Archives: MRCGP AKT

AKT-5729

A patient of yours with COPD who is in his 60s wants to travel to Spain on holiday. He plans to fly, but is prepared to drive and take the ferry if you tell him that he is not fit to do so.

You currently manage his COPD with a high dose seretide inhaler and PRN salbutamol. On examination at the surgery he looks relatively well. He has good bilateral air entry on auscultation of his chest and sparse bilateral wheeze.

How far should he be able to walk without shortness of breath to be able to fly?

AKT-5730

A 68-year-old gentleman presents for review. His notes indicate that he was recently treated with furosemide for heart failure after presenting with gradually increasing shortness of breath and bibasal crepitations. Despite taking the medication for the last week, he reports feeling no better and has marked exertional breathlessness. On examination, he is centrally cyanosed with finger clubbing and fine bibasal inspiratory crepitations. There is no evidence of peripheral edema. What is the most likely diagnosis?

AKT-5731

A 65-year-old man presents with a productive cough and fever. He has smoked 20 cigarettes per day for 40 years.

On examination he has dullness to percussion and reduced air entry at the right lung base. He doesn’t have any pain and is not breathless. You arrange a chest x ray, prescribe antibiotics and review him in one week.

He now feels better with less cough and no fever. His chest x ray reports an area of consolidation with a small pleural effusion at the right lung base. The radiologist recommends a follow up x ray in four weeks.

When the patient returns for the result of the follow up x ray the radiologist reports that there is little change in the appearances.

What is the most appropriate management of this patient?

AKT-5735

A 65-year-old man presents with haemoptysis and a cough for four weeks. Has been a publican for 35 years. He is a lifelong non-smoker and drinks around 20 units of alcohol per week.

He did not worry too much about his symptoms because he is a non-smoker, the amount of blood was very small and he also has a cold with a productive cough.

He has no abnormality in his chest on examination.

What is the most appropriate management?

AKT-5734

A 72-year-old man comes to the clinic with symptoms of a respiratory tract infection, including cough, shortness of breath, confusion, and diarrhea. He has recently returned from a long-term stay at a hotel in Spain. During the examination, you note a temperature of 39.2°C and signs of consolidation in the right lower lobe. Blood tests reveal an elevated white count and a sodium level of 128. What is the most appropriate statement regarding this man’s pneumonia?

AKT-5738

A 59-year-old presents with a complaint of breathlessness that has been ongoing for six months. The patient recently underwent spirometry testing with the practice nurse and the post bronchodilator results are as follows:

• FEV1/FVC ratio: 0.64
• FEV1 (% predicted) 60%

Despite receiving a short acting muscarinic antagonist from a colleague, the patient reports persistent breathlessness. Based on NICE guidance, what would be the most suitable course of action?

AKT-5736

You see a 35-year-old patient in your morning emergency clinic who takes Beclomethasone 400 micrograms daily for her asthma. She is currently using her salbutamol more often than normal. Over the past two weeks she has been suffering with a ‘cold’ and feels her breathing has worsened. She is bringing up a small amount of white phlegm but doesn’t complain of fevers. She tends to become wheezy (particularly at night). There are no associated chest pains but she does feel her chest is tight.

On examination, she is afebrile and her oxygen saturations of 95% in air. Her peak flow is 340 L/min (usually 475 L/min). She is able to speak in full sentences. Her respiratory rate is 20 respirations per minute and pulse is 88 bpm.

What would be the most appropriate treatment option for this patient?

AKT-5737

A 68-year-old woman with a recent diagnosis of chronic obstructive pulmonary disease (COPD) is seen.

Her spirometry shows an FEV1 of 42% predicted with an FEV1:FVC ratio of 64%. Her current treatment consists of a short-acting beta agonist (SABA) used as required which was started when a clinical diagnosis was made two to three months ago prior to her having had the spirometry performed. A chest x Ray was normal and she gave up cigarettes a few weeks ago. Her home peak flow measurments show a 30% diurnal variation.

On reviewing her symptoms she needs to use the SABA at least four times a day and despite this still feels persistently breathless. In addition, she tells you that over the last few years she gets attacks of ‘bronchitis’ two to three times a year. You can see from her notes that she has received at least two courses of antibiotics each year for the last three years for acute episodes of productive cough and shortness of breath.

Which of the following is the next most appropriate step in her pharmacological management?

AKT-5732

A 58-year-old complains of breathlessness for four months.
She has recently seen the practice nurse for spirometry testing and these are her post bronchodilator results:
FEV1/FVC ratio 0.60
FEV1 (% predicted) 65%
What is the most appropriate initial management for this patient?

AKT-5733

A 49-year-old female becomes ill after returning from a foreign holiday.

She complains of a dry cough, myalgia, abdominal pain and diarrhoea. She has a temperature of 38.3°C and auscultation of the chest reveals bibasal crepitations.

She had seen the out of hours GP two days previously who had prescribed her amoxicillin but this has not produced a clinical response.

Blood tests show:

Haemoglobin 136 g/L (130-180)

WBC 14.1 ×109/L (4-11)

Neutrophils 12.2 ×109/L (1.5-7)

Lymphocytes 0.9 ×109/L (1.5-4)

Sodium 121 mmol/L (137-144)

Potassium 4.3 mmol/L (3.5-4.9)

Urea 10.3 mmol/L (2.5-7.5)

Creatinine 176 µmol/L (60-110)

What is the most likely causative organism?