1.A 23 year old nurse presents with nocturnal cough and wheeze. She has smoked 10 cigarettes daily for 6 years and is clinically well with a pulse rate of 70 beats per minute, respiratory rate 15 per minute and no chest signs. She has previously been well. Which one of the options below would be of most use in confirming her diagnosis? [Show Discussion]
A. Arterial blood gases
B. Chest X-Ray
C. Serial peak flow readings
D. Pulse oximetry
E. Spirometry
Answer: C
The distinction between asthma and COPD is made by considering the history and if necessary further investigations such as spirometry. Furthermore, despite the fact that she smokes, COPD is much more likely in patients over 35. This is a typical history for asthma. The fact that she is well when she sees you the next day and has no apparent abnormalities should not dissuade you from making this diagnosis. She should of course be discouraged from smoking.ABGs (even if they could be done in primary care) are inappropriate and likely to be normal, as is pulse oximetry – certainly during the daytime. In this setting (especially in a young woman) CXR is unlikely to be helpful – although if she does not respond to treatment should be considered. Bearing in mind that asthma is reversible airways obstruction spirometry may be normal – depending on whether it is don at a time when there is bronchospasm. Serial PFR is helpful on two countsa) A variability of 20% (usually lowest early in the morning or after trigger) is virtually diagnostic if the patient’s technique is adequate. It is important that the morning reading is done as soon as possible after rising and that the evening is around 5pm.b) It allows patients to self monitor in the future and play an active part in their ongoing management
Sunday, 8 February 2009
AKT Exam Questions
Theme: All the patients have recently been discharged from hospital. Match the patient scenarios below to a chosen option
1. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a knee replacement on Diclofenac 50mg tds as well as her other medications.
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: B
Stop the Diclofenac which has dangerous interactions with Warfarin and could potentially exacerbate renal problems in association with Ramipril.
2. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a chest infection on Erythromycin 500mg qds as well as her other medications
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: C
Erythromycin potentiates the action of warfarin but is presumably essential for whatever reason. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.
3. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a UTI on Ciprofloxacin 500mg bd as well as her other medications
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: C
Ciprofloxacin potentiates the action of warfarin but is presumably essential. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.
4. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She was admitted with a fall and is continuing to do so.
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: C
Persistent falls contra-indicate Warfarin. IN this case it is important however to exclude arrthymias (especially bradycardias with bisoprolol) and postural hypotension.
5. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She complains of insomnia and falls. The hospital have prescribed Mirtazepine 30mg at night for significant depression.
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: A
Assuming she is depressed, she may get better given time with mirtazepine. She requires careful cardiovascular assessment however – including postural blood pressures.
Theme – Prescribing for the Elderly
6. A 78 year old woman with longstanding hypertension consults you with marked ankle oedema. Her current medication is:- Ramipril 5mg daily; Amlodipine 5mg daily; Aspirin 75mg daily; Simvastatin 40mg daily and Lactulose 15ml at night. You can find no evidence of heart failure and her urine is negative. Her blood pressure is 140/78. Which one immediate intervention is most likely to help her?
A. Addition of Bendroflumethazide 5mg daily
B. Addition of Furosemide 40mg daily
C. Addition of Bumetamide 1mg daily
D. Stopping Amlodipine
E. Stopping Aspirin
F. Stopping Simvastatin
Answer: D
Stop Amlodipine. Despite its many benefits in this age group Amlodipine is a common cause of ankle oedema.
7. A 70 year old man presents to you as a new patient. He informs you that since a stroke two years ago he has suffered from dizziness and increasing difficulty mobilising. Initial recovery was good. His repeat prescriptions (from previous GP) are:- Ramipril 10mg daily; Indapamide 1.5mg daily; Aspirin 75mg daily; Atorvastatin 40mg daily; Furosemide 40mg daily; Prochlorperazine 5mg daily. Which focussed examinations below are most likely to lead to a management plan?
A. Cranial nerves and cerebellum
B. Mental state and reflexes
C. Muscle power and blood pressure
D. Postural blood pressure and gait
E. Pyramidal tracts and joint position sense
Answer: d
Postural blood pressure and gait. Regrettably this is not an uncommon scenario – inappropriate drug regimes find their way on to repeat prescribing systems (in this case a thiazide and loop diuretic which have synergistic actions) Consequences are treated symptomatically (in this case with a phenothiazine) which can itself cause Parkinsonism
1. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a knee replacement on Diclofenac 50mg tds as well as her other medications.
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: B
Stop the Diclofenac which has dangerous interactions with Warfarin and could potentially exacerbate renal problems in association with Ramipril.
2. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a chest infection on Erythromycin 500mg qds as well as her other medications
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: C
Erythromycin potentiates the action of warfarin but is presumably essential for whatever reason. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.
3. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a UTI on Ciprofloxacin 500mg bd as well as her other medications
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: C
Ciprofloxacin potentiates the action of warfarin but is presumably essential. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.
4. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She was admitted with a fall and is continuing to do so.
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: C
Persistent falls contra-indicate Warfarin. IN this case it is important however to exclude arrthymias (especially bradycardias with bisoprolol) and postural hypotension.
5. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She complains of insomnia and falls. The hospital have prescribed Mirtazepine 30mg at night for significant depression.
A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment
Answer: A
Assuming she is depressed, she may get better given time with mirtazepine. She requires careful cardiovascular assessment however – including postural blood pressures.
Theme – Prescribing for the Elderly
6. A 78 year old woman with longstanding hypertension consults you with marked ankle oedema. Her current medication is:- Ramipril 5mg daily; Amlodipine 5mg daily; Aspirin 75mg daily; Simvastatin 40mg daily and Lactulose 15ml at night. You can find no evidence of heart failure and her urine is negative. Her blood pressure is 140/78. Which one immediate intervention is most likely to help her?
A. Addition of Bendroflumethazide 5mg daily
B. Addition of Furosemide 40mg daily
C. Addition of Bumetamide 1mg daily
D. Stopping Amlodipine
E. Stopping Aspirin
F. Stopping Simvastatin
Answer: D
Stop Amlodipine. Despite its many benefits in this age group Amlodipine is a common cause of ankle oedema.
7. A 70 year old man presents to you as a new patient. He informs you that since a stroke two years ago he has suffered from dizziness and increasing difficulty mobilising. Initial recovery was good. His repeat prescriptions (from previous GP) are:- Ramipril 10mg daily; Indapamide 1.5mg daily; Aspirin 75mg daily; Atorvastatin 40mg daily; Furosemide 40mg daily; Prochlorperazine 5mg daily. Which focussed examinations below are most likely to lead to a management plan?
A. Cranial nerves and cerebellum
B. Mental state and reflexes
C. Muscle power and blood pressure
D. Postural blood pressure and gait
E. Pyramidal tracts and joint position sense
Answer: d
Postural blood pressure and gait. Regrettably this is not an uncommon scenario – inappropriate drug regimes find their way on to repeat prescribing systems (in this case a thiazide and loop diuretic which have synergistic actions) Consequences are treated symptomatically (in this case with a phenothiazine) which can itself cause Parkinsonism
Monday, 2 February 2009
AKT Questions:
Theme – Endoscopy The following patients all have gastrointestinal symptoms. Initial management should include one of the options below. Each option may be used once, more than once or not at all:-
1. A man of 48 who has a history of endoscopically proven duodenal ulceration five years ago for which he received H. Pylori eradication but was lost to follow up. He has recurrent dyspepsia but no red flag symptoms
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy
Answer: D
In these circumstances H. Pylori should be rechecked in the first instance (breath test or Stool antigen) and either PPI or eradication depending on the result.
2. 39 year old female nurse who has typical symptoms of reflux. Her body mass index is 35 and she had an initial response to two months high dose proton pump inhibitor.
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy
Answer: D
This patient should have lifestyle advice, H pylori testing and eradication if positive (even though her symptoms may initially get worse). If negative it would be reasonable to give a proton pump inhibitor as required but review her.
3. A man of 57 with recent onset persistent dyspepsia but no other "red flags".
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy
Answer: C
He should also have a blood screen and helicobacter testing.
4. A woman of 70 with recent onset of difficulty in swallowing
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy
Answer: B
This would be an indication for a "two week" referral.
5. A woman of 70 who takes diclofenac and is found to have a haemoglobin of 9.0 with an iron deficient picture
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy.
Answer: C
If the endoscopy does not explain the anaemia she should have a colonoscopy.
1. A man of 48 who has a history of endoscopically proven duodenal ulceration five years ago for which he received H. Pylori eradication but was lost to follow up. He has recurrent dyspepsia but no red flag symptoms
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy
Answer: D
In these circumstances H. Pylori should be rechecked in the first instance (breath test or Stool antigen) and either PPI or eradication depending on the result.
2. 39 year old female nurse who has typical symptoms of reflux. Her body mass index is 35 and she had an initial response to two months high dose proton pump inhibitor.
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy
Answer: D
This patient should have lifestyle advice, H pylori testing and eradication if positive (even though her symptoms may initially get worse). If negative it would be reasonable to give a proton pump inhibitor as required but review her.
3. A man of 57 with recent onset persistent dyspepsia but no other "red flags".
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy
Answer: C
He should also have a blood screen and helicobacter testing.
4. A woman of 70 with recent onset of difficulty in swallowing
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy
Answer: B
This would be an indication for a "two week" referral.
5. A woman of 70 who takes diclofenac and is found to have a haemoglobin of 9.0 with an iron deficient picture
A. Endoscopy the same day
B. Endoscopy within two weeks
C. Endoscopy routinely (within three months)
D. No need for endoscopy.
Answer: C
If the endoscopy does not explain the anaemia she should have a colonoscopy.
AKT Questions
1. OPTIONS:
a ) Amyotrophic lateral sclerosis
b ) Cerebrovascular accident
c ) Gastro-oesophageal reflux
d ) Hypoparathyroidism
e ) Hypothyroidism
f ) Laryngeal carcinoma
g ) Recurrent laryngeal nerve palsy
INSTRUCTION: For each of the patients below, choose the most likely cause of hoarseness above. Each option can be used once, more than once or not at all.
A. A 37 year old woman with a BMI of 34 has a history of dyspepsia. She is presenting with hoarseness which is worse in the morning.
The Correct answer is c.
B . A 68 year old man describes difficulty swallowing over the last few months. He is experiencing difficulties walking. He now presents with hoarseness.
The Correct answer is a.
C . A 53 year old woman, who underwent thyroid surgery four weeks ago, is now presenting with hoarseness.
The Correct answer is g.
2. Although hypothyroidism can cause vocal changes, hoarseness which is worse in the morning is likely to be associated with GORD. Obesity predisposes to GORD. Hoarseness, dysphagia and other motor symptoms are most likely to be caused by motor neurone disease (amyotrophic lateral sclerosis). Neck surgery can result in recurrent laryngeal nerve palsy in 1-2% of cases.
3. A double-blind, randomised, placebo-controlled trial, conducted in primary care, of a new drug for stroke prevention shows statistical and clinical evidence that the drug is superior to placebo in preventing stroke. In deciding whether or not to use this new drug, which one of the following statistics is most useful?
a ) NNK (Number Needed to Know)
b ) NNT (Number Needed to Treat)
c ) RRR (Relative Risk Reduction)
d ) CER (Control Event Rate)
e ) RRI (Relative Risk Increase)
Answer: B
The NNT (Number Needed to Treat) calculates the number of patients a clinician needs to treat in order to prevent one additional adverse outcome.
4. “The expanding use of qualitative research methodology has allowed us to gain knowledge about the characteristics, complexities and interrelationships of phenomena such as an individual’s experiences, emotions, beliefs and motives” (David Silverman, 2004). By applying this methodology in the primary care setting, we can obtain a greater understanding of the patients’ perspective and use this to improve patient health, the health care system and health service delivery. Which one of the following terms would you most associate with Qualitative rather than Quantitative research?
a ) Purposive sampling
b ) Controlled trials
c ) Randomisation
d ) Confidence interval
e ) Double blind
Answer: A
The randomised double blind controlled trial is the gold standard in quantitative research. Prospective studies can be used in Quantitative and Qualitative studies. Confidence intervals are used in statistics in relation to numeric data in Quantitative research. Purposive sampling is a sampling method used in Qualitative Research and is the selection of the most productive sample to answer the research question.
5. Your Practice Manager, of 10 years standing, has been off work for the last six months, with a diagnosis of Multiple Sclerosis. She contacts the Partners and asks if she can have a meeting and this is agreed. During the meeting, she confirms the diagnosis, stating that she realises the consequences of her physical impairment and its effect on her employability. Her mood and behaviour are entirely normal. She states that she is having some difficulties with normal day-to-day activities such as climbing stairs, doing housework, going shopping etc. She states that she wishes to return to work, as she is confident she can carry out all her previous management duties. She realises that getting to her upstairs office could be problematical and a whole day’s work could be overtiring. As her employer, which two management decisions would be most appropriate?
a ) Take her back as Practice Manager on a flexible, part-time basis
b ) Enforce her to take early ill-health retirement
c ) Revamp her working place environment
d ) Take her back as a Telephonist on a flexible ,part-time basis
e ) Take her back as Practice Manager only on a full time basis
f ) Tell her to keep getting sickness certificates from her Doctor
g ) Terminate her employment
The correct answers are, a, c.
Discrimination occurs against a disabled person if an employer treats someone less favourably than others who do not have a disability. The employer has a duty to look at whether there are any reasonable adjustments that can help the disabled person return to work (e.g. Changing hours, changing the local work place environment). The Disability Discrimination Act (2005) extends the definition of discrimination to people with progressive conditions such as Cancer, Multiple Sclerosis, and H.I.V.
a ) Amyotrophic lateral sclerosis
b ) Cerebrovascular accident
c ) Gastro-oesophageal reflux
d ) Hypoparathyroidism
e ) Hypothyroidism
f ) Laryngeal carcinoma
g ) Recurrent laryngeal nerve palsy
INSTRUCTION: For each of the patients below, choose the most likely cause of hoarseness above. Each option can be used once, more than once or not at all.
A. A 37 year old woman with a BMI of 34 has a history of dyspepsia. She is presenting with hoarseness which is worse in the morning.
The Correct answer is c.
B . A 68 year old man describes difficulty swallowing over the last few months. He is experiencing difficulties walking. He now presents with hoarseness.
The Correct answer is a.
C . A 53 year old woman, who underwent thyroid surgery four weeks ago, is now presenting with hoarseness.
The Correct answer is g.
2. Although hypothyroidism can cause vocal changes, hoarseness which is worse in the morning is likely to be associated with GORD. Obesity predisposes to GORD. Hoarseness, dysphagia and other motor symptoms are most likely to be caused by motor neurone disease (amyotrophic lateral sclerosis). Neck surgery can result in recurrent laryngeal nerve palsy in 1-2% of cases.
3. A double-blind, randomised, placebo-controlled trial, conducted in primary care, of a new drug for stroke prevention shows statistical and clinical evidence that the drug is superior to placebo in preventing stroke. In deciding whether or not to use this new drug, which one of the following statistics is most useful?
a ) NNK (Number Needed to Know)
b ) NNT (Number Needed to Treat)
c ) RRR (Relative Risk Reduction)
d ) CER (Control Event Rate)
e ) RRI (Relative Risk Increase)
Answer: B
The NNT (Number Needed to Treat) calculates the number of patients a clinician needs to treat in order to prevent one additional adverse outcome.
4. “The expanding use of qualitative research methodology has allowed us to gain knowledge about the characteristics, complexities and interrelationships of phenomena such as an individual’s experiences, emotions, beliefs and motives” (David Silverman, 2004). By applying this methodology in the primary care setting, we can obtain a greater understanding of the patients’ perspective and use this to improve patient health, the health care system and health service delivery. Which one of the following terms would you most associate with Qualitative rather than Quantitative research?
a ) Purposive sampling
b ) Controlled trials
c ) Randomisation
d ) Confidence interval
e ) Double blind
Answer: A
The randomised double blind controlled trial is the gold standard in quantitative research. Prospective studies can be used in Quantitative and Qualitative studies. Confidence intervals are used in statistics in relation to numeric data in Quantitative research. Purposive sampling is a sampling method used in Qualitative Research and is the selection of the most productive sample to answer the research question.
5. Your Practice Manager, of 10 years standing, has been off work for the last six months, with a diagnosis of Multiple Sclerosis. She contacts the Partners and asks if she can have a meeting and this is agreed. During the meeting, she confirms the diagnosis, stating that she realises the consequences of her physical impairment and its effect on her employability. Her mood and behaviour are entirely normal. She states that she is having some difficulties with normal day-to-day activities such as climbing stairs, doing housework, going shopping etc. She states that she wishes to return to work, as she is confident she can carry out all her previous management duties. She realises that getting to her upstairs office could be problematical and a whole day’s work could be overtiring. As her employer, which two management decisions would be most appropriate?
a ) Take her back as Practice Manager on a flexible, part-time basis
b ) Enforce her to take early ill-health retirement
c ) Revamp her working place environment
d ) Take her back as a Telephonist on a flexible ,part-time basis
e ) Take her back as Practice Manager only on a full time basis
f ) Tell her to keep getting sickness certificates from her Doctor
g ) Terminate her employment
The correct answers are, a, c.
Discrimination occurs against a disabled person if an employer treats someone less favourably than others who do not have a disability. The employer has a duty to look at whether there are any reasonable adjustments that can help the disabled person return to work (e.g. Changing hours, changing the local work place environment). The Disability Discrimination Act (2005) extends the definition of discrimination to people with progressive conditions such as Cancer, Multiple Sclerosis, and H.I.V.
AKT Questions
1. A 26-year-old woman presents having slipped off of a kerb 15 minutes earlier and twisted her left ankle while running for a bus. She has been helped to the surgery by two friends, who are supporting her on each side. She states that, although she was able to weight-bear immediately after the accident, she is now unable to do so because of the pain. She is a normally fit and healthy woman. According to the Ottawa Ankle and Foot Rules, which one of the following examination findings, in this case, is an immediate indication for onward referral for x-ray of the ankle?
a ) Bone tenderness over the anterior edge of the lateral malleolus
b ) Bone tenderness over the posterior edge of the lateral malleolus
c ) Bruising and tenderness over the anterior talofibular ligament
d ) Inability to weight-bear on the affected ankle at the time of examination
e ) Pain over the dorsal ligaments on resisted dorsiflexion of the foot
Answer: B
Findings other than B are present in soft tissue injury and do not obligate radiological assessment. Inability to weight-bear immediately after the injury, rather than at the time of examination (by which time soft tissue swelling contributes to the pain), is suspicious of a fracture and indicates an X-ray. The Ottawa Ankle and Foot Rules are not validated for use in those under 18 years of age. Their use can reduce the need for X-rays by around 25% and are readily applied to the primary care setting. See reference for full details of 'the Rules'.
2. A trainer relates to his registrar how, over the years, he has written down ideas, memories, connections, or emotions – the patient who gives a gift, the relative who is bereaved, the colleague who inspires. The audience is the writer himself. What single adjective best describes this form of writing?
a ) Analytical
b ) Biographical
c ) Creative
d ) Historical
e ) Reflective
Answer: E
3. OPTIONS:
a ) Acute closed-angle glaucoma
b ) Bacterial conjunctivitis
c ) Episcleritis
d ) Keratitis
e ) Orbital cellulitis
f ) Scleritis
g ) Subconjunctival haemorrhage
INSTRUCTION: For each patient with a painful red eye, select the single most likely above diagnosis. Each option can be used once, more than once or not at all.
A . A 26 year old man, with no significant past history, presents to you with a three day history of increasing pain and redness of his left eye. He has been unable to wear his contact lenses due to the pain. He has blurred vision and is photophobic in this eye. On examination, he has pericorneal redness of the eye. His pupil reacts normally to light. Insertion of fluorescein reveals an irregular green patch on his cornea.
The Correct answer is d.
B . A 78 year old woman with dementia is visited urgently by you. She is unable to give a history but the nursing home staff report that she has become increasingly distressed and has vomited twice. She is moaning and rocking back and forth holding her head. While examining her, you notice her right eye is red while the left is normal. The redness is around the cornea and the pupil is unreactive to light. Insertion of fluorescein reveals no staining.
The Correct answer is a.
C . A 32 year old woman presents with an acutely painful red right eye and blurred vision. She has had recent swollen joints and takes a non steroidal anti-inflammatory. On examination, she is distressed with the pain and there is marked vasodilation of the vessels all over the white of her eye and it has a bluish appearance. Visual acuity in the right eye is 6/18. Insertion of fluorescein reveals no staining.
The Correct answer is f.
Keratitis can cause ulceration of the cornea which can be sight threatening due to scarring if not treated rapidly. If suspected, an immediate ophthalmology referral is necessary. Acute closed-angle glaucoma necessitates immediate ophthalmology assessment to avoid loss of sight. Symptoms may be preceded by warning haloes and on examination the cornea will be oedematous and appear hazy. Scleritis is often associated with connective tissue diseases. It is very painful and requires urgent ophthalmology assessment as systemic treatment may be required. Without treatment, permanent loss of vision may occur in the affected eye or even perforation of the globe. In posterior scleritis the sclera may look normal. Therefore any rheumatoid patient with a very painful eye should be referred for further assessment. Episcleritis is much less serious and usually affects only part of the eye and is less painful. It can be treated using NSAIDs.
4. OPTIONS:
a ) Amyotrophic lateral sclerosis
b ) Cerebrovascular accident
c ) Gastro-oesophageal reflux
d ) Hypoparathyroidism
e ) Hypothyroidism
f ) Laryngeal carcinoma
g ) Recurrent laryngeal nerve palsy
INSTRUCTION: For each of the patients below, choose the most likely cause of hoarseness above. Each option can be used once, more than once or not at all.
A . A 37 year old woman with a BMI of 34 has a history of dyspepsia. She is presenting with hoarseness which is worse in the morning.
The Correct answer is c.
B . A 68 year old man describes difficulty swallowing over the last few months. He is experiencing difficulties walking. He now presents with hoarseness.
The Correct answer is a.
C . A 53 year old woman, who underwent thyroid surgery four weeks ago, is now presenting with hoarseness.
The Correct answer is g.
a ) Bone tenderness over the anterior edge of the lateral malleolus
b ) Bone tenderness over the posterior edge of the lateral malleolus
c ) Bruising and tenderness over the anterior talofibular ligament
d ) Inability to weight-bear on the affected ankle at the time of examination
e ) Pain over the dorsal ligaments on resisted dorsiflexion of the foot
Answer: B
Findings other than B are present in soft tissue injury and do not obligate radiological assessment. Inability to weight-bear immediately after the injury, rather than at the time of examination (by which time soft tissue swelling contributes to the pain), is suspicious of a fracture and indicates an X-ray. The Ottawa Ankle and Foot Rules are not validated for use in those under 18 years of age. Their use can reduce the need for X-rays by around 25% and are readily applied to the primary care setting. See reference for full details of 'the Rules'.
2. A trainer relates to his registrar how, over the years, he has written down ideas, memories, connections, or emotions – the patient who gives a gift, the relative who is bereaved, the colleague who inspires. The audience is the writer himself. What single adjective best describes this form of writing?
a ) Analytical
b ) Biographical
c ) Creative
d ) Historical
e ) Reflective
Answer: E
3. OPTIONS:
a ) Acute closed-angle glaucoma
b ) Bacterial conjunctivitis
c ) Episcleritis
d ) Keratitis
e ) Orbital cellulitis
f ) Scleritis
g ) Subconjunctival haemorrhage
INSTRUCTION: For each patient with a painful red eye, select the single most likely above diagnosis. Each option can be used once, more than once or not at all.
A . A 26 year old man, with no significant past history, presents to you with a three day history of increasing pain and redness of his left eye. He has been unable to wear his contact lenses due to the pain. He has blurred vision and is photophobic in this eye. On examination, he has pericorneal redness of the eye. His pupil reacts normally to light. Insertion of fluorescein reveals an irregular green patch on his cornea.
The Correct answer is d.
B . A 78 year old woman with dementia is visited urgently by you. She is unable to give a history but the nursing home staff report that she has become increasingly distressed and has vomited twice. She is moaning and rocking back and forth holding her head. While examining her, you notice her right eye is red while the left is normal. The redness is around the cornea and the pupil is unreactive to light. Insertion of fluorescein reveals no staining.
The Correct answer is a.
C . A 32 year old woman presents with an acutely painful red right eye and blurred vision. She has had recent swollen joints and takes a non steroidal anti-inflammatory. On examination, she is distressed with the pain and there is marked vasodilation of the vessels all over the white of her eye and it has a bluish appearance. Visual acuity in the right eye is 6/18. Insertion of fluorescein reveals no staining.
The Correct answer is f.
Keratitis can cause ulceration of the cornea which can be sight threatening due to scarring if not treated rapidly. If suspected, an immediate ophthalmology referral is necessary. Acute closed-angle glaucoma necessitates immediate ophthalmology assessment to avoid loss of sight. Symptoms may be preceded by warning haloes and on examination the cornea will be oedematous and appear hazy. Scleritis is often associated with connective tissue diseases. It is very painful and requires urgent ophthalmology assessment as systemic treatment may be required. Without treatment, permanent loss of vision may occur in the affected eye or even perforation of the globe. In posterior scleritis the sclera may look normal. Therefore any rheumatoid patient with a very painful eye should be referred for further assessment. Episcleritis is much less serious and usually affects only part of the eye and is less painful. It can be treated using NSAIDs.
4. OPTIONS:
a ) Amyotrophic lateral sclerosis
b ) Cerebrovascular accident
c ) Gastro-oesophageal reflux
d ) Hypoparathyroidism
e ) Hypothyroidism
f ) Laryngeal carcinoma
g ) Recurrent laryngeal nerve palsy
INSTRUCTION: For each of the patients below, choose the most likely cause of hoarseness above. Each option can be used once, more than once or not at all.
A . A 37 year old woman with a BMI of 34 has a history of dyspepsia. She is presenting with hoarseness which is worse in the morning.
The Correct answer is c.
B . A 68 year old man describes difficulty swallowing over the last few months. He is experiencing difficulties walking. He now presents with hoarseness.
The Correct answer is a.
C . A 53 year old woman, who underwent thyroid surgery four weeks ago, is now presenting with hoarseness.
The Correct answer is g.
1. Following prostatic biopsy, a 65 year old man, with spinal pain, has been confirmed as suffering from prostatic carcinoma. You are asked to prescribe him Goserelin, every 12 weeks and Cyproterone for three weeks. He asks you the reasons for having this combined therapy. The addition of the anti-androgen reduces the risk of which one of the following side effects of the gonadorelin analogue?
a ) Injection-site reaction
b ) Tumour ’flare’
c ) Hair loss
d ) Mood change
e ) Peripheral oedema
Answer: B
During the initial stage (1-2 weeks) of using Goserelin, increased production of testosterone may be associated with progression of prostate cancer. In susceptible patients, this tumour ‘flare’ may cause spinal cord compression, ureteric obstruction or increased bone pain. To reduce this risk, anti-androgen treatment (eg. Cyproterone) should be started three days before the Goserelin and continued for three weeks. The other recognised side-effects quoted will not be affected by this short term use of the anti- androgen.
2. In the process of critically appraising a randomised controlled trial (RCT), which one of the following terms is used to describe the generalisability of the trial results to your own defined patient population?
a ) Heterogeneity
b ) Reproducibility
c ) Significance
d ) External validity
e ) Positive predictive value
Answer: D
In assessments of the validity of studies of healthcare interventions, selection bias refers to systematic differences between comparison groups in prognosis or responsiveness to treatment. Random allocation with adequate concealment of allocation protects against selection bias. Other means of selecting who receives the intervention of interest, particularly leaving it up to the providers and recipients of care, are more prone to bias because decisions about care can be related to prognosis and responsiveness to treatment.
Selection bias is sometimes used to describe a systematic error in reviews due to how studies are selected for inclusion. Publication bias is an example of this type of selection bias.
Selection bias, confusingly, is also sometimes used to describe a systematic difference in characteristics between those who are selected for study and those who are not. This affects the generalisability (external validity) of a study but not its (internal) validity.
3. Your new registrar is keen to utilise her Information Management & Technology skills to enhance the care of her patients. Which one of the following is an online clinical decision support system specifically for general practitioners?
a ) MEDLINE
b ) PRODIGY
c ) NeLH
d ) OMNI
e ) EMIS
f ) VISION
Answer: B
PRODIGY is an online clinical decision support system for general practitioners. MEDLINE and OMNI are medical web-based information systems. NeLH provides access to the best current knowledge available for improving healthcare, clinical practice and patient choice. EMIS and VAMP VISION are practice based computer systems.
a ) Injection-site reaction
b ) Tumour ’flare’
c ) Hair loss
d ) Mood change
e ) Peripheral oedema
Answer: B
During the initial stage (1-2 weeks) of using Goserelin, increased production of testosterone may be associated with progression of prostate cancer. In susceptible patients, this tumour ‘flare’ may cause spinal cord compression, ureteric obstruction or increased bone pain. To reduce this risk, anti-androgen treatment (eg. Cyproterone) should be started three days before the Goserelin and continued for three weeks. The other recognised side-effects quoted will not be affected by this short term use of the anti- androgen.
2. In the process of critically appraising a randomised controlled trial (RCT), which one of the following terms is used to describe the generalisability of the trial results to your own defined patient population?
a ) Heterogeneity
b ) Reproducibility
c ) Significance
d ) External validity
e ) Positive predictive value
Answer: D
In assessments of the validity of studies of healthcare interventions, selection bias refers to systematic differences between comparison groups in prognosis or responsiveness to treatment. Random allocation with adequate concealment of allocation protects against selection bias. Other means of selecting who receives the intervention of interest, particularly leaving it up to the providers and recipients of care, are more prone to bias because decisions about care can be related to prognosis and responsiveness to treatment.
Selection bias is sometimes used to describe a systematic error in reviews due to how studies are selected for inclusion. Publication bias is an example of this type of selection bias.
Selection bias, confusingly, is also sometimes used to describe a systematic difference in characteristics between those who are selected for study and those who are not. This affects the generalisability (external validity) of a study but not its (internal) validity.
3. Your new registrar is keen to utilise her Information Management & Technology skills to enhance the care of her patients. Which one of the following is an online clinical decision support system specifically for general practitioners?
a ) MEDLINE
b ) PRODIGY
c ) NeLH
d ) OMNI
e ) EMIS
f ) VISION
Answer: B
PRODIGY is an online clinical decision support system for general practitioners. MEDLINE and OMNI are medical web-based information systems. NeLH provides access to the best current knowledge available for improving healthcare, clinical practice and patient choice. EMIS and VAMP VISION are practice based computer systems.
AKT Questions
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.
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.
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