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  • Question 1 - You are cleaning out your medicine cabinet and you come across some expired...

    Incorrect

    • You are cleaning out your medicine cabinet and you come across some expired ampoules of diamorphine. You want to dispose of them.
      Who among the following individuals could witness their destruction?

      Your Answer: Any senior practice nurse

      Correct Answer: Any practice manager

      Explanation:

      Destruction and Disposal of Controlled Drugs

      Destruction and disposal of controlled drugs are strictly regulated and require an authorized witness to observe and counter-sign the controlled drugs register to confirm destruction has taken place, even after the drugs have expired. It is important to note that not everyone is allowed to witness the destruction of controlled drugs. The list of authorized witnesses includes any Police Constable, Inspectors of the General Pharmaceutical Council, CCG chief pharmacist or pharmaceutical prescribing adviser who reports directly to the chief executive or to a director of the CCG, a registered medical practitioner who has been appointed to the CCG Professional Executive Committee or equivalent, the CCG board executive member with responsibility for clinical governance or risk management, and the medical director of a CCG.

      It is crucial to understand that practice nurses or GP partners are not allowed to witness the destruction of controlled drugs. While any Police Constable or CCG Medical Directors may witness the destruction of CDs, there are also other possible authorized witnesses. However, in practice, it is not practical for CCG Medical Directors to visit practices solely for the purpose of witnessing the destruction of CDs, and regions will have their own protocols in place for the collection and/or destruction of CDs. It is also important to note that patient-held CDs returned to community pharmacies or dispensing doctors’ practices do not require an authorized witness to be present for them to be destroyed. This distinction is essential to remember, especially when being tested on it in the AKT exam.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      24.3
      Seconds
  • Question 2 - A 38-year-old woman comes in for evaluation. Her spouse reports that she had...

    Incorrect

    • A 38-year-old woman comes in for evaluation. Her spouse reports that she had a disagreement with their daughter, causing her to leave the house. Following this incident, she has been unable to speak. Physical examination of her chest and throat reveals no abnormalities. What is the most appropriate term to describe this scenario?

      Your Answer: Expressive aphasia

      Correct Answer: Psychogenic aphonia

      Explanation:

      Understanding Aphonia: The Inability to Speak

      Aphonia is a medical condition that refers to the inability to speak. It can be caused by various factors, including recurrent laryngeal nerve palsy, which can occur after a thyroidectomy. In this case, the nerve that controls the vocal cords is damaged, leading to difficulty in speaking.

      Another cause of aphonia is psychogenic, which means that it is related to psychological factors. This can include anxiety, depression, or other mental health conditions that affect the ability to communicate verbally.

      It is important to note that aphonia is different from mutism, which is the inability to speak due to a physical or neurological condition. In contrast, aphonia is typically a temporary condition that can be treated with appropriate medical or psychological interventions.

      Overall, understanding aphonia is crucial for identifying and addressing the underlying causes of this condition. Whether it is related to a physical or psychological issue, seeking medical attention can help individuals regain their ability to speak and improve their quality of life.

    • This question is part of the following fields:

      • Mental Health
      53.4
      Seconds
  • Question 3 - A 6-year-old child is brought to the emergency room by her mother after...

    Incorrect

    • A 6-year-old child is brought to the emergency room by her mother after she noticed a red rash on her daughter's legs that doesn't disappear when pressed. The child has been unwell with a fever and cough since yesterday, but her symptoms have worsened throughout the day. The mother is worried because her daughter is also complaining of a headache and has cold hands and feet. During the examination, the child is found to have a petechial rash on her lower legs and a temperature of 38.4ºC. The mother reports that her daughter is allergic to penicillin and had a rash and vomiting after taking amoxicillin for an ear infection 2 years ago. What is the most appropriate course of action?

      Your Answer: Reassure petechiae are likely secondary to cough but admit to paediatrics for further tests.=

      Correct Answer: Phone 999 + administer intramuscular benzylpenicillin

      Explanation:

      Understanding Meningococcal Septicaemia

      Meningococcal septicaemia is a serious condition that can cause high morbidity and mortality if not treated early. It is the leading infectious cause of death in early childhood, making it crucial to have a high index of suspicion. According to the 2010 NICE guidelines, meningococcal disease can present as meningitis, septicaemia, or a combination of both.

      NICE divides the symptoms of meningococcal septicaemia into three categories: common nonspecific symptoms/signs, less common nonspecific symptoms/signs, and more specific symptoms/signs. Common nonspecific symptoms/signs include fever, vomiting, and lethargy, while less common nonspecific symptoms/signs include chills and shivering. More specific symptoms/signs include a non-blanching rash, altered mental state, capillary refill time more than 2 seconds, unusual skin colour, shock, hypotension, leg pain, and cold hands/feet.

      If meningococcal septicaemia is suspected, it is important to give intramuscular or intravenous benzylpenicillin unless there is a history of anaphylaxis. However, if giving benzylpenicillin will delay hospital transfer, it should not be given. NICE recommends phoning 999 in case of suspected meningococcal septicaemia.

    • This question is part of the following fields:

      • Children And Young People
      70.1
      Seconds
  • Question 4 - A 76-year-old male with prostate cancer visits his doctor complaining of lower back...

    Correct

    • A 76-year-old male with prostate cancer visits his doctor complaining of lower back pain accompanied by shooting pains down both legs to the knee. During the examination, the doctor observes decreased tone in the lower limbs and is unable to elicit ankle and knee reflexes.

      What is the probable location of the lesion?

      Your Answer: Cauda equina

      Explanation:

      The classic presentation of cauda equina syndrome includes lower back pain, reduced perianal sensation, and sciatica, with urinary incontinence as a late sign. Bilateral sciatica and lower back pain are typical symptoms. Referred hip pain may be felt in the knee and lower back, but it would not be associated with sciatica or lower motor neuron signs in the legs. A conus medullaris lesion would present with leg weakness and early painless retention and constipation. A sciatic nerve lesion would not be bilateral, so it is unlikely in a patient with bilateral sciatica and lower back pain. A bilateral L5 nerve root lesion would cause sciatica that may extend to the toes, numbness in the foot and/or toes (especially on the side of the big toe), and foot drop, but ankle and knee reflexes would remain intact.

      Understanding Cauda Equina Syndrome

      Cauda equina syndrome (CES) is a rare but serious condition that occurs when the nerve roots in the lower back are compressed. This can lead to permanent nerve damage and long-term leg weakness, as well as urinary and bowel incontinence. It is important to consider CES in any patient who presents with new or worsening lower back pain.

      The most common cause of CES is a central disc prolapse, typically occurring at L4/5 or L5/S1. Other causes include tumors, infections, trauma, and hematomas. CES may present in a variety of ways, including low back pain, bilateral sciatica, reduced sensation or pins-and-needles in the perianal area, and decreased anal tone. Urinary dysfunction, such as incontinence, reduced awareness of bladder filling, and loss of urge to void, is also a possible symptom.

      It is crucial to recognize that there is no one symptom or sign that can diagnose or exclude CES. However, checking anal tone in patients with new-onset back pain is good practice, even though studies show that it has poor sensitivity and specificity for CES. In case of suspected CES, an urgent MRI is necessary. The management of CES involves surgical decompression.

    • This question is part of the following fields:

      • Neurology
      41.7
      Seconds
  • Question 5 - A 28-year-old female presents at home with a few days of lower cramping...

    Correct

    • A 28-year-old female presents at home with a few days of lower cramping abdominal pain and some scanty brownish PV discharge. Her last menstrual period was 8 weeks ago, and she typically has regular 28/5 cycles. She is sexually active but doesn't use any regular contraception.

      Upon examination, she is haemodynamically unstable and has generalised abdominal tenderness. A pregnancy test is not available, but her partner is willing to go to the Pharmacy to obtain one if necessary.

      What is the most appropriate next step to take?

      Your Answer: Call 999

      Explanation:

      Urgent Action Required for Haemodynamically Unstable Patient

      The most appropriate course of action in this case is to call 999 and request an ambulance. This patient may have an ectopic pregnancy or may be miscarrying, and is therefore unstable and requires immediate resuscitation and transfer to hospital. While waiting for the ambulance, an attempt at IV cannulation and fluid resuscitation should be made.

      Arranging an assessment at the EPAU within 24 hours is inappropriate, as the patient is haemodynamically unstable and requires urgent admission via ambulance. Conducting a pelvic exam is not appropriate as this patient is haemodynamically unstable and has abdominal tenderness. Similarly, conducting a urine pregnancy test or taking blood for a serum βHCG would only cause unnecessary delay.

      It is crucial to prioritize the patient’s immediate medical needs and take urgent action to ensure their safety and well-being.

    • This question is part of the following fields:

      • Gynaecology And Breast
      121.6
      Seconds
  • Question 6 - A 16-year-old female complains of an itchy eye with watery discharge on one...

    Correct

    • A 16-year-old female complains of an itchy eye with watery discharge on one side. She reports feeling generally healthy with no changes to her vision or fever. The patient wears contact lenses but has not had an optician appointment recently.

      During the examination, the patient displays injected conjunctiva in the affected eye, but there is no apparent redness or swelling around the eye. The application of topical fluorescein doesn't reveal any corneal staining.

      What would be the best course of action for managing this patient's condition?

      Your Answer: Advise she should not wear contact lenses for the duration of her symptoms

      Explanation:

      It is not recommended to wear contact lenses when experiencing conjunctivitis, which is likely the case for this 15-year-old with viral conjunctivitis. While it is possible that her prescription may not be up to date, this doesn’t affect her susceptibility to infection or more severe conditions. Warm compresses are more effective for treating styes or chalazion, which present as lumps on the eyelid, rather than viral conjunctivitis. Since the fluorescein test did not show any corneal stains, there is no need for ophthalmology referral. However, if a contact lens wearer with these symptoms had staining, they would require a visit to eye casualty as this would indicate a corneal injury. While topical antihistamine eye drops may be used for allergic conjunctivitis, the unilateral nature of the presentation makes this diagnosis less likely. Topical chloramphenicol is the preferred treatment for bacterial conjunctivitis, but the watery discharge suggests viral conjunctivitis instead.

      Infective conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes that are accompanied by a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

      In most cases, infective conjunctivitis is a self-limiting condition that resolves on its own within one to two weeks. However, patients are often offered topical antibiotic therapy, such as Chloramphenicol or topical fusidic acid. Chloramphenicol drops are given every two to three hours initially, while chloramphenicol ointment is given four times a day initially. Topical fusidic acid is an alternative and should be used for pregnant women. For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. It is important to advise patients not to share towels and to avoid wearing contact lenses during an episode of conjunctivitis. School exclusion is not necessary.

    • This question is part of the following fields:

      • Eyes And Vision
      81.4
      Seconds
  • Question 7 - You assess a 5 month old girl who was hospitalized due to a...

    Incorrect

    • You assess a 5 month old girl who was hospitalized due to a urinary tract infection and showed improvement after receiving antibiotics within 48 hours. She was discharged after 2 days. As per NICE guidelines, what follow-up (if any) should be scheduled?

      Your Answer: Ultrasound within 6 weeks and DMSA in 4-6 months time

      Correct Answer: Ultrasound scan within 6 weeks

      Explanation:

      According to NICE guidelines, if a child under 6 months old has a UTI that responds well to antibiotics within 48 hours, an ultrasound scan should be done within 6 weeks. However, if the UTI is atypical or recurrent, additional tests such as ultrasound during the acute infection, DMSA 4-6 months after the acute infection, and MCUG are recommended.

      An atypical UTI may present with symptoms such as being seriously ill, poor urine flow, an abdominal or bladder mass, elevated creatinine, failure to respond to antibiotics within 48 hours, or non-E. coli organisms. Recurrent UTI is defined as having two or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, one episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episodes of UTI with cystitis/lower urinary tract infection, or three or more episodes of UTI with cystitis/lower urinary tract infection.

      Urinary tract infections (UTIs) in children require investigation to identify any underlying causes and potential kidney damage. Unlike in adults, the development of a UTI in childhood may indicate renal scarring. The National Institute for Health and Care Excellence (NICE) recommends imaging the urinary tract for infants under six months who present with their first UTI and respond to treatment, within six weeks. Children over six months who respond to treatment do not require imaging unless there are features suggestive of an atypical infection, such as being seriously ill, having poor urine flow, an abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to antibiotics within 48 hours, or infection with non-E. coli organisms.

      Further investigations may include a urine microscopy and culture, as only 50% of children with a UTI have pyuria, making microscopy or dipstick of the urine inadequate for diagnosis. A static radioisotope scan, such as DMSA, can identify renal scars and should be done 4-6 months after the initial infection. Micturating cystourethrography (MCUG) can identify vesicoureteric reflux and is only recommended for infants under six months who present with atypical or recurrent infections.

    • This question is part of the following fields:

      • Children And Young People
      44.6
      Seconds
  • Question 8 - A 32-year-old man with schizophrenia reports that thoughts are leaking out of his...

    Correct

    • A 32-year-old man with schizophrenia reports that thoughts are leaking out of his head and being read by others around him.
      What is the correct term for this symptom?

      Your Answer: Thought broadcast

      Explanation:

      Understanding Different Types of Thought Experiences

      There are various types of thought experiences that individuals may encounter. One of these is thought broadcast, where others can seemingly hear or read one’s thoughts as they are being broadcasted from the individual. On the other hand, thought insertion and withdrawal refer to the experience of having thoughts inserted into or taken out of one’s mind by an external force. In thought blocking, individuals may suddenly find themselves unable to continue speaking as their minds go blank. Meanwhile, thought echo involves hearing one’s own thoughts being spoken aloud after thinking them. Finally, auditory hallucinations refer to the perception of hearing sounds or voices without any external stimulus. Understanding these different types of thought experiences can help individuals better recognize and cope with them.

    • This question is part of the following fields:

      • Mental Health
      26.9
      Seconds
  • Question 9 - A 36-year-old cocaine user, Sarah, visits the clinic and asks for a prescription...

    Correct

    • A 36-year-old cocaine user, Sarah, visits the clinic and asks for a prescription for methadone. She had taken methadone at 30 mg once a day last year. Sarah is currently using the same amount of cocaine as she did last year and wants to resume taking 30 mg of methadone to manage withdrawal symptoms. However, you have no experience prescribing methadone and feel unsure about doing so. What is the best course of action?

      Your Answer: Not prescribe methadone

      Explanation:

      Prescribing methadone is a serious matter that requires an experienced and competent prescriber. It is important that the prescriber doesn’t feel pressured to prescribe the drug due to patient demands. As you are not confident in prescribing methadone, it would be unsafe for you to do so.

      Before prescribing methadone, it is essential to confirm opioid dependence through a thorough history, examination, and toxicology screening using urine or oral fluid swabs. The prescribing process should involve a multidisciplinary team, including the patient’s drug team or local drug worker and pharmacist.

      Methadone should be prescribed at a low dose and titrated upwards. The standard concentration is 1 mg/ml oral solution, with higher concentrations rarely used. The starting dose should be between 10 mg and 30 mg daily, depending on the amount and method of heroin or other opioids being used. Methadone is typically taken once daily.

      Understanding Opioid Misuse and its Management

      Opioid misuse is a serious problem that can lead to various complications and health risks. Opioids are substances that bind to opioid receptors, including natural opiates like morphine and synthetic opioids like buprenorphine and methadone. Signs of opioid misuse include rhinorrhoea, needle track marks, pinpoint pupils, drowsiness, watering eyes, and yawning.

      Complications of opioid misuse can range from viral and bacterial infections to venous thromboembolism and overdose, which can lead to respiratory depression and death. Psychological and social problems such as craving, crime, prostitution, and homelessness can also arise.

      In case of an opioid overdose, emergency management involves administering IV or IM naloxone, which has a rapid onset and relatively short duration of action. Harm reduction interventions such as needle exchange and testing for HIV, hepatitis B & C may also be offered.

      Patients with opioid dependence are usually managed by specialist drug dependence clinics or GPs with a specialist interest. Treatment options may include maintenance therapy or detoxification, with methadone or buprenorphine recommended as the first-line treatment by NICE. Compliance is monitored using urinalysis, and detoxification can last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community. Understanding opioid misuse and its management is crucial in addressing this growing public health concern.

    • This question is part of the following fields:

      • Smoking, Alcohol And Substance Misuse
      59.1
      Seconds
  • Question 10 - A 79-year-old gentleman comes to the clinic complaining of worsening lower urinary tract...

    Incorrect

    • A 79-year-old gentleman comes to the clinic complaining of worsening lower urinary tract symptoms that have been affecting his quality of life for the past three months. He reports experiencing increased hesitancy, weak urine stream, and a feeling of incomplete emptying. Upon examination, his abdomen and genitals appear normal, while a PR exam reveals a smooth, enlarged prostate. His urine dipstick is negative, and his PSA level is 1.3ng/mL. He denies experiencing any weight loss, fevers, or new bone or back pain. He is currently taking tamsulosin to alleviate his symptoms. What is the most appropriate additional medical therapy to offer this patient?

      Your Answer: Finasteride

      Correct Answer: Oxybutynin

      Explanation:

      Management of Lower Urinary Tract Symptoms

      Managing lower urinary tract symptoms is a crucial aspect of general practice. It is essential to distinguish between the causes of these symptoms to make the correct management decisions. For obstructive symptoms, 5-alpha reductase inhibitors such as finasteride play a vital role in causing prostatic shrinkage by inhibiting the conversion of testosterone to dihydrotestosterone, which is an important prostatic growth factor.

      However, alpha blockers such as alfuzosin and doxazosin would not be appropriate choices as they are already present in the form of tamsulosin. On the other hand, antimuscarinic medications like oxybutynin and tolterodine are used in the management of overactive bladder, which is more likely to present with symptoms of urgency and frequency rather than obstructive symptoms.

      In summary, understanding the underlying cause of lower urinary tract symptoms is crucial in determining the appropriate management strategy. 5-alpha reductase inhibitors are effective in managing obstructive symptoms, while alpha blockers and antimuscarinic medications are more suitable for other types of symptoms.

    • This question is part of the following fields:

      • Kidney And Urology
      58.6
      Seconds
  • Question 11 - A 15-year-old male with a history of asthma is brought in by his...

    Incorrect

    • A 15-year-old male with a history of asthma is brought in by his worried father due to the sudden appearance of a rash on his leg. The patient reports no new product usage or trauma. His father also expresses concerns about his recent lack of motivation in school.

      Upon examination, there are distinct linear lesions forming geometric shapes on the left lower leg and dorsal aspect of the foot. The patient appears healthy, and there are no other notable findings.

      What is the probable diagnosis?

      Your Answer: Eczema herpeticum

      Correct Answer: Dermatitis artefacta

      Explanation:

      The sudden appearance of well-defined skin lesions in a linear pattern, accompanied by a lack of concern or emotional response, is indicative of dermatitis artefacta. This condition is often associated with self-inflicted injuries that stem from underlying psychological issues, such as deliberate self-harm or attention-seeking behavior. The lesions are typically geometric in shape and appear in easily accessible areas, such as the limbs or face. Patients with dermatitis artefacta may deny causing the lesions themselves. The patient’s declining grades may be linked to psychological difficulties that have led to this form of self-harm.

      Understanding Dermatitis Artefacta

      Dermatitis artefacta is a rare condition that affects individuals of any age, but is more common in females. It is characterised by self-inflicted skin lesions that patients typically deny are self-induced. The condition is strongly associated with personality disorder, dissociative disorders, and eating disorders, with a prevalence of up to 33% in patients with bulimia or anorexia.

      Patients with dermatitis artefacta present with well-demarcated linear or geometric lesions that appear suddenly and do not evolve over time. The lesions may be caused by scratching with fingernails or other objects, burning skin with cigarettes, or chemical exposure. Commonly affected areas include the face and dorsum of the hands. Despite the severity of the skin lesions, patients may display a nonchalant attitude, known as la belle indifference.

      Diagnosis of dermatitis artefacta is based on clinical history and exclusion of other dermatological conditions. Biopsy of skin lesions is not routine but may be helpful to exclude other conditions. Psychiatric assessment may be necessary. Differential diagnosis includes other dermatological conditions and factitious disorders such as Munchausen syndrome and malingering.

      Management of dermatitis artefacta involves a multidisciplinary approach with dermatologists, psychologists, and psychiatrists. Direct confrontation is unhelpful and may discourage patients from seeking medical help. Treatment includes providing occlusive dressing, topical antibiotics, and bland emollients. Selective serotonin reuptake inhibitors and cognitive behavioural therapy may be helpful, although evidence is limited.

      In summary, dermatitis artefacta is a rare condition that requires a multidisciplinary approach for management. Understanding the clinical features, risk factors, and differential diagnosis is crucial for accurate diagnosis and appropriate treatment.

    • This question is part of the following fields:

      • Dermatology
      54.1
      Seconds
  • Question 12 - A 23-year-old woman with stable sickle cell anaemia presents with an erythematous rash...

    Incorrect

    • A 23-year-old woman with stable sickle cell anaemia presents with an erythematous rash all over her body, which is associated with painful swollen joints. On examination she has clinical signs of anaemia. The full blood count shows absent reticulocytes in the peripheral blood.
      Which pathogen is most likely to have caused her symptoms?

      Your Answer: Rubella virus

      Correct Answer: Parvovirus B19

      Explanation:

      Parvovirus B19 Infection: Symptoms, Transmission, and Complications

      Parvovirus B19 infection is a common viral illness that is primarily spread through respiratory droplets, but can also be transmitted through contaminated surfaces. Children between the ages of 6 and 10 are most commonly affected, with up to 70% of the population having been infected by the age of 20. Susceptible adults can also become infected, often through exposure to the virus from their own children. Epidemics tend to occur every 4-5 years, with peak infection rates in the winter and spring.

      The most common symptom of parvovirus B19 infection is erythema infectiosum, a rash illness characterized by a red rash on the face and extremities. The rash typically appears 17-22 days after exposure to the virus and is preceded by mild fever and fatigue. In addition to the rash, more than 80% of adults with parvovirus B19 infection experience joint pain and swelling, particularly in the small joints of the hands and feet. A positive test for parvovirus B19-specific IgM indicates current or recent infection.

      While parvovirus B19 infection typically doesn’t cause significant anemia in individuals with normal red-cell lifespan and function, it can lead to a more severe form of anemia called aplastic crisis in individuals with shortened red-cell lifespan, such as those with sickle-cell anemia. During the acute phase of aplastic crisis, there is a lack of reticulocytes in the blood and erythroid aplasia in the bone marrow. However, recovery is typically marked by the presence of reticulocytosis and giant pronormoblasts in the bone marrow.

      In summary, parvovirus B19 infection is a common viral illness that can cause a range of symptoms, including rash and joint pain. While typically not severe, it can lead to complications in individuals with certain medical conditions.

    • This question is part of the following fields:

      • Infectious Disease And Travel Health
      39.4
      Seconds
  • Question 13 - A 25-year-old man presents to the clinic with symptoms of acute sinusitis. He...

    Incorrect

    • A 25-year-old man presents to the clinic with symptoms of acute sinusitis. He had a severe cold 10 days ago and thought he was recovering, but now has pain over his left cheek and a purulent nasal discharge, more pronounced from the left nostril. On examination, he is febrile with a temperature of 38.5°C and is tender when pressure is applied over the left maxilla. As he is feeling unwell, you decide to prescribe antibiotics, but he has a penicillin allergy. What would be your approach to treating this patient?

      Your Answer: Cefuroxime for 7 days

      Correct Answer: Doxycycline for 5 days

      Explanation:

      Antibiotic Treatment for Acute Sinusitis

      Some important points to consider when treating acute sinusitis with antibiotics include the choice and duration of treatment. It is important to note that NICE CKS doesn’t recommend antibiotic treatment for uncomplicated acute sinusitis lasting 10 days or less. However, if antibiotic treatment is deemed appropriate, it is crucial to be familiar with the options available.

      For patients who are not allergic to penicillin, a 5-day course of Phenoxymethylpenicillin is the first choice. However, if the patient is allergic to penicillin, the options are limited to a 5-day course of doxycycline or a 7-day course of Clarithromycin. It is important to read the question carefully and take note of any allergies mentioned in the vignette.

      In summary, when considering antibiotic treatment for acute sinusitis, it is important to follow NICE CKS guidelines and be aware of the appropriate choice and duration of treatment based on the patient’s allergy status.

    • This question is part of the following fields:

      • Evidence Based Practice, Research And Sharing Knowledge
      189.3
      Seconds
  • Question 14 - A 68-year-old man presents with voiding difficulties. He reports passing urine twice a...

    Incorrect

    • A 68-year-old man presents with voiding difficulties. He reports passing urine twice a night, hesitancy of stream, and no frequency. He has also experienced a reduced appetite for the past 6 weeks and increased fatigue in the early evening. Upon examination, his abdomen is soft with no masses, but a digital rectal exam reveals a firm, irregularly enlarged prostate with no identifiable median sulcus. A urine dipstick shows the presence of blood and leukocytes. His blood test results are as follows: PSA 4.9 ng/ml; K+ 4.9 (3.5-5.5 mmol/L); Na 134 (135-145 mmol/l); creatinine 107 (60-110 μmol/l); urea 8.6 (2.8 - 8.5 mmol/L); and fasting glucose of 4.9. What is the most appropriate management option for this patient?

      Your Answer: Arrange a bladder ultrasound with post void residual volume

      Correct Answer: Referral to urologist to be seen within 2 weeks

      Explanation:

      Understanding PSA Testing and Biopsy Risks for Prostate Cancer

      Prostate-specific antigen (PSA) testing is a common screening tool for prostate cancer. However, it should not be measured without a digital examination. If the screen is positive, a biopsy may be needed, which carries risks such as infection, haematuria, and haematospermia, as well as a small mortality risk. It’s important to note that about one-third of men with a raised PSA will have prostate cancer, but biopsies can miss about one-fifth of cancers.

      When counselling a man for PSA testing, it’s crucial to explain the potential risks and benefits. Urgent referral is not necessary if the prostate is simply enlarged and the PSA is within the age-specific reference range. The Prostate Cancer Risk Management Programme recommends age-specific cut-off PSA measurements, with a threshold of 3.5 ng/ml for men under 50, over 3.5 ng/ml for men aged 50-59, 4.0 ng/ml for men aged 60-69, and clinical judgement for men aged 70 and over.

      Understanding the nuances of PSA testing and biopsy risks can help men make informed decisions about their prostate health.

    • This question is part of the following fields:

      • Kidney And Urology
      101.9
      Seconds
  • Question 15 - A woman is 28 weeks pregnant. It is a single pregnancy and there...

    Incorrect

    • A woman is 28 weeks pregnant. It is a single pregnancy and there have been no complications so far. She is planning to take a 4 hour flight next month. She has no additional risk factors for DVT but wants to know if she should take medication to lower her risk of blood clots.

      What guidance would you provide her regarding pharmacological prophylaxis for air travel during pregnancy?

      Your Answer: No pharmacological prophylaxis is needed in her case

      Correct Answer: Pharmacological prophylaxis is only required for flights longer than 6 hours

      Explanation:

      Thromboprophylaxis for Pregnant Women during Air Travel

      Low-molecular-weight heparin (LMWH) is not necessary for pregnant women who are traveling by air, unless they have additional risk factors for thrombosis such as a history of deep vein thrombosis (DVT), known thrombophilia, or morbid obesity. Aspirin is not recommended for thromboprophylaxis during pregnancy and air travel. According to the Royal College of Obstetricians and Gynaecologists (RCOG), medium to long-haul flights lasting more than 4 hours pose an increased risk for pregnant women. Therefore, it is important to consider the duration of the flight when assessing the need for thromboprophylaxis.

    • This question is part of the following fields:

      • Improving Quality, Safety And Prescribing
      41.8
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  • Question 16 - A 39-year-old teacher is being evaluated after starting an antidepressant. She initially presented...

    Incorrect

    • A 39-year-old teacher is being evaluated after starting an antidepressant. She initially presented with various symptoms of depression and a PHQ-9 score of 18. She has experienced several significant life events leading up to her diagnosis.

      She is married with a daughter in college, but has a strong support system from her family. You decided to initiate treatment with sertraline 50 mg, but she reports no improvement in her depression and your assessment agrees.

      Despite the lack of effectiveness in her treatment thus far, she appears to be tolerating the medication without any adverse effects.

      Based on NICE guidelines for depression treatment, at what point in her treatment would you consider increasing the dosage if she has not responded?

      Your Answer:

      Correct Answer: Six to eight weeks

      Explanation:

      Treatment for Depression: Considerations for Medication Adjustment

      When treating depression, it is important to monitor the patient’s response to medication. If there is no improvement within three to four weeks, it may be necessary to increase the dose or switch to a different antidepressant. However, if there is some improvement at four weeks, it is recommended to continue treatment for an additional two to four weeks before making any further changes.

      In this particular case, the patient is tolerating the medication well and has support from her husband. Therefore, the focus should be on adjusting the medication. This recommendation is based on NICE guidance on Depression in adults (CG90) and is supported by other publications. By closely monitoring the patient’s response and making appropriate adjustments, healthcare providers can help improve outcomes for those struggling with depression.

    • This question is part of the following fields:

      • Mental Health
      0
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  • Question 17 - An 8-year-old boy comes to the clinic complaining of joint pain, fever, and...

    Incorrect

    • An 8-year-old boy comes to the clinic complaining of joint pain, fever, and feeling tired. He was seen in the clinic two weeks ago for a sore throat. During the examination, he has a sinus tachycardia, a pink rash in the form of rings on his trunk, and a systolic murmur.
      What is the best diagnosis and treatment plan?

      Your Answer:

      Correct Answer: She has rheumatic fever and should be admitted for appropriate treatment

      Explanation:

      Misdiagnosis of a Heart Murmur: Understanding the Differences between Rheumatic Fever, Lyme Disease, HSP, Juvenile Idiopathic Arthritis, and Scarlet Fever

      A heart murmur can be a concerning symptom, but it is important to correctly diagnose the underlying condition. Rheumatic fever, Lyme disease, Henoch–Schönlein purpura (HSP), juvenile idiopathic arthritis, and scarlet fever can all present with a heart murmur, but each has distinct features that can help differentiate them.

      Rheumatic fever requires the presence of recent streptococcal infection and the fulfilment of Jones criteria, which include major criteria such as carditis, arthritis, Sydenham’s chorea, subcutaneous nodules, and erythema marginatum, as well as minor criteria such as fever, arthralgia, raised ESR or CRP, and prolonged PR interval on an electrocardiogram.

      Lyme disease presents with erythema migrans, arthralgia, and other symptoms depending on the stage of the disease, but a heart murmur is not a typical feature.

      HSP is characterised by purpura, arthritis, abdominal pain, gastrointestinal bleeding, orchitis, and nephritis.

      Juvenile idiopathic arthritis is chronic arthritis occurring before the age of 16 years that lasts for at least six weeks in the absence of any other cause, and may involve few or many joints, with additional features in some subsets, but it should not present with a heart murmur.

      Scarlet fever is characterised by a widespread red rash, fever, tachycardia, myalgia, and circumoral pallor, rather than joint pain.

      In summary, a heart murmur can be a symptom of various conditions, but a thorough evaluation of other symptoms and criteria is necessary to make an accurate diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 18 - A 30-year-old male comes to the clinic with a deep wound on his...

    Incorrect

    • A 30-year-old male comes to the clinic with a deep wound on his hand caused by a terrier bite. The wound is accompanied by swelling. After receiving tetanus immunisation and wound cleaning, what would be the most suitable antibiotic regimen for this patient?

      Your Answer:

      Correct Answer: Trimethoprim oral

      Explanation:

      Prophylactic Antibiotics in Dog Bites

      The use of prophylactic antibiotics in dog bites is a controversial topic. However, evidence supports their use in deep wounds, bites to the hands, and signs of infection. It is also important to consider immune compromise as an indication, along with involvement of deep structures such as joints or tendons, or in the presence of prosthetic joints.

      For complicated animal bites, including those from cats or humans, co-amoxiclav is recommended as the first-line treatment. It is important to note that the treatment of animal bites, especially those on the hand, may require more than just antibiotics. Seeking the advice of a plastic surgeon for debridement or tendon repair may also be necessary. Proper treatment and care can help prevent further complications and promote healing.

    • This question is part of the following fields:

      • Urgent And Unscheduled Care
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  • Question 19 - A 44-year-old man collapsed with sudden onset breathlessness associated with haemoptysis earlier that...

    Incorrect

    • A 44-year-old man collapsed with sudden onset breathlessness associated with haemoptysis earlier that day. He is usually fit and well with no significant past medical history and is not on any regular medication.

      His family brought him, unannounced, to the surgery reception and when you see him he appears pale and he feels noticeably short of breath at rest. He is complaining of sharp pains in the right side of his chest when he breathes in.

      Clinical examination reveals a patient who is short of breath at rest. His blood pressure is 98/68, pulse rate is 108 bpm and his respiratory rate 24 breaths per minute. Oxygen saturations are 93 % in room air. His temperature is 36.2 °C. Auscultation of the heart and lungs is normal. He has no calf swelling.

      There is no history of gastric ulceration or drug allergies.

      Which of the following would be the most appropriate immediate next step in the assessment and management of this patient?

      Your Answer:

      Correct Answer: Arrange an immediate 'blue-light ambulance' for rapid transfer to hospital without any delay

      Explanation:

      Management of Suspected Pulmonary Embolism

      When a patient presents with sudden onset breathlessness, haemoptysis, pleuritic pain, hypotension, tachycardia, increased respiratory rate, and low oxygen saturations, pulmonary embolism (PE) should be suspected. It is important to note any risk factors that may increase the likelihood of an embolism. The absence of signs of deep vein thrombosis doesn’t exclude the possibility of a PE.

      Immediate admission to the hospital should be arranged for patients with suspected PE who have signs of haemodynamic instability or are pregnant or have given birth within the past 6 weeks. Management should not be delayed for results of a chest X-ray or ECG. Therefore, the correct option is to arrange immediate transfer to the hospital by blue light. Prescribing a non-steroidal anti-inflammatory drug fails to appreciate the possibility of pulmonary embolism and should not be selected.

      In summary, prompt recognition and management of suspected PE is crucial to prevent morbidity and mortality.

    • This question is part of the following fields:

      • Respiratory Health
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  • Question 20 - A 32-year-old man has suddenly developed left-sided facial weakness and comes to the...

    Incorrect

    • A 32-year-old man has suddenly developed left-sided facial weakness and comes to the clinic on the same day. He is experiencing difficulty in closing his left eye, has lost taste on the front of the tongue, and is sensitive to loud noise. The entire left side of his face is affected, and he cannot wrinkle his forehead on the left side.
      What is the most suitable course of action for managing this patient?

      Your Answer:

      Correct Answer: Prednisolone 25 mg twice a day

      Explanation:

      Facial Nerve Palsy: Causes, Symptoms, and Treatment Options

      Facial nerve palsy is a condition that affects the facial nerve, resulting in the inability to wrinkle the forehead. This indicates a lower motor neurone (LMN) lesion, which is often caused by a viral infection such as herpes simplex type 1 or varicella zoster. In the past, the majority of cases were labelled idiopathic or Bell’s palsy, but recent research has shed light on the underlying causes.

      Other symptoms of facial nerve palsy may include hyperacusis, inability to produce tears, and loss of taste. In an upper motor neurone lesion, the upper facial muscles are partially spared due to alternative pathways in the brain stem.

      Treatment for facial nerve palsy typically involves prednisolone, which should be given within 72 hours of onset and continued for 10 days. Aciclovir is no longer recommended, and there is no evidence supporting the use of steroids in children. Referral to an ophthalmologist may be necessary if the cornea is exposed despite attempts to close the eyelid.

      While most patients recover fully from facial nerve palsy, some may experience permanent nerve damage or severe sequelae. It is important to seek medical attention promptly to ensure the best possible outcome.

    • This question is part of the following fields:

      • Neurology
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  • Question 21 - A 9-month-old girl has gradually become more short of breath following an upper...

    Incorrect

    • A 9-month-old girl has gradually become more short of breath following an upper respiratory tract infection and her mother is very worried about her. What is the single finding on examination that is a high-risk sign rather than an intermediate sign?

      Your Answer:

      Correct Answer: Respiratory rate 60/min

      Explanation:

      Assessing and Managing Respiratory Tract Infections in Children: NICE Traffic-Light System

      When a child presents with respiratory tract infection and chest signs, it is important to assess the underlying condition and level of risk. The NICE traffic-light system is a useful tool for identifying the likelihood of serious illness in a feverish child. High-risk (red) signs such as grunting, moderate or severe chest indrawing, and observed pallor of the skin require immediate hospital admission. Other signs, such as intermediate (amber) risk features, may require a safety net or referral to specialist paediatric care for further assessment. Effective assessment and management can help ensure the best possible outcomes for children with respiratory tract infections.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 22 - A 65-year-old man presented with an episode of right-sided weakness that lasted 10...

    Incorrect

    • A 65-year-old man presented with an episode of right-sided weakness that lasted 10 minutes and fully resolved.

      Examination reveals that he is in atrial fibrillation.

      Assuming he remains in atrial fibrillation which of the following is the most appropriate management regime?

      Your Answer:

      Correct Answer: No additional drug treatment

      Explanation:

      Anticoagulation Recommendation for High Risk Stroke Patient

      This patient is at high risk for future stroke and therefore requires anticoagulation with warfarin. Their CHADS2 score is 2, indicating a higher likelihood of stroke. The most appropriate initial target range for their INR is 2-3, with a target INR of 2.5. This will help to reduce their risk of stroke and improve their overall health outcomes. It is important to closely monitor their INR levels and adjust their medication dosage as needed to maintain the target range.

    • This question is part of the following fields:

      • Cardiovascular Health
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  • Question 23 - A 6-year-old boy complaining of acute abdominal pain is brought to see you...

    Incorrect

    • A 6-year-old boy complaining of acute abdominal pain is brought to see you by his mother. His mother tells you that he has been having bouts of abdominal pain for the last few days that she thought would settle with time. In addition, she tells you that he has also developed a rash on his legs and has been complaining that his knees and ankles are sore. He is opening his bowels normally and passing urine normally. Prior to the last few days he has been entirely well. He has no significant past medical history and is not on any regular medications.

      You examine him and he is afebrile and alert. His blood pressure is 118/82 mmHg. There is no significant lymphadenopathy. His abdomen is soft with no masses. He has some mild tenderness on deep palpation around the umbilicus and lower abdomen. There is an obvious purpuric rash over the extensor surfaces of his legs and buttocks. You also notice a few similar lesions on the extensor surfaces of his arms. His trunk is unaffected by the rash.

      He has full range of movements in his joints which are not inflamed, however there is discomfort when manipulating his knees and ankles and his ankles appear slightly puffy.

      Which of the following tests is most useful in guiding further management of this patient?

      Your Answer:

      Correct Answer: Urine dipstick

      Explanation:

      Henoch-Schönlein Purpura (HSP) in Children

      Henoch-Schönlein purpura (HSP) is a vasculitic condition that commonly affects children between the ages of 3 and 10. The core clinical features of HSP include a characteristic skin rash, joint pain, periarticular oedema, renal involvement, and abdominal pain. The skin rash, known as ‘palpable’ purpura, typically affects the buttocks and extensor surfaces of the legs and arms. Renal involvement can lead to hypertension, haematuria, and proteinuria, which can result in nephrotic and nephritic syndromes.

      Urine dipstick testing is essential in making a clinical diagnosis and guiding management and follow-up. Regular follow-up is necessary during the convalescent period as HSP can lead to chronic renal problems in some patients. Therefore, early detection and management of renal manifestations are crucial in preventing long-term complications. If left untreated, HSP can cause significant morbidity and mortality in children.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 24 - A 28-year-old woman returns home from the hospital after the birth of her...

    Incorrect

    • A 28-year-old woman returns home from the hospital after the birth of her first child. Over the next week she becomes increasingly irritable, feels low in mood and is very anxious that she is not taking good care of her baby.
      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Postpartum blues

      Explanation:

      Postpartum Mental Health Conditions: Understanding the Differences

      Postpartum mental health conditions can affect women after giving birth. It is important to understand the differences between these conditions to provide appropriate care and support.

      Postpartum blues is a common and short-lived condition that occurs in the first week after delivery. Symptoms include irritability, crying, depression, and emotional lability. Reassurance and explanation are usually enough to resolve this condition.

      Major depression is not suggested in the vignette and there is no indication of an ongoing depressive illness.

      Generalised anxiety disorder requires symptoms to be present for at least six months, which is not the case in this scenario.

      Postpartum depression is more persistent and debilitating than postpartum blues. It can interfere with the mother’s ability to care for herself or her child and typically develops over the first three months after delivery.

      Postpartum psychosis has a dramatic onset within the first two weeks after delivery. Symptoms include restlessness, insomnia, irritability, rapidly shifting mood, and disorganized behavior. Delusional beliefs or auditory hallucinations may instruct the mother to harm herself or her infant.

      Understanding the differences between these conditions can help healthcare providers provide appropriate care and support for women experiencing postpartum mental health conditions.

    • This question is part of the following fields:

      • Mental Health
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  • Question 25 - A 28-year-old man returns from a holiday in Spain. He is worried about...

    Incorrect

    • A 28-year-old man returns from a holiday in Spain. He is worried about the multiple white patches on his upper chest where he failed to get a proper suntan. Upon examination, these patches have well-defined scaly white skin and a significant lack of pigmentation compared to the tanned areas. What is the most suitable treatment option from the following list?

      Your Answer:

      Correct Answer: Clotrimazole cream

      Explanation:

      Understanding and Treating Pityriasis Versicolor

      Pityriasis versicolor is a skin condition caused by the yeast Malassezia furfur. It presents as patches of scaling skin that become depigmented compared to surrounding normal skin areas, particularly noticeable during the summer months. The lesions primarily involve the trunk but may spread to other areas. The condition is not contagious as the organism is commensal.

      Treatment usually involves topical antifungals such as clotrimazole, terbinafine, or miconazole. Selenium sulphide, an anti-dandruff shampoo, can also be used. However, the condition may recur, and repeat treatments may be necessary. Oral agents such as itraconazole or fluconazole are only used if topical treatments fail.

      Skin camouflage can be used to disguise lesions of vitiligo, which may be distressing for patients. The charity organization ‘Changing Faces’ provides this service. Hydrocortisone and fusidic acid are ineffective in treating pityriasis versicolor.

    • This question is part of the following fields:

      • Dermatology
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  • Question 26 - A 27-year-old man urgently books an appointment at your clinic. He complains of...

    Incorrect

    • A 27-year-old man urgently books an appointment at your clinic. He complains of left-sided facial pain and malaise that has been ongoing for two weeks. He mentions that his symptoms initially improved after a week, but then worsened again, and he now feels worse than he did initially. He has no significant medical history.

      During the examination, you note a low-grade fever of 37.9 degrees, but all other observations are normal. Anterior rhinoscopy reveals a purulent discharge from the left middle meatus, but there are no abnormalities in the eyes or periorbital tissues.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Bacterial sinusitis

      Explanation:

      The man’s symptoms suggest bacterial sinusitis, as he has experienced a double sickening where his symptoms initially improved but then suddenly worsened. This is often caused by a secondary bacterial infection following a viral rhinosinusitis. The presence of a fever and purulent discharge seen on rhinoscopy further support this diagnosis.

      Trigeminal neuralgia would not cause a fever, while sialadenitis would result in swelling of only one salivary gland. Cavernous sinus thrombosis is a rare complication of bacterial sinusitis and is not likely in this case.

      Acute sinusitis is a condition where the mucous membranes of the paranasal sinuses become inflamed. This inflammation is usually caused by infectious agents such as Streptococcus pneumoniae, Haemophilus influenza, and rhinoviruses. Certain factors can predispose individuals to this condition, including nasal obstruction, recent local infections, swimming/diving, and smoking. Symptoms of acute sinusitis include facial pain, nasal discharge, and nasal obstruction. Treatment options include analgesia, intranasal decongestants or nasal saline, and intranasal corticosteroids. Oral antibiotics may be necessary for severe presentations, but they are not typically required. In some cases, an initial viral sinusitis can worsen due to secondary bacterial infection, which is known as double-sickening.

    • This question is part of the following fields:

      • Ear, Nose And Throat, Speech And Hearing
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  • Question 27 - A 32-year-old pregnant woman has been diagnosed with gestational diabetes at 35 weeks...

    Incorrect

    • A 32-year-old pregnant woman has been diagnosed with gestational diabetes at 35 weeks gestation and started on insulin therapy. She has not experienced any hypoglycaemic episodes since starting treatment. As her delivery is expected at around 40 weeks, she has been advised to consult her GP regarding driving. Currently, she holds a group 1 driving licence. What advice should be given to the patient regarding driving?

      Your Answer:

      Correct Answer: Doesn't need to inform the DVLA. However, should check blood glucose two hours before driving and every two hours during the journey

      Explanation:

      Patients on insulin are not always required to inform the DVLA, except for those on temporary treatment for less than three months or those with gestational diabetes who are taking insulin for less than three months after delivery. If a patient falls under these exceptions, they can continue driving but must follow the guidelines for insulin-taking patients, which include checking their blood glucose two hours before driving and every two hours during the journey. It is incorrect to assume that a patient can continue driving as normal without any stipulations, even if they do not need to inform the DVLA.

      DVLA Regulations for Drivers with Diabetes Mellitus

      The DVLA has recently changed its regulations for drivers with diabetes who use insulin. Previously, these individuals were not allowed to hold an HGV license. However, as of October 2011, the following standards must be met for all drivers using hypoglycemic inducing drugs, including sulfonylureas: no severe hypoglycemic events in the past 12 months, full hypoglycemic awareness, regular blood glucose monitoring at least twice daily and at times relevant to driving, an understanding of the risks of hypoglycemia, and no other complications of diabetes.

      For those on insulin who wish to apply for an HGV license, they must complete a VDIAB1I form. Group 1 drivers on insulin can still drive a car as long as they have hypoglycemic awareness, no more than one episode of hypoglycemia requiring assistance within the past 12 months, and no relevant visual impairment. Drivers on tablets or exenatide do not need to notify the DVLA, but if the tablets may induce hypoglycemia, there must not have been more than one episode requiring assistance within the past 12 months. Those who are diet-controlled alone do not need to inform the DVLA.

      To demonstrate adequate control, the Honorary Medical Advisory Panel on Diabetes Mellitus recommends that applicants use blood glucose meters with a memory function to measure and record blood glucose levels for at least three months prior to submitting their application. These regulations aim to ensure the safety of all drivers on the road.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 28 - A 20-year-old woman presents to the clinic with complaints of breakthrough bleeding while...

    Incorrect

    • A 20-year-old woman presents to the clinic with complaints of breakthrough bleeding while taking her combined oral contraceptive pill containing 30 mcg ethinylestradiol with levonorgestrel. She started the pill two cycles ago and takes 21 active pills with a seven day pill-free interval. Although she is not currently sexually active, she plans to be in the near future. She reports no missed pills, recent illnesses, or other medication use. What is the probable cause of her breakthrough bleeding?

      Your Answer:

      Correct Answer: Chlamydia infection

      Explanation:

      Breakthrough Bleeding and the Combined Pill

      Breakthrough bleeding is a common issue that can occur when taking the combined pill. It is important to first check compliance with pill usage, as missed pills or erratic usage can lead to bleeding problems. Other factors such as intercurrent illness or the use of other medications should also be considered. Pregnancy should be ruled out with a test, especially if any pills have been missed or pill efficacy has been compromised. Additionally, sexually transmitted infections should be considered and appropriate tests performed.

      For women who have recently started using the combined pill, breakthrough bleeding is a common occurrence in the first few months of use. It is important to discuss this with a healthcare provider and be reassured that it usually settles with time. If breakthrough bleeding persists, a change in approach may be necessary. Lower dose pills (20 mcg ethinyloestradiol) are more likely to cause breakthrough bleeding, and switching to a higher dose pill (30 mcg) may be an option. Overall, it is important to address breakthrough bleeding promptly to ensure the effectiveness and safety of the combined pill.

    • This question is part of the following fields:

      • Gynaecology And Breast
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  • Question 29 - A 68-year old woman with type 2 diabetes attends annual review at the...

    Incorrect

    • A 68-year old woman with type 2 diabetes attends annual review at the GP practice. She currently takes lisinopril 10 mg OM, atorvastatin 20 mg ON, metformin 1 g BD, pioglitazone 45 mg OM and gliclazide 80 mg OM.

      You discuss her progress and she tells you that she has episodes in the late morning where she feels generally out of sorts with lightheadedness and has had some blurred vision. She has checked her blood sugar during one of these episodes and it is 2.5 mmol/L (3-6).

      Which one of her medicines is the most likely cause of her symptoms?

      Your Answer:

      Correct Answer: Atorvastatin

      Explanation:

      Understanding the Cause of Hypoglycaemic Episodes

      This patient is experiencing hypoglycaemic episodes that are causing symptoms of blurred vision and lightheadedness. The most likely cause of these episodes is the sulphonylurea medication. Sulphonylureas stimulate insulin secretion, which can lead to significant problems with hypoglycaemia. On the other hand, metformin increases insulin sensitivity and reduces hepatic gluconeogenesis, while pioglitazone reduces insulin resistance. Hypoglycaemia is uncommon with these medications. The ACE inhibitor or statin would not be a factor in this presentation.

      Gliclazide is a good choice of sulphonylurea as it is often the longer acting agents such as glibenclamide that cause more profound and severe problems with hypoglycaemia. However, it is important to note that all sulphonylureas carry the risk of hypoglycaemia. Understanding the cause of hypoglycaemic episodes is crucial in managing diabetes and ensuring the safety of patients.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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  • Question 30 - A 54-year-old man with insulin-dependent type 2 diabetes mellitus has visited his GP...

    Incorrect

    • A 54-year-old man with insulin-dependent type 2 diabetes mellitus has visited his GP after experiencing his second severe hypoglycaemic episode. During both episodes, he had limited awareness and required his wife to administer glucose gel. He currently holds a group 1 driving licence. What advice should be given regarding his ability to drive?

      Your Answer:

      Correct Answer: Stop driving immediately and inform the DVLA

      Explanation:

      Individuals with diabetes who have experienced two episodes of hypoglycemia requiring assistance are required to relinquish their driving license.

      DVLA Regulations for Drivers with Diabetes Mellitus

      The DVLA has recently changed its regulations for drivers with diabetes who use insulin. Previously, these individuals were not allowed to hold an HGV license. However, as of October 2011, the following standards must be met for all drivers using hypoglycemic inducing drugs, including sulfonylureas: no severe hypoglycemic events in the past 12 months, full hypoglycemic awareness, regular blood glucose monitoring at least twice daily and at times relevant to driving, an understanding of the risks of hypoglycemia, and no other complications of diabetes.

      For those on insulin who wish to apply for an HGV license, they must complete a VDIAB1I form. Group 1 drivers on insulin can still drive a car as long as they have hypoglycemic awareness, no more than one episode of hypoglycemia requiring assistance within the past 12 months, and no relevant visual impairment. Drivers on tablets or exenatide do not need to notify the DVLA, but if the tablets may induce hypoglycemia, there must not have been more than one episode requiring assistance within the past 12 months. Those who are diet-controlled alone do not need to inform the DVLA.

      To demonstrate adequate control, the Honorary Medical Advisory Panel on Diabetes Mellitus recommends that applicants use blood glucose meters with a memory function to measure and record blood glucose levels for at least three months prior to submitting their application. These regulations aim to ensure the safety of all drivers on the road.

    • This question is part of the following fields:

      • Metabolic Problems And Endocrinology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Improving Quality, Safety And Prescribing (0/2) 0%
Mental Health (1/2) 50%
Children And Young People (0/2) 0%
Neurology (1/1) 100%
Gynaecology And Breast (1/1) 100%
Eyes And Vision (1/1) 100%
Smoking, Alcohol And Substance Misuse (1/1) 100%
Kidney And Urology (0/2) 0%
Dermatology (0/1) 0%
Infectious Disease And Travel Health (0/1) 0%
Evidence Based Practice, Research And Sharing Knowledge (0/1) 0%
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