women. It tends to present n young men with morning back pain and stiffness. As progressive spinal fusion occurs there can be reduced spinal movement, with kyphosis and sacroiliac joint pain. It is associated with plantar fascitis, lung fibrosis, inflammatory bowel disease and amyloidosis. X-ray of the spine might show a "bamboo spine" with vertebral fusion. The diagnosis is associated with HLA-B27 positivity.
3. Which one of the following food items has the highest glycaemic index?
A. cucumber
B. oranges.
C. peanuts
D. potatoes
E. tomatoes
Answer: D
The GI index and nutrition are popular in the exam as this is important with regard to diabetes and also dieting. Foods with low GI give a smaller rise in blood glucose and are said to result in better glycaemic control in diabetes. Potatoes have a high GI, whereas cucumber has the lowest.
4. Which one of the following is true of psoriasis?
A. topical steroids should be the mainstay of treatment.
B. oral steroids cause pustular psoriasis
C. psoriatic arthropathy never occurs in the absence of a typical rash.
d. Methotrexate is only used to treat the arthropathy.
E. can be cured outright.
Answer: B
Topical steroids are used to treat psoriasis, but second line and for short periods. Oral steroids can produce dramatic pustular psoriasis. Psoriatic arthropathy can occur without skin changes but usually there are nail changes. Methotrexate is used to treat psoriasis without arthropathy and at this point in time the disease is not curable.
5. A 19-year old man has had perineal pain for the past 3 days and has developed fever. He also describes dysuria. On rectal examination he is found to have a tender boggy prostate gland. Which one of the following actions is the most appropriate next step?
A. an HIV test should be organised as soon as possible.
B. a urine sample should be obtained for culture.
C. antibiotics should be started only after any culture results are received.
D. rectal tissue should be swabbed and sent to the laboratory.
E. the prostate should be massaged to obtain Prostatic fluid for culture.
Answer: B
This patient has symptoms consistent with acute prostatitis. Fever, arthralgia, low abdominal pain and a urethral discharge are all common symptom. Diagnosis is made by urine culture. Prostatic massage should be avoided as it can allow the infection to disseminate and will be painful to the patient.
6. A 55-year-old patient has longstanding treated hypertension. He has had his eGFR measured on annual basis. Last year his eGFR was estimated at 54 ml/min/1.73m2. This year he has an unexplained fall in eGFR to 41 ml/min/1.73m2. He feels otherwise well. Which one of the following actions is the most appropriate?
A. arrange renal US and only refer to renal team if US is abnormal.
B. repeat eGFR in 6 months.
C. repeat eGFR in one year.
D. routine OP referral to the renal team.
E. urgent OP referral to the renal team
Answer: D
Patients who have an unexplained fall in eGFR might warrant routine referral to the renal team. An unexplained annual fall in eGFR of >15% is considered significant by the renal association. NICE guidelines also suggest referral for patients with a fall in eGFR. Those with at least a 5-ml/min unexplained fall in eGFR over one year (or less) should be referred. A renal US is also indicated in these patients.
7. A child has just registered with your practice because his family has moved to the area. He has recently been diagnosed with hereditary spherocytosis. Which one of the following statements about this condition is true?
A. it is X-linked recessive condition.
B. it is associated with aplastic crises
C. it is usually diagnosed incidentally in adulthood on routine blood testing
D. patients should be treated with vit. B12 supplementation.
E. there is usually no clinical signs.
Answer: B
Hereditary spherocytosis is an autosomal recessive condition that affects 1 in 5000 live births. It usually presents in childhood as jaundice or with aplastic crises, usually triggered by parvovirus infections. Most children receive folic acid supplementation. Splenomegaly is common. It is rarely diagnosed in adulthood.
A. it cannot be diagnosed before the age of four.
B. it involves the voluntary passage of faeces.
C. it I particularly a common problem in lower socioeconomic groups.
D. it is best managed with a coercive approach to potty training.
E. it is more common in females.
Answer: A
Encompresis is the involuntary passage of fully formed faeces and is not a diagnosis that can be made before the age of four. It is an uncommon disorder but much more common in boys. Coercive potty training is likely to worsen the condition. Organic disorders such as Hirschprung's disease must be excluded before psychiatric management is considered. The treatment of choice includes behavioural management, such as the use of a start chart, along with parental counselling or family therapy to help modify hostile attitudes.
2. A 34-year-old man presents to his GP with a 6-month Hx of back pain with no recent Hx of trauma. There are no red flag symptoms. He works long hours as an IT technician. You see from the notes that he has presented in the past with intermittent episodes of back stiffness and occasional neck ache. He is otherwise fit and well, though he was treated with a steroid injection for plantar fascitis last year. On examination, he has no neurological signs but does have reduced range of movement in his cervical spine, particularly for extension. Which one of the following options is the most likely diagnosis?
A. ankylosing spondylitis
B. mechanical back pain
C. osteoarthritis
D. rheumatoid arthritis
E. wedge fracture
Answer: A
AS has prevalence of approximately 1 in 2200 and affects men twice as frequently as women. It tends to present n young men with morning back pain and stiffness. As progressive spinal fusion occurs there can be reduced spinal movement, with kyphosis and sacroiliac joint pain. It is associated with plantar fascitis, lung fibrosis, inflammatory bowel disease and amyloidosis. X-ray of the spine might show a "bamboo spine" with vertebral fusion. The diagnosis is associated with HLA-B27 positivity.
3. Which one of the following food items has the highest glycaemic index?
A. cucumber
B. oranges.
C. peanuts
D. potatoes
E. tomatoes
Answer: D
The GI index and nutrition are popular in the exam as this is important with regard to diabetes and also dieting. Foods with low GI give a smaller rise in blood glucose and are said to result in better glycaemic control in diabetes. Potatoes have a high GI, whereas cucumber has the lowest.
4. Which one of the following is true of psoriasis?
A. topical steroids should be the mainstay of treatment.
B. oral steroids cause pustular psoriasis
C. psoriatic arthropathy never occurs in the absence of a typical rash.
d. Methotrexate is only used to treat the arthropathy.
E. can be cured outright.
Answer: B
Topical steroids are used to treat psoriasis, but second line and for short periods. Oral steroids can produce dramatic pustular psoriasis. Psoriatic arthropathy can occur without skin changes but usually there are nail changes. Methotrexate is used to treat psoriasis without arthropathy and at this point in time the disease is not curable.
5. A 19-year old man has had perineal pain for the past 3 days and has developed fever. He also describes dysuria. On rectal examination he is found to have a tender boggy prostate gland. Which one of the following actions is the most appropriate next step?
A. an HIV test should be organised as soon as possible.
B. a urine sample should be obtained for culture.
C. antibiotics should be started only after any culture results are received.
D. rectal tissue should be swabbed and sent to the laboratory.
E. the prostate should be massaged to obtain Prostatic fluid for culture.
Answer: B
This patient has symptoms consistent with acute prostatitis. Fever, arthralgia, low abdominal pain and a urethral discharge are all common symptom. Diagnosis is made by urine culture. Prostatic massage should be avoided as it can allow the infection to disseminate and will be painful to the patient.
6. A 55-year-old patient has longstanding treated hypertension. He has had his eGFR measured on annual basis. Last year his eGFR was estimated at 54 ml/min/1.73m2. This year he has an unexplained fall in eGFR to 41 ml/min/1.73m2. He feels otherwise well. Which one of the following actions is the most appropriate?
A. arrange renal US and only refer to renal team if US is abnormal.
B. repeat eGFR in 6 months.
C. repeat eGFR in one year.
D. routine OP referral to the renal team.
E. urgent OP referral to the renal team
Answer: D
Patients who have an unexplained fall in eGFR might warrant routine referral to the renal team. An unexplained annual fall in eGFR of >15% is considered significant by the renal association. NICE guidelines also suggest referral for patients with a fall in eGFR. Those with at least a 5-ml/min unexplained fall in eGFR over one year (or less) should be referred. A renal US is also indicated in these patients.
7. A child has just registered with your practice because his family has moved to the area. He has recently been diagnosed with hereditary spherocytosis. Which one of the following statements about this condition is true?
A. it is X-linked recessive condition.
B. it is associated with aplastic crises
C. it is usually diagnosed incidentally in adulthood on routine blood testing
D. patients should be treated with vit. B12 supplementation.
E. there is usually no clinical signs.
Answer: B
Hereditary spherocytosis is an autosomal recessive condition that affects 1 in 5000 live births. It usually presents in childhood as jaundice or with aplastic crises, usually triggered by parvovirus infections. Most children receive folic acid supplementation. Splenomegaly is common. It is rarely diagnosed in adulthood.
Wednesday, 31 December 2008
AKT Questions
1. A 60 year old Partner in the Practice is persistently late in starting his surgeries. On at least three occasions, you have thought that you have smelled alcohol on his breath. During a consultation eight weeks ago, a patient alleges that the Partner concerned had said that he would refer her to a consultant, yet she has not received any word about it. You cannot see any reference to the referral in the computer record. What is the single most appropriate course of action?
a ) Meet him suggesting a Partnership meeting
b ) Report him to GMC
c ) Adopt a wait and observe policy
d ) Meet him privately and in isolation
e ) Report him to his Appraiser
Anse: A
This is a difficult management situation to deal with in real life. It is thus, a difficult scenario to be confronted with in a question format, as opinion and emphasis may not fully fit into right or wrong categories. However, it is included to stimulate thought.First and foremost, you must protect patients from risk of harm posed by a colleague’s conduct, performance or health. You must, however, have sufficient evidence before proceeding and must not act maliciously.As there are concerns over a number of fronts, it would be inappropriate to do nothing. Under the Age Discrimination Act, 2006, one cannot discriminate against anyone on the basis of age. Whilst risking relationship problems, it is important to be totally open and transparent, and approach the issues in an up-front, yet fair and conciliatory, manner with the person concerned. It is important to have colleagues also present so that responsibilities are shared and a plan of action jointly agreed.
2. A 65 year old patient, who has ischaemic heart disease and polymyalgia rheumatica, has symptoms of dyspepsia. He is on the multiple medications below. Which one of these is the least likely cause of his dyspepsia?
a ) Amlodipine
b ) Diclofenac
c ) Aspirin
d ) Bisoprolol
e ) Prednisolone
Answer: D
Amlodipine can commonly cause abdominal pain, nausea and GI upset. NSAIDs, aspirin and prednisolone are common causes of dyspepsia.
3. OPTIONS:
a ) Diverticular disease
b ) Endometriosis
c ) Interstitial cystitis
d ) Irritable bowel syndrome
e ) Follicular ovarian cyst
f ) Pelvic inflammatory disease
g ) Piriformis syndrome
INSTRUCTION: Pelvic pain is a common presentation in women. Select the single most likely diagnosis above for each of the clinical presentations below. Each option can be used once, more than once or not at all.
A. A 27 year old nulliparous woman presents with symptoms of dysmenorrhoea, dyspareunia and lower abdominal pain which is usually cyclical in nature. Diagnosis was confirmed on laparoscopy.
The Correct answer is b.
B . A 31 year old woman presents with lower abdominal pain and a bloating sensation. She suffers from mild flatulence and altered bowel habit. Her periods are heavy but the symptoms are unrelated to her menstrual cycle.
The Correct answer is d.
C . A 29 year old woman presents with abdominal bloating and a sharp severe transient left sided pain. She is not sexually active but has not had a period for three months. Pregnancy test is negative. Pelvic examination suggests a swelling in the left iliac fossa.
The Correct answer is e.
Endometriosis is characterised by ectopic endometrial tissue, which can cause dysmenorrhoea, dyspareunia, pelvic pain, and subfertility. Diagnosis is made by laparoscopy. Most endometrial deposits are found in the pelvis (ovaries, peritoneum, uterosacral ligaments, pouch of Douglas, and rectovaginal septum). Extrapelvic deposits, including those in the umbilicus and diaphragm, are rare. Irritable bowel syndrome (IBS) is a chronic non-inflammatory condition characterised by abdominal pain, altered bowel habit (diarrhoea or constipation), and abdominal bloating, but with no identifiable structural or biochemical disorder. Symptom based criteria, such as the Manning, the Rome I and the Rome II aid diagnosis but their main use is in defining populations in clinical trials. The most common type of simple ovarian cyst is the graafian follicle cyst, follicular cyst, or dentigerous cyst. This type can form when ovulation doesn't occur, and a follicle doesn't rupture or release its egg but instead grows until it becomes a cyst, or when a mature follicle involutes (collapses on itself). It can grow to about 2.3 inches in diameter. It is thin-walled and filled with clear fluid. Its rupture can create sharp, severe pain. Piriformis syndrome has remained a controversial diagnosis since its initial description in 1928. It is usually caused by a neuritis of the proximal sciatic nerve. The piriformis muscle can either irritate or compress the proximal sciatic nerve due to spasm and/or contracture.
4. A 65 year old woman has been on Lithium Carbonate for 10 years with good effect. Due to mild hypertension she was started on bendroflumethiazide 2.5mg. Six months later she went on holiday for two weeks to southern Europe. Three days before leaving she developed diarrhoea with watery stools every few hours and abdominal pain. She vomited once and remained nauseous. Two days after her return home, she attends you as she still has diarrhoea and nausea and is having some difficulty walking. You notice that her speech is a little slurred. She has a mild fever (37.6oC). Which one of the following investigations is the most appropriate?
a ) Check a stool sample for infection
b ) Check serum lithium level
c ) Check thyroid function
d ) Check urea and electrolytes
e ) Check white cell count
Answer: B
Lithium has a narrow therapeutic:toxic ratio. Sodium imbalance and dehydration are common precipitants of toxicity. This woman is at added risk of this because of the thiazide diuretic which would probably have best been avoided in the management of her hypertension. Patients on Lithium should be counselled about the risks of dehydration.
5. A 68 year old retired railway worker has Chronic Heart Failure (CHF) secondary to Ischaemic Heart Disease. He is already on an Angiotensin Converting Enzyme (ACE) inhibitor and his symptoms of exertional dyspnoea are well controlled. According to best evidence, which one of the following should you consider adding to his medication in order to reduce his risk of mortality due to CHF?
a ) Atorvastatin
b ) Bisoprolol
c ) Flecainide
d ) Furosemide
e ) Isosorbide mononitrate
Answer: B
Few drugs have been shown to reduce mortality in cardiac failure. They include Spironolactone, ACE inhibitors, and Beta blockers. Beta blockers reduce mortality in moderate as well as severe heart failure, and in all age groups, including the elderly. The evidence for loop diuretics is controversial
6. A 60 year old man, who worked underground in the coal industry for 30 years, has noticed a progressive deterioration in his hearing over several years. He relates that he had his adenoids removed as a child because of ear infections. He has had a hearing test organised by his former Trades Union. He brings the audiometry printout to you for your advice. It shows a loss of 60Db at a frequency of 4kHZ in both ears. What single most likely condition does this illustrate?
a ) Chronic otitis media
b ) Presbycusis
c ) Acoustic neuroma
d ) Noise-induced deafness
e ) Otosclerosis
Answer: D
The loss at 4kHz is characteristic of noise- induced deafness. As the deafness worsens, the loss can extend into the 8kHz frequency. The loss is typically sensori-neural
7. A four year old girl is brought along by her mother because of concerns about her increasing need for her reliever inhaler. Her current preventative treatment is 200mcg inhaled beclometasone metered dose inhaler (MDI) twice daily. Over the last 4-6 weeks she has required her salbutamol MDI at least three times per week, often overnight. There is no evidence of acute respiratory infection. She is using a spacer device, and her technique and compliance are good. According to the current British Thoracic Society/SIGN Guideline on Asthma, which one of the following interventions is the next management step?
a ) Add inhaled ipratropium bromide 20mcg t.d.s.
b ) Add inhaled salmeterol 50mcg b.d.
c ) Add inhaled sodium cromoglicate 10mg q.d.s.
d ) Add oral montelukast 4mg o.d
e ) Increase inhaled beclometasone dose to 400mcg b.d.
Answer: D
At presentation, this child is at Management Step 2, whereby she is using regular standard-dose inhaled corticosteroid, plus as-required inhaled short-acting ß2 agonist. To gain improved control, she must move up to Step 3, which for children between two and five years of age, requires the addition of an oral leukotriene receptor antagonist. Currently, only montelukast is licenced for use in this age group. It should be noted that Step 3 for adults and children over 5 is significantly different.
9. A 42 year old man, who regularly consumes 60 units of alcohol a week, presents to you asking for detoxification. He has never before been through alcohol detoxification and expresses a wish for a home- based programme. He is referred to the Community Alcohol Service which agrees that he is a suitable candidate and you are asked to prescribe Chlordiazepoxide. On Day 2 of his programme you receive a phone call from his alcohol worker telling you that he has started to have visual and tactile hallucinations, is disorientated and aggressive and has a temperature of 38.5 degrees C. She asks your advice. What is the single most appropriate next step?
a ) Arrange for a nurse to give intramuscular haloperidol today.
b ) Arrange for a nurse to give intramuscular thiamine today
c ) Arrange for a hospital physician to see him today
d ) Arrange for a psychiatrist to see him today
e ) Arrange for a higher oral dose of Chlordiazepoxide today
Answer: C
What is described here is Delirium Tremens. An acute infection could present in a similar way and needs to be excluded. However, a fever is a symptom of DTs. Untreated Delirium Tremens carries a mortality of up to 5%. Although some psychiatrists will admit patients with DTs, cases are generally treated by the acute medical service because there is often a coexisting medical condition such as pancreatitis, pneumonia or other infection. Haloperidol is an anti psychotic drug but has no place in the community management of alcohol induced psychotic symptoms. Although Diazepam is a benzodiazepine, it has a greater potential for misuse than Chlordiazepoxide and is the benzodiazepine most frequently associated with alcohol related fatalities. Thiamine is prescribed in potential or actual Korsakov’s syndrome
10. OPTIONS:
a ) Asperger’s syndrome
b ) Autism
c ) Cerebral palsy
d ) Cri du Chat
e ) Down’s syndrome
f ) Edward’s syndrome
g ) Fragile X syndrome
INSTRUCTION: For each of the patients below, choose the most likely diagnosis above. Each option can be used once, twice or not at all.
A . A three year old boy is brought to you by his worried grandmother. He used to go to nursery, but his mum stopped taking him because it was too demanding for him. His speech is poor. Gran says that he prefers his own company. When he gets stressed he bangs his head on the wall. He has a normal physical appearance.
The Correct answer is b.
2 . A five year old girl is having a difficult time making friends at school. At the recent parents’ night, the teacher described her as capable, but lacking in imagination, and a bit eccentric. She has only a few topics of conversation which interest her, including airports. She has a normal physical appearance.
The Correct answer is a.
3 . A 15 months old baby is referred to you by the health visitor. He has developmental delay. He is a poor sleeper. You examine him. He has some facial asymmetry. He moves all limbs normally. You note that he has enlarged testicles. He appears quite aggressive towards you.
The Correct answer i G
Developmental delay and school problems are common presentations for learning disabilities in primary care. GPs should recognise the common presentations and features in order to initiate appropriate specialist referral for formal diagnosis and management. Macroorchidism (enlarged testicles) is a common feature in males with learning disability; but it is particularly common in fragile X syndrome
a ) Meet him suggesting a Partnership meeting
b ) Report him to GMC
c ) Adopt a wait and observe policy
d ) Meet him privately and in isolation
e ) Report him to his Appraiser
Anse: A
This is a difficult management situation to deal with in real life. It is thus, a difficult scenario to be confronted with in a question format, as opinion and emphasis may not fully fit into right or wrong categories. However, it is included to stimulate thought.First and foremost, you must protect patients from risk of harm posed by a colleague’s conduct, performance or health. You must, however, have sufficient evidence before proceeding and must not act maliciously.As there are concerns over a number of fronts, it would be inappropriate to do nothing. Under the Age Discrimination Act, 2006, one cannot discriminate against anyone on the basis of age. Whilst risking relationship problems, it is important to be totally open and transparent, and approach the issues in an up-front, yet fair and conciliatory, manner with the person concerned. It is important to have colleagues also present so that responsibilities are shared and a plan of action jointly agreed.
2. A 65 year old patient, who has ischaemic heart disease and polymyalgia rheumatica, has symptoms of dyspepsia. He is on the multiple medications below. Which one of these is the least likely cause of his dyspepsia?
a ) Amlodipine
b ) Diclofenac
c ) Aspirin
d ) Bisoprolol
e ) Prednisolone
Answer: D
Amlodipine can commonly cause abdominal pain, nausea and GI upset. NSAIDs, aspirin and prednisolone are common causes of dyspepsia.
3. OPTIONS:
a ) Diverticular disease
b ) Endometriosis
c ) Interstitial cystitis
d ) Irritable bowel syndrome
e ) Follicular ovarian cyst
f ) Pelvic inflammatory disease
g ) Piriformis syndrome
INSTRUCTION: Pelvic pain is a common presentation in women. Select the single most likely diagnosis above for each of the clinical presentations below. Each option can be used once, more than once or not at all.
A. A 27 year old nulliparous woman presents with symptoms of dysmenorrhoea, dyspareunia and lower abdominal pain which is usually cyclical in nature. Diagnosis was confirmed on laparoscopy.
The Correct answer is b.
B . A 31 year old woman presents with lower abdominal pain and a bloating sensation. She suffers from mild flatulence and altered bowel habit. Her periods are heavy but the symptoms are unrelated to her menstrual cycle.
The Correct answer is d.
C . A 29 year old woman presents with abdominal bloating and a sharp severe transient left sided pain. She is not sexually active but has not had a period for three months. Pregnancy test is negative. Pelvic examination suggests a swelling in the left iliac fossa.
The Correct answer is e.
Endometriosis is characterised by ectopic endometrial tissue, which can cause dysmenorrhoea, dyspareunia, pelvic pain, and subfertility. Diagnosis is made by laparoscopy. Most endometrial deposits are found in the pelvis (ovaries, peritoneum, uterosacral ligaments, pouch of Douglas, and rectovaginal septum). Extrapelvic deposits, including those in the umbilicus and diaphragm, are rare. Irritable bowel syndrome (IBS) is a chronic non-inflammatory condition characterised by abdominal pain, altered bowel habit (diarrhoea or constipation), and abdominal bloating, but with no identifiable structural or biochemical disorder. Symptom based criteria, such as the Manning, the Rome I and the Rome II aid diagnosis but their main use is in defining populations in clinical trials. The most common type of simple ovarian cyst is the graafian follicle cyst, follicular cyst, or dentigerous cyst. This type can form when ovulation doesn't occur, and a follicle doesn't rupture or release its egg but instead grows until it becomes a cyst, or when a mature follicle involutes (collapses on itself). It can grow to about 2.3 inches in diameter. It is thin-walled and filled with clear fluid. Its rupture can create sharp, severe pain. Piriformis syndrome has remained a controversial diagnosis since its initial description in 1928. It is usually caused by a neuritis of the proximal sciatic nerve. The piriformis muscle can either irritate or compress the proximal sciatic nerve due to spasm and/or contracture.
4. A 65 year old woman has been on Lithium Carbonate for 10 years with good effect. Due to mild hypertension she was started on bendroflumethiazide 2.5mg. Six months later she went on holiday for two weeks to southern Europe. Three days before leaving she developed diarrhoea with watery stools every few hours and abdominal pain. She vomited once and remained nauseous. Two days after her return home, she attends you as she still has diarrhoea and nausea and is having some difficulty walking. You notice that her speech is a little slurred. She has a mild fever (37.6oC). Which one of the following investigations is the most appropriate?
a ) Check a stool sample for infection
b ) Check serum lithium level
c ) Check thyroid function
d ) Check urea and electrolytes
e ) Check white cell count
Answer: B
Lithium has a narrow therapeutic:toxic ratio. Sodium imbalance and dehydration are common precipitants of toxicity. This woman is at added risk of this because of the thiazide diuretic which would probably have best been avoided in the management of her hypertension. Patients on Lithium should be counselled about the risks of dehydration.
5. A 68 year old retired railway worker has Chronic Heart Failure (CHF) secondary to Ischaemic Heart Disease. He is already on an Angiotensin Converting Enzyme (ACE) inhibitor and his symptoms of exertional dyspnoea are well controlled. According to best evidence, which one of the following should you consider adding to his medication in order to reduce his risk of mortality due to CHF?
a ) Atorvastatin
b ) Bisoprolol
c ) Flecainide
d ) Furosemide
e ) Isosorbide mononitrate
Answer: B
Few drugs have been shown to reduce mortality in cardiac failure. They include Spironolactone, ACE inhibitors, and Beta blockers. Beta blockers reduce mortality in moderate as well as severe heart failure, and in all age groups, including the elderly. The evidence for loop diuretics is controversial
6. A 60 year old man, who worked underground in the coal industry for 30 years, has noticed a progressive deterioration in his hearing over several years. He relates that he had his adenoids removed as a child because of ear infections. He has had a hearing test organised by his former Trades Union. He brings the audiometry printout to you for your advice. It shows a loss of 60Db at a frequency of 4kHZ in both ears. What single most likely condition does this illustrate?
a ) Chronic otitis media
b ) Presbycusis
c ) Acoustic neuroma
d ) Noise-induced deafness
e ) Otosclerosis
Answer: D
The loss at 4kHz is characteristic of noise- induced deafness. As the deafness worsens, the loss can extend into the 8kHz frequency. The loss is typically sensori-neural
7. A four year old girl is brought along by her mother because of concerns about her increasing need for her reliever inhaler. Her current preventative treatment is 200mcg inhaled beclometasone metered dose inhaler (MDI) twice daily. Over the last 4-6 weeks she has required her salbutamol MDI at least three times per week, often overnight. There is no evidence of acute respiratory infection. She is using a spacer device, and her technique and compliance are good. According to the current British Thoracic Society/SIGN Guideline on Asthma, which one of the following interventions is the next management step?
a ) Add inhaled ipratropium bromide 20mcg t.d.s.
b ) Add inhaled salmeterol 50mcg b.d.
c ) Add inhaled sodium cromoglicate 10mg q.d.s.
d ) Add oral montelukast 4mg o.d
e ) Increase inhaled beclometasone dose to 400mcg b.d.
Answer: D
At presentation, this child is at Management Step 2, whereby she is using regular standard-dose inhaled corticosteroid, plus as-required inhaled short-acting ß2 agonist. To gain improved control, she must move up to Step 3, which for children between two and five years of age, requires the addition of an oral leukotriene receptor antagonist. Currently, only montelukast is licenced for use in this age group. It should be noted that Step 3 for adults and children over 5 is significantly different.
9. A 42 year old man, who regularly consumes 60 units of alcohol a week, presents to you asking for detoxification. He has never before been through alcohol detoxification and expresses a wish for a home- based programme. He is referred to the Community Alcohol Service which agrees that he is a suitable candidate and you are asked to prescribe Chlordiazepoxide. On Day 2 of his programme you receive a phone call from his alcohol worker telling you that he has started to have visual and tactile hallucinations, is disorientated and aggressive and has a temperature of 38.5 degrees C. She asks your advice. What is the single most appropriate next step?
a ) Arrange for a nurse to give intramuscular haloperidol today.
b ) Arrange for a nurse to give intramuscular thiamine today
c ) Arrange for a hospital physician to see him today
d ) Arrange for a psychiatrist to see him today
e ) Arrange for a higher oral dose of Chlordiazepoxide today
Answer: C
What is described here is Delirium Tremens. An acute infection could present in a similar way and needs to be excluded. However, a fever is a symptom of DTs. Untreated Delirium Tremens carries a mortality of up to 5%. Although some psychiatrists will admit patients with DTs, cases are generally treated by the acute medical service because there is often a coexisting medical condition such as pancreatitis, pneumonia or other infection. Haloperidol is an anti psychotic drug but has no place in the community management of alcohol induced psychotic symptoms. Although Diazepam is a benzodiazepine, it has a greater potential for misuse than Chlordiazepoxide and is the benzodiazepine most frequently associated with alcohol related fatalities. Thiamine is prescribed in potential or actual Korsakov’s syndrome
10. OPTIONS:
a ) Asperger’s syndrome
b ) Autism
c ) Cerebral palsy
d ) Cri du Chat
e ) Down’s syndrome
f ) Edward’s syndrome
g ) Fragile X syndrome
INSTRUCTION: For each of the patients below, choose the most likely diagnosis above. Each option can be used once, twice or not at all.
A . A three year old boy is brought to you by his worried grandmother. He used to go to nursery, but his mum stopped taking him because it was too demanding for him. His speech is poor. Gran says that he prefers his own company. When he gets stressed he bangs his head on the wall. He has a normal physical appearance.
The Correct answer is b.
2 . A five year old girl is having a difficult time making friends at school. At the recent parents’ night, the teacher described her as capable, but lacking in imagination, and a bit eccentric. She has only a few topics of conversation which interest her, including airports. She has a normal physical appearance.
The Correct answer is a.
3 . A 15 months old baby is referred to you by the health visitor. He has developmental delay. He is a poor sleeper. You examine him. He has some facial asymmetry. He moves all limbs normally. You note that he has enlarged testicles. He appears quite aggressive towards you.
The Correct answer i G
Developmental delay and school problems are common presentations for learning disabilities in primary care. GPs should recognise the common presentations and features in order to initiate appropriate specialist referral for formal diagnosis and management. Macroorchidism (enlarged testicles) is a common feature in males with learning disability; but it is particularly common in fragile X syndrome
Friday, 28 November 2008
AKT Questions
1. A 70 year old patient with metastatic lung cancer is being treated with a slow release morphine preparation for pain relief. Which one of the following is a recognised side effect of this treatment?
a ) Hyperthermia
b ) Urinary retention
c ) Convulsions
d ) Jaundice
e ) Excess salivation
Answer: B
Side effects of morphine salts include hypothermia and dry mouth among many others. Morphine has an effect on the muscle of the urinary tract, causing the sphincter to contract. This may lead to urinary retention.
2. OPTIONS:
a ) Agitated depression
b ) Alzheimers dementia
c ) Anxiety disorder
d ) Bi-polar disorder
e ) Psychotic state
f ) Multi-infarct dementia
g ) Personality disorder
INSTRUCTION: For each clinical scenario below, select the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A 38 year old woman attends the surgery. She is tense and agitated with feelings of impending doom. She describes a lump in her throat, is prone to palpitations and has tingling in her hands. She finds it difficult to pinpoint why she feels like this.
The Correct answer is c.
2 . A 19 year old student attends the surgery accompanied by a friend. She is withdrawn and pre-occupied. On questioning, her friend says she has been under a lot of stress recently with exams. She has commented that residents of a neighbouring flat are listening to what she is thinking.
The Correct answer is e.
3 . A 60 year old man attends the surgery with his wife. He is over bearing and euphoric. He has a history of depression. His wife comments that he has been socialising and drinking more than usual. He is spending outwith his financial means and has great plans for a bizarre business venture.
The Correct answer is d.
Anxiety is a normal response to an unusual or stressful event; it is the psychological component of the "flight or fight" response. Anxiety is considered abnormal when it is excessively severe or it occurs in the absence of a stressful event or it impairs social, physical or occupational functioning.A psychosis is any major mental disorder of organic or emotional origin that is marked by a derangement of personality and loss of contact with reality. A psychosis is characterised by loss of insight into the fact that one is mentally ill, usually as part of a more general disturbance of the normal relationship between reality and imagination, fact and fantasy. The two most important symptoms of a psychotic disorder are hallucinations and delusions.Bipolar affective disorder is a condition where there are periodic swings of mood periods of months or years between manic episodes and depressed episodes
3. A 72 year old man has metastatic cancer of the prostate gland but has been doing quite well.. For the past two days, he has had low back pain which is worse when he moves but with no radiation. He increased his dose of co-codamol 30/500 two days ago. His wife has just phoned to say he cannot get out of bed and is unable to empty his bladder. He is constipated and his bowels last opened three days ago. You perform a rectal examination and find his rectum is empty and notice that he has poor anal tone. Which is the single most appropriate course of action?
a ) Arrange for hospital specialist review today
b ) Arrange an urgent domiciliary physiotherapy assessment
c ) Arrange for the District Nurse to come and catheterise him
d ) Change his co-codamol to morphine
e ) Prescribe a laxative
Answer: A
This man has probably developed spinal cord compression which is often preceded by back pain. His constipation is a result of this rather than an increase in his codeine intake. He needs urgent assessment and may respond well to radiotherapy if this can be arranged urgently (Oxford Textbook of GP suggests within 24-48 hours of onset of neurological signs.) A high dose of dexamethasone 16mg/day will help reduce compression prior to radiotherapy. Once paralysed less than 5% of patients will walk again.
4. A 45 year old man, with a long history of ear infections, states that his left ear has been discharging continuously over the last three months. His hearing has worsened and he has experienced dizziness. There is a feeling of fullness in the ear. In addition, there is an ache behind the ear, especially at night. On examination, there is a faecal smelling discharge and granulation tissue can be seen. What is the single most likely diagnosis?
a ) Chronic otitis media
b ) Tympanosclerosis
c ) Chronic otitis externa
d ) Cholesteatoma
e ) Middle ear osteoma
Answer: D
The history is strongly suggestive of cholesteatoma, the principle cause of which is recurring ear infections. Cholesteatoma consists of squamous epithelium that is trapped in the middle ear or mastoid. It is slow growing and causes destruction of bone. This results in a conductive deafness. Facial nerve damage can occur. Rarely, erosion of the cranial bone occurs with resultant meningitis.
5. OPTIONS:
a ) Amotivational syndrome
b ) Cardiovascular collapse
c ) Hallucinations
d ) Perforation of nasal septum
e ) Renal failure
f ) Seizures
g ) Tinnitus
INSTRUCTION: Match the following scenarios of drug misuse with the most likely above side effect. Each option can be used once, more than once or not at all.
1 . A 48 year old man who self-harms using coproxamol.
The Correct answer is b.
2 . A 42 year old woman who has been smoking cannabis “for years”.
The Correct answer is a.
3 . A 34 year old doctor who has been abusing benzodiazepines for over a year, but stopped yesterday.
The Correct answer is f
Coproxamol in self harm can cause hepatic failure. In addition, the dextropropoxyphene component, and its metabolites are cardiotoxic and can cause dysrhythmias and cardiovascular collapse Patients showing disinterest in work, family and friends may be suffering from the long term effects of cannabis abuse (amotivational syndrome). Sudden withdrawal from benzodiazepines can elicit seizures. Benzodiazepines are a relatively common drug of abuse in medics.
6. A 55 year old man has had ulcerative colitis for 20 years. It is usually well controlled on mesalazine 4g daily. Having developed recent back pain, he has been taking ibuprofen 400mg three times a day (which was prescribed for his wife). For the past week, he has had an increase in the frequency of his bowel motions which now occur four times a day and are more liquid than usual. He has had no rectal bleeding or fever. What is the single most appropriate drug adjustment to make?
a ) Add loperamide
b ) Add oral prednisolone
c ) Add rectal prednisolone
d ) Increase mesalazine
e ) Stop ibuprofen
Answer: E
NSAIDs are noted for precipitating a relapse in inflammatory bowel disease and should be avoided. Loperamide is of use as a maintenance treatment; but has no place in the management of a relapse such as is described here. Prednisolone is useful in bringing more severe symptoms under control (e.g. more than four motions per day with rectal bleeding and systemic upset). In such a case, a dose of 40mg daily is recommended in combination with a rectal preparation. There should be a gradual reduction over a period of eight weeks as a rapid withdrawal often results in a relapse. The maximum dose of mesalazine is 4g daily and there is nothing to be gained by increasing this.
a ) Hyperthermia
b ) Urinary retention
c ) Convulsions
d ) Jaundice
e ) Excess salivation
Answer: B
Side effects of morphine salts include hypothermia and dry mouth among many others. Morphine has an effect on the muscle of the urinary tract, causing the sphincter to contract. This may lead to urinary retention.
2. OPTIONS:
a ) Agitated depression
b ) Alzheimers dementia
c ) Anxiety disorder
d ) Bi-polar disorder
e ) Psychotic state
f ) Multi-infarct dementia
g ) Personality disorder
INSTRUCTION: For each clinical scenario below, select the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A 38 year old woman attends the surgery. She is tense and agitated with feelings of impending doom. She describes a lump in her throat, is prone to palpitations and has tingling in her hands. She finds it difficult to pinpoint why she feels like this.
The Correct answer is c.
2 . A 19 year old student attends the surgery accompanied by a friend. She is withdrawn and pre-occupied. On questioning, her friend says she has been under a lot of stress recently with exams. She has commented that residents of a neighbouring flat are listening to what she is thinking.
The Correct answer is e.
3 . A 60 year old man attends the surgery with his wife. He is over bearing and euphoric. He has a history of depression. His wife comments that he has been socialising and drinking more than usual. He is spending outwith his financial means and has great plans for a bizarre business venture.
The Correct answer is d.
Anxiety is a normal response to an unusual or stressful event; it is the psychological component of the "flight or fight" response. Anxiety is considered abnormal when it is excessively severe or it occurs in the absence of a stressful event or it impairs social, physical or occupational functioning.A psychosis is any major mental disorder of organic or emotional origin that is marked by a derangement of personality and loss of contact with reality. A psychosis is characterised by loss of insight into the fact that one is mentally ill, usually as part of a more general disturbance of the normal relationship between reality and imagination, fact and fantasy. The two most important symptoms of a psychotic disorder are hallucinations and delusions.Bipolar affective disorder is a condition where there are periodic swings of mood periods of months or years between manic episodes and depressed episodes
3. A 72 year old man has metastatic cancer of the prostate gland but has been doing quite well.. For the past two days, he has had low back pain which is worse when he moves but with no radiation. He increased his dose of co-codamol 30/500 two days ago. His wife has just phoned to say he cannot get out of bed and is unable to empty his bladder. He is constipated and his bowels last opened three days ago. You perform a rectal examination and find his rectum is empty and notice that he has poor anal tone. Which is the single most appropriate course of action?
a ) Arrange for hospital specialist review today
b ) Arrange an urgent domiciliary physiotherapy assessment
c ) Arrange for the District Nurse to come and catheterise him
d ) Change his co-codamol to morphine
e ) Prescribe a laxative
Answer: A
This man has probably developed spinal cord compression which is often preceded by back pain. His constipation is a result of this rather than an increase in his codeine intake. He needs urgent assessment and may respond well to radiotherapy if this can be arranged urgently (Oxford Textbook of GP suggests within 24-48 hours of onset of neurological signs.) A high dose of dexamethasone 16mg/day will help reduce compression prior to radiotherapy. Once paralysed less than 5% of patients will walk again.
4. A 45 year old man, with a long history of ear infections, states that his left ear has been discharging continuously over the last three months. His hearing has worsened and he has experienced dizziness. There is a feeling of fullness in the ear. In addition, there is an ache behind the ear, especially at night. On examination, there is a faecal smelling discharge and granulation tissue can be seen. What is the single most likely diagnosis?
a ) Chronic otitis media
b ) Tympanosclerosis
c ) Chronic otitis externa
d ) Cholesteatoma
e ) Middle ear osteoma
Answer: D
The history is strongly suggestive of cholesteatoma, the principle cause of which is recurring ear infections. Cholesteatoma consists of squamous epithelium that is trapped in the middle ear or mastoid. It is slow growing and causes destruction of bone. This results in a conductive deafness. Facial nerve damage can occur. Rarely, erosion of the cranial bone occurs with resultant meningitis.
5. OPTIONS:
a ) Amotivational syndrome
b ) Cardiovascular collapse
c ) Hallucinations
d ) Perforation of nasal septum
e ) Renal failure
f ) Seizures
g ) Tinnitus
INSTRUCTION: Match the following scenarios of drug misuse with the most likely above side effect. Each option can be used once, more than once or not at all.
1 . A 48 year old man who self-harms using coproxamol.
The Correct answer is b.
2 . A 42 year old woman who has been smoking cannabis “for years”.
The Correct answer is a.
3 . A 34 year old doctor who has been abusing benzodiazepines for over a year, but stopped yesterday.
The Correct answer is f
Coproxamol in self harm can cause hepatic failure. In addition, the dextropropoxyphene component, and its metabolites are cardiotoxic and can cause dysrhythmias and cardiovascular collapse Patients showing disinterest in work, family and friends may be suffering from the long term effects of cannabis abuse (amotivational syndrome). Sudden withdrawal from benzodiazepines can elicit seizures. Benzodiazepines are a relatively common drug of abuse in medics.
6. A 55 year old man has had ulcerative colitis for 20 years. It is usually well controlled on mesalazine 4g daily. Having developed recent back pain, he has been taking ibuprofen 400mg three times a day (which was prescribed for his wife). For the past week, he has had an increase in the frequency of his bowel motions which now occur four times a day and are more liquid than usual. He has had no rectal bleeding or fever. What is the single most appropriate drug adjustment to make?
a ) Add loperamide
b ) Add oral prednisolone
c ) Add rectal prednisolone
d ) Increase mesalazine
e ) Stop ibuprofen
Answer: E
NSAIDs are noted for precipitating a relapse in inflammatory bowel disease and should be avoided. Loperamide is of use as a maintenance treatment; but has no place in the management of a relapse such as is described here. Prednisolone is useful in bringing more severe symptoms under control (e.g. more than four motions per day with rectal bleeding and systemic upset). In such a case, a dose of 40mg daily is recommended in combination with a rectal preparation. There should be a gradual reduction over a period of eight weeks as a rapid withdrawal often results in a relapse. The maximum dose of mesalazine is 4g daily and there is nothing to be gained by increasing this.
Tuesday, 25 November 2008
AKT Questions
1. A 25 year old Russian immigrant presents with a low-grade pyrexia, generalised lymphadenopathy and a symmetrical maculopapular rash. The rash involves the scalp, palms of the hands and soles of the feet. He was also concerned about a shallow ulcerated patch on his groin but this now seems to be resolving. What is the single most likely diagnosis?
a ) Chancroid
b ) Herpes genitalis
c ) Lymphogranuloma venereum
d ) Rubella
e ) Secondary syphilis
Answer: E
Although Syphilis can be co-existent with HIV infection the symptoms described are classical of secondary syphilis. STDs appear to be very common in the former Soviet block at present. Chancroid - Haemophilus ducreyi, the microbial agent of chancroid, used to be probably the most common cause of genital ulcers in many parts of the world. However, the pattern of genital ulcer disease (GUD) is changing. Lymphogranuloma venereum is a sexually transmitted disease caused by the invasive Chlamydia trachomatis.. LGV is primarily an infection of lymphatics and lymph nodes. It gains entrance through breaks in the skin, or it can cross the epithelial cell layer of mucous membranes. A rash is not typical. The classical exanthems are not associated with genital ulceration.
2. A 50 year old man presents with reflux-type symptoms for the first time. On questioning, he has had no haematemesis nor melaena, no weight loss and no difficulty swallowing. He has taken bendroflumethiazide 2.5mgs daily for hypertension for the last two years and amlodipine was added four months ago. He states that he drinks less than 10 units of alcohol per week. His BP today is116/70. You decide on an intervention strategy and will review him in four weeks. Which one of the following actions is the most appropriate, at this point in time?
a ) Commence triple therapy
b ) Commence lansoprazole 30mg daily
c ) Cease bendroflumethiazide
d ) Commence gaviscon advance 8 tablets daily
e ) Cease amlodipine
Answer: E
NICE Guideline 17 outlines a stepwise approach to management. If there are no alarm signs, one should initially review suspect medication and address lifestyle precipitants before commencing antacids/PPIs or initiating investigations. Calcium antagonists can commonly cause dyspepsia.
3. 32-year-old male solicitor attends after experiencing two episodes of severe and debilitating headache in the last two days. On both occasions, he developed a rapid-onset, severe headache focused around his left eye, which became noticeably red and watery. Each time the headache lasted for one hour before resolving. He took no analgesia. He felt nauseated by the intensity of the pain, but experienced no visual disturbance or other neurological symptoms. He smokes 15 cigarettes a day and drinks 10 units of alcohol per week. He has no residual symptoms, and clinical examination is normal. Which one of the following treatments would be the licensed drug of choice to be taken at the onset of any subsequent attack?
a ) Dispersible Aspirin 900mg orally
b ) Ergotamine 2mg suppository per rectum
c ) Sumatriptan 6mg injection subcutaneously
d ) Verapamil 80mg tablet orally
e ) Zolmitriptan 5mg orodispersible tablet
Answer: C
This is classic Cluster Headache. It is five times commoner in males than females, and affects smokers more than non-smokers. Sumatriptan by s/c injection is the treatment of choice, and the only triptan licensed for this indication. Verapamil and ergotamine are recognised for prophylaxis only. Cluster Headache rarely responds to standard analgesia.
a ) Chancroid
b ) Herpes genitalis
c ) Lymphogranuloma venereum
d ) Rubella
e ) Secondary syphilis
Answer: E
Although Syphilis can be co-existent with HIV infection the symptoms described are classical of secondary syphilis. STDs appear to be very common in the former Soviet block at present. Chancroid - Haemophilus ducreyi, the microbial agent of chancroid, used to be probably the most common cause of genital ulcers in many parts of the world. However, the pattern of genital ulcer disease (GUD) is changing. Lymphogranuloma venereum is a sexually transmitted disease caused by the invasive Chlamydia trachomatis.. LGV is primarily an infection of lymphatics and lymph nodes. It gains entrance through breaks in the skin, or it can cross the epithelial cell layer of mucous membranes. A rash is not typical. The classical exanthems are not associated with genital ulceration.
2. A 50 year old man presents with reflux-type symptoms for the first time. On questioning, he has had no haematemesis nor melaena, no weight loss and no difficulty swallowing. He has taken bendroflumethiazide 2.5mgs daily for hypertension for the last two years and amlodipine was added four months ago. He states that he drinks less than 10 units of alcohol per week. His BP today is116/70. You decide on an intervention strategy and will review him in four weeks. Which one of the following actions is the most appropriate, at this point in time?
a ) Commence triple therapy
b ) Commence lansoprazole 30mg daily
c ) Cease bendroflumethiazide
d ) Commence gaviscon advance 8 tablets daily
e ) Cease amlodipine
Answer: E
NICE Guideline 17 outlines a stepwise approach to management. If there are no alarm signs, one should initially review suspect medication and address lifestyle precipitants before commencing antacids/PPIs or initiating investigations. Calcium antagonists can commonly cause dyspepsia.
3. 32-year-old male solicitor attends after experiencing two episodes of severe and debilitating headache in the last two days. On both occasions, he developed a rapid-onset, severe headache focused around his left eye, which became noticeably red and watery. Each time the headache lasted for one hour before resolving. He took no analgesia. He felt nauseated by the intensity of the pain, but experienced no visual disturbance or other neurological symptoms. He smokes 15 cigarettes a day and drinks 10 units of alcohol per week. He has no residual symptoms, and clinical examination is normal. Which one of the following treatments would be the licensed drug of choice to be taken at the onset of any subsequent attack?
a ) Dispersible Aspirin 900mg orally
b ) Ergotamine 2mg suppository per rectum
c ) Sumatriptan 6mg injection subcutaneously
d ) Verapamil 80mg tablet orally
e ) Zolmitriptan 5mg orodispersible tablet
Answer: C
This is classic Cluster Headache. It is five times commoner in males than females, and affects smokers more than non-smokers. Sumatriptan by s/c injection is the treatment of choice, and the only triptan licensed for this indication. Verapamil and ergotamine are recognised for prophylaxis only. Cluster Headache rarely responds to standard analgesia.
Monday, 24 November 2008
AKT Questions
1. OPTIONS:
a ) Candidiasis
b ) Chlamydia
c ) Gonorrhoea
d ) HIV
e ) Herpes simplex
f ) Scabies
g ) Syphilis
INSTRUCTION: Genital infection presents in general practice in a variety of ways. Sexually transmitted infection can lead to significant morbidity and needs to be managed appropriately in primary care. For each of the following patients below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A 31 year old woman attends with a history of a febrile illness for five days followed by development of severe pain in the vulval area. Examination reveals numerous small ulcers. There is bilateral inguinal lyphadenopathy. She has been in a stable monogamous relationship for two years.
The Correct answer is e.
2 . A 22 year old man presents with a painful right knee, sore eyes and dysuria after an episode of unprotected intercourse with a new partner two weeks previously.
The Correct answer is b.
3 . A 35 year old homosexual man presents with a non itchy maculopapular rash on the palms of his hands and the soles of his feet, three months after a holiday in Brighton.
The Correct answer is g.
Herpes simplex can occur months or years into a stable relationship. Sexually acquired reactive arthritis (SARA) should be thought of in a patient who ‘can’t see, can’t pee and can’t bend the knee’. Chlamydia is the cause in 70% of cases. Secondary Syphilis is the great mimicker, and presents in a variety of ways, at least four weeks after the infective episode. Commonly it presents as a non itchy maculopapular rash affecting the palms and soles.
2. A 67 year old woman, who had chemotherapy two years ago, has metastatic breast carcinoma. During the past three weeks, she has become increasingly weak, tired and thirsty. She has had some nausea, is constipated and has lost her appetite. She has generalised aches and pains and has been a little confused. Which single biochemical abnormality is most likely to be implicated?
a ) Hypercalcaemia
b ) Hypocalcaemia
c ) Hypokalaemia
d ) Hypermagnesaemia
e ) Hypomagnesaemia
Answer: A
Hypercalcaemia usually has a non-specific presentation and includes the symptoms described exhibited by the patient. About 40% of breast tumours are liable to result in this especially where there is bone spread. Hypocalcaemia and hypokalaemia are both associated with tetany and there is no direct link with malignancy. Hypomagnesaemia is occasionally associated with cisplatin chemotherapy. Hypermagnesaemia is a rare condition found in neonates – again with no malignant association.
3. A 36 year old woman presents in the middle of a surgery with an acute flare up of her asthma symptoms. She complains of feeling more breathless and wheezy. Which one of the following signs, on its own, would prompt you to have her admitted as an emergency to hospital?
a ) Peak flow is reduced to 60% of her usual
b ) Resting pulse rate is 100/min
c ) Pulse oximetry shows SpO2 to be 90%
d ) Respiratory rate is 20/min
e ) Wheeze present throughout both lung fields
Answer: C
Immediate hospital admission is necessary if signs of life threatening asthma are present – peak flow <33% of best/predicted, SpO2 <92%, silent chest, cyanosis, feeble respiratory effort, bradycardia, dysrhythmia, hypotension, exhaustion, confusion, coma.
4. A 30 year old woman complains of frequent headaches. She describes a unilateral, throbbing headache associated with photophobia and nausea which can last more than 24hrs. For the last three months, the headaches have occurred at least once a week. She has been taking paracetamol but this has not helped. She has asthma and uses salbutamol and belcometasone inhalers. She has no other significant past medical history. Examination is normal. She asks for medication to help prevent her headaches occurring. Which is the single most appropriate drug?
a ) Co-codamol
b ) Pizotifen
c ) Propranolol
d ) Rizatriptan
e ) Topiramate
Answer: B
Co-codamol and Rizatriptan are used in the treatment of acute migraine but not for prevention. Overuse of both of these can lead to an increase in headache frequency. Propranolol is contraindicated in asthma and Topiramate should only be prescribed under specialist supervision for migraine.
5. A 25 year old woman comes to see you complaining of having had a bad cough for six days. She is coughing up green phlegm. She has no chest pain. She smokes 20/day. On examination, she is apyrexial and her chest is clear. She has no significant past history and is not on regular medication. She has tried taking regular paracetamol but now thinks she needs an antibiotic to help “clear this up”. What is the single most appropriate initial way to manage this patient according to current guidelines?
a ) Organise a Chest X Ray
b ) Prescribe an antibiotic
c ) Prescribe codeine linctus
d ) Send a sputum sample for culture
e ) Treat conservatively
Answer: E
There is no evidence to suggest that the use of an antibiotic/cough bottle/sputum sample/CXR for non-pneumonic lower respiratory tract infections in previously well adults is useful.
a ) Candidiasis
b ) Chlamydia
c ) Gonorrhoea
d ) HIV
e ) Herpes simplex
f ) Scabies
g ) Syphilis
INSTRUCTION: Genital infection presents in general practice in a variety of ways. Sexually transmitted infection can lead to significant morbidity and needs to be managed appropriately in primary care. For each of the following patients below, choose the most likely diagnosis from the list above. Each option can be used once, more than once or not at all.
1 . A 31 year old woman attends with a history of a febrile illness for five days followed by development of severe pain in the vulval area. Examination reveals numerous small ulcers. There is bilateral inguinal lyphadenopathy. She has been in a stable monogamous relationship for two years.
The Correct answer is e.
2 . A 22 year old man presents with a painful right knee, sore eyes and dysuria after an episode of unprotected intercourse with a new partner two weeks previously.
The Correct answer is b.
3 . A 35 year old homosexual man presents with a non itchy maculopapular rash on the palms of his hands and the soles of his feet, three months after a holiday in Brighton.
The Correct answer is g.
Herpes simplex can occur months or years into a stable relationship. Sexually acquired reactive arthritis (SARA) should be thought of in a patient who ‘can’t see, can’t pee and can’t bend the knee’. Chlamydia is the cause in 70% of cases. Secondary Syphilis is the great mimicker, and presents in a variety of ways, at least four weeks after the infective episode. Commonly it presents as a non itchy maculopapular rash affecting the palms and soles.
2. A 67 year old woman, who had chemotherapy two years ago, has metastatic breast carcinoma. During the past three weeks, she has become increasingly weak, tired and thirsty. She has had some nausea, is constipated and has lost her appetite. She has generalised aches and pains and has been a little confused. Which single biochemical abnormality is most likely to be implicated?
a ) Hypercalcaemia
b ) Hypocalcaemia
c ) Hypokalaemia
d ) Hypermagnesaemia
e ) Hypomagnesaemia
Answer: A
Hypercalcaemia usually has a non-specific presentation and includes the symptoms described exhibited by the patient. About 40% of breast tumours are liable to result in this especially where there is bone spread. Hypocalcaemia and hypokalaemia are both associated with tetany and there is no direct link with malignancy. Hypomagnesaemia is occasionally associated with cisplatin chemotherapy. Hypermagnesaemia is a rare condition found in neonates – again with no malignant association.
3. A 36 year old woman presents in the middle of a surgery with an acute flare up of her asthma symptoms. She complains of feeling more breathless and wheezy. Which one of the following signs, on its own, would prompt you to have her admitted as an emergency to hospital?
a ) Peak flow is reduced to 60% of her usual
b ) Resting pulse rate is 100/min
c ) Pulse oximetry shows SpO2 to be 90%
d ) Respiratory rate is 20/min
e ) Wheeze present throughout both lung fields
Answer: C
Immediate hospital admission is necessary if signs of life threatening asthma are present – peak flow <33% of best/predicted, SpO2 <92%, silent chest, cyanosis, feeble respiratory effort, bradycardia, dysrhythmia, hypotension, exhaustion, confusion, coma.
4. A 30 year old woman complains of frequent headaches. She describes a unilateral, throbbing headache associated with photophobia and nausea which can last more than 24hrs. For the last three months, the headaches have occurred at least once a week. She has been taking paracetamol but this has not helped. She has asthma and uses salbutamol and belcometasone inhalers. She has no other significant past medical history. Examination is normal. She asks for medication to help prevent her headaches occurring. Which is the single most appropriate drug?
a ) Co-codamol
b ) Pizotifen
c ) Propranolol
d ) Rizatriptan
e ) Topiramate
Answer: B
Co-codamol and Rizatriptan are used in the treatment of acute migraine but not for prevention. Overuse of both of these can lead to an increase in headache frequency. Propranolol is contraindicated in asthma and Topiramate should only be prescribed under specialist supervision for migraine.
5. A 25 year old woman comes to see you complaining of having had a bad cough for six days. She is coughing up green phlegm. She has no chest pain. She smokes 20/day. On examination, she is apyrexial and her chest is clear. She has no significant past history and is not on regular medication. She has tried taking regular paracetamol but now thinks she needs an antibiotic to help “clear this up”. What is the single most appropriate initial way to manage this patient according to current guidelines?
a ) Organise a Chest X Ray
b ) Prescribe an antibiotic
c ) Prescribe codeine linctus
d ) Send a sputum sample for culture
e ) Treat conservatively
Answer: E
There is no evidence to suggest that the use of an antibiotic/cough bottle/sputum sample/CXR for non-pneumonic lower respiratory tract infections in previously well adults is useful.
Tuesday, 14 October 2008
AKT Questions
1. OPTIONS:
a ) Colorectal carcinoma
b ) Endometrial carcinoma
c ) Liver carcinoma
d ) Oesophageal carcinoma
e ) Ovarian carcinoma
f ) Pancreatic carcinoma
g ) Small bowel carcinoma
INSTRUCTION: For each patient below, choose the most likely diagnosis from the list above. Each option may be used once, more than once or not at all.
1 . A 60 year old woman presents with a three month history of anorexia and epigastric discomfort. Over this time, she has lost 5kgs in weight. She is now experiencing some difficulty swallowing and has vomited after meals. On examination, the abdomen seems non tender and no masses are felt; weight loss is evident.
The Correct answer is d.
2 . A 60 year old woman presents with abdominal pain and distension. She has been vomiting. She tells you that, about eight weeks ago, her bowel had become much more loose and frequent. On examination, the whole abdomen is tender and distended, with no masses felt; bowel sounds are high pitched.
The Correct answer is a.
3 . A 60 year old woman presents with a six month history of non-specific abdominal pain and bloating. She was treated for irritable bowel with no improvement. On examination, the whole abdomen is tender, especially over the caecum, with no masses felt. Pelvic examination suggests a fullness in the right fornix.
The Correct answer is e.
The alarm signs associated with oesophageal and gastric cancer are dysphagia, anorexia, vomiting and weight loss.
Patients over 50 years with any of the following for more than 6 weeks should be referred urgently for investigation of colorectal cancer:
• Rectal bleeding with change in bowel habit
• Rectal bleeding without anal symptoms
• Palpable abdominal mass
• Intestinal obstruction Retrospective studies show that women with ovarian cancer present with non specific symptoms including abdominal pain and bloating, changes in bowel habit, urinary and/or pelvic symptoms. Many have been misdiagnosed as irritable bowel.
2. OPTIONS:
a ) Amoxicillin
b ) Beclometasone inhaler
c ) Ipratropium inhaler
d ) Montelukast
e ) Prednisolone
f ) Salbutamol inhaler
g ) Salmeterol inhaler
INSTRUCTION: For each of the following patients, choose the single most appropriate drug treatment from the above list. Each option may be used once, more than once or not at all.
1 . A six year old girl is brought to see you in the surgery. Mum has noticed that she has been coughing more over the last three months since a really bad cold. Some nights she disturbs other family members with her coughing. Examination is unremarkable. She keeps well otherwise and is on no other medication.
The Correct answer is f.
2 . A 67 year old man presents to the out of hours service with a two day history of increasing shortness of breath and cough. He is coughing up clear sputum but this is not new as he tells you he is a smoker. He has no other associated symptoms. He doesn’t feel his usual inhalers are helping but all he can tell you is that he has a blue one and a brown one. He is getting SOB getting washed and dressed but can still manage. He is apyrexial, pulse 88/min, respiratory rate 18/min, chest is wheezy.
The Correct answer is e.
3 . A 26 year old man, who has had asthma since childhood, has noticed he is more wheezy recently. Usually he would rarely use his reliever inhaler but in the last month he has used it 1-2 times a day. He also uses a beclometasone inhaler and has doubled the dose of this himself to a total of 800mcg a day but feels his symptoms have not improved much. He has no other significant past medical history. Examination is normal.
The Correct answer is g.
A trial of a bronchodilator can help confirm how likely a diagnosis of asthma is. He has non purulent sputum so an antibiotic is unnecessary but oral prednisolone is recommended for an acute flare up of breathlessness affecting activities of daily living. A trial of a long acting beta 2 agonist is recommended in adults if they have inadequate symptom control with inhaled steroids at doses between 200-800mcg/day (beclometasone).
3. In patients with a diagnosis of moderately severe Chronic Obstructive Airways Disease (COPD), which one of the following treatments has been shown in a systematic review to reduce mortality?
a ) Antibiot. ics in COPD exacerbations
b ) Cardioselective beta blockers for up to 12 weeks
c ) Carbocisteine for up to 12 weeks
d ) Inhaled steroids for at least two years
e ) Daily anticholinergic therapy for more than one month
answer: A
In COPD exacerbations, with increased cough and sputum purulence, antibiotics, regardless of choice, reduce the risk of short-term mortality by 77%. Therefore their use is supported in those who are moderately to severely ill.
4. OPTIONS:
a ) Acute rotator cuff tear
b ) Adhesive capsulitis
c ) Cervical spondylosis
d ) Gout
e ) Herpes zoster
f ) Pneumothorax
g ) Polymyalgia rheumatica
INSTRUCTION: For each patient below with shoulder pain, select the single most likely diagnosis above. Each option may be used once, more than once or not at all.
1 . A 63 year old woman has a one week history of pain in the left shoulder in a C4 distribution It is unpleasant and burning in character, and unrelated to exertion. She has a full range of neck and shoulder movement.
The Correct answer is e.
2 . A 70 year old woman has a two week history of pain and stiffness in both shoulders, occurring during the night, and easing off somewhat an hour after getting up. She has found that Ibuprofen helps.
The Correct answer is g.
3 . A 35 year old man suddenly develops left shoulder pain, worse on inspiration, after a fit of coughing several days ago. He has an excellent range of shoulder movement.
The Correct answer is f.
5. OPTIONS:
a ) Dermovate ointment
b ) Emollient
c ) Hydrocortisone cream
d ) Oral antibiotic
e ) Potassium permanganate wet wraps
f ) Oral antifungal
g ) Topical tar based product
INSTRUCTION: For each scenario below, choose the single most appropriate treatment from the above options. Each option can be used once, more than once or not at all.
1 . An infant of six months is brought to you with a severe nappy rash. Having consulted the health visitor, mum has tried an antifungal cream, with no effect. You note that the rash spares the skin flexures.
The Correct answer is c.
2 . A 53 year old smoker attends with intensely itchy hands. Examination reveals pustular lesions on the palms of the hands and the soles of the feet. You think this is palmoplantar pustulosis.
The Correct answer is a.
3 . A one year old child presents with an exudative, weeping eczema.
The Correct answer is e.
6. A 65 year old man presents with a three month history of dyspnoea and ankle oedema. On examination, he has a regular pulse of 108/minute, BP 140/90 and bilateral basal crepitations. Which one of the following tests would aid your decision in referring for echocardiography?
a ) Brain natriuretic peptide (BNP)
b ) Cholesterol (Cho)
c ) Creatinine Kinase (CK)
d ) Lactose Dehydrogenase (LDH)
e ) Troponins T and I
answer: A
Brain natriuretic peptide or NT pro- BNP and/or ECG should be recorded to indicate the need for echocardiography in patients with suspected CHF. There are local variations in the availability of BNP testing.
7. A 73 year old man attends with poor urinary stream, urinary hesitancy and nocturia. He was assessed by urology and the diagnosis was made of benign prostatic hypertrophy. You decide to start finasteride. Which one of the following is a known side-effect of this drug?
a ) Baldness
b ) Ejaculation disorders
c ) Increased libido
d ) Increased PSA level
e ) Priapism
answer: B
Anti-androgens, such as Finasteride, cause ejaculation disorders and reduce libido. A low strength of Finasteride is used to treat male-pattern baldness. Anti-androgens reduce the level of prostate cancer markers.
8. A 48 year old woman presents with a 24 hour history of a painful red eye, lacrimation, photophobia and blurred vision. Her visual acuity is 6/18 in the affected eye, and 6/6 in the other. Fluorescein shows a central patch of irregular uptake of stain. Which one of the following is the most likely diagnosis?
a ) Acute iritis
b ) Bacterial conjunctivitis
c ) Blepharitis
d ) Dendritic corneal ulcer
e ) Episcleritis
Answer: D
Dendritic ulcer is caused by herpes simplex virus, requires treatment with acyclovir 3% eye ointment, and should be referred immediately for ophthalmological assessment. Use of steroid drops can result in massive ulceration and blindness.
a ) Colorectal carcinoma
b ) Endometrial carcinoma
c ) Liver carcinoma
d ) Oesophageal carcinoma
e ) Ovarian carcinoma
f ) Pancreatic carcinoma
g ) Small bowel carcinoma
INSTRUCTION: For each patient below, choose the most likely diagnosis from the list above. Each option may be used once, more than once or not at all.
1 . A 60 year old woman presents with a three month history of anorexia and epigastric discomfort. Over this time, she has lost 5kgs in weight. She is now experiencing some difficulty swallowing and has vomited after meals. On examination, the abdomen seems non tender and no masses are felt; weight loss is evident.
The Correct answer is d.
2 . A 60 year old woman presents with abdominal pain and distension. She has been vomiting. She tells you that, about eight weeks ago, her bowel had become much more loose and frequent. On examination, the whole abdomen is tender and distended, with no masses felt; bowel sounds are high pitched.
The Correct answer is a.
3 . A 60 year old woman presents with a six month history of non-specific abdominal pain and bloating. She was treated for irritable bowel with no improvement. On examination, the whole abdomen is tender, especially over the caecum, with no masses felt. Pelvic examination suggests a fullness in the right fornix.
The Correct answer is e.
The alarm signs associated with oesophageal and gastric cancer are dysphagia, anorexia, vomiting and weight loss.
Patients over 50 years with any of the following for more than 6 weeks should be referred urgently for investigation of colorectal cancer:
• Rectal bleeding with change in bowel habit
• Rectal bleeding without anal symptoms
• Palpable abdominal mass
• Intestinal obstruction Retrospective studies show that women with ovarian cancer present with non specific symptoms including abdominal pain and bloating, changes in bowel habit, urinary and/or pelvic symptoms. Many have been misdiagnosed as irritable bowel.
2. OPTIONS:
a ) Amoxicillin
b ) Beclometasone inhaler
c ) Ipratropium inhaler
d ) Montelukast
e ) Prednisolone
f ) Salbutamol inhaler
g ) Salmeterol inhaler
INSTRUCTION: For each of the following patients, choose the single most appropriate drug treatment from the above list. Each option may be used once, more than once or not at all.
1 . A six year old girl is brought to see you in the surgery. Mum has noticed that she has been coughing more over the last three months since a really bad cold. Some nights she disturbs other family members with her coughing. Examination is unremarkable. She keeps well otherwise and is on no other medication.
The Correct answer is f.
2 . A 67 year old man presents to the out of hours service with a two day history of increasing shortness of breath and cough. He is coughing up clear sputum but this is not new as he tells you he is a smoker. He has no other associated symptoms. He doesn’t feel his usual inhalers are helping but all he can tell you is that he has a blue one and a brown one. He is getting SOB getting washed and dressed but can still manage. He is apyrexial, pulse 88/min, respiratory rate 18/min, chest is wheezy.
The Correct answer is e.
3 . A 26 year old man, who has had asthma since childhood, has noticed he is more wheezy recently. Usually he would rarely use his reliever inhaler but in the last month he has used it 1-2 times a day. He also uses a beclometasone inhaler and has doubled the dose of this himself to a total of 800mcg a day but feels his symptoms have not improved much. He has no other significant past medical history. Examination is normal.
The Correct answer is g.
A trial of a bronchodilator can help confirm how likely a diagnosis of asthma is. He has non purulent sputum so an antibiotic is unnecessary but oral prednisolone is recommended for an acute flare up of breathlessness affecting activities of daily living. A trial of a long acting beta 2 agonist is recommended in adults if they have inadequate symptom control with inhaled steroids at doses between 200-800mcg/day (beclometasone).
3. In patients with a diagnosis of moderately severe Chronic Obstructive Airways Disease (COPD), which one of the following treatments has been shown in a systematic review to reduce mortality?
a ) Antibiot. ics in COPD exacerbations
b ) Cardioselective beta blockers for up to 12 weeks
c ) Carbocisteine for up to 12 weeks
d ) Inhaled steroids for at least two years
e ) Daily anticholinergic therapy for more than one month
answer: A
In COPD exacerbations, with increased cough and sputum purulence, antibiotics, regardless of choice, reduce the risk of short-term mortality by 77%. Therefore their use is supported in those who are moderately to severely ill.
4. OPTIONS:
a ) Acute rotator cuff tear
b ) Adhesive capsulitis
c ) Cervical spondylosis
d ) Gout
e ) Herpes zoster
f ) Pneumothorax
g ) Polymyalgia rheumatica
INSTRUCTION: For each patient below with shoulder pain, select the single most likely diagnosis above. Each option may be used once, more than once or not at all.
1 . A 63 year old woman has a one week history of pain in the left shoulder in a C4 distribution It is unpleasant and burning in character, and unrelated to exertion. She has a full range of neck and shoulder movement.
The Correct answer is e.
2 . A 70 year old woman has a two week history of pain and stiffness in both shoulders, occurring during the night, and easing off somewhat an hour after getting up. She has found that Ibuprofen helps.
The Correct answer is g.
3 . A 35 year old man suddenly develops left shoulder pain, worse on inspiration, after a fit of coughing several days ago. He has an excellent range of shoulder movement.
The Correct answer is f.
5. OPTIONS:
a ) Dermovate ointment
b ) Emollient
c ) Hydrocortisone cream
d ) Oral antibiotic
e ) Potassium permanganate wet wraps
f ) Oral antifungal
g ) Topical tar based product
INSTRUCTION: For each scenario below, choose the single most appropriate treatment from the above options. Each option can be used once, more than once or not at all.
1 . An infant of six months is brought to you with a severe nappy rash. Having consulted the health visitor, mum has tried an antifungal cream, with no effect. You note that the rash spares the skin flexures.
The Correct answer is c.
2 . A 53 year old smoker attends with intensely itchy hands. Examination reveals pustular lesions on the palms of the hands and the soles of the feet. You think this is palmoplantar pustulosis.
The Correct answer is a.
3 . A one year old child presents with an exudative, weeping eczema.
The Correct answer is e.
6. A 65 year old man presents with a three month history of dyspnoea and ankle oedema. On examination, he has a regular pulse of 108/minute, BP 140/90 and bilateral basal crepitations. Which one of the following tests would aid your decision in referring for echocardiography?
a ) Brain natriuretic peptide (BNP)
b ) Cholesterol (Cho)
c ) Creatinine Kinase (CK)
d ) Lactose Dehydrogenase (LDH)
e ) Troponins T and I
answer: A
Brain natriuretic peptide or NT pro- BNP and/or ECG should be recorded to indicate the need for echocardiography in patients with suspected CHF. There are local variations in the availability of BNP testing.
7. A 73 year old man attends with poor urinary stream, urinary hesitancy and nocturia. He was assessed by urology and the diagnosis was made of benign prostatic hypertrophy. You decide to start finasteride. Which one of the following is a known side-effect of this drug?
a ) Baldness
b ) Ejaculation disorders
c ) Increased libido
d ) Increased PSA level
e ) Priapism
answer: B
Anti-androgens, such as Finasteride, cause ejaculation disorders and reduce libido. A low strength of Finasteride is used to treat male-pattern baldness. Anti-androgens reduce the level of prostate cancer markers.
8. A 48 year old woman presents with a 24 hour history of a painful red eye, lacrimation, photophobia and blurred vision. Her visual acuity is 6/18 in the affected eye, and 6/6 in the other. Fluorescein shows a central patch of irregular uptake of stain. Which one of the following is the most likely diagnosis?
a ) Acute iritis
b ) Bacterial conjunctivitis
c ) Blepharitis
d ) Dendritic corneal ulcer
e ) Episcleritis
Answer: D
Dendritic ulcer is caused by herpes simplex virus, requires treatment with acyclovir 3% eye ointment, and should be referred immediately for ophthalmological assessment. Use of steroid drops can result in massive ulceration and blindness.
Subscribe to:
Posts (Atom)