1. You are reading a research paper regarding a new blood test that can be used to screen for colorectal cancer. It shows the following data:
Cancer present Cancer absent Total no. of cases
Blood test positive 80 40 120
Blood test negative 20 60 80
Total no. of cases 100 100 200
What is the specificity of this new test?
a ) 20%
b ) 33%
c ) 60%
d ) 66%
e ) 75%
f ) 80%
Answer: C
Specificity is a measure of how well the test identifies those who do not have disease as not having disease (60%). Sensitivity is a measure of how well the test identifies those with disease as having disease (80%). The positive predictive value indicates how many people with a positive result have the disease (66%). The negative predictive value indicates how many people with a negative result do not have the disease (75%).
2. OPTIONS:
a ) Vitreous haemorrhage
b ) Proliferative retinopathy
c ) Macular degeneration
d ) Papilloedema
e ) Retinal vein occlusion
f ) Retinitis pigmentosa
g ) Optic neuritis
INSTRUCTION: For each of the patients below, select the fundal condition above that is most likely to be consistent with their symptoms and signs. Each option can be used once, more than once or not at all.
A. A 72 year old woman is a heavy smoker. She complains of increasing difficulty in recognising peoples’ faces and is having difficulty reading. She has been frightened by seeing a dark shape just as she wakens up. She says that her Venetian blinds appear wavy. Her assisted acuity is 6/18 bilaterally .Her BP is 170/100.
The Correct answer is c.
B . A 17 year old man has noticed that his vision has been poor in the evenings for the last six months, and this has resulted in him tripping up frequently. His acuity is 6/6 bilaterally. He has been told that a grandparent and a great-grandparent went blind in their 50’s.
The Correct answer is f.
C. A 56 year old HGV driver describes difficulty reversing his vehicle. He has given it some minor scrapes, and thinks there may be something wrong with his vision. He has been troubled by severe headaches for weeks. His acuity is 6/6 bilaterally. Visual field testing reveals a homonymous hemianopia.
The Correct answer is d.
50% of intracranial tumours have focal neurology at presentation.
Monday, 2 February 2009
Sunday, 1 February 2009
more AKT questions
1. OPTIONS:
a ) Can never drive again after episode
b ) Can continue to drive after episode
c ) Cannot drive for one month after episode
d ) Cannot drive for 12 months after episode
e ) Cannot drive for 24 hours after episode
f ) Cannot drive for 6 months after episode
g ) Cannot drive for 24 months after episode
INSTRUCTION: According to current driving regulations from the Driver and Vehicle Licensing Agency (DVLA), choose the single most appropriate answer from the above list for each of the following. Each option may be used once, more than once or not at all.
A. A 72 year old man presents with a one hour history of complete loss of power in his left hand which occurred two days previously. The symptoms have now completely resolved and he has been well since. There were no associated symptoms. He has no significant medical history and is on no regular medication. He regularly drives to visit his wife in a nursing home.
The Correct answer is c.
B . A 21 year old woman describes an episode of loss of consciousness the previous day. She was standing at work, felt hot and then was aware of everything starting to go black. The next thing she remembers was lying on the ground. Her friend says she went very pale and dropped to the ground. Her limbs were twitching. She came round fully recovered in less than five minutes. She has been well since. She has a car for personal use.
The Correct answer is b.
C. A 24 year old man presents with an episode of collapse that happened that morning at home. He says he was getting ready for work and felt fine. He then found himself lying on the bedroom floor with no memory of falling. He felt exhausted, his muscles ached all over, and he had wet himself. He thinks he must have been on the floor for some time. He has no significant past history and is on no medication. His job involves driving a car.
The Correct answer is d.
After a TIA or stroke, patients may drive after a minimum of one month providing there is no residual neurological deficit at this point and they are clinically well. There is no need to stop driving after a simple faint. After an initial diagnosis of epilepsy, a licence is revoked for a year with a medical assessment at the end of this time.
2. A 70 year old woman, with spirometry confirmed COPD without reversibility, is attending the nurse- led COPD clinic. She complains to the nurse of gradually increasing breathlessness on minimal exertion, orthopnoea and fatigue. She is not feverish or complaining of increased coloured sputum. The practice nurse wants to try Tiotropium but feels something else might be amiss. She asks you to attend. You carry out a cardio-respiratory examination and find a few bilateral basal crepitations and pitting oedema of both ankles. Which single initial investigation would be most appropriate?
a ) Brain natriuretic peptide(BNP)
b ) Echocardiography
c ) 24 hour ECG
d ) Repeat spirometry
e ) Urinalysis
Answer: E
In this situation, initial basic investigations such as urinalysis and eGFR should be carried out first as renal failure symptoms are similar to those of chronic heart failure. Since the diagnosis of chronic heart failure is often incorrect when based on clinical symptoms and signs alone, confirmation by echocardiography is now a requirement of the Quality Outcomes Framework of the new GMS contract. It is also a recommendation made by SIGN even for the frail elderly. However, the presence of a normal Brain natriuretic peptide (BNP) blood test (if available locally) and a normal ECG will make the diagnosis of chronic heart failure unlikely
3. OPTIONS:
a ) Osteoarthrtitis
b ) Gout
c ) Haemarthrosis
d ) Pseudogout
e ) Trauma
f ) Septic arthritis
g ) Rheumatoid arthritis
INSTRUCTION: Choose the single most likely diagnosis above for each clinical scenario presented below. Each option can be used once, more than once or not at all.
A. A 60 year old man presents with an acutely painful first metatarsophalyngeal joint on his right foot which has been grumbling on for a week since he was on holiday In Tenerife.
The Correct answer is b.
B. A 75 year old woman, with known osteoarthritis, requests a home visit as she has awoken to find her left knee acutely painful, red and swollen. She complains of nausea. On examination, the knee is hot and swollen with restricted movement. Her pulse is 110. Temp 37.0.
The Correct answer is f.
C . A 43 year old diabetic patient hobbles into the surgery complaining of a two day history of increasing swelling and redness of her left ankle. She cannot remember injuring it. She can weightbear with difficulty. The joint is hot and swollen. She has a mild pyrexia of 37.8 C
The Correct answer is f.
Septic arthritis has a case fatality of around 11%. Delayed or inadequate diagnosis leads to joint damage. Patients with a short history of a hot swollen and tender joint (joints) should be regarded as having septic arthritis until proven otherwise, even in the absence of fever.
4. With reference to the Medicines and Healthcare products Regulatory Agency (MHRA) 'Yellow Card Scheme' for reporting adverse drug reactions (ADRs), which one of the following statements is correct?
a ) ADRs of any severity should be reported for new, black triangle drugs or vaccines
b ) An ADR report should be submitted only when causality between a drug and an adverse reaction is certain
c ) Herbal remedies are excluded from the ADR scheme
d ) Only a designated Healthcare Professional can report an ADR
e ) Patient consent is required before submitting an ADR report on their behalf
Answer: A
Causality does not have to be proven – suspicion is enough. Herbal remedies are included in the scheme. Anyone, patients included, may file a report. Patient consent is not required as no patient-specific personal information is required.
5. A 39 year old woman presents with a six month history of prolonged and heavy menstruation. She feels a heaviness in her lower abdomen. She has had two first trimester miscarriages in the previous 18 months. LMP was three weeks ago. Her last ultrasound scan was suspicious of a bulky uterus. There is no weight loss .She has a borderline low haemoglobin and low ferritin levels. She has had only moderate symptomatic relief from tranexamic acid and mefenamic acid. What is the single most likely diagnosis?
a ) Adenomyosis
b ) Endometrial carcinoma
c ) Myometrial fibroids
d ) Cervical carcinoma
e ) Endometrial polyp
Answer: C
Fibroids (uterine leiomyomas) are benign tumours of the smooth muscle cells of the uterus. Women with fibroids can be asymptomatic or may present with menorrhagia (30%), pelvic pain with or without dysmenorrhoea or pressure symptoms (34%), infertility (27%), and recurrent pregnancy loss (3%). Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue within the myometrium. The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively).
6. A research project looking at the management of moderate hypertension divides its subjects into two groups. Group A, with 1776 subjects, receives anti-hypertensive medication. Group B, with 1800 subjects, receives a placebo. After five years the risk of a stroke in Group A is 12%, while in group B it is 20%. What is the Number Needed to Treat (NNT) to prevent one extra stroke?
a ) 2.00
b ) 1.25
c ) 8.00
d ) 12.50
e ) 58.00
Anser: D
NNT is the reciprocal of the absolute risk reduction. For patients with moderate hypertension, receiving placebo treatments, about 20% would be expected to have a stroke over the next five years. This risk is reduced to 12% with antihypertensive drugs. This results in an absolute risk reduction of 0.20-0.12=0.08. The reciprocal of this number is 12.5 - implying that a doctor would need to treat about 12.5 moderately hypertensive patients for five years before he or she could expect to prevent one extra stroke.
7. OPTIONS:
a ) Dental caries
b ) Furuncle
c ) Nasopharyngeal carcinoma
d ) Otitis externa
e ) Otitis media
f ) Ramsay Hunt syndrome
g ) Temporomandibular joint dysfunction
INSTRUCTION: Match the following scenarios with the most likely diagnosis above. Each option can be used once, more than once or not at all.
1 . A 78 year old man with dysphagia and earache.
The Correct answer is c.
2 . A 75 year old man with facial weakness, a focal rash and earache.
The Correct answer is f.
3 . A 45 year old woman with earache worsened by eating and yawning.
The Correct answer is g.
In older patients, a diagnosis of dysphagia is often due to neurological causes such as a CVA. Earache is not a common feature of stroke. Earache with dysphagia suggests the presence of a nasopharyngeal carcinoma. Facial weakness in this age group can suggest stroke. However, in the context of a rash in the external auditory canal and earache, the most likely unifying diagnosis is Ramsay Hunt syndrome. In an adult with earache worsened by eating, dental caries is a possibility. The fact that the symptoms are worsened by yawning makes temporomandibular joint dysfunction more likely.
8. A 55 year old man, who is a heavy smoker, and has a history of hypertension, is seen on an emergency home visit. On examination, his blood pressure is 180/110 with an irregular pulse of 90 bpm. There is no evidence of cardiac failure. He has a mild expressive dysphasia with a left hemiparesis. According to his wife these symptoms have been present for more than 12 hours. He denies any headache and is fully conscious and orientated. With regard to the gold standard, what is the single most appropriate referral plan?
a ) Refer urgently for a neurology appointment (1-2 days).
b ) Refer as an emergency to the nearest hospital.
c ) Refer to a TIA clinic within 1 week.
d ) Refer as an emergency to the nearest stroke unit.
e ) Refer to the stroke clinic within 1 week
Answer: D
All patients with acute stroke should ideally be admitted to a multidisciplinary stroke unit as soon as possible. All patients with acute stroke should undergo CT brain scanning within 24 hours. Stroke outcome is significantly better when patients are treated in an organised stroke unit compared to either general hospital care or organised care at home. High blood pressure should not normally be lowered in the acute phase of stroke. Aspirin should be given as soon as possible after the onset of stroke symptoms once a diagnosis of primary haemorrhage has been excluded (by CT scanning). Following a TIA, the risk of stroke is approximately 7 times greater than the risk in the general population, especially in the first few weeks. Patients should be assessed and investigated in a specialist clinic within 7 days.
a ) Can never drive again after episode
b ) Can continue to drive after episode
c ) Cannot drive for one month after episode
d ) Cannot drive for 12 months after episode
e ) Cannot drive for 24 hours after episode
f ) Cannot drive for 6 months after episode
g ) Cannot drive for 24 months after episode
INSTRUCTION: According to current driving regulations from the Driver and Vehicle Licensing Agency (DVLA), choose the single most appropriate answer from the above list for each of the following. Each option may be used once, more than once or not at all.
A. A 72 year old man presents with a one hour history of complete loss of power in his left hand which occurred two days previously. The symptoms have now completely resolved and he has been well since. There were no associated symptoms. He has no significant medical history and is on no regular medication. He regularly drives to visit his wife in a nursing home.
The Correct answer is c.
B . A 21 year old woman describes an episode of loss of consciousness the previous day. She was standing at work, felt hot and then was aware of everything starting to go black. The next thing she remembers was lying on the ground. Her friend says she went very pale and dropped to the ground. Her limbs were twitching. She came round fully recovered in less than five minutes. She has been well since. She has a car for personal use.
The Correct answer is b.
C. A 24 year old man presents with an episode of collapse that happened that morning at home. He says he was getting ready for work and felt fine. He then found himself lying on the bedroom floor with no memory of falling. He felt exhausted, his muscles ached all over, and he had wet himself. He thinks he must have been on the floor for some time. He has no significant past history and is on no medication. His job involves driving a car.
The Correct answer is d.
After a TIA or stroke, patients may drive after a minimum of one month providing there is no residual neurological deficit at this point and they are clinically well. There is no need to stop driving after a simple faint. After an initial diagnosis of epilepsy, a licence is revoked for a year with a medical assessment at the end of this time.
2. A 70 year old woman, with spirometry confirmed COPD without reversibility, is attending the nurse- led COPD clinic. She complains to the nurse of gradually increasing breathlessness on minimal exertion, orthopnoea and fatigue. She is not feverish or complaining of increased coloured sputum. The practice nurse wants to try Tiotropium but feels something else might be amiss. She asks you to attend. You carry out a cardio-respiratory examination and find a few bilateral basal crepitations and pitting oedema of both ankles. Which single initial investigation would be most appropriate?
a ) Brain natriuretic peptide(BNP)
b ) Echocardiography
c ) 24 hour ECG
d ) Repeat spirometry
e ) Urinalysis
Answer: E
In this situation, initial basic investigations such as urinalysis and eGFR should be carried out first as renal failure symptoms are similar to those of chronic heart failure. Since the diagnosis of chronic heart failure is often incorrect when based on clinical symptoms and signs alone, confirmation by echocardiography is now a requirement of the Quality Outcomes Framework of the new GMS contract. It is also a recommendation made by SIGN even for the frail elderly. However, the presence of a normal Brain natriuretic peptide (BNP) blood test (if available locally) and a normal ECG will make the diagnosis of chronic heart failure unlikely
3. OPTIONS:
a ) Osteoarthrtitis
b ) Gout
c ) Haemarthrosis
d ) Pseudogout
e ) Trauma
f ) Septic arthritis
g ) Rheumatoid arthritis
INSTRUCTION: Choose the single most likely diagnosis above for each clinical scenario presented below. Each option can be used once, more than once or not at all.
A. A 60 year old man presents with an acutely painful first metatarsophalyngeal joint on his right foot which has been grumbling on for a week since he was on holiday In Tenerife.
The Correct answer is b.
B. A 75 year old woman, with known osteoarthritis, requests a home visit as she has awoken to find her left knee acutely painful, red and swollen. She complains of nausea. On examination, the knee is hot and swollen with restricted movement. Her pulse is 110. Temp 37.0.
The Correct answer is f.
C . A 43 year old diabetic patient hobbles into the surgery complaining of a two day history of increasing swelling and redness of her left ankle. She cannot remember injuring it. She can weightbear with difficulty. The joint is hot and swollen. She has a mild pyrexia of 37.8 C
The Correct answer is f.
Septic arthritis has a case fatality of around 11%. Delayed or inadequate diagnosis leads to joint damage. Patients with a short history of a hot swollen and tender joint (joints) should be regarded as having septic arthritis until proven otherwise, even in the absence of fever.
4. With reference to the Medicines and Healthcare products Regulatory Agency (MHRA) 'Yellow Card Scheme' for reporting adverse drug reactions (ADRs), which one of the following statements is correct?
a ) ADRs of any severity should be reported for new, black triangle drugs or vaccines
b ) An ADR report should be submitted only when causality between a drug and an adverse reaction is certain
c ) Herbal remedies are excluded from the ADR scheme
d ) Only a designated Healthcare Professional can report an ADR
e ) Patient consent is required before submitting an ADR report on their behalf
Answer: A
Causality does not have to be proven – suspicion is enough. Herbal remedies are included in the scheme. Anyone, patients included, may file a report. Patient consent is not required as no patient-specific personal information is required.
5. A 39 year old woman presents with a six month history of prolonged and heavy menstruation. She feels a heaviness in her lower abdomen. She has had two first trimester miscarriages in the previous 18 months. LMP was three weeks ago. Her last ultrasound scan was suspicious of a bulky uterus. There is no weight loss .She has a borderline low haemoglobin and low ferritin levels. She has had only moderate symptomatic relief from tranexamic acid and mefenamic acid. What is the single most likely diagnosis?
a ) Adenomyosis
b ) Endometrial carcinoma
c ) Myometrial fibroids
d ) Cervical carcinoma
e ) Endometrial polyp
Answer: C
Fibroids (uterine leiomyomas) are benign tumours of the smooth muscle cells of the uterus. Women with fibroids can be asymptomatic or may present with menorrhagia (30%), pelvic pain with or without dysmenorrhoea or pressure symptoms (34%), infertility (27%), and recurrent pregnancy loss (3%). Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue within the myometrium. The condition is typically found in women in the ages between 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea & menorrhagia, respectively).
6. A research project looking at the management of moderate hypertension divides its subjects into two groups. Group A, with 1776 subjects, receives anti-hypertensive medication. Group B, with 1800 subjects, receives a placebo. After five years the risk of a stroke in Group A is 12%, while in group B it is 20%. What is the Number Needed to Treat (NNT) to prevent one extra stroke?
a ) 2.00
b ) 1.25
c ) 8.00
d ) 12.50
e ) 58.00
Anser: D
NNT is the reciprocal of the absolute risk reduction. For patients with moderate hypertension, receiving placebo treatments, about 20% would be expected to have a stroke over the next five years. This risk is reduced to 12% with antihypertensive drugs. This results in an absolute risk reduction of 0.20-0.12=0.08. The reciprocal of this number is 12.5 - implying that a doctor would need to treat about 12.5 moderately hypertensive patients for five years before he or she could expect to prevent one extra stroke.
7. OPTIONS:
a ) Dental caries
b ) Furuncle
c ) Nasopharyngeal carcinoma
d ) Otitis externa
e ) Otitis media
f ) Ramsay Hunt syndrome
g ) Temporomandibular joint dysfunction
INSTRUCTION: Match the following scenarios with the most likely diagnosis above. Each option can be used once, more than once or not at all.
1 . A 78 year old man with dysphagia and earache.
The Correct answer is c.
2 . A 75 year old man with facial weakness, a focal rash and earache.
The Correct answer is f.
3 . A 45 year old woman with earache worsened by eating and yawning.
The Correct answer is g.
In older patients, a diagnosis of dysphagia is often due to neurological causes such as a CVA. Earache is not a common feature of stroke. Earache with dysphagia suggests the presence of a nasopharyngeal carcinoma. Facial weakness in this age group can suggest stroke. However, in the context of a rash in the external auditory canal and earache, the most likely unifying diagnosis is Ramsay Hunt syndrome. In an adult with earache worsened by eating, dental caries is a possibility. The fact that the symptoms are worsened by yawning makes temporomandibular joint dysfunction more likely.
8. A 55 year old man, who is a heavy smoker, and has a history of hypertension, is seen on an emergency home visit. On examination, his blood pressure is 180/110 with an irregular pulse of 90 bpm. There is no evidence of cardiac failure. He has a mild expressive dysphasia with a left hemiparesis. According to his wife these symptoms have been present for more than 12 hours. He denies any headache and is fully conscious and orientated. With regard to the gold standard, what is the single most appropriate referral plan?
a ) Refer urgently for a neurology appointment (1-2 days).
b ) Refer as an emergency to the nearest hospital.
c ) Refer to a TIA clinic within 1 week.
d ) Refer as an emergency to the nearest stroke unit.
e ) Refer to the stroke clinic within 1 week
Answer: D
All patients with acute stroke should ideally be admitted to a multidisciplinary stroke unit as soon as possible. All patients with acute stroke should undergo CT brain scanning within 24 hours. Stroke outcome is significantly better when patients are treated in an organised stroke unit compared to either general hospital care or organised care at home. High blood pressure should not normally be lowered in the acute phase of stroke. Aspirin should be given as soon as possible after the onset of stroke symptoms once a diagnosis of primary haemorrhage has been excluded (by CT scanning). Following a TIA, the risk of stroke is approximately 7 times greater than the risk in the general population, especially in the first few weeks. Patients should be assessed and investigated in a specialist clinic within 7 days.
Saturday, 31 January 2009
new AKT Questions
1. A 50 year old man has a blood pressure of 158/88. He has no known atherosclerotic disease but is keen to prevent it. He asks if he should take aspirin. At which calculated absolute risk of a cardiovascular or cerebrovascular event is it appropriate to start aspirin 75mg?
a ) Greater than, or equal to, 10% over five years
b ) Greater than, or equal to, 10% over 10years
c ) Greater than, or equal to, 15% over five years
d ) Greater than, or equal to, 15% over 10 years
e ) Greater than ,or equal to, 20% over five years
f ) Greater than, or equal to, 20% over 10 years
Answer: F
Asymptomatic individuals, without established atherosclerotic disease, but with a calculated cardiovascular risk of more than, or equal to, 20% in 10 years, should be considered for aspirin 75mg daily.
2. A 40 year old woman presents with intermittent abdominal pain which she says is totally relieved by defaecation. Which one of the following symptoms would suggest further investigations are mandatory?
a ) Loose stools
b ) Blood in stools
c ) Feeling of incomplete evacuation
d ) Increased stool frequency
e ) Mucus in stools
Answer: B
According to the Manning Criteria for the diagnosis of irritable bowel syndrome, the diagnosis may be made if three or more of the following are present: abdominal pain, relief of pain with defecation, increased stool frequency with pain, looser stools with pain, mucus in stools and feeling of incomplete evacuation. If any of the following red flag symptoms are present a full GI work up is needed: being over 50 years old, having weight loss, blood in stools, anaemia or fever.
3. A 40 year old doctor, who has just returned from a six month sojourn in Central America, presents with a painless nodule of his right upper eyelid. It has been growing slowly over the last six weeks. What is the single most likely infected cause of the swelling?
a ) Leishmaniasis
b ) Leprosy
c ) Malaria
d ) Schistosomiasis
e ) Trypanosomiasis
Answer: A
He is presenting with a chalazion. With increasing international travel, it is important to take a travel history. Leishmaniasis is found in the rain forests of Central and Southern America. It can commonly present as an infected chalazion
4. A 54 year old man, with a moderate learning disability, is brought to see you by his carer. She states that his behaviour has been deteriorating over the last three weeks. He hasn’t been responding when spoken to and hasn’t been doing things when asked. He becomes aggressive when confronted. In particular, he has refused to turn down the volume on his TV and this is causing arguments with other residents. He has been well otherwise, with no change in eating or toilet habit. He has no relevant history or medication. He answers all questions with the response “I’m fine” but this is his usual. On examination, he is apyrexial, pulse and BP are normal. His chest and abdomen are normal. Which one of the following is the most likely diagnosis?
a ) Absence seizures
b ) Depression
c ) Ear wax
d ) Early onset dementia
e ) Urinary tract infection
Answer: C
Due to communication difficulties, people with learning disabilities may not complain of any sensory changes and, therefore, simple problems like a build up of ear wax can present in an unusual way. One must be alert to such atypical, and often simple, explanations.
5. OPTIONS:
a ) 2 weeks
b ) 4 weeks
c ) 6 weeks
d ) 8 weeks
e ) 12 weeks
f ) 26 weeks
g ) 52 weeks
INSTRUCTION: For each patient below who has had a Myocardial Infarction (MI), select the single most appropriate time scale above to fit their circumstances. Each option may be used once, more than once or not at all.
A. Mr A is 50 years old and has recently had an uncomplicated MI. This is his first cardiovascular event and he has made a straightforward recovery. For how long after the event should he be advised to refrain from driving his car? (He does not hold a PSV or HGV licence)
The Correct answer is b.
B. Mrs B is 50 years old and has recently had an uncomplicated MI. This is her first cardiovascular event and she has made a straightforward recovery. She works as a dinner lady. This involves a lot of lifting and carrying of heavy pots and pans as well as supervision of children. She misses the company at work and is keen to get back to her own job. According to the British Heart Foundation when should she be advised that she may return to her work?
The Correct answer is e.
C. 3 . Mr C is 45 years old and has recently had an uncomplicated MI. This is his first cardiovascular event and he has made a straightforward recovery. He is able to climb two flights of stairs without difficulty. His daughter has recently had a baby and he is keen to visit. This would involve a flight of three hours. How long after his MI do most airlines advise before he can fly?
The Correct answer is a.
Mrs B must be considered to be a heavy manual worker and as such should be advised to wait for three months before going back to her work. The British Heart Foundation has a useful leaflet on activity after an MI- Heart Information Series No7. Most airlines will not carry passengers for two weeks after an uncomplicated MI but will then do so if they can climb a flight of stairs without difficulty.
7. OPTIONS:
a ) Prostate cancer
b ) Bladder calculus
c ) Chronic prostatitis
d ) Urinary tract infection
e ) Urethritis
f ) Benign prostatic hypertrophy
g ) Urethral stricture
INSTRUCTION: Choose the single most likely option above for each of the scenarios below. Each option can be used once, more than once or not at all.
1 . A 58 year old patient, who has previously been catheterized and has undergone a T.U.R.P, complains of diminishing urine flow over a period of months. Rectal examination reveals no prostatic enlargement.
The Correct answer is g.
2 . A 65 year old patient presents with terminal dribbling, poor flow and hesitancy. Rectal examination reveals a smooth and symmetrical swelling. The surface is flattened and it is difficult to get the examining finger forward round each side.
The Correct answer is f.
3 . A 32 year old diabetic man presents with chronic, perineal pain of varying severity and frequency. It is exacerbated by sitting on a hard chair. He also describes low back pain extending down his left leg with bouts of fever and dysuria. Rectal examination reveals an enlarged, firm, and irregular prostate.
The Correct answer is c.
Prostate cancer is rare below the age of 50. Benign prostatic hypertrophy is a common condition in older men; it is unusual before 50 years of age and is most common between 60 and 70
8. A 67 year old woman, who is well known to you, has been diagnosed with Alzheimer’s disease and is in a care home. You are asked to see her because she has become aggressive and violent towards carers and other residents. Carers have followed NICE guidance on the management of aggression with no success. You manage to examine her and can find no obvious cause for her deterioration. You decide that she will need admission for further assessment in order to exclude other remediable causes for her agitation, and that it is justifiable to sedate her at this point. Which the single most appropriate drug for this purpose?
a ) IM haloperidol
b ) Oral diazepam
c ) Oral chlorpromazine
d ) IM lorazepam
e ) Oral lorazepam
Answr: E
Agitation and aggression should be managed by non-pharmacological methods where possible. The use of drugs is often unnecessary, and they can increase the risk of cerebrovascular events. If the risks have been considered and are justified, oral drugs are preferable to parenteral routes. Oral lorazepam, haloperidol or olanzapine in the lowest effective dose are the preferred drugs. Careful patient monitoring after sedation is mandatory.
10. A 23 year old man, who is a reformed intravenous drug misuser, was screened by the practice for blood borne viruses. He was found to be suffering from chronic Hepatitis C. He is accepted on to a treatment programme and is given pegylated Interferon and Ribavirin. He presents to you complaining of feeling extremely tired and not wanting to do anything. His appetite is poor and his bowel is looser than usual. He has lost weight. As a precaution you check his bloods. Which one of the following is the most likely diagnosis?
a ) Crohn’s disease
b ) Depression
c ) Gastric carcinoma
d ) Psychotic illness
e ) Renal failure
Answer: B
This combination of drugs has a very wide range of adverse side effects including effects on the liver, heart, kidney, gastrointestinal and haemopoietic systems. However, depression and flu-like symptoms are much more common.
a ) Greater than, or equal to, 10% over five years
b ) Greater than, or equal to, 10% over 10years
c ) Greater than, or equal to, 15% over five years
d ) Greater than, or equal to, 15% over 10 years
e ) Greater than ,or equal to, 20% over five years
f ) Greater than, or equal to, 20% over 10 years
Answer: F
Asymptomatic individuals, without established atherosclerotic disease, but with a calculated cardiovascular risk of more than, or equal to, 20% in 10 years, should be considered for aspirin 75mg daily.
2. A 40 year old woman presents with intermittent abdominal pain which she says is totally relieved by defaecation. Which one of the following symptoms would suggest further investigations are mandatory?
a ) Loose stools
b ) Blood in stools
c ) Feeling of incomplete evacuation
d ) Increased stool frequency
e ) Mucus in stools
Answer: B
According to the Manning Criteria for the diagnosis of irritable bowel syndrome, the diagnosis may be made if three or more of the following are present: abdominal pain, relief of pain with defecation, increased stool frequency with pain, looser stools with pain, mucus in stools and feeling of incomplete evacuation. If any of the following red flag symptoms are present a full GI work up is needed: being over 50 years old, having weight loss, blood in stools, anaemia or fever.
3. A 40 year old doctor, who has just returned from a six month sojourn in Central America, presents with a painless nodule of his right upper eyelid. It has been growing slowly over the last six weeks. What is the single most likely infected cause of the swelling?
a ) Leishmaniasis
b ) Leprosy
c ) Malaria
d ) Schistosomiasis
e ) Trypanosomiasis
Answer: A
He is presenting with a chalazion. With increasing international travel, it is important to take a travel history. Leishmaniasis is found in the rain forests of Central and Southern America. It can commonly present as an infected chalazion
4. A 54 year old man, with a moderate learning disability, is brought to see you by his carer. She states that his behaviour has been deteriorating over the last three weeks. He hasn’t been responding when spoken to and hasn’t been doing things when asked. He becomes aggressive when confronted. In particular, he has refused to turn down the volume on his TV and this is causing arguments with other residents. He has been well otherwise, with no change in eating or toilet habit. He has no relevant history or medication. He answers all questions with the response “I’m fine” but this is his usual. On examination, he is apyrexial, pulse and BP are normal. His chest and abdomen are normal. Which one of the following is the most likely diagnosis?
a ) Absence seizures
b ) Depression
c ) Ear wax
d ) Early onset dementia
e ) Urinary tract infection
Answer: C
Due to communication difficulties, people with learning disabilities may not complain of any sensory changes and, therefore, simple problems like a build up of ear wax can present in an unusual way. One must be alert to such atypical, and often simple, explanations.
5. OPTIONS:
a ) 2 weeks
b ) 4 weeks
c ) 6 weeks
d ) 8 weeks
e ) 12 weeks
f ) 26 weeks
g ) 52 weeks
INSTRUCTION: For each patient below who has had a Myocardial Infarction (MI), select the single most appropriate time scale above to fit their circumstances. Each option may be used once, more than once or not at all.
A. Mr A is 50 years old and has recently had an uncomplicated MI. This is his first cardiovascular event and he has made a straightforward recovery. For how long after the event should he be advised to refrain from driving his car? (He does not hold a PSV or HGV licence)
The Correct answer is b.
B. Mrs B is 50 years old and has recently had an uncomplicated MI. This is her first cardiovascular event and she has made a straightforward recovery. She works as a dinner lady. This involves a lot of lifting and carrying of heavy pots and pans as well as supervision of children. She misses the company at work and is keen to get back to her own job. According to the British Heart Foundation when should she be advised that she may return to her work?
The Correct answer is e.
C. 3 . Mr C is 45 years old and has recently had an uncomplicated MI. This is his first cardiovascular event and he has made a straightforward recovery. He is able to climb two flights of stairs without difficulty. His daughter has recently had a baby and he is keen to visit. This would involve a flight of three hours. How long after his MI do most airlines advise before he can fly?
The Correct answer is a.
Mrs B must be considered to be a heavy manual worker and as such should be advised to wait for three months before going back to her work. The British Heart Foundation has a useful leaflet on activity after an MI- Heart Information Series No7. Most airlines will not carry passengers for two weeks after an uncomplicated MI but will then do so if they can climb a flight of stairs without difficulty.
7. OPTIONS:
a ) Prostate cancer
b ) Bladder calculus
c ) Chronic prostatitis
d ) Urinary tract infection
e ) Urethritis
f ) Benign prostatic hypertrophy
g ) Urethral stricture
INSTRUCTION: Choose the single most likely option above for each of the scenarios below. Each option can be used once, more than once or not at all.
1 . A 58 year old patient, who has previously been catheterized and has undergone a T.U.R.P, complains of diminishing urine flow over a period of months. Rectal examination reveals no prostatic enlargement.
The Correct answer is g.
2 . A 65 year old patient presents with terminal dribbling, poor flow and hesitancy. Rectal examination reveals a smooth and symmetrical swelling. The surface is flattened and it is difficult to get the examining finger forward round each side.
The Correct answer is f.
3 . A 32 year old diabetic man presents with chronic, perineal pain of varying severity and frequency. It is exacerbated by sitting on a hard chair. He also describes low back pain extending down his left leg with bouts of fever and dysuria. Rectal examination reveals an enlarged, firm, and irregular prostate.
The Correct answer is c.
Prostate cancer is rare below the age of 50. Benign prostatic hypertrophy is a common condition in older men; it is unusual before 50 years of age and is most common between 60 and 70
8. A 67 year old woman, who is well known to you, has been diagnosed with Alzheimer’s disease and is in a care home. You are asked to see her because she has become aggressive and violent towards carers and other residents. Carers have followed NICE guidance on the management of aggression with no success. You manage to examine her and can find no obvious cause for her deterioration. You decide that she will need admission for further assessment in order to exclude other remediable causes for her agitation, and that it is justifiable to sedate her at this point. Which the single most appropriate drug for this purpose?
a ) IM haloperidol
b ) Oral diazepam
c ) Oral chlorpromazine
d ) IM lorazepam
e ) Oral lorazepam
Answr: E
Agitation and aggression should be managed by non-pharmacological methods where possible. The use of drugs is often unnecessary, and they can increase the risk of cerebrovascular events. If the risks have been considered and are justified, oral drugs are preferable to parenteral routes. Oral lorazepam, haloperidol or olanzapine in the lowest effective dose are the preferred drugs. Careful patient monitoring after sedation is mandatory.
10. A 23 year old man, who is a reformed intravenous drug misuser, was screened by the practice for blood borne viruses. He was found to be suffering from chronic Hepatitis C. He is accepted on to a treatment programme and is given pegylated Interferon and Ribavirin. He presents to you complaining of feeling extremely tired and not wanting to do anything. His appetite is poor and his bowel is looser than usual. He has lost weight. As a precaution you check his bloods. Which one of the following is the most likely diagnosis?
a ) Crohn’s disease
b ) Depression
c ) Gastric carcinoma
d ) Psychotic illness
e ) Renal failure
Answer: B
This combination of drugs has a very wide range of adverse side effects including effects on the liver, heart, kidney, gastrointestinal and haemopoietic systems. However, depression and flu-like symptoms are much more common.
Monday, 26 January 2009
AKT Questins
1. As part of their annual review for hypertension, your patients have urea and electrolytes measured. Significant numbers are now coming back with evidence of chronic renal impairment. Which of the following statements about this condition are true? Select three statements only.
A. Most laboratories now provide a measurement of the patient’s true glomerular filtration rate (GFR) which is a definitive guide to renal function
B.Patients with eGFR > 60 ml/min per 1.73 m2 do not have renal impairment
C.An eGFR < 15 is the cut-off for stage 5 chronic renalimpairment, at which point patients should be considered for dialysis
D. A blood pressure treatment goal of < 125/75 is indicatedfor patients with proteinuria
E. A high-protein diet is required in patients with proteinuria to replace urinary losses
F. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in patients with only one kidney
G. Patients with moderate-to-severe chronic renal impairment should follow a diet restricted in potassium
Answer: C,D,G
The result measured by laboratories is an estimated GFR (or eGFR), which assumes standard body surface area and race. Patients who have, for instance, had an amputation may receive erroneous results. An eGFR between 60 and 89 correlates with mild renal impairment. Stage 5 chronic kidney disease is defined as eGFR < 15. Low protein diet has been shown to reduce death rate in chronic renal disease. Patients with only one kidney are prone to renal impairment and should all be considered for ACE inhibitors.
A. Most laboratories now provide a measurement of the patient’s true glomerular filtration rate (GFR) which is a definitive guide to renal function
B.Patients with eGFR > 60 ml/min per 1.73 m2 do not have renal impairment
C.An eGFR < 15 is the cut-off for stage 5 chronic renalimpairment, at which point patients should be considered for dialysis
D. A blood pressure treatment goal of < 125/75 is indicatedfor patients with proteinuria
E. A high-protein diet is required in patients with proteinuria to replace urinary losses
F. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated in patients with only one kidney
G. Patients with moderate-to-severe chronic renal impairment should follow a diet restricted in potassium
Answer: C,D,G
The result measured by laboratories is an estimated GFR (or eGFR), which assumes standard body surface area and race. Patients who have, for instance, had an amputation may receive erroneous results. An eGFR between 60 and 89 correlates with mild renal impairment. Stage 5 chronic kidney disease is defined as eGFR < 15. Low protein diet has been shown to reduce death rate in chronic renal disease. Patients with only one kidney are prone to renal impairment and should all be considered for ACE inhibitors.
more free AKT questions
1. Which of the following statements about screening for colorectal cancer are true? Select three options only.
A. The presence of a latent phase with precancerous lesions makes colorectal cancer ideal for screening
B. Colonoscopy is the only screening method proven to reduce mortality
C. Of patients with colorectal cancer 90% have symptoms of rectal bleeding
D. Proposed national screening for colorectal cancer will target those aged 50-74 years
E. Flexible sigmoidoscopy in women of average risk picks up only 35% of cancers
F. Of patients with iron-deficient anaemia in general practice 11% were found to have gastrointestinal cancer
Answer: A,E, F
fecal occult blood testing isthe only screening method proven to cut death rates. the proposed screenig programme will start in 2010 an scren the age group 60-69 years. the CONCeRN study showed low sensitivity for colonoscopy in women of average risk. rectal bleeding occurs in less than 50% of colorectal cancer.
2. A patient with dyspepsia has recently had an upper gastrointestinal endoscopy. His histology comes back positive for Helicobacter pylori. Which of the following statements about the management of this situation are true? Select two answers only.
A. Serological testing is highly sensitive and specific
B. Resistance to metronidazole is common in inner city areas
C. Eradication therapy involves a combination of amoxicillin and a proton pump inhibitor
D. Serological testing can be repeated after 4 weeks to confirm eradication
E. Prescriptions for Heliclear (amoxicillin, clarithromycin and lansoprazole) treatment packs are charged three prescription charges
Answer: B, E
Breath esting, CLO testing and stol antigen tsts are senstive and senstive. eradication therapy involves high dose amoxicillin, clarithromycin and lansoprazol. serological testing tkes 6-12 months to retur to normal.
3. A 73-year-old mentions at a routine blood pressure check-up that he has to get up four or five times a night to go to the toilet. This is disturbing his wife to the point that he has moved into the spare room. Examination reveals a smooth enlarged prostate and you send blood for PSA (prostate-specific antigen) testing and a urine specimen for culture. This comes back clear and his PSA level is 3.6. Which of the following statements about his management is true?
A. He should be referred for a prostate biopsy
B. Transurethral resection of the prostate is the treatment of choice in this patient C. Finasteride will provide rapid relief from his symptoms with no risk of postural hypotension
D. Saw palmetto has been shown to have a placebo effect only
E. a-Blockers are the first-line treatment in this patient group
Answer: E
Surgery should be reserved for patients with bladder outflow obstruction or in those in whom medical therapy fails. Finasteride is effective but takes some weeks to work. Its mode of action is to shrink the prostate. Saw palmetto has been shown to be an effective treatment for prostatism.
4. A 56-year-old man presents with unprovoked, painless, macroscopic haematuria. Dipstick testing confirms the presence of blood but no leucocytes or nitrites. Which of the following may be a cause of these symptoms?
A. Renal colic
B. Beetroot consumption
C. Urinary tract infection
D. Bladder tumour
E. Renal trauma
F. all of the above.
Answe: D
Painless macroscopic haematuria should be considered to be the result of renal tract cancer until proven otherwise. A UTI would be associated with dysuria and leucocytes and nitrites. Beetroot may discolour the urine but would not affect dipstick results. Trauma and colic are associated with pain, although haematuria may be a sign of a coagulopathy.
A. The presence of a latent phase with precancerous lesions makes colorectal cancer ideal for screening
B. Colonoscopy is the only screening method proven to reduce mortality
C. Of patients with colorectal cancer 90% have symptoms of rectal bleeding
D. Proposed national screening for colorectal cancer will target those aged 50-74 years
E. Flexible sigmoidoscopy in women of average risk picks up only 35% of cancers
F. Of patients with iron-deficient anaemia in general practice 11% were found to have gastrointestinal cancer
Answer: A,E, F
fecal occult blood testing isthe only screening method proven to cut death rates. the proposed screenig programme will start in 2010 an scren the age group 60-69 years. the CONCeRN study showed low sensitivity for colonoscopy in women of average risk. rectal bleeding occurs in less than 50% of colorectal cancer.
2. A patient with dyspepsia has recently had an upper gastrointestinal endoscopy. His histology comes back positive for Helicobacter pylori. Which of the following statements about the management of this situation are true? Select two answers only.
A. Serological testing is highly sensitive and specific
B. Resistance to metronidazole is common in inner city areas
C. Eradication therapy involves a combination of amoxicillin and a proton pump inhibitor
D. Serological testing can be repeated after 4 weeks to confirm eradication
E. Prescriptions for Heliclear (amoxicillin, clarithromycin and lansoprazole) treatment packs are charged three prescription charges
Answer: B, E
Breath esting, CLO testing and stol antigen tsts are senstive and senstive. eradication therapy involves high dose amoxicillin, clarithromycin and lansoprazol. serological testing tkes 6-12 months to retur to normal.
3. A 73-year-old mentions at a routine blood pressure check-up that he has to get up four or five times a night to go to the toilet. This is disturbing his wife to the point that he has moved into the spare room. Examination reveals a smooth enlarged prostate and you send blood for PSA (prostate-specific antigen) testing and a urine specimen for culture. This comes back clear and his PSA level is 3.6. Which of the following statements about his management is true?
A. He should be referred for a prostate biopsy
B. Transurethral resection of the prostate is the treatment of choice in this patient C. Finasteride will provide rapid relief from his symptoms with no risk of postural hypotension
D. Saw palmetto has been shown to have a placebo effect only
E. a-Blockers are the first-line treatment in this patient group
Answer: E
Surgery should be reserved for patients with bladder outflow obstruction or in those in whom medical therapy fails. Finasteride is effective but takes some weeks to work. Its mode of action is to shrink the prostate. Saw palmetto has been shown to be an effective treatment for prostatism.
4. A 56-year-old man presents with unprovoked, painless, macroscopic haematuria. Dipstick testing confirms the presence of blood but no leucocytes or nitrites. Which of the following may be a cause of these symptoms?
A. Renal colic
B. Beetroot consumption
C. Urinary tract infection
D. Bladder tumour
E. Renal trauma
F. all of the above.
Answe: D
Painless macroscopic haematuria should be considered to be the result of renal tract cancer until proven otherwise. A UTI would be associated with dysuria and leucocytes and nitrites. Beetroot may discolour the urine but would not affect dipstick results. Trauma and colic are associated with pain, although haematuria may be a sign of a coagulopathy.
Friday, 9 January 2009
AKT Questions
1. The following are notifiable diseases in England and Wales
a. acute encephalitis T
b. dysentery T
c. pulmonary tuberculosis T
d. chicken pox F
e. Kawasaki disease F
Bacterial: anthrax, diphtheria, leptosporosis, pertussis, plague, Brucellosis, tetanus, typhus, cholera, dysentery, food poisoning, paratyphoid fever, typhoid, leprosy, tuberculosis, meningitis, meningococcal infection, ophthalmia neonatorum, erysipelas, scarlet fever.
Viral: acute encephalitis, AIDS, hepatitis B, measles, mumps,rubella, poliomyelitis, rabies, varicella (encephalitis- chickenpox isn't) , yellow fever.
Protozoal: malaria.
Chicken pox is notifiable in Scotland.
2. Theme:Causes of deafness
A Acoustic neuroma
B Alport's syndrome
C Barotrauma
D Drug induced
E Hypothyroidism
F Meningitis
G Otitis media
H Paget's disease
I Pendred's syndrome
J Radiotherapy
K Stroke
Select the most likely cause of deafness in the following cases:
-A 75-year-old male presents as he has increasing problems with deafness. He suffers from Parkinson's disease and takes l-dopa therapy.On examination, he has a pill rolling tremor and reduced mobility. There is also enlargement of the skull.
Answer: H
Although this man has Parkinson's disease, the description of a large skull suggests Paget's disease as the cause of deafness as l-dopa does not cause deafness. Paget's causes enlargement of the bone in the inner ear which can be responsible for the conductive deafness
- A 20-year-old female presents with increasing deafness. She only takes the oral contraceptive pill. On examination, there is nil of note but urinalysis reveals blood ++ and protein++.
Answer: B
Alport's syndrome is an inherited condition associated with sensorineural deafness and renal dysfunction.
- A 54-year-old female presents with a two month history of increasing deafness in the left ear. She has a history of hypertension for which she takes lisinopril and amlodipine. On examination she has decreased hearing in the left ear both through air and bone and there is loss of the corneal reflex on the left side.
Answer: A
The sensorineural deafness suggests involvement of the VIII cranial nerve and the loss of corneal reflex indicates involvement of the V cranial nerve. This would occur in the posterior fossa of the brain and hence the likely lesion is an acoustic neuroma.
3. You have been informed by the local hospital that a 4-year-old patient from your practice has been admitted with definite meningococcal sepsis. There have not been any previous cases. You need to organise appropriate prophylaxis. Which of the following is the single most appropriate group to treat?
a. All family members
b. All family members and friends who have played with the child in the last 48 hours
c. All family members and children at the same nursery
d. All household members
e. All household members and children at the same nursery
Answer: D
This is a congenital abnormality, presenting as prolonged conjugated jaundice. A history of dark urine and pale stools might also be given. This requires urgent corrective surgery. A significant number of children operated on after 6 weeks of age develop chronic hepatic failure and some require liver transplantation.
In full-term babies, physiological jaundice is usually visible from day 2 or day 3, peaks at day 5, and has resolved by day 14. Treatment consists of ensuring adequate milk intake and ruling out any other causes (ie infection, rhesus or aBo incompatibility). If the bilirubin level is rising rapidly, phototherapy might be necessary but can usually be avoided if feeding issues are addressed early. Physiological jaundice in preterm infants starts sooner and usually lasts longer, up to 21 days.
A sudden onset of respiratory distress in a child of 18 months to 3 years should raise the suspicion of an inhaled foreign body. If there is a suggestive history and/or unilateral clinical signs it is an important diagnosis to rule out. Urgent paediatric assessment is required.
Many children aged under 3 years wheeze with viral infections. no treatment is usually necessary. a trial of salbutamol via inhaler and spacer can be given to children aged over 1 year if respiratory distress is severe or if there is a strong family history of atopy.
Recurrent lower respiratory tract infections and poor weight gain warrant further investigation. The most likely diagnosis in the white population is cystic fibrosis. Other pathologies such as immunodeficiencies, congenital lung abnormalities and rarer causes of bronchiectasis such as primary ciliary dyskinesia should be considered if cystic fibrosis tesing is negative.
Children with chronic neurological conditions often have gastrooesophageal reflux and are at high risk of recurrent aspiration. Fundoplication and gastrostomy feeds can help. Infections need to be treated early and aggressively because this is the main cause of mortality in this group of patients.
a. acute encephalitis T
b. dysentery T
c. pulmonary tuberculosis T
d. chicken pox F
e. Kawasaki disease F
Bacterial: anthrax, diphtheria, leptosporosis, pertussis, plague, Brucellosis, tetanus, typhus, cholera, dysentery, food poisoning, paratyphoid fever, typhoid, leprosy, tuberculosis, meningitis, meningococcal infection, ophthalmia neonatorum, erysipelas, scarlet fever.
Viral: acute encephalitis, AIDS, hepatitis B, measles, mumps,rubella, poliomyelitis, rabies, varicella (encephalitis- chickenpox isn't) , yellow fever.
Protozoal: malaria.
Chicken pox is notifiable in Scotland.
2. Theme:Causes of deafness
A Acoustic neuroma
B Alport's syndrome
C Barotrauma
D Drug induced
E Hypothyroidism
F Meningitis
G Otitis media
H Paget's disease
I Pendred's syndrome
J Radiotherapy
K Stroke
Select the most likely cause of deafness in the following cases:
-A 75-year-old male presents as he has increasing problems with deafness. He suffers from Parkinson's disease and takes l-dopa therapy.On examination, he has a pill rolling tremor and reduced mobility. There is also enlargement of the skull.
Answer: H
Although this man has Parkinson's disease, the description of a large skull suggests Paget's disease as the cause of deafness as l-dopa does not cause deafness. Paget's causes enlargement of the bone in the inner ear which can be responsible for the conductive deafness
- A 20-year-old female presents with increasing deafness. She only takes the oral contraceptive pill. On examination, there is nil of note but urinalysis reveals blood ++ and protein++.
Answer: B
Alport's syndrome is an inherited condition associated with sensorineural deafness and renal dysfunction.
- A 54-year-old female presents with a two month history of increasing deafness in the left ear. She has a history of hypertension for which she takes lisinopril and amlodipine. On examination she has decreased hearing in the left ear both through air and bone and there is loss of the corneal reflex on the left side.
Answer: A
The sensorineural deafness suggests involvement of the VIII cranial nerve and the loss of corneal reflex indicates involvement of the V cranial nerve. This would occur in the posterior fossa of the brain and hence the likely lesion is an acoustic neuroma.
3. You have been informed by the local hospital that a 4-year-old patient from your practice has been admitted with definite meningococcal sepsis. There have not been any previous cases. You need to organise appropriate prophylaxis. Which of the following is the single most appropriate group to treat?
a. All family members
b. All family members and friends who have played with the child in the last 48 hours
c. All family members and children at the same nursery
d. All household members
e. All household members and children at the same nursery
Answer: D
The following groups would be classed as close contacts and require prophylaxis:
people in the same household
people who have slept in the house during the 7 days prior to the onset of the illness
people who have spent several hours a day in the house inthe last 7 days
â€کKissing contacts’, ie boy/girlfriend
students sharing the same room or flat as the case
anyone who gave mouth-to-mouth resuscitation to the index case
Those attending the same childminder as the index case in the last 7 days.
Groups not requiring prophylaxis:
school, nursery or playgroup contacts
students on the same course or in the same hall of residence who are not in the above categories.
4. THEME: VOMITING
A Cow’s milk protein intolerance
B Gastroenteritis
C Gastro-oesophageal reflux
D Hiatus hernia
E Hirschprung’s disease
F Lactose intolerance
G Overfeeding
H Posseting
I Pyloric stenosis
J Reduced gastric motility
For each of the following clinical situations, choose the single most likely diagnosis from the list of options given above. Each option can be used once, more than once or not at all.
A 1-week-old baby is brought by his mother. He was born at home. Mum is concerned that he is vomiting and not feeding well. On questioning, his mother tells you that she cannot remember her child opening his bowels. On examination, the child appears grey, his abdomen is distended and firm. He vomits forcefully when you palpate his abdomen.
E Correct answer
Classically presents in the neonatal period with failure to pass meconium within 24 hours and features of obstruction. It is caused by aganglionosis of the distal bowel. If only a small segment of large bowel is affected children can present several years later with chronic constipation. diagnosis is made by rectal biopsy.
A 6-week-old baby is brought to see you with increasing vomiting. His mother reports that he feeds very well and is always hungry. Initially he vomited small amounts after some feeds. Over the last week, he has had large vomits after every feed. On examination, the baby is alert and hungry but appears to have lost weight.
I Correct answer
Caused by hypertrophy of the pyloric sphincter. Classically presents at 6 weeks with a preceding history of worsening vomiting as the pylorus becomes increasingly hypertrophied with use. Babies usually feed very well and are very hungry. Weight loss can be dramatic. Management includes stopping feeds, correction of electrolyte imbalance and surgical correction. The prognosis is very good.
A 6-week-old baby has a history of vomiting. His mother reports that from the age of 1 week her child has vomited after almost every feed. He is distressed when he vomits and if he is laid flat after a feed. He is thriving and examination is unremarkable.
C Correct answer
Common in infancy, due to relatively poor muscle tone. Symptoms improve with age. This is due to stronger muscle tone, introduction of dietary solids and a more upright posture for the baby. in severe cases there can be failure to thrive and feeding aversion because of the distress associated with feeds. there are several management options:
Keeping the child upright (no proved benefit)
Propping up the head of the bed (no proved benefit)
Thickening agents (proved benefit)
Antacids, eg Gaviscon (no proved benefit)
Ranitidine (proved benefit)
Omeprazole and domperidone, often used but not licensed.
A 6-week-old baby has a history of vomiting. His mother reports that he vomits after feeds, two or three times a day. He is described as a hungry baby. He takes 300 ml every 3 hours during the day, having seven feeds in 24 hours. His weight is above the 99th centile. Examination is otherwise unremarkable.
G Correct answer
Full-term babies normally require 150 ml/kg/day of milk. Particularly hungry babies might need more than this to settle them but volumes over 200 ml/kg/day are not recommended. Overfeeding is common and often results in vomiting.
An 8-month-old baby has a history of vomiting. She attends nursery 3 days per week. She has a 2-day history of vomiting after some feeds and the vomiting is worsening today. She is opening her bowels regularly and had one loose stool this morning. Examination is unremarkable, although she cries throughout.
B Correct answer
Mild, self-limiting episodes of gastroenteritis are common in this age group. Infants who attend nursery have twice the number of viral infections as those that do not.
5. THEME: JAUNDICE
A ABO incompatibility
B Biliary atresia
C Breast milk jaundice
D Galactosaemia
E Gilbert syndrome
F Hepatitis
G Hypothyroidism
H Physiological jaundice
I Rhesus incompatibility
J Sepsis
For each of the following clinical situations choose the single most likely diagnosis from the options given above. Each option can be used once, more than once or not all.
· A 20-day-old baby is noted to be jaundiced by the health visitor. The baby is breastfeeding well and gaining weight well and the baby’s mother has no concerns. On further questioning, she tells you that the baby’s urine is dark in colour and that the stools are the same colour as the baby’s nappy. Examination reveals no abnormality.
This is a congenital abnormality, presenting as prolonged conjugated jaundice. A history of dark urine and pale stools might also be given. This requires urgent corrective surgery. A significant number of children operated on after 6 weeks of age develop chronic hepatic failure and some require liver transplantation.
· A 10-day-old baby is noted to be jaundiced by the health visitor. The baby is breastfeeding well and gaining weight well. The jaundice was first noted on day 2 of life. The baby’s mother is concerned that her baby has a red rash in the nappy area and some small spots on the face. Examination reveals no other abnormalities.
C Correct answer
Babies who are breastfed are more likely to become jaundiced because they are taking less milk volume in the first 48 hours. The jaundice also takes longer to resolve than in formula-fed babies. This is not harmful and there is no need to stop breastfeeding.
·A 4-day-old baby is brought to your surgery by his father. He is concerned that the baby has not been feeding well for the past 24 hours. On examination, the baby is jaundiced and floppy and the heart rate is 160/minute. The father cannot give you any further history.
J Correct answer
Infection can present with jaundice in the neonatal period. Onset of jaundice in the first 24 hours of life warrants investigation for sepsis. After this time there are usually other symptoms and signs indicating infection, as in this case. In prolonged jaundice (visible after 14 days), an untreated infective cause (eg urinary tract infection) should be ruled out.
· A 6-day-old baby is brought to your surgery by her mother. She is the third baby in the family and the mother is concerned about her baby’s feeding. She describes her baby as sleepy and floppy and taking a long time to finish bottles. The mother says that the baby has been jaundiced since day 3 of life. On examination, the baby is jaundiced and floppy with a large fontanelle.
G Correct answer
Hypothyroidism can present in the neonatal period as jaundice, poor tone and poor feeding. examination is usually otherwise normal, although a large fontanelle and umbilical hernia may be features. Urgent investigation and treatment is necessary as mental retardation develops early and is irreversible. Screening for hypothyroidism is now part of the national neonatal screening programme, but the result would not be available at this stage. If there is clinical suspicion of hypothyroidism it is important to check the baby’s full thyroid function profile as the screening test only measures thyroid-stimulating hormone levels.
· You see a 6-day-old baby who is jaundiced. The baby was noted to be jaundiced on day 2 of life. Bilirubin levels were checked in the hospital and the baby did not require any treatment. Although he took a few days to start feeding, he is now breastfeeding well. The mother feels he is slightly less jaundiced than yesterday. Other than jaundice you can find no other abnormalities on examination.
In full-term babies, physiological jaundice is usually visible from day 2 or day 3, peaks at day 5, and has resolved by day 14. Treatment consists of ensuring adequate milk intake and ruling out any other causes (ie infection, rhesus or aBo incompatibility). If the bilirubin level is rising rapidly, phototherapy might be necessary but can usually be avoided if feeding issues are addressed early. Physiological jaundice in preterm infants starts sooner and usually lasts longer, up to 21 days.
6. THEME: WHEEZE
A Anaphylaxis
B Asthma
C Bronchiolitis
D Chronic lung disease
E Croup
F Cystic fibrosis
G Foreign body inhalation
H Primary ciliary dyskinesia
I Recurrent aspiration
J Virus-induced wheeze
For each of the following clinical situations, choose the single most likely diagnosis from the options given above. Each option can be used once, more than once or not at all.
· A 2-year-old child is brought to see you with sudden onset of wheeze and shortness of breath. The symptoms started when the child was at nursery this morning. She has been otherwise well. There is no significant past medical or family history. On examination, she is distressed, with mild subcostal recession; there is an audible wheeze. On auscultation, you can hear wheeze on the right side of the chest, with good air entry throughout.
A sudden onset of respiratory distress in a child of 18 months to 3 years should raise the suspicion of an inhaled foreign body. If there is a suggestive history and/or unilateral clinical signs it is an important diagnosis to rule out. Urgent paediatric assessment is required.
·A 20-month-old boy is brought to see you with respiratory distress. He has been unwell for 2 days with a runny nose, cough and reduced feeding. He is normally fit and well. On examination, the child is coryzal and has a temp of 38.1 °C. His respiratory rate is 32/minute, with mild subcostal recession. Wheeze can be heard throughout the chest with good air entry. He has a blanching maculopapular rash on his trunk
Many children aged under 3 years wheeze with viral infections. no treatment is usually necessary. a trial of salbutamol via inhaler and spacer can be given to children aged over 1 year if respiratory distress is severe or if there is a strong family history of atopy.
·A white 22-month-old boy is brought to see you by his mother. They have recently moved to the area. His mother tells you that he often needs antibiotics for his chest and that this is why she has brought him in now. On examination, the child is small and thin (weight and height are on 0.4th centile) with visible Harrison’s sulci. He has mild subcostal recession. Wheeze can be heard throughout the chest.
Recurrent lower respiratory tract infections and poor weight gain warrant further investigation. The most likely diagnosis in the white population is cystic fibrosis. Other pathologies such as immunodeficiencies, congenital lung abnormalities and rarer causes of bronchiectasis such as primary ciliary dyskinesia should be considered if cystic fibrosis tesing is negative.
·You are asked to visit a 3-year-old girl at home. She is not known to you but from her notes you see that she has diagnoses of cerebral palsy, kyphoscoliosis and severe gastro-oesophageal reflux. She is fed via a gastrostomy tube. She has symptoms of a moist cough and fever. On examination, she has a respiratory rate of 28/minute and wheeze and crepitations throughout the chest.
Children with chronic neurological conditions often have gastrooesophageal reflux and are at high risk of recurrent aspiration. Fundoplication and gastrostomy feeds can help. Infections need to be treated early and aggressively because this is the main cause of mortality in this group of patients.
· A 6-week-old baby is brought to see you with breathing difficulties. She was born at 33 weeks’ gestation and was discharged home 2 weeks ago. She has a 24-hour history of fast, noisy breathing and reduced feeding and the mother thinks that she might have stopped breathing just now in the waiting room. On examination, there is subcostal recession and wheeze is heard bilaterally.
C Correct answer
Bronchiolitis is a viral illness affecting infants aged under 1 year. It is predominantly caused by respiratory syncitial virus (rsv). Clinical features include respiratory distress, wheeze, coryzal symptoms, lowgrade temperature and reduced feeding. Treatment is supportive. Those under the age of 2 months, ex-premature babies and those with existing pathology (eg cardiac disease) are at particular risk and can develop apnoeas. Paluvizumab, a monoclonal antibody against rsv, is now available, though it is very expensive. It is currently offered to premature babies with significant lung disease and to some children with cardiac problems
Thursday, 8 January 2009
AKT Questions
1. A 33- year-old woman presents with a 6-month history of a progressively painful area in the upper outer quadrant of her right breast. She has been on oral contraception intermittently for nearly 15 years. Clinically, there is as area of moderate nodularity in the right breast but no discrete lesion is palpable. Select the single most likely diagnosis from the list below?
A. benign breast change
B. breast carcinoma
C. fibroadenoma.
D. haematoma
E. mondor's disease.
Answer: A
Painful nodularity of the breast (unilateral or bilateral) is characteristic of benign breast change (sometimes referred to as "abnormalities of normal development and involution" or ANDI, "fibroadenosis" or "fibrocystic changes"). It affects 1/3 of all women and often causes anxiety in premenopausal women. The symptoms can be cyclical and evening primrose oil provides symptomatic relief.
2. Which of the following statements about Crohn's disease is true?
A. active disease should be treated initially with mesalazine
B. antimycobacterial therapies are an effective treatment if used early
C. anti-TNF-α therapy is associated with remission rates of 80%.
d. Crohn's disease only affects the colon
E. patients should be referred early for surgery.
Answer: B
Mesalazine is no better than placebo in the management of active disease. Its main use is in prevention of relapse after surgery. Infliximab is an effective anti-TNF-α therapy in up to 80% of cases, but only 24% are steroid free. Surgery should be reserved for patients who do not respond to steroids, Methotrexate or Infliximab. Antibiotics should only be used for septic complications and perianal disease. Crohn' disease can affect any part of the GI tract from the mouth to the anus.
A. benign breast change
B. breast carcinoma
C. fibroadenoma.
D. haematoma
E. mondor's disease.
Answer: A
Painful nodularity of the breast (unilateral or bilateral) is characteristic of benign breast change (sometimes referred to as "abnormalities of normal development and involution" or ANDI, "fibroadenosis" or "fibrocystic changes"). It affects 1/3 of all women and often causes anxiety in premenopausal women. The symptoms can be cyclical and evening primrose oil provides symptomatic relief.
2. Which of the following statements about Crohn's disease is true?
A. active disease should be treated initially with mesalazine
B. antimycobacterial therapies are an effective treatment if used early
C. anti-TNF-α therapy is associated with remission rates of 80%.
d. Crohn's disease only affects the colon
E. patients should be referred early for surgery.
Answer: B
Mesalazine is no better than placebo in the management of active disease. Its main use is in prevention of relapse after surgery. Infliximab is an effective anti-TNF-α therapy in up to 80% of cases, but only 24% are steroid free. Surgery should be reserved for patients who do not respond to steroids, Methotrexate or Infliximab. Antibiotics should only be used for septic complications and perianal disease. Crohn' disease can affect any part of the GI tract from the mouth to the anus.
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