Below is a series of management options for patients who present to you with a sore throat. From the list of patients below select the single most appropriate management option. Each option may be used once, more than once, or not at all.
1. A 50 year old woman recently commenced on carbimazole for thyrotoxicosis presents with a sore throat and headache for one day. On examination her pharynx is red, her temperature 37.0 and she looks well.
A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days
Answer: D
This patient needs a full blood count the same day to exclude a carbimazole induced blood dyscrasia. If this is normal the decision on antibiotics can be made later.
2. A four year old child with a sore throat of two days duration. The family are due to go on holiday in three days. His throat looks red (but there are no exudates), he has mild cervical lymphadenopathy but there is no fever.
A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days
Answer: C
3. A 19 year old female student who presents with sore throat, fever, anterior and posterior cervical lymphadenopathy and who has a foul tonsillar exudate on examination.
A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days
Answer: F
She also needs a FBC and glandular fever screen since she could well have glandular fever. Amoxycillin is undesirable in this patient for two reasons:
1. She may develop a rash if she has glandular fever
2. It will interfere with the OCP if she is on it - which Penicillin V will not.
4. A 10 year old boy presents with his third attack of "tonsillitis". He has no cough. On examination he looks unwell, has tonsillar exudates, cervical lymphadenopathy and a temperature of 38.7 degrees centigrade.
A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days
Answer: F
see NICE guidance. He has four centor criteria. The recommended duration of antibiotics (if given) is 10 days
5. A two year old travelling person attends as an emergency. On examination she is snuffly but well, temperature 36.6 degrees C. Her throat is mildly injected.
A. Amoxycillin for five days
B. Amoxycillin for 10 days
C. Delayed antibiotic prescription
D. No antibiotics
E. Penicillin V for five days
F. Penicillin V for 10 days
Answer: D
There are no positive Centor criteria and management should be centred on parental education and the development of a shared management plan
Thursday, 18 March 2010
AKT revision
1. Which one of the following features is not consistent with acute conjunctivitis?
A. Bilateral red eyes
B. Lymphadenopathy
C. Mild photophobia
D. Papillae under an everted upper lid
E. Reduced visual acuity
Answer: E
2.A 25 year old male patient (with no significant past medical history) presents with a painful red right eye. On examination his corrected visual acuity is 6/12 in the affected eye, the redness is concentrated around the cornea and his right pupil is smaller than his left. Which of the following options represents the single most likely diagnosis?
A. Allergic Conjunctivitis
B. Glaucoma
C. Iritis
D. Marginal keratitis
E. Viral conjunctivitis
Answer: C
This is unlikely to be acute conjunctivitis because of the pattern of injection "circumlimbal", the reduction in visual acuity and the pupilary change. In this age group acute glaucoma would be unlikely - especially in the absence of any ophthalmic history.
3. A two month year old boy presents acutely with his third episode of conjunctivitis. Both he and his mother are otherwise well. What is the the single most appropriate management plan whilst awaiting swabs?
A. No antibiotic treatment
B. Oral antibiotic treatment
C. Topical antibiotic treatment
D. Both oral and topical antibiotic treatment
Answer: A
The most likely cause is naso-lacrimal duct obstruction although it is essential to exclude Ophthalmia Neonatorum (notably from Chlamydia) with this story . If swabs are negative most cases of acute conjunctivitis will resolve without treatment and if the cause of the problem is duct obstruction gentle massage of the nose (cephalo caudally whilst feeding) is said to help.
4. Which one of the following statements is true about acute sinusitis in adults?
A. Antibiotics are usually indicated in the presence of a purulent discharge
B. Decongestants have been shown to be effective
C. Plain X-Ray of the paranasal sinuses is a useful investigation in primary care
D. Sinusitis is more likely if symptoms are not preceded by an URTI
E. Sinusitis is more likely if there is pain in the teeth than if there is not
Answer: C
A. Bilateral red eyes
B. Lymphadenopathy
C. Mild photophobia
D. Papillae under an everted upper lid
E. Reduced visual acuity
Answer: E
2.A 25 year old male patient (with no significant past medical history) presents with a painful red right eye. On examination his corrected visual acuity is 6/12 in the affected eye, the redness is concentrated around the cornea and his right pupil is smaller than his left. Which of the following options represents the single most likely diagnosis?
A. Allergic Conjunctivitis
B. Glaucoma
C. Iritis
D. Marginal keratitis
E. Viral conjunctivitis
Answer: C
This is unlikely to be acute conjunctivitis because of the pattern of injection "circumlimbal", the reduction in visual acuity and the pupilary change. In this age group acute glaucoma would be unlikely - especially in the absence of any ophthalmic history.
3. A two month year old boy presents acutely with his third episode of conjunctivitis. Both he and his mother are otherwise well. What is the the single most appropriate management plan whilst awaiting swabs?
A. No antibiotic treatment
B. Oral antibiotic treatment
C. Topical antibiotic treatment
D. Both oral and topical antibiotic treatment
Answer: A
The most likely cause is naso-lacrimal duct obstruction although it is essential to exclude Ophthalmia Neonatorum (notably from Chlamydia) with this story . If swabs are negative most cases of acute conjunctivitis will resolve without treatment and if the cause of the problem is duct obstruction gentle massage of the nose (cephalo caudally whilst feeding) is said to help.
4. Which one of the following statements is true about acute sinusitis in adults?
A. Antibiotics are usually indicated in the presence of a purulent discharge
B. Decongestants have been shown to be effective
C. Plain X-Ray of the paranasal sinuses is a useful investigation in primary care
D. Sinusitis is more likely if symptoms are not preceded by an URTI
E. Sinusitis is more likely if there is pain in the teeth than if there is not
Answer: C
Monday, 8 March 2010
AKT Revision
1.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
A patient with ischaemic heart disease who has anaphylaxis to eggs.
True
There are very few contraindications to influenza vaccination which is also licensed in children. Generally speaking, it should be targeted to those with chronic disease and not (as in case 10) to the 'worried well'.
2. Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Chronic kidney disease stage four
False
3.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Diabetes (type 1)
False
4.
Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Healthy individual with multiple absences from work due to recurrent 'flu'
True
There are very few contraindications to influenza vaccination which is also licensed in children. Generally speaking, it should be targeted to those with chronic disease and not (as in case 10) to the 'worried well'.
5.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Lung cancer with bony metastases on chemotherapy
False
6.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Severe neutropoenia due to myelodysplasia
False
A patient with ischaemic heart disease who has anaphylaxis to eggs.
True
There are very few contraindications to influenza vaccination which is also licensed in children. Generally speaking, it should be targeted to those with chronic disease and not (as in case 10) to the 'worried well'.
2. Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Chronic kidney disease stage four
False
3.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Diabetes (type 1)
False
4.
Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Healthy individual with multiple absences from work due to recurrent 'flu'
True
There are very few contraindications to influenza vaccination which is also licensed in children. Generally speaking, it should be targeted to those with chronic disease and not (as in case 10) to the 'worried well'.
5.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Lung cancer with bony metastases on chemotherapy
False
6.Prevention of influenza—in which of the following patients is the routine administration of influenza vaccine inappropriate?
Severe neutropoenia due to myelodysplasia
False
AKT revision
1. A 23-year-old woman who is 12 weeks into her first pregnancy has failed to stop smoking by simple means asks whether you can help. You would like to balance the patient’s needs against best available evidence. Which one of the following options would be most appropriate?
A. Acupuncture
B. Buproprion
C. Nicotine lozenges
D. Nicotine patches
E. arenicline
Answer: C
There is no evidence that acupuncture works, buproprion and varenicline are contraindicated in both pregnancy and breastfeeding. It would seem prudent to minimize the duration of exposure of the fetus to nicotine—thus nicotine lozenges would be preferable to the longer acting patches.
- The following patient, who has failed to stop smoking by simple means, asks whether you can help. You would like to balance the patient’s needs against best available evidence.
A. Acupuncture
B. Buproprion
C. Nicotine lozenges
D. Nicotine patches
E. Varenicline
2. A 17-year-old boy whose grandfather has just died of lung cancer, who is still at school and smokes 10 cigarettes per day. He seems motivated.
Answer: D
The initial options would be between nicotine lozenges and patches. Since he is still at school (and teachers tend to object to chewing gum), D would be preferable.
3. A 52-year-old man with a history of seizures who relapsed after stopping nicotine replacement therapy (NRT) 6 months before and would prefer to try something else.
Answer: E
Buproprion is contraindicated due to the seizures and there is no evidence for acupuncture. While NRT may be used again, it would be reasonable to go along with the patient’s wishes.
4. A 32-year-old woman who considers herself a 'social smoker' in that she smokes approximately 20 cigarettes per week
Answer: C
There is some evidence that even 'light' smokers can be helped by smoking cessation therapy. This is an important subgroup (12 % of smokers do not smoke daily).
5. A 60-year-old man with ischaemic heart disease and mild COPD who has quit successfully with varenicline but fears relapse.
Answer: E
Acupuncture has no evidence of efficacy and there is no evidence that buproprion prevents relapse. NRT is an option (but he has ischaemic heart disease) and there is evidence that varenicline will prevent relapse if prescribed for a further 3 months.
6.A 65-year-old woman who would like help to reduce her habit but who does not wish to stop completely at the moment.
Answer: C
There is evidence that if the requests of such patients are granted, then they are more likely to quit in the future. There is, however, no evidence of long-term health benefit from 'cutting down'. NRT is licensed for this use and the evidence is actually for nicotine chewing gum. The choice of lozenges rather than patches is therefore for this reason as well as preventing the double effect of a patch (long acting) and a cigarette.
A. Acupuncture
B. Buproprion
C. Nicotine lozenges
D. Nicotine patches
E. arenicline
Answer: C
There is no evidence that acupuncture works, buproprion and varenicline are contraindicated in both pregnancy and breastfeeding. It would seem prudent to minimize the duration of exposure of the fetus to nicotine—thus nicotine lozenges would be preferable to the longer acting patches.
- The following patient, who has failed to stop smoking by simple means, asks whether you can help. You would like to balance the patient’s needs against best available evidence.
A. Acupuncture
B. Buproprion
C. Nicotine lozenges
D. Nicotine patches
E. Varenicline
2. A 17-year-old boy whose grandfather has just died of lung cancer, who is still at school and smokes 10 cigarettes per day. He seems motivated.
Answer: D
The initial options would be between nicotine lozenges and patches. Since he is still at school (and teachers tend to object to chewing gum), D would be preferable.
3. A 52-year-old man with a history of seizures who relapsed after stopping nicotine replacement therapy (NRT) 6 months before and would prefer to try something else.
Answer: E
Buproprion is contraindicated due to the seizures and there is no evidence for acupuncture. While NRT may be used again, it would be reasonable to go along with the patient’s wishes.
4. A 32-year-old woman who considers herself a 'social smoker' in that she smokes approximately 20 cigarettes per week
Answer: C
There is some evidence that even 'light' smokers can be helped by smoking cessation therapy. This is an important subgroup (12 % of smokers do not smoke daily).
5. A 60-year-old man with ischaemic heart disease and mild COPD who has quit successfully with varenicline but fears relapse.
Answer: E
Acupuncture has no evidence of efficacy and there is no evidence that buproprion prevents relapse. NRT is an option (but he has ischaemic heart disease) and there is evidence that varenicline will prevent relapse if prescribed for a further 3 months.
6.A 65-year-old woman who would like help to reduce her habit but who does not wish to stop completely at the moment.
Answer: C
There is evidence that if the requests of such patients are granted, then they are more likely to quit in the future. There is, however, no evidence of long-term health benefit from 'cutting down'. NRT is licensed for this use and the evidence is actually for nicotine chewing gum. The choice of lozenges rather than patches is therefore for this reason as well as preventing the double effect of a patch (long acting) and a cigarette.
Saturday, 27 February 2010
AKT
1. You are teaching a group of medical students basic clinical skills. Which one of the following statements is true?
A. Extrapyramidal syndromes characteristically produce an upper motor neurone pattern
B. Fasciculation of the tongue is an upper motor neurone feature of motor neurone disease
C. Lesions of peripheral nerves are usually upper motor neurone in type
D. Lower motor neurone lesions cause ankle clonus
E. Upgoing plantar responses and absent ankle jerks imply both upper and lower motor neurone lesions
Answer: E
This seemingly incompatible combination seen in conditions in which both upper and lower motor neurone lesions are present. These include advanced B12 deficiency and perhaps most commonly combined lumbar spondylosis and cervical myelopathy. While MND could, at least in theory, produce this pattern, it would not be characteristic. Remember that upper motor neurone lesions (that is lesions above the dorsal column cell or cranial nerve nucleus involve the pyramidal (corticospinal) tracts and produce spastic tone, increased reflexes, a characteristic pattern of weakness and sometimes ankle clonus. Plantar responses will be extensor. In contrast lower motor neurone lesions produce a flaccid tone, reduced reflexes and sometimes muscle fasciculation.
2. A right-handed male actor aged 66 presents with gradual deterioration of clarity in his speech. He has no problems with his teeth, pains in his mouth or associated neurological problems. Which is the single most likely site of his problem?
A. Bilateral upper motor neurone lesion of cranial nerves 1X and X
B. Left hemisphere
C. Lower motor neurone lesion of cranial nerves 1X and X
D. Midbrain
E. Right hemisphere
D. Midbrain
E. Right hemisphere
Answer: C
Motor neurone disease features high on the differential diagnosis here and careful assessment should be made of this patient’s swallowing and respiratory function. Dominant hemispheric lesions would be expected to produce dysphasia (not as in this case a dysarthria) and since the 1X and X nerve nuclei are below the level of the midbrain, a lesion at this site would not produce a LMN weakness. A bilateral corticospinal lesion, however, will produce (so called) ‘Pseudobulbar palsy’—the commonest causes of which are motor neurone disease and cerebrovascular disease. These are almost inevitably associated with other neuropsychiatric signs such as bilateral spasticity and emotional lability.
3. A 66-year-old man, known to have motor neurone disease presents with the gradual onset of breathlessness. Which is the single most helpful measure of respiratory function? [Show
A. Forced expiratory volume in 1 second (FEV1)
B. Forced vital capacity (FVC)
C. Forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC)
D. Oxygen saturation
E. Peak flow rate
Answer: B
Patients with MND may have weakness of the intercostal muscles and the diaphragm. Symptoms may vary from breathlessness to orthopnoea (the latter especially if there is diaphragmatic involvement). More non-specific symptoms include daytime drowsiness due to changes in sleep pattern caused by hypercapnia—this, as in other causes of hypercapnia, may produce a morning headache.FEV1 is an important measure but is of most use in obstructive airways disease. While the FEV1/FVC would probably show a restrictive pattern in MND, the information gained from the combination is of less use than the FVC alone. The FVC (or more correctly the VC) not only indicates severity but is also easy to measure serially. Oxygen saturation alone, while relevant, may be expected to be fairly normal even in relatively advanced disease due to the shape of the oxygen dissociation curve. Peak flow is not relevant in this context.
4. A man with motor neurone disease is prescribed riluzole for motor neurone disease. You see the patient regularly and have a ‘shared care’ arrangement for monitoring the therapy. Which one of the following blood tests requires regular monitoring? [Show Discussion]
A. Fasting glucose
B. Full blood count
C. Liver function
D. Renal function
E. Thyroid function
A. Fasting glucose
B. Full blood count
C. Liver function
D. Renal function
E. Thyroid function
Answer: C
Assuming normal baseline hepatic function, LFTs should be checked every month for 3 months, every 3 months for a further 9 months and every year thereafter.
5. A male patient has type 2 respiratory failure secondary to advanced motor neurone disease. When discussing options with him which is the single most appropriate initial way of delivering respiratory support should he wish to stay at home? [Show Discussion]
A. Endotracheal tube
B. Iron lung
C. Mask
D. Non-invasive ventilation
E. Tracheostomy
A. Endotracheal tube
B. Iron lung
C. Mask
D. Non-invasive ventilation
E. Tracheostomy
Answer: D
These portable devices are available via specialized respiratory units and prolong life. Further details of these (and other palliative measures) from the motor neurone disease association. http://www.mndassociation.org/
6. Which one of the following statements is true when considering a peripheral neuropathy
A. Examination should include testing from distally to proximally in the legs
B. Feet and hands are usually equally affected
C. Hyper-reflexia is characteristic
D. Hypertension is among the common causes
E. Joint position sense is usually absent if there is disturbance of pinprick sensation
B. Feet and hands are usually equally affected
C. Hyper-reflexia is characteristic
D. Hypertension is among the common causes
E. Joint position sense is usually absent if there is disturbance of pinprick sensation
Answer: A
There are many causes of peripheral neuropathy (alcohol and diabetes being two of the most common). Testing is best done for a given modality by first comparing the feet with (say) the upper leg which is likely to be normal. If there is a reproducible difference, it is then helpful to go from distal to proximal to see where sensation changes. The legs are usually affected before the hands and if anything hyporeflexia would be the norm. Hypertension is not a recognized cause and joint position sense loss would characteristically be a dorsal column problem.
7. The photograph below illustrates a previously fit middle-aged man who is recovering from a problem which started acutely 3 weeks before. Which one of the statements below is true? (See Figure 1)
A. He has a left-sided lower motor neurone weakness
B. He has a right-sided lower motor neurone weakness
C. He has a left-sided upper motor neurone weakness
D. He has a right-sided upper motor neurone weakness
B. He has a right-sided lower motor neurone weakness
C. He has a left-sided upper motor neurone weakness
D. He has a right-sided upper motor neurone weakness
Answer: A
This is most likely to be due to a Bell’s palsy. If this were an upper motor neurone weakness, the eye would not have been so obviously affected due to bilateral innervations. He does not require imaging or for that matter neurological referral unless atypical. If the weakness is prolonged (or recovery incomplete), the patient may benefit from assessment in a specialist facial nerve clinic.
Monday, 15 February 2010
AKT
1. A 59 year-old woman with rheumatoid arthritis requires antibiotic prophylaxis for recurrent urinary tract infections. She is currently taking methotrexate on a weekly basis.Which is the SINGLE LEAST appropriate antibiotic to prescribe for this patient? Select ONE option only.
A. Cefalexin
B. Ciprofloxacin
C. Co-amoxiclav
D. Nitrofurantoin
E. Trimethoprim
Answer: E
The BNF states that the excretion of methotrexate is possibly reduced by ciprofloxacin, which increases the risk of methotrexate toxicity. However, this is not as significant as the methotrexate-trimethoprim interaction.There is a risk of cholestatic jaundice with co-amoxiclav, and it would therefore be less suitable for prolonged use in any patient with a history of liver disease.The most serious complication of methotrexate therapy is bone marrow suppression, and hence the need for regular blood monitoring with a full blood count. The concomitant use of an anti-folate drug (e.g. trimethoprim) increases the risk of bone marrow suppression, and should therefore be avoided, especially for prolonged treatment courses.
2. A 30 year-old man presents with an eight month history of low back pain and stiffness which is worse in the mornings. He has a long history of bilateral heel pain.Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only. [Show Discussion]
A. Ankylosing spondylitis
B. Osteoarthritis
C. Psoriatic arthritis
D. Reactive arthritis
E. Rheumatoid arthritis
Answer: A
The history of stiffness suggests an inflammatory condition in this patient. Ankylosing spondylitis is more common in young men. There may be a positive family history, and there is a strong association with HLA B27. Extra-articular manifestations include Anterior uveitis, Apical lung fibrosis, AV heart block, Aortic regurgitation and aortitis, Amyloidosis, Achilles tendonitis and plantar fasciitis.This would be the main differential diagnosis here, as psoriatic arthritis can present with a spondyloarthropathy or sacroiliitis.It would be unusual for symptoms to continue for eight months with a reactive arthritis, and there would be usually be a preceding history of (typically) a gastrointestinal infection.
3. A 15 year-old boy presents with a two month history of fever and a painful, red swelling just above his left knee. There is no history of trauma.Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.
A. Ewing’s sarcoma
B. Juvenile idiopathic arthritis
C. Osgood-Schlatter’s disease
D. Osteomyelitis
E. Reactive arthritis
Answer: A
This is a rare but important diagnosis not to miss. It accounts for 2% of all childhood cancers. It is more common in males and typically presents in children and young adults aged 5-20 years. It may mimic an infective process, but red flag symptoms of fever, persistent pain (including nocturnal and rest pain) and persistent localised swelling should prompt an urgent referral to exclude a malignant lesion.Juvenile idiopathic arthritis refers to the onset of arthritis in a patient under the age of 16, which lasts for more than three months. If there are associated systemic features (e.g. fever, rash, lymphadenopathy), then it is referred to as Still’s disease.Osgood-Schlatter’s disease is an overuse condition which presents with pain (often bilateral) and tenderness over the tibial tuberosity, usually around the time of the pubertal growth spurt. Symptoms improve with rest. There should be no red flag symptoms present.Osteomyelitis would be unlikely in the absence of trauma, although can occur (e.g. from haematogenous spread).
4. A 38 year-old man presents having recently joined your practice. He is currently taking bendroflumethiazide for hypertension. He complains of recurrent episodic swelling and pain in his right ankle over the last three years. The practice nurse elicited the following clinical information at a new patient check yesterday:BMI 34.6BP 144/90Smoking status Ex-smokerAlcohol intake 40 units per weekUrinalysis Protein 1+Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only. [Show Discussion]
A. Gout
B. Osteoarthritis
C. Psoriatic arthritis
D. Reiter’s syndrome
E. Rheumatoid arthritis
Answer: A
The combination of alcohol excess and use of bendroflumethiazide make gout the most likely diagnosis here. Most cases of gout are idiopathic, but identifiable causes include: increased purine levels (e.g. diet and alcohol), decreased urate excretion (e.g. renal failure) and drugs (e.g. thiazide and loop diuretics). Common sites of involvement include the metatarsophalangeal joint (MTPJ) of the big toe, the ankle joint and the finger joints. Factors precipitating acute attacks of gout include dehydration, alcohol, trauma and infection.Osteoarthritis would be unlikely in a 38 year-old patient.The asymmetrical oligoarthropathy subtype of psoriatic arthritis would be the main differential diagnosis here. However, this is less common than gout, and therefore less likely.Reiter’s syndrome is a triad of urethritis, conjunctivitis and seronegative arthritis. There is an association with HLA B27 and it usually occurs following a genital or gastrointestinal infection (e.g. chlamydia, gonorrhoea, shigella or campylobacter).Rheumatoid arthritis typically presents as a symmetrical polyarthropathy with morning stiffness affecting the small joints of the hands and feet. It affects women more commonly than men.
5. A 22 year-old woman presents to an out of hours GP after slipping on a wet pavement. She complains of pain in her right ankle.According to the Ottawa ankle rules, which SINGLE clinical finding indicates the need for an ankle x-ray? Select ONE option only. [Show Discussion]
A. Bony tenderness over the anterior tip of the medial malleolus
B. Bony tenderness over the posterior tip of the lateral malleolus
C. Inability to dorsiflex the ankle
D. Inability to plantarflex the ankle
E. Swelling over the lateral malleolus
Answer: B
The Ottawa rules clearly state the indications for a plain film x-ray of the ankle, foot and knee.An ankle x-ray is required only if there is pain in the malleolar area, associated with any of the following:
• Pain on palpation over the posterior tip/edge of the lateral malleolus
• Pain on palpation over the posterior tip/edge of the medial malleolus
• Inability to weight bear
The Ottawa rules can be found at www.gp-training.net
6. A 56 year-old woman presents complaining of thoracic back pain. A plain film x-ray of her thoracic spine confirms a vertebral wedge fracture at T10. Her GP requests a DEXA scan to assess bone mineral density.Which SINGLE result would confirm a diagnosis of osteoporosis in this patient? Select ONE option only. [Show Discussion]
A. T score of -2.6
B. T score of -2.1
C. T score of +1.7
D. Z score of -1.3
E. Z score of +2.2
Answer: A
Bone mineral density (BMD) is usually expressed as the number of standard deviations (SD) from the young adult mean. This is known as the T score. Normal bone density is within 1 SD of the young adult mean (i.e. T score > -1). Osteopenia is defined by a T score between -1 and -2.5. Osteoporosis is defined as a T score < -2.5. BMD can also be expressed as the number of standard deviations from the age-related mean. This is the Z score, which enables a patient's risk to be compared to other patients of the same age
7. A 67 year-old man complains of aches and pains in his lower back and pelvis. The pain is constant and worse at night. Investigations including blood tests and a lumbar spine x-ray are requested. The lumbar spine x-ray reveals characteristic changes of Paget’s disease.Which is the SINGLE MOST likely bone profile result to be expected in Paget’s disease? Select ONE option only. [Show Discussion]
A. Low serum calcium, normal alkaline phosphatase
B. Normal serum calcium, normal alkaline phosphatase
C. Normal serum calcium, raised alkaline phosphatase
D. Raised serum calcium, normal alkaline phosphatase
E. Raised serum calcium, raised alkaline phosphatase
Answer: C
In Paget’s disease, the classical biochemical finding is an elevated alkaline phosphatase with a normal serum calcium. This reflects an increase in osteoclastic activity and bone turnover. Mild hypercalcaemia can occasionally be found if the patient has been immobile for a prolonged period.
A. Cefalexin
B. Ciprofloxacin
C. Co-amoxiclav
D. Nitrofurantoin
E. Trimethoprim
Answer: E
The BNF states that the excretion of methotrexate is possibly reduced by ciprofloxacin, which increases the risk of methotrexate toxicity. However, this is not as significant as the methotrexate-trimethoprim interaction.There is a risk of cholestatic jaundice with co-amoxiclav, and it would therefore be less suitable for prolonged use in any patient with a history of liver disease.The most serious complication of methotrexate therapy is bone marrow suppression, and hence the need for regular blood monitoring with a full blood count. The concomitant use of an anti-folate drug (e.g. trimethoprim) increases the risk of bone marrow suppression, and should therefore be avoided, especially for prolonged treatment courses.
2. A 30 year-old man presents with an eight month history of low back pain and stiffness which is worse in the mornings. He has a long history of bilateral heel pain.Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only. [Show Discussion]
A. Ankylosing spondylitis
B. Osteoarthritis
C. Psoriatic arthritis
D. Reactive arthritis
E. Rheumatoid arthritis
Answer: A
The history of stiffness suggests an inflammatory condition in this patient. Ankylosing spondylitis is more common in young men. There may be a positive family history, and there is a strong association with HLA B27. Extra-articular manifestations include Anterior uveitis, Apical lung fibrosis, AV heart block, Aortic regurgitation and aortitis, Amyloidosis, Achilles tendonitis and plantar fasciitis.This would be the main differential diagnosis here, as psoriatic arthritis can present with a spondyloarthropathy or sacroiliitis.It would be unusual for symptoms to continue for eight months with a reactive arthritis, and there would be usually be a preceding history of (typically) a gastrointestinal infection.
3. A 15 year-old boy presents with a two month history of fever and a painful, red swelling just above his left knee. There is no history of trauma.Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.
A. Ewing’s sarcoma
B. Juvenile idiopathic arthritis
C. Osgood-Schlatter’s disease
D. Osteomyelitis
E. Reactive arthritis
Answer: A
This is a rare but important diagnosis not to miss. It accounts for 2% of all childhood cancers. It is more common in males and typically presents in children and young adults aged 5-20 years. It may mimic an infective process, but red flag symptoms of fever, persistent pain (including nocturnal and rest pain) and persistent localised swelling should prompt an urgent referral to exclude a malignant lesion.Juvenile idiopathic arthritis refers to the onset of arthritis in a patient under the age of 16, which lasts for more than three months. If there are associated systemic features (e.g. fever, rash, lymphadenopathy), then it is referred to as Still’s disease.Osgood-Schlatter’s disease is an overuse condition which presents with pain (often bilateral) and tenderness over the tibial tuberosity, usually around the time of the pubertal growth spurt. Symptoms improve with rest. There should be no red flag symptoms present.Osteomyelitis would be unlikely in the absence of trauma, although can occur (e.g. from haematogenous spread).
4. A 38 year-old man presents having recently joined your practice. He is currently taking bendroflumethiazide for hypertension. He complains of recurrent episodic swelling and pain in his right ankle over the last three years. The practice nurse elicited the following clinical information at a new patient check yesterday:BMI 34.6BP 144/90Smoking status Ex-smokerAlcohol intake 40 units per weekUrinalysis Protein 1+Which is the SINGLE MOST likely diagnosis in this patient? Select ONE option only. [Show Discussion]
A. Gout
B. Osteoarthritis
C. Psoriatic arthritis
D. Reiter’s syndrome
E. Rheumatoid arthritis
Answer: A
The combination of alcohol excess and use of bendroflumethiazide make gout the most likely diagnosis here. Most cases of gout are idiopathic, but identifiable causes include: increased purine levels (e.g. diet and alcohol), decreased urate excretion (e.g. renal failure) and drugs (e.g. thiazide and loop diuretics). Common sites of involvement include the metatarsophalangeal joint (MTPJ) of the big toe, the ankle joint and the finger joints. Factors precipitating acute attacks of gout include dehydration, alcohol, trauma and infection.Osteoarthritis would be unlikely in a 38 year-old patient.The asymmetrical oligoarthropathy subtype of psoriatic arthritis would be the main differential diagnosis here. However, this is less common than gout, and therefore less likely.Reiter’s syndrome is a triad of urethritis, conjunctivitis and seronegative arthritis. There is an association with HLA B27 and it usually occurs following a genital or gastrointestinal infection (e.g. chlamydia, gonorrhoea, shigella or campylobacter).Rheumatoid arthritis typically presents as a symmetrical polyarthropathy with morning stiffness affecting the small joints of the hands and feet. It affects women more commonly than men.
5. A 22 year-old woman presents to an out of hours GP after slipping on a wet pavement. She complains of pain in her right ankle.According to the Ottawa ankle rules, which SINGLE clinical finding indicates the need for an ankle x-ray? Select ONE option only. [Show Discussion]
A. Bony tenderness over the anterior tip of the medial malleolus
B. Bony tenderness over the posterior tip of the lateral malleolus
C. Inability to dorsiflex the ankle
D. Inability to plantarflex the ankle
E. Swelling over the lateral malleolus
Answer: B
The Ottawa rules clearly state the indications for a plain film x-ray of the ankle, foot and knee.An ankle x-ray is required only if there is pain in the malleolar area, associated with any of the following:
• Pain on palpation over the posterior tip/edge of the lateral malleolus
• Pain on palpation over the posterior tip/edge of the medial malleolus
• Inability to weight bear
The Ottawa rules can be found at www.gp-training.net
6. A 56 year-old woman presents complaining of thoracic back pain. A plain film x-ray of her thoracic spine confirms a vertebral wedge fracture at T10. Her GP requests a DEXA scan to assess bone mineral density.Which SINGLE result would confirm a diagnosis of osteoporosis in this patient? Select ONE option only. [Show Discussion]
A. T score of -2.6
B. T score of -2.1
C. T score of +1.7
D. Z score of -1.3
E. Z score of +2.2
Answer: A
Bone mineral density (BMD) is usually expressed as the number of standard deviations (SD) from the young adult mean. This is known as the T score. Normal bone density is within 1 SD of the young adult mean (i.e. T score > -1). Osteopenia is defined by a T score between -1 and -2.5. Osteoporosis is defined as a T score < -2.5. BMD can also be expressed as the number of standard deviations from the age-related mean. This is the Z score, which enables a patient's risk to be compared to other patients of the same age
7. A 67 year-old man complains of aches and pains in his lower back and pelvis. The pain is constant and worse at night. Investigations including blood tests and a lumbar spine x-ray are requested. The lumbar spine x-ray reveals characteristic changes of Paget’s disease.Which is the SINGLE MOST likely bone profile result to be expected in Paget’s disease? Select ONE option only. [Show Discussion]
A. Low serum calcium, normal alkaline phosphatase
B. Normal serum calcium, normal alkaline phosphatase
C. Normal serum calcium, raised alkaline phosphatase
D. Raised serum calcium, normal alkaline phosphatase
E. Raised serum calcium, raised alkaline phosphatase
Answer: C
In Paget’s disease, the classical biochemical finding is an elevated alkaline phosphatase with a normal serum calcium. This reflects an increase in osteoclastic activity and bone turnover. Mild hypercalcaemia can occasionally be found if the patient has been immobile for a prolonged period.
AKT
1. A 34 year-old woman complains of tingling and numbness in her right hand for the past three weeks which is keeping her awake at night. The numbness is worst in the thumb, with some radiation to the right elbow.What is the SINGLE MOST likely diagnosis in this patient? Select ONE option only.
A. Cervical spondylosis
B. De Quervain’s tenosynovitis
C. Median nerve entrapment
D. Multiple sclerosis
E. Ulnar nerve entrapment
Answer: C
This is a typical history of carpal tunnel syndrome which is due to median nerve entrapment in the carpal tunnel at the wrist. Symptoms are worst at night, and pain and parasthesia can extend proximally in to the elbow and shoulder in some cases which may cause some confusion or difficulty with diagnosis. Tinel’s and Phalen’s tests are useful examination tools to help confirm the diagnosis, although they can often be negative in the presence of otherwise classical symptoms. In Tinel’s test, tapping over the carpal tunnel causes tingling in the distribution of the median nerve (thumb and radial two and a half fingers). In Phalen’s test, symptoms are elicited by forcible palmar flexion of the wrist causes venous engorgement of the carpal tunnel.Cervical spondylosis is common in the elderly, but would be unlikely in a 34 year-old patient.De Quervain’s tenosynovitis is an overuse condition. It is characterised by localised tenderness over the extensor and abductor tendon sheaths of the thumb.The most common site of ulnar nerve entrapment is at the elbow, and this typically causes parasthesia and/or weakness in the ring and little fingers.
2. A 62 year-old woman presents with pain and stiffness in both shoulders for the last four weeks. Her symptoms are worse in the mornings, and she also admits to low mood and recent-onset headaches.
A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis
Answer: H
The history of morning stiffness points towards this being an inflammatory condition, and in this age group polymyalgia rheumatica is common. It may be associated with other systemic and non-specific features such as malaise, anorexia, low-grade fever, weight loss and depression. The history of headaches raises the possibility of associated temporal arteritis, and this requires urgent further assessment.
3. A 56 year-old man presents with bilateral shoulder pain and weakness for the last three months. He has noticed increasing difficulty in lifting himself out of his armchair at home. Investigations reveal a raised C reactive protein and creatine kinase. [Show Discussion]
A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis
Answer: I
The history of objective weakness here suggests a possible muscular problem. In polymyositis the limb girdle or proximal muscles are most severely affected, but typically their bulk is preserved beyond that expected from their weakness. Raised C reactive protein and creatine kinase levels reflect the acute and chronic inflammation of skeletal muscle which occur in this condition.
4. A 44 year-old woman presents with pain in all of her joints for the last four months. Her symptoms are worse in the shoulders and hips. On examination she has multiple sites of tenderness including over both trapezius muscles. [Show Discussion]
A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis
Answer: B
Fibromyalgia is characterised by chronic widespread pain (for more than three months) and the presence of at least 11 out of 18 specified ‘tender points’.
A. Cervical spondylosis
B. De Quervain’s tenosynovitis
C. Median nerve entrapment
D. Multiple sclerosis
E. Ulnar nerve entrapment
Answer: C
This is a typical history of carpal tunnel syndrome which is due to median nerve entrapment in the carpal tunnel at the wrist. Symptoms are worst at night, and pain and parasthesia can extend proximally in to the elbow and shoulder in some cases which may cause some confusion or difficulty with diagnosis. Tinel’s and Phalen’s tests are useful examination tools to help confirm the diagnosis, although they can often be negative in the presence of otherwise classical symptoms. In Tinel’s test, tapping over the carpal tunnel causes tingling in the distribution of the median nerve (thumb and radial two and a half fingers). In Phalen’s test, symptoms are elicited by forcible palmar flexion of the wrist causes venous engorgement of the carpal tunnel.Cervical spondylosis is common in the elderly, but would be unlikely in a 34 year-old patient.De Quervain’s tenosynovitis is an overuse condition. It is characterised by localised tenderness over the extensor and abductor tendon sheaths of the thumb.The most common site of ulnar nerve entrapment is at the elbow, and this typically causes parasthesia and/or weakness in the ring and little fingers.
2. A 62 year-old woman presents with pain and stiffness in both shoulders for the last four weeks. Her symptoms are worse in the mornings, and she also admits to low mood and recent-onset headaches.
A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis
Answer: H
The history of morning stiffness points towards this being an inflammatory condition, and in this age group polymyalgia rheumatica is common. It may be associated with other systemic and non-specific features such as malaise, anorexia, low-grade fever, weight loss and depression. The history of headaches raises the possibility of associated temporal arteritis, and this requires urgent further assessment.
3. A 56 year-old man presents with bilateral shoulder pain and weakness for the last three months. He has noticed increasing difficulty in lifting himself out of his armchair at home. Investigations reveal a raised C reactive protein and creatine kinase. [Show Discussion]
A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis
Answer: I
The history of objective weakness here suggests a possible muscular problem. In polymyositis the limb girdle or proximal muscles are most severely affected, but typically their bulk is preserved beyond that expected from their weakness. Raised C reactive protein and creatine kinase levels reflect the acute and chronic inflammation of skeletal muscle which occur in this condition.
4. A 44 year-old woman presents with pain in all of her joints for the last four months. Her symptoms are worse in the shoulders and hips. On examination she has multiple sites of tenderness including over both trapezius muscles. [Show Discussion]
A. Chronic fatigue syndrome
B. Fibromyalgia
C. Hypothyroidism
D. Limb-girdle muscular dystrophy
E. Motor neurone disease
F. Myasthenia gravis
G. Osteoarthritis
H. Polymyalgia rheumatica
I. Polymyositis
J. Rheumatoid arthritis
Answer: B
Fibromyalgia is characterised by chronic widespread pain (for more than three months) and the presence of at least 11 out of 18 specified ‘tender points’.
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