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 She is withdrawn and pre-occupied.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.
Friday, 28 November 2008
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.
Sunday, 5 October 2008
AKT Questions
1. A taxi driver re-attends your surgery. A urine sample taken one week before shows a positive test for metabolites of morphine verifying his story of drug misuse. He would like to go on to Buprenorphine (Subutex) as he hopes to detoxify quickly after a period of stabilisation. You agree. What is the single most common side effect of this regime?
a ) Respiratory depression
b ) Drowsiness
c ) Abdominal Pain
d ) Acute opiate withdrawal
e ) Depression
Answer: D
In patients taking a high level of opiates, Buprenorphine may precipitate withdrawal effects due to its partial antagonist activity on mu opioid receptors. It is for this reason that it is very safe in overdose, rarely causing typical opioid symptoms such as respiratory depression, drowsiness or abdominal pain and vomiting. These symptoms are more typically seen with Methadone, Lofexidine and Naltrexone respectively. Buprenorphine may however be implicated in respiratory depression if combined with alcohol or benzodiazepines.
2. A 23 year old man presents with a five day history of right lower lumbar pain with no obvious trigger factor, no radiation and no other symptoms. On examination, you find right lower lumbar paraspinal tenderness and reduced lumbar movements. Which is the single best evidence-based management plan?
a ) Acupuncture
b ) Staying active
c ) Back exercises
d ) Epidural injection
e ) Lumbar support
Answer: B
"Clinical Evidence" indicates that, for acute low back pain, advice to stay active and non steroidal anti inflammatory drugs are beneficial. Back exercises are unlikely to be beneficial and acupuncture, epidural steroid injection and lumbar support are of unknown effectiveness.
3. A woman has terminal pancreatic cancer and is on a syringe driver containing diamorphine in water. Her pain is very well controlled; but she has distressing respiratory secretions and is also very restless. Which two of the following could best be added to her syringe driver to control these symptoms?
a ) Cyclizine
b ) Dexamethasone
c ) Hyoscine hydrobromide
d ) Levomepromazine
e ) Metoclopramide
f ) Prochlorperazine
Answer: C & D
Hyoscine is very effective at controlling secretions in its hydrobromide form, whereas in its butylbromide form it is valuable for relief of bowel colic. It has some sedative effects but these would probably not be sufficient to control the woman’s restlessness. Levomepromazine would be ideal for this. Cyclizine and metoclopramide are useful anti emetics but cyclizine is particularly liable to precipitate with diamorphine. Dexamethasone can be given in a syringe driver to reduce cerebral oedema
4. A 49 year old man presents with a five week history of epigastric pain after meals. It is sometimes awakening him in the night. He has also been vomiting and is sure he has lost weight. On examination, you find epigastric tenderness, with no mass nor peritonism. An FBC is normal. Which is the single most appropriate investigation?
a ) Abdominal ultrasound
b ) Barium meal
c ) Serum amylase estimation
d ) Helicobacter pylori test
e ) Upper GI endoscopy
Answer: E
SIGN and NICE both recommend upper gastrointestinal endoscopy as the investigation of choice in dyspepsia with alarm symptoms (persistent vomiting, anorexia, weight loss, gastrointestinal blood loss or epigastric mass).
5. A 45 year old woman presents with tiredness, lethargy, dry skin constipation and weight gain. Of the following, which is the single most likely additional clinical feature that may be present?
a ) Carpal tunnel syndrome
b ) Proptosis
c ) Amenorrhoea
d ) Pre-tibial myxoedema
e ) Delirium
Answer: A
In Hypothyroidism mucopolysaccharide deposition can occur throughout the body affecting all organ systems. Pre-tibial myxoedema (swellings above the lateral malleoli) occurs in Graves Disease (overactive thyroid). Altered mental state can occur with depression and dementia and rarely myxoedematous coma. Other autoimmune diseases such as pernicious anaemia can be associated with hypothyroidism. Iron and folate deficiencies can occur with microcytic anaemias and macrocytosis.
a ) Respiratory depression
b ) Drowsiness
c ) Abdominal Pain
d ) Acute opiate withdrawal
e ) Depression
Answer: D
In patients taking a high level of opiates, Buprenorphine may precipitate withdrawal effects due to its partial antagonist activity on mu opioid receptors. It is for this reason that it is very safe in overdose, rarely causing typical opioid symptoms such as respiratory depression, drowsiness or abdominal pain and vomiting. These symptoms are more typically seen with Methadone, Lofexidine and Naltrexone respectively. Buprenorphine may however be implicated in respiratory depression if combined with alcohol or benzodiazepines.
2. A 23 year old man presents with a five day history of right lower lumbar pain with no obvious trigger factor, no radiation and no other symptoms. On examination, you find right lower lumbar paraspinal tenderness and reduced lumbar movements. Which is the single best evidence-based management plan?
a ) Acupuncture
b ) Staying active
c ) Back exercises
d ) Epidural injection
e ) Lumbar support
Answer: B
"Clinical Evidence" indicates that, for acute low back pain, advice to stay active and non steroidal anti inflammatory drugs are beneficial. Back exercises are unlikely to be beneficial and acupuncture, epidural steroid injection and lumbar support are of unknown effectiveness.
3. A woman has terminal pancreatic cancer and is on a syringe driver containing diamorphine in water. Her pain is very well controlled; but she has distressing respiratory secretions and is also very restless. Which two of the following could best be added to her syringe driver to control these symptoms?
a ) Cyclizine
b ) Dexamethasone
c ) Hyoscine hydrobromide
d ) Levomepromazine
e ) Metoclopramide
f ) Prochlorperazine
Answer: C & D
Hyoscine is very effective at controlling secretions in its hydrobromide form, whereas in its butylbromide form it is valuable for relief of bowel colic. It has some sedative effects but these would probably not be sufficient to control the woman’s restlessness. Levomepromazine would be ideal for this. Cyclizine and metoclopramide are useful anti emetics but cyclizine is particularly liable to precipitate with diamorphine. Dexamethasone can be given in a syringe driver to reduce cerebral oedema
4. A 49 year old man presents with a five week history of epigastric pain after meals. It is sometimes awakening him in the night. He has also been vomiting and is sure he has lost weight. On examination, you find epigastric tenderness, with no mass nor peritonism. An FBC is normal. Which is the single most appropriate investigation?
a ) Abdominal ultrasound
b ) Barium meal
c ) Serum amylase estimation
d ) Helicobacter pylori test
e ) Upper GI endoscopy
Answer: E
SIGN and NICE both recommend upper gastrointestinal endoscopy as the investigation of choice in dyspepsia with alarm symptoms (persistent vomiting, anorexia, weight loss, gastrointestinal blood loss or epigastric mass).
5. A 45 year old woman presents with tiredness, lethargy, dry skin constipation and weight gain. Of the following, which is the single most likely additional clinical feature that may be present?
a ) Carpal tunnel syndrome
b ) Proptosis
c ) Amenorrhoea
d ) Pre-tibial myxoedema
e ) Delirium
Answer: A
In Hypothyroidism mucopolysaccharide deposition can occur throughout the body affecting all organ systems. Pre-tibial myxoedema (swellings above the lateral malleoli) occurs in Graves Disease (overactive thyroid). Altered mental state can occur with depression and dementia and rarely myxoedematous coma. Other autoimmune diseases such as pernicious anaemia can be associated with hypothyroidism. Iron and folate deficiencies can occur with microcytic anaemias and macrocytosis.
Friday, 3 October 2008
AKT Psychiatry
1. A 33-year-old man comes for review of his depression. He has now been taking citalopram for 12 weeks with minimal effect on his symptoms. It is decided to switch him to venlafaxine. How should this be done?
A. 2 week period of overlapping the drugs
B. Withdraw citalopram with the commencement of venlafaxine once citalopram has been stopped
C. Wait 1 week after withdrawing citalopram before commencing venlafaxine
D. Wait 2 weeks after withdrawing citalopram before commencing venlafaxine
E. 1 week period of overlapping the drugs
Answer: B
The following is based on the Clinical Knowledge Summaries depression guidelinesSwitching from one SSRI to another SSRI
the first SSRI should be withdrawn before the second is started
if switching from fluoxetine then leave a gap of 4-7 days as it has a long half-life
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- exceptions include fluoxetine (should be withdrawn prior to TCAs being started) and clomipramine (should not be given with a SSRI)Switching from a SSRI to venlafaxine
withdraw the SSRI
start venlafaxine the next day (unless fluoxetine - wait 4-7 days as above)
2. A 34-year-old man confides in you that he experienced childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?
A. Hyperarousal
B. Emotional numbing
C. Nightmares
D. Loss of inhibitions
E. Avoidance
Answer: D
Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example a major disaster or childhood sexual abuse. It encompasses what became known as 'shell shock' following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one monthFeatures
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing – lack of ability to experience feelings, feeling detached
from other people
depression
drug or alcohol misuse
anger
unexplained physical symptoms
Management
following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
watchful waiting may be used for mild symptoms lasting less than 4 weeks
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended
3. A 24-year-old male is admitted to the Emergency Department complaining of severe abdominal pain. On examination he is shivering and rolling around the trolley. He has previously been investigated for abdominal pain and no cause has been found. He states that unless he is given morphine for the pain he will kill himself. This is an example of:
A. Hypochondrial disorder
B. Conversion disorder
C. Malingering
D. Munchausen's syndrome
E. Somatisation disorder
Answr: C
Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
Hypochondrial disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Conversion disorder
typically involve loss of motor or sensory function
some patients may experience secondary gain from loss of function
patients may be indifferent to their apparent disorder
Dissociative disorder
dissociation is a process of 'separating off' certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Munchausen's syndrome
also known as factitious disorder
the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
4. Which one of the following statements regarding cognitive behavioural therapy is incorrect?
A. May be useful in the management of generalised anxiety disorder
B. Can be used for patients already taking antidepressants
C. Usually consists of one to two hour sessions once per week
D. Should be completed within 4 months
E. Patients usually get around 35-40 hours in total
Answer: E
Main points
useful in the management of depression and anxiety disorders
usually consists of one to two hour sessions once per week
should be completed within 4 months
patients usually get around 16-20 hours in total
5. Which one of the following is not a first-rank symptom of schizophrenia?
A. Thought broadcasting
B. Visual hallucinations
C. Thought withdrawal
D. Delusional perceptions
E. Auditory hallucinations
Schneider's first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient's behaviour
Thought disorder*:
thought insertion
thought withdrawal
thought broadcasting
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'.
Other features of schizophrenia include
impaired insight
incongruity/blunting of affect (inappropriate emotion for circumstances)
decreased speech
neologisms: made-up words
catatonia
negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
*occasionally referred to as thought alienation
A. 2 week period of overlapping the drugs
B. Withdraw citalopram with the commencement of venlafaxine once citalopram has been stopped
C. Wait 1 week after withdrawing citalopram before commencing venlafaxine
D. Wait 2 weeks after withdrawing citalopram before commencing venlafaxine
E. 1 week period of overlapping the drugs
Answer: B
The following is based on the Clinical Knowledge Summaries depression guidelinesSwitching from one SSRI to another SSRI
the first SSRI should be withdrawn before the second is started
if switching from fluoxetine then leave a gap of 4-7 days as it has a long half-life
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- exceptions include fluoxetine (should be withdrawn prior to TCAs being started) and clomipramine (should not be given with a SSRI)Switching from a SSRI to venlafaxine
withdraw the SSRI
start venlafaxine the next day (unless fluoxetine - wait 4-7 days as above)
2. A 34-year-old man confides in you that he experienced childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?
A. Hyperarousal
B. Emotional numbing
C. Nightmares
D. Loss of inhibitions
E. Avoidance
Answer: D
Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example a major disaster or childhood sexual abuse. It encompasses what became known as 'shell shock' following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one monthFeatures
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing – lack of ability to experience feelings, feeling detached
from other people
depression
drug or alcohol misuse
anger
unexplained physical symptoms
Management
following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
watchful waiting may be used for mild symptoms lasting less than 4 weeks
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended
3. A 24-year-old male is admitted to the Emergency Department complaining of severe abdominal pain. On examination he is shivering and rolling around the trolley. He has previously been investigated for abdominal pain and no cause has been found. He states that unless he is given morphine for the pain he will kill himself. This is an example of:
A. Hypochondrial disorder
B. Conversion disorder
C. Malingering
D. Munchausen's syndrome
E. Somatisation disorder
Answr: C
Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
Hypochondrial disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Conversion disorder
typically involve loss of motor or sensory function
some patients may experience secondary gain from loss of function
patients may be indifferent to their apparent disorder
Dissociative disorder
dissociation is a process of 'separating off' certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Munchausen's syndrome
also known as factitious disorder
the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
4. Which one of the following statements regarding cognitive behavioural therapy is incorrect?
A. May be useful in the management of generalised anxiety disorder
B. Can be used for patients already taking antidepressants
C. Usually consists of one to two hour sessions once per week
D. Should be completed within 4 months
E. Patients usually get around 35-40 hours in total
Answer: E
Main points
useful in the management of depression and anxiety disorders
usually consists of one to two hour sessions once per week
should be completed within 4 months
patients usually get around 16-20 hours in total
5. Which one of the following is not a first-rank symptom of schizophrenia?
A. Thought broadcasting
B. Visual hallucinations
C. Thought withdrawal
D. Delusional perceptions
E. Auditory hallucinations
Schneider's first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient's behaviour
Thought disorder*:
thought insertion
thought withdrawal
thought broadcasting
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'.
Other features of schizophrenia include
impaired insight
incongruity/blunting of affect (inappropriate emotion for circumstances)
decreased speech
neologisms: made-up words
catatonia
negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
*occasionally referred to as thought alienation
Thursday, 2 October 2008
AKT Questions
1. Arrythmias: Concerning the above ECG and the list of available options.
a. Atrial Flutter
b. Ventricular Fibrillation
c. Premature Atrial Complex
d. 2nd Degree AV Block
e. Complete Heart Block
f. Mobitz type I
What abnormal rhythm is represented by the ECQ tracing above?
Answer: D
This is 2nd degree AV block (Mobitz II). It is almost always a disease of the distal conduction system. It is characterised by intermittently nonconducted P waves not preceded by PR prolongation and not followed by PR shortening. It is important as it may progress to Complete Heart Block
2. Depression: The NICE guidelines 2006 recommend one particular package of computerised Cognitive Behavioural Therapy (CBT) for the treatment of depression. Which package is this?
A.Beating the Blues
B. COPE
C. FearFighter
D. OCFighter
E. Overcoming Depression
Answer: A
NICE has made the following recommendations about the use of computerised cognitive behavioural therapy (CCBT) to treat depression and anxiety. It recommends using: 1. Beating the Blues for people with mild and moderate depression. 2. FearFighter for people with panic and phobia.
3. Pelvic Inflammatory Disease: Which ONE of the following is the most common causative organism implicated in Pelvic Inflammatory Disease (PID) in the UK?
A. Candida Albicans
B. Chlamydia trachomatis
C. Human Papilloma Virus
D. Mycoplasma genitalium
E Neisseria gonorrhoeae
Answer: B
The most common organism to cause PID in the UK is Chlamydia trachomatis (in at least 50%). Gonorrhoea (Neisseria gonorrhoea) is also a fairly common cause. Both may occur together, but in at least 20% of patients with PID no definite cause is found.
4. Whooping Cough: Which ONE of the following most closely matches the incubation period for Whooping Cough?
A. 0 - 5 days
B. 15 - 30 days
C. 5 - 15 days
D. > 30 days
E. none of the above
Answer: C
The incubation period of whooping cough (bordetella pertusis) - the time between contracting the infection and the appearance of the main symptoms - can vary from 5 to 15 days or even longer (as long as 20 days).
5. Intracranial Malignancy: A 57 year old gentleman well know to you presents to your clinic complaining of increasing headaches. He has an inoperable end-stage primary glioblastoma with raised intracranial pressure. What would you prescribe to help with his pain?
A. Amitryptilline
B. Dexamethasone
C. Paracetamol
D. Tramadol
E. Voltarol
Answer: B
In a palliative care setting such as this, short courses of high dose corticosteroids are often effective in reducing the oedema and raised intracranial pressure of brain malignancies.
6. Identification Of Heart Sounds: In which ONE of the following pathologies might you hear an opening snap after the second heart sound?
A. Aortic Regurgitation
B. Aortic Regurgitation
C. Aortic Stenosis
D. Mitral Stenosis
E. Patent Foramen Ovale
Answer: D
In Mitral Stenosis, an opening snap, which is an additional high pitched sound, may be heard after the A2 (aortic) component of the second heart sound. In individuals with mitral stenosis the pressure in the left ventricle can drop rapidly leading to forceful opening of the valve and hence the opening snap.
7. Osteoporosis: Which ONE of the following is NOT a risk factor for the development of osteoporosis?
A. Below Average BMI
B. Coeliac Disease
C. Female sex
D. High dietary salt intake
E. Hyperthyroidism
Answer: D
Whilst the WHO recognises limiting salt intake as part of a 'healthy lifestyle' and together with a number of other measures in attempting to delay or prevent the development of Osteoporosis, there is no definitve evidence that salt is a risk factor for Osteoporosis. Na-induced calciuria has been well documented and provides a physiological basis for the proposed role of dietary Na (or salt) as a risk factor for osteoporosis. However, the evidence is based primarily on acute salt-loading studies, and there are insufficient data on the effects of high salt intake on net Ca retention to predict long-term effects on bone health. Whilst a randomized longitudinal study of different sodium intake in two groups could clarify the role of sodium in bone mass, research to date has failed to confirm high dietary salt intake as a risk factor in the development of osteoporosis.
8. Breast Pathology: For each of the following scenarios select the most likely diagnosis.
a. Ductal carcinoma in-situ
b. Fibroadenoma
c. Benign mammary dysplasia
d. Phyllodes tumour
e. Duct ectasia
f. Fat necrosis
g. Carcinoma of the breast
h. Paget's disease of the nipple
1. A 42 year old woman presents with a firm palpable mass in her left breast. She has noticed the size has increased rapidly over the past 3 months and she has become concerned. There is no involvemnt or discharge from the nipple. Some tenderness over the left breast is noted with shiny, almost translucent skin, and the size is estimated at 5x8x10 cm.
Answer: D
Phyllodes tumours are rare, predominantly benign (around 90%), tumours that account for only about 1% of tumours of the breast. It is typically moveable with a smooth texture and relatively large in size (around 5cm). It is interesting to note it tends to involve the left breast more commonly than the right.
2. A 52 year old woman presents with a tender small but firm lump in her left breast. There is evidence of recent injury with overlying bruising and tenderness. Coarse calcification is noted on mammography and fat globules on excision biopsy.
Answer: E
3. A 57 year old lady with known intraductal breast carcinoma presents following left mastectomy with discharge of the nipple on that side accompanied by itching and flaking.
Answer: H
The incidence of Paget's diseae of the breast is around 4% of cases of female breast cancer. This syndrome presents as eczematoid skin changes such as redness and mild flaking of the nipple skin. As Paget's advances, symptoms may include tingling, itching, increased sensitivity, burning, and pain. There may also be discharge from the nipple. Most cases are associated with invasive breast cancer and some cases occur following mastectomy (as in this scenario) even if there is no breast tissue present. You should also note that it may also involve the aereolar skin in addition to the nipple.
9. Pathogenic Organisms: For each of the following clinical infections select the MOST LIKELY pathogenic organism from the list of available options.
a. Mycoplasma Pneumoniae
b. Haemophilus Influenzae
c. Staphylococcus Aureus
d. Bacteroides Fragilis
e. Polymicrobial
f. Escherichia Coli
1. A 23 year old woman with Crohn's disease and an associated perirectal abscess.
Answer: E
2. A 45 year old smoker with Community Acquired pneumonia
Answer:B
3. A 60 year old male with a Urinary Tract Infection.
Answer: F
4. A 68 year old gentleman with Bacterial Endocarditis
Answer: C
A variety of risk factors are associated with abcess development, these include Crohn's disease, radiation fibrosis, carcinoma and trauma. A perirectal abscess is usually an aerobic and anaerobic polymicrobial infection. Bacteroides Fragilis is the predominant anaerobe and other common bacteria include Escherichia Coli, Proteus, Bacteroides and Streptococcus. This is not to be confused with a perianal abscess which is easily palpable, not accompanied by fever or a raised white cell count unless concomitant with an immunosupressed state.
The most likely pathogen in community acquired pneumonia is streptococcus pneumoniae, however it is not offered as an option - haemophilus influenzae being the next most likely pathogen and therefore the correct choice. You should always remember that up to 13% of community acquired pneuomnia is viral in origin.
As with females, the usual route of inoculation in males is with gram-negative aerobic bacilli from the gut, with Escherichia coli being the most common offending organism. In males aged 3 months to 50 years. The incidence of UTI in men approaches that of women only in men older than 60 years.
Most cases of endocarditis are caused by a select group of organisms. Gram-positive bacteria, particularly alpha-haemolytic streptococci, staphylococcus aureus and coagualse-negative staphylococci are the most common. Enterococci are a rare cause but are often resistant to antibitotic treatment. Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella species (HACEK organisms) are particularly common in neonates and immunocompromised children. A patient may have typical clinical and/or echocardiographical findings of endocarditis but have persistently negative blood cultures. In this instance there may have been recent antibiotic therapy or infection with a fastidious organism.
10. Raynaud's Phenomenon: The most common cause of Raynaud's Phenomenon is?
A. Idiopathic
B. Rheumatoid arthritis
C. Scleroderma
D. Systemic Lupus Erythematosus
E. Through the use of vibrating tools or machinery
Answer: A
90% of cases of Raynaud's phenomenon are idiopathic.
Subscribe to:
Posts (Atom)