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Question 1
Incorrect
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A 70-year-old man presents to your clinic with a complaint of recurrent nosebleeds from his right nostril over the past week. The bleeding lasts for about 30 minutes but is not severe. The patient has a history of ischemic heart disease and is on regular medication of aspirin 75 mg and atorvastatin 40 mg. He denies any allergies and has no other significant medical history. On examination, there is no visible bleeding point, and all vital signs are normal. What is the most appropriate management for this patient, in addition to general epistaxis advice?
Your Answer: Attempt silver nitrate cautery of the left nostril
Correct Answer: Prescribe topical Naseptin (chlorhexidine/neomycin) cream
Explanation:Recurrent nosebleeds without any concerning symptoms can be effectively treated with Naseptin cream, which contains chlorhexidine and neomycin. While severe cases may require emergency care, mild cases can be managed in primary care. According to NICE guidelines, topical treatment with Naseptin cream is a suitable first-line approach.
If the nosebleeds are heavy but not currently active, persist despite topical treatment, or the patient is taking anticoagulant medication, referral to an ENT ‘hot clinic’ may be necessary. If the nosebleeds continue to recur despite treatment, referral to an ENT outpatient clinic for SPA ligation may be considered.
In primary care, silver nitrate cautery may be attempted if a clear bleeding point can be identified and the healthcare provider has the appropriate skills and experience. However, patients should not stop taking antiplatelet medication without consulting their healthcare provider.
Understanding Epistaxis: Causes and Management
Epistaxis, commonly known as nosebleeds, can be categorized into anterior and posterior bleeds. Anterior bleeds usually have a visible source of bleeding and occur due to an injury to the network of capillaries that form Kiesselbach’s plexus. On the other hand, posterior haemorrhages tend to be more severe and originate from deeper structures. They are more common in older patients and pose a higher risk of aspiration and airway obstruction.
Most cases of epistaxis are benign and self-limiting. However, exacerbation factors such as nose picking, nose blowing, trauma to the nose, insertion of foreign bodies, bleeding disorders, and immune thrombocytopenia can trigger nosebleeds. Other causes include hereditary haemorrhagic telangiectasia, granulomatosis with polyangiitis, and cocaine use.
If the patient is haemodynamically stable, bleeding can be controlled with first aid measures such as sitting with their torso forward and their mouth open, pinching the cartilaginous area of the nose firmly for at least 20 minutes, and using a topical antiseptic to reduce crusting and the risk of vestibulitis. If bleeding persists, cautery or packing may be necessary. Cautery should be used initially if the source of the bleed is visible, while packing may be used if cautery is not viable or the bleeding point cannot be visualized.
Patients that are haemodynamically unstable or compromised should be admitted to the emergency department, while those with a bleed from an unknown or posterior source should be admitted to the hospital. Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre. Overall, understanding the causes and management of epistaxis is crucial in providing effective care for patients experiencing nosebleeds.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 2
Correct
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A 35-year-old teacher presents with heavy periods. She reports using 8-10 pads daily during her 10-day long periods. She has two children and doesn't want any more at this time. She experiences mild cramping but no pain. Her busy schedule makes it difficult for her to remember to take medication daily. Blood tests reveal iron deficiency and she is prescribed iron tablets. Pelvic ultrasound shows no abnormalities. What is the recommended initial treatment for menorrhagia in this patient?
Your Answer: Mirena
Explanation:Treatment Options for Menorrhagia
Menorrhagia, or heavy menstrual bleeding, can be effectively treated with the Mirena intrauterine device. It is important to note that the Mirena also serves as a long-term contraceptive, making it a suitable option for many women. The copper coil, on the other hand, can actually increase vaginal bleeding and should be avoided in cases of menorrhagia. While the combined oral contraceptive pill is a viable option, it may not be the best choice for women with busy or unpredictable lifestyles. The progesterone-only pill is a third-line option, but there is no reason not to use the Mirena as a first-line treatment. Non-steroidal anti-inflammatory drugs like mefenamic acid may be helpful for dysmenorrhoea, but are not typically used for menorrhagia. For more information on treatment options for menorrhagia, visit http://cks.nice.org.uk/menorrhagia#!scenario.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 3
Incorrect
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A 78-year-old male attends clinic with his daughter who reports that her father has become disinterested and withdrawn.
Which of the following would favour a diagnosis of dementia rather than depression?Your Answer: Agitation
Correct Answer: Self-reported concern of poor memory
Explanation:Differentiating between Alzheimer’s and Depression
Urinary incontinence is an uncommon symptom associated with depression, but it is more typical of dementia or normal pressure hydrocephalus. On the other hand, impaired memory and concern over memory deficits can be found in both depression and dementia. Therefore, it can be challenging to differentiate between Alzheimer’s and depression based on these symptoms alone. Mayo Clinic suggests that a combination of symptoms and medical tests can help differentiate between the two conditions. Proper diagnosis and treatment can improve the quality of life for individuals and their families.
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This question is part of the following fields:
- Mental Health
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Question 4
Correct
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A 75-year-old nursing home resident presents with a severely itchy rash. Upon examination, red linear lesions are observed on the wrists and elbows, while red papules are present on the penis. What is the best course of action for management?
Your Answer: Topical permethrin
Explanation:Although lichen planus can have similar symptoms, scabies is more likely to cause intense itching. Additionally, lichen planus is less frequently seen in older individuals, as it typically affects those between the ages of 30 and 60.
Scabies: Causes, Symptoms, and Treatment
Scabies is a skin condition caused by the mite Sarcoptes scabiei, which is spread through prolonged skin contact. It is most commonly seen in children and young adults. The mite burrows into the skin, laying its eggs in the outermost layer. The resulting intense itching is due to a delayed hypersensitivity reaction to the mites and eggs, which occurs about a month after infection. Symptoms include widespread itching, linear burrows on the fingers and wrists, and secondary features such as excoriation and infection.
The first-line treatment for scabies is permethrin 5%, followed by malathion 0.5% if necessary. Patients should be advised to avoid close physical contact until treatment is complete and to treat all household and close contacts, even if asymptomatic. Clothing, bedding, and towels should be laundered, ironed, or tumble-dried on the first day of treatment to kill off mites. The insecticide should be applied to all areas, including the face and scalp, and left on for 8-12 hours for permethrin or 24 hours for malathion before washing off. Treatment should be repeated after 7 days.
Crusted scabies, also known as Norwegian scabies, is a severe form of the condition seen in patients with suppressed immunity, particularly those with HIV. The skin is covered in hundreds of thousands of mites, and isolation is essential. Ivermectin is the treatment of choice.
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This question is part of the following fields:
- Dermatology
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Question 5
Incorrect
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Your surgery serves an area of West London that is frequented by large numbers of tourists and economic migrants who come to the UK for a few months for work.
With respect to health service provision, which one of the following is true with respect to provision of health services and charging to elderly visitors?Your Answer: Pandemic influenza care is free, irrespective of where the patient originates
Correct Answer: NATO staff are only partially eligible for free treatment
Explanation:Eligibility for Free NHS Care
The rules for receiving free NHS care can be complex and detailed, but in general, patients from the European Economic Area (EEA), certain Commonwealth countries, and Ukraine are entitled to free healthcare. Additionally, there is a list of procedures and consultations, such as family planning, that are also covered under free healthcare.
If a patient has been accepted for permanent residence, they are not charged for NHS care, regardless of their home country. It is important to note that eligibility for free NHS care can vary depending on individual circumstances, so it is always best to check with the NHS or a healthcare professional to confirm eligibility.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 6
Correct
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A 67-year-old woman presents with a general feeling of unwellness. She reports low mood and energy, along with body aches. She is experiencing increased nausea, constipation, and reflux, which has led to a decrease in her appetite. However, she is staying well hydrated. Her medical history includes well-controlled type 2 diabetes, GORD, and recently diagnosed hypertension. Recent blood tests revealed Hb of 135 g/L (115 - 160), urea of 5 mmol/L (2.0 - 7.0), and creatinine of 60 µmol/L (55 - 120). What is the most likely diagnosis?
Your Answer: Primary hyperparathyroidism
Explanation:The patient’s symptoms of depression, nausea, constipation, and bone pain suggest a diagnosis of primary hyperparathyroidism. This condition is characterized by hypercalcaemia, which can cause the ‘moans, groans, and bones’ of hyperparathyroidism. Other common symptoms include polydipsia, polyuria, hypertension, renal stones, and pancreatitis.
It is important to distinguish primary hyperparathyroidism from secondary hyperparathyroidism, which is usually caused by renal disease. In this case, the patient’s recent blood tests showed normal renal function, making secondary hyperparathyroidism less likely. Primary hypoparathyroidism, a congenital condition, is also unlikely as it would cause low calcium and high phosphate levels, resulting in different symptoms than those presented by the patient.
Secondary hypoparathyroidism, which can result in depression due to chronic hypocalcaemia, is also unlikely as it is usually caused by damage to the parathyroid glands from neck surgery or radiation therapy, which the patient has not undergone.
Therefore, primary hyperparathyroidism remains the most likely diagnosis for this patient’s symptoms.
Primary Hyperparathyroidism: Causes, Symptoms, and Treatment
Primary hyperparathyroidism is a condition that is commonly seen in elderly females and is characterized by an unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is usually caused by a solitary adenoma, hyperplasia, multiple adenoma, or carcinoma. While around 80% of patients are asymptomatic, the symptomatic features of primary hyperparathyroidism may include polydipsia, polyuria, depression, anorexia, nausea, constipation, peptic ulceration, pancreatitis, bone pain/fracture, renal stones, and hypertension.
Primary hyperparathyroidism is associated with hypertension and multiple endocrine neoplasia, such as MEN I and II. To diagnose this condition, doctors may perform a technetium-MIBI subtraction scan or look for a characteristic X-ray finding of hyperparathyroidism called the pepperpot skull.
The definitive management for primary hyperparathyroidism is total parathyroidectomy. However, conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal, the patient is over 50 years old, and there is no evidence of end-organ damage. Patients who are not suitable for surgery may be treated with cinacalcet, a calcimimetic that mimics the action of calcium on tissues by allosteric activation of the calcium-sensing receptor.
In summary, primary hyperparathyroidism is a condition that can cause various symptoms and is commonly seen in elderly females. It can be diagnosed through various tests and managed through surgery or medication.
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This question is part of the following fields:
- Kidney And Urology
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Question 7
Incorrect
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A 50-year-old man presents with widespread erythema and scaling of the skin to the extent that nearly the whole of the skin surface is involved.
Which of the following is the most likely diagnosis?
Your Answer: Toxic epidermal necrolysis
Correct Answer: Erythroderma
Explanation:Erythroderma is a condition where the skin becomes red all over the body, affecting at least 90% of the skin surface. It can occur suddenly or gradually and is often accompanied by skin peeling. The cause can be related to various skin disorders, including eczema, drug reactions, and cancer. Psoriasis is the most common cause in adults. Patients with erythroderma should be hospitalized as it can lead to fever, heart failure, and dehydration. Asteatotic eczema is a type of eczema that causes dry, itchy, and cracked skin, usually on the shins of elderly patients. Atopic eczema is a chronic inflammatory skin disease that often starts in infancy and is associated with high levels of immunoglobulin E. Ichthyosis is a condition where the skin is persistently scaly and can be congenital or acquired. Toxic epidermal necrolysis is a severe skin disorder that can be life-threatening and is often caused by drug reactions.
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This question is part of the following fields:
- Dermatology
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Question 8
Incorrect
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A 65-year-old woman came to the clinic with a complaint of intermittent swelling of her tongue and face that has been occurring for the past ten weeks. The episodes last for 36 hours and then resolve on their own. She has tried taking oral antihistamines but they did not help. Her medical history is significant for hypertension which was diagnosed and treated with appropriate medications six months ago. There is no other relevant medical or family history. What medication is most likely causing her symptoms?
Your Answer: Enalapril
Correct Answer: Bendroflumethiazide
Explanation:ACE Inhibitors and Angioedema
ACE inhibitors are medications that can lead to the development of angioedema, a condition characterized by swelling in various parts of the body. This is because ACE inhibitors block the action of the ACE enzyme, which is responsible for breaking down bradykinin. When bradykinin accumulates in the body, it causes blood vessels to dilate and become more permeable, leading to the accumulation of fluid in the interstitium. This can result in rapid swelling, particularly in areas with less connective tissue, such as the face.
Interestingly, ACE inhibitor-induced angioedema appears to be more common in African-American individuals. If angioedema occurs, the medication should be discontinued immediately and an alternative treatment should be sought. One option is an angiotensin II receptor antagonist, which works similarly to ACE inhibitors but doesn’t affect bradykinin levels. It is important to monitor patients closely for signs of angioedema when prescribing ACE inhibitors, particularly in those with a history of the condition.
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This question is part of the following fields:
- Cardiovascular Health
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Question 9
Correct
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A 56-year-old man comes to the clinic complaining of severe pain and redness in his big toe. He appears to be in good health and there are no signs of infection or fever. He reports a history of gout and suspects that it has returned. He is currently on a regular dose of allopurinol. What would be the most suitable course of action?
Your Answer: Continue allopurinol and commence colchicine
Explanation:Patients with an acute flare of gout who are already on allopurinol treatment should not discontinue it during the attack, as per the current NICE CKS guidance. Colchicine is a suitable option for acute gout treatment, and oral steroids can be used if colchicine or NSAIDs are not tolerated. Hospital review on the same day is not necessary unless there are red flag features or evidence of a septic joint. Aspirin is not recommended for gout treatment.
Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with a delayed start recommended until inflammation has settled. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Other options for refractory cases include febuxostat, uricase, and pegloticase.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 10
Correct
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A 35-year-old woman comes in for a check-up on her asthma management. Upon reviewing her medical history, you notice that she has never had a Pap smear and bring this to her attention. She discloses that she is a lesbian and has never engaged in sexual activity with a man. What advice should you provide in this situation?
Your Answer: She should have cervical screening as per normal
Explanation:Lesbian and bisexual women are at risk of contracting HPV, the virus responsible for causing cervical cancer, through genital contact or oral sex. As a result, it is important for them to undergo regular cervical screening. However, the uptake of screening among lesbian women is significantly lower than that of the general female population, often due to misinformation provided by healthcare providers.
Understanding Cervical Cancer Screening in the UK
Cervical cancer screening is a well-established program in the UK that aims to detect Premalignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.
The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification. Patients with mild dyskaryosis who were HPV negative could be treated as having normal results. The NHS has now moved to an HPV first system, where a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.
All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. Cervical screening cannot be offered to women over 64, unlike breast screening, where patients can self-refer once past screening age. In Scotland, screening is offered from 25-64 every five years.
In special situations, cervical screening in pregnancy is usually delayed until three months postpartum, unless there has been missed screening or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.
While there is limited evidence to support it, the current advice given out by the NHS is that the best time to take a cervical smear is around mid-cycle. Understanding the cervical cancer screening program in the UK is crucial for women to take control of their health and prevent cervical cancer.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 11
Incorrect
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A 28-year-old woman presents with a week long history of an offensive smelling greenish-yellow vaginal discharge with associated dysuria but not frequency. She doesn't complain of lower abdominal pain but admits to dyspareunia.
She has not been seen by you personally at the clinic and has social problems with frequent episodes of homelessness. She is unkempt and admits to sleeping on the streets. She refuses your request that she should be seen at the local genito-urinary medicine (GUM) clinic but asks you for treatment so that she can leave. Her scant records are full of did not attend entries.
Examination reveals a greenish-yellow discharge but is otherwise unremarkable and you suspect that this lady has uncomplicated gonorrhoea.
According to the latest NICE guidance, what is the single most appropriate approach for this woman?Your Answer: Ceftriaxone 1 g intramuscular injection as a single dose
Correct Answer: Azithromycin 1g orally as a single dose
Explanation:Approaching a Question on Gonorrhoea Treatment
When faced with a question on gonorrhoea treatment, it is important to exercise judgement and use examination technique to narrow down the options. For instance, if a patient is asking for treatment and has a history of non-compliance with previous follow up, referring them to gynaecology and taking a swab may not be useful if they are refusing referral to a genito-urinary medicine (GUM) clinic.
In such a scenario, the three treatment options left are the focus. While it is important to have some understanding of the guidance, even if one is unfamiliar with the individual drugs and doses, knowing that the current first line recommendation involves IM Ceftriaxone as a single dose can help narrow down the choices. This approach is useful in the actual AKT examination, where one may not know everything, but can increase their chances of success by logically narrowing down the options.
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This question is part of the following fields:
- Sexual Health
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Question 12
Correct
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A 12-year-old girl is brought to see you during an out-of-hours shift.
She has a past history of asthma and usually takes salbutamol 100 mcg 2 puffs as required and beclomethasone 100 mcg twice a day. Her usual peak flow is 280. She has been on her current inhalers for over a year with no problems or flare-ups.Over the last two days she has become increasingly wheezy and this seems to have been triggered by an upper respiratory tract infection.
On examination, she has a temperature of 37.5℃, and has a widespread polyphonic wheeze on auscultation of the chest. Her peak flow rate is measured at 190. Oxygen saturations are 97% in air. There is no respiratory distress.
She receives six puffs of salbutamol via a spacer and following this feels much better, with a PEFR of 260. The child is monitored in the department for a further hour and remains stable with her chest sounding clear.
What is the most appropriate management plan?Your Answer: Advise use of salbutamol two to four puffs 4 hourly until acute infection resolved
Explanation:Management of Acute Asthma Exacerbation in Children
This article discusses the appropriate management of acute asthma exacerbation in children. In cases where the exacerbation is caused by an upper respiratory tract infection, symptom control and short-term measures are crucial. Adding long-acting beta agonists or leukotriene receptor antagonists is not recommended during acute exacerbation.
Hospital referral is not necessary if the child has no worrying features, no respiratory distress, and good oxygen saturations. However, advice on worsening should be given in case of relapse. Steroid treatment should be considered with any acute exacerbation, with oral prednisolone 1-2 mg/kg up to a maximum of 40 mg per day for three to five days.
Doubling the inhaled beclomethasone is not the correct answer. Instead, regular use of salbutamol during the current illness should be advised to prevent relapse and improve symptoms acutely. Delivery through a spacer device should also be encouraged. By following these guidelines, healthcare professionals can effectively manage acute asthma exacerbation in children.
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This question is part of the following fields:
- Urgent And Unscheduled Care
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Question 13
Incorrect
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A man visits your clinic after a year as he requires an increase in his dosage of methylphenidate. As per NICE guidelines, what assessments will you need to conduct as a physician?
Your Answer: Check HR and BP
Correct Answer: Check height, weight, HR and BP
Explanation:Monitoring and Side Effects of Methylphenidate Therapy for ADHD
Height and growth should be regularly monitored and plotted on a growth chart for children receiving methylphenidate therapy for attention deficit hyperactivity disorder (ADHD). Growth retardation is a serious potential side effect, and weight loss may also occur. In addition, heart rate and blood pressure should be monitored and recorded on a centile chart before and after each dose change, as well as routinely every three months. Methylphenidate is a central nervous system stimulant that is used as part of a comprehensive treatment program for children with severe ADHD. However, patients who experience sustained resting tachycardia, arrhythmia, or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions should have their dose reduced and be referred to a pediatrician. Routine blood tests and ECGs are not recommended unless there is a clinical indication. It is important to record pulse, blood pressure, psychiatric symptoms, appetite, weight, and height at initiation of therapy, following each dose adjustment, and at least every six months thereafter.
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This question is part of the following fields:
- Children And Young People
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Question 14
Incorrect
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During a home visit to a 58-year-old patient with a lower respiratory tract infection, who is also housebound due to motor neurone disease, you review her medications. What regular medication/s should you consider initiating?
Your Answer: Riluzole
Correct Answer: Vitamin D
Explanation:It is recommended to provide daily vitamin D supplements to all patients who are confined to their homes.
Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society’s 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.
Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.
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This question is part of the following fields:
- Respiratory Health
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Question 15
Incorrect
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A 54 year old man is admitted as an inpatient for treatment of a duodenal ulcer. Upon waking this morning, he experiences severe inflammation in his first metatarsophalangeal joint. The joint is swollen and tender, and a sample of the fluid is sent for microscopy. The patient has a history of hypertension. What is the most appropriate initial medication to prescribe?
Your Answer: Indomethacin
Correct Answer: Colchicine
Explanation:Due to the presence of a duodenal ulcer, diclofenac and indomethacin are not recommended for the patient. Instead, colchicine is a viable option. While allopurinol is effective in preventing future attacks, it should not be administered during the acute phase.
It is important to investigate the patient for conditions such as hypertension and ischaemic heart disease, which may be linked to gout.
Encouraging weight loss and advising the patient to avoid alcohol can be beneficial in managing gout.
Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with a delayed start recommended until inflammation has settled. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Other options for refractory cases include febuxostat, uricase, and pegloticase.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 16
Incorrect
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You decide to do a practice audit of your pediatric repeat prescribing system.
You have a discussion with your colleagues about the expected rate of prescribing errors in this population.
What percentage of pediatric prescriptions, upon evaluation, exhibit a prescribing or monitoring mistake?Your Answer: Around 25%
Correct Answer: Around 75%
Explanation:GMC Study on Prescribing and Monitoring Errors in the UK
A recent study conducted by the General Medical Council (GMC) in the UK has shed light on the frequency and causes of prescribing and monitoring errors. The study analyzed 6,000 prescriptions and found that nearly 5% of them contained errors related to prescribing or monitoring. The most common cause of these errors was incomplete information on the prescription, accounting for a third of all errors identified.
This study provides valuable insights into the activities that can lead to prescribing and monitoring errors, helping to guide healthcare professionals towards safer practices. While exact figures may not be expected in an AKT examination, knowledge of the general outcomes of this study is reasonable and can be useful in clinical practice. By understanding the common causes of prescribing and monitoring errors, healthcare professionals can take steps to minimize the risk of such errors occurring in the future.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 17
Incorrect
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In which scenario would the heritability score be expected to be the least?
Your Answer: Mumps
Correct Answer: Cystic fibrosis
Explanation:Heritability Scores of Different Disorders
Mumps, a contagious viral infection, has the lowest heritability score among the disorders mentioned. This means that the risk of developing mumps is primarily due to exposure to the infective agent rather than genetic factors. On the other hand, the other disorders listed have a genetic component in their development. For instance, cystic fibrosis is caused by a mutation in a specific gene and is inherited in an autosomal recessive manner. Understanding the heritability scores of different disorders can help in identifying the underlying causes and developing appropriate treatment strategies.
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This question is part of the following fields:
- Genomic Medicine
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Question 18
Correct
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Anna is a 35-year-old woman who has come to her GP complaining of sudden lower back pain. Her medical history doesn't indicate any alarming symptoms and her neurological examination appears normal.
What initial pain relief medication should the GP suggest?Your Answer: Ibuprofen
Explanation:According to NICE guidelines, the initial treatment for lower back pain should involve NSAIDS like ibuprofen or naproxen. Codeine with or without paracetamol can be used as a second option. In case of muscle spasm, benzodiazepines may be considered. However, topical NSAIDS are not recommended for this condition.
Management of Lower Back Pain: NICE Guidelines
Lower back pain is a common condition that affects many people. In 2016, the National Institute for Health and Care Excellence (NICE) updated their guidelines on the management of lower back pain. These guidelines apply to patients with nonspecific lower back pain, which means it is not caused by malignancy, infection, trauma, or other specific conditions.
According to the updated guidelines, NSAIDs are now recommended as the first-line treatment for back pain. Paracetamol monotherapy is relatively ineffective for back pain, so NSAIDs are a better option. Proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs.
Lumbar spine x-ray should not be offered as an investigation for nonspecific back pain. MRI should only be offered to patients with nonspecific back pain if the result is likely to change management, or if malignancy, infection, fracture, cauda equina, or ankylosing spondylitis is suspected. MRI is the most useful imaging modality as it can see neurological and soft tissue structures.
Patients with low back pain should be encouraged to self-manage and stay physically active through exercise. A group exercise program within the NHS is recommended for people with back pain. Manual therapy, such as spinal manipulation, mobilization, or soft tissue techniques like massage, can be considered as part of a treatment package that includes exercise and psychological therapy. Radiofrequency denervation and epidural injections of local anesthetic and steroid can also be used for acute and severe sciatica.
In summary, the updated NICE guidelines recommend NSAIDs as the first-line treatment for nonspecific back pain. Patients should be encouraged to self-manage and stay physically active through exercise. MRI is the most useful imaging modality for investigating nonspecific back pain. Other treatments, such as manual therapy, radiofrequency denervation, and epidural injections, can be considered as part of a treatment package that includes exercise and psychological therapy.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 19
Incorrect
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What is a recognized phase in the Cycle of Change?
Your Answer: precontemplation
Correct Answer: Recirculation
Explanation:The Cycle of Change: Understanding the Stages of Personal Transformation
The Cycle of Change is a model that illustrates the different stages individuals go through when making changes in their lives. The first stage is precontemplation, where the person is not yet aware that a problem exists. The next stage is contemplation, where the person begins to recognize the issue and considers making a change. The third stage is action, where the person takes steps towards making the change. The fourth stage is maintenance, where the person works to sustain the change. However, it is important to note that relapse can occur, which is a full return to the old behavior.
Understanding the Cycle of Change can be helpful in personal transformation, as it allows individuals to recognize where they are in the process and what steps they need to take to move forward. By acknowledging the different stages and potential setbacks, individuals can better prepare themselves for the challenges that come with making significant changes in their lives.
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This question is part of the following fields:
- Consulting In General Practice
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Question 20
Correct
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You are evaluating a 54-year-old male patient who you initiated on 2.5mg of ramipril two weeks ago for stage 2 hypertension. He has a history of mild chronic kidney disease (CKD) diagnosed two years ago. He is not taking any other medications and has no significant past medical history. On a previous assessment, you noted some pulmonary oedema, and an echo revealed normal left-ventricular function. A urine dip was unremarkable. He remains hypertensive today, but apart from shortness of breath on exertion, he is asymptomatic. There is no notable family history.
Two weeks ago, his blood tests showed an estimated glomerular filtration rate (eGFR) of 67 mL/min/1.73 m2. The rest of his blood results were:
- Na+ 139 mmol/l
- K+ 4.9 mmol/l
- Urea 6.5 mmol/l
- Creatinine 110 µmol/l
This week, his blood tests show an eGFR of 65 mL/min/1.73 m2. The rest of his renal function showed:
- Na+ 141 mmol/l
- K+ 5.0 mmol/l
- Urea 6.9 mmol/l
- Creatinine 140 µmol/l
What is the likely underlying diagnosis in this patient?Your Answer: Renal artery stenosis
Explanation:If a patient experiences an increase in serum creatinine after starting an ACE-inhibitor like ramipril, it may indicate renal artery stenosis. Other signs of this condition include refractory hypertension and recurrent pulmonary edema with normal left ventricular function. A normal urine dip makes options 1, 2, and 3 unlikely, and there are no symptoms of cancer, infection, or diabetes. While polycystic kidney disease is a possibility, it is inherited in an autosomal dominant manner and typically presents with hypertension, kidney stones, haematuria, or an abdominal mass. However, given the patient’s history and lack of family history of renal disease, renal artery stenosis is the more likely diagnosis.
Chronic kidney disease (CKD) is a condition where the kidneys are not functioning properly. To estimate renal function, serum creatinine levels are often used, but this may not be accurate due to differences in muscle. Therefore, formulas such as the Modification of Diet in Renal Disease (MDRD) equation are used to estimate the glomerular filtration rate (eGFR). The MDRD equation takes into account serum creatinine, age, gender, and ethnicity. However, factors such as pregnancy, muscle mass, and recent red meat consumption may affect the accuracy of the result.
CKD can be classified based on the eGFR. Stage 1 CKD is when the eGFR is greater than 90 ml/min, but there are signs of kidney damage on other tests. If all kidney tests are normal, there is no CKD. Stage 2 CKD is when the eGFR is between 60-90 ml/min with some sign of kidney damage. Stage 3a and 3b CKD are when the eGFR is between 45-59 ml/min and 30-44 ml/min, respectively, indicating a moderate reduction in kidney function. Stage 4 CKD is when the eGFR is between 15-29 ml/min, indicating a severe reduction in kidney function. Stage 5 CKD is when the eGFR is less than 15 ml/min, indicating established kidney failure, and dialysis or a kidney transplant may be necessary. It is important to note that normal U&Es and no proteinuria are required for a diagnosis of CKD.
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This question is part of the following fields:
- Kidney And Urology
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Question 21
Incorrect
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A 27-year-old man comes back from a year-long trip to Central and South America. He complains of a lesion on his lower lip that has been ulcerating for the past 2 months. Upon examination, it is found that his nasal and oral mucosae are also affected. What is the probable diagnosis?
Your Answer: Chagas disease
Correct Answer: Leishmaniasis
Explanation:Leishmaniasis is the probable diagnosis for this patient, as the presence of a primary skin lesion accompanied by mucosal involvement is a typical indication of infection with Leishmania brasiliensis.
Leishmaniasis: A Disease Caused by Sandfly Bites
Leishmaniasis is a disease caused by the protozoa Leishmania, which are transmitted through the bites of sandflies. There are three main forms of the disease: cutaneous, mucocutaneous, and visceral. Cutaneous leishmaniasis is characterized by a crusted lesion at the site of the bite, which may be accompanied by an underlying ulcer. It is typically diagnosed through a punch biopsy from the edge of the lesion. Mucocutaneous leishmaniasis can spread to involve the mucosae of the nose, pharynx, and other areas. Visceral leishmaniasis, also known as kala-azar, is the most severe form of the disease and is characterized by fever, sweats, rigors, massive splenomegaly and hepatomegaly, poor appetite, weight loss, and grey skin. The gold standard for diagnosis is bone marrow or splenic aspirate. Treatment is necessary for cutaneous leishmaniasis acquired in South or Central America due to the risk of mucocutaneous leishmaniasis, while disease acquired in Africa or India can be managed more conservatively.
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This question is part of the following fields:
- Dermatology
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Question 22
Incorrect
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A 56-year-old woman visits the General Practitioner for a check-up. She mentions that her friends have informed her about her bad breath. From where is this patient's issue most likely originating?
Your Answer: Nasal cavities
Correct Answer: Mouth
Explanation:Causes and Treatment of Halitosis
Halitosis, commonly known as bad breath, affects 80-90% of people with persistent symptoms. The National Institute for Health and Care Excellence identifies poor oral hygiene, smoking, periodontal disease, dry mouth, dentures, and poor denture hygiene as the primary causes of halitosis. In such cases, referral to a dentist and a trial of antibacterial mouthwash and toothpaste may be appropriate.
Less common causes of halitosis include sinusitis, foreign body in the nasal cavities, tonsillitis, tonsil stones in the throat, bronchiectasis in the respiratory tract, acid reflux, and Helicobacter pylori in the gastrointestinal tract. Pseudo-halitosis is a condition in which people falsely believe they have bad breath.
In conclusion, halitosis can be caused by various factors, and treatment depends on the underlying cause. Maintaining good oral hygiene and seeking medical attention when necessary can help alleviate symptoms and improve overall oral health.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 23
Incorrect
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A 55-year-old man presents to the GP clinic with complaints of lower back pain, fevers, and weight loss. He has also noticed a weakened urinary stream and increased frequency of urination over the past six months. On examination, including digital rectal examination, there are no significant findings. The GP recommends that he see the practice phlebotomist to check his prostate serum antigen level. What is the most probable factor that could lead to a false positive result?
Your Answer: A prostate biopsy performed three months ago
Correct Answer: A confirmed UTI, successfully treated two weeks ago
Explanation:Factors Affecting PSA Measurement
Prostate serum antigen (PSA) measurement is a crucial screening tool for detecting prostate cancer. However, recent urinary tract infections can increase PSA levels, which may remain elevated for up to a month. There are several other factors that can influence PSA levels, including recent prostate biopsy, vigorous exercise within the last 48 hours, and ejaculation within the last 48 hours. It is recommended that men avoid PSA testing under these circumstances. On the other hand, there is no evidence to suggest that an intercurrent illness, such as an upper respiratory tract infection, affects PSA levels. Proper understanding of these factors can help ensure accurate PSA measurement and reliable prostate cancer detection.
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This question is part of the following fields:
- Kidney And Urology
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Question 24
Correct
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A young adult presents with bradycardia of 40 beats per minute and small pupils.
Which of the following substances could be responsible for these clinical signs?Your Answer: Methadone
Explanation:Common Drugs and Their Effects
Methadone, a synthetic compound similar to morphine and heroin, is often used as a substitute for an abused opiate. However, it has almost equal addiction liability. Opiates cause pinpoint pupils and bradycardia. Cannabis, on the other hand, affects motor control and impairs balance, tracking ability, hand-eye coordination, reaction time, and physical strength. It also produces a fast heart rate at low doses, but larger doses can slow the heart and lower blood pressure, leading to sudden death in some cases. Cocaine powerfully constricts blood vessels, leading to a massive rise in blood pressure and a risk of stroke. Khat, a leaf chewed mostly in Africa, has stimulant properties similar to amphetamine and causes tachycardia. LSD, when taken orally, induces perceptual changes, particularly visual hallucinations, accompanied by mild hypertension, tachycardia, mydriasis, flushing, salivation, lacrimation, and mild ataxia. The effects may last eight to 12 hours, and mood changes range from ecstatic euphoria to terrifying gloom and despair. While accidental death or suicide under the influence of LSD is reported, dependence is not recognized.
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This question is part of the following fields:
- Smoking, Alcohol And Substance Misuse
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Question 25
Incorrect
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What is the most suitable medication for preventing symptoms of alcohol withdrawal such as seizures or delirium tremens?
Your Answer: Temazepam
Correct Answer: Acamprosate
Explanation:Medications for Alcohol Dependence and Withdrawal
Acamprosate is a medication that can be helpful in maintaining abstinence in individuals with alcohol dependence. Buprenorphine, on the other hand, is an opioid analgesic. Bupropion is commonly used as a supplement for smoking cessation, but it is contraindicated in patients who are experiencing acute alcohol withdrawal. Long-acting benzodiazepines are the preferred treatment for preventing symptoms of acute withdrawal. Diazepam is a commonly used benzodiazepine, but chlordiazepoxide is recommended as the first choice because it has less of a market for illicit use.
By using these medications, individuals with alcohol dependence can receive the support they need to maintain abstinence and manage withdrawal symptoms. It is important to work closely with a healthcare provider to determine the best course of treatment for each individual’s unique needs. Proper medication management, along with therapy and support, can greatly improve the chances of successful recovery.
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This question is part of the following fields:
- Smoking, Alcohol And Substance Misuse
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Question 26
Incorrect
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A 35-year-old practice nurse, who is employed by you but is not a patient at your practice, develops contact dermatitis from a chemical used to clean the work surface in a treatment room at your practice.
Which of the following should you do?Your Answer: Prescribe a potent steroid
Correct Answer: Prescribe a mild steroid
Explanation:Dermatitis and Work-Related Exposure
Dermatitis is a skin condition that can be caused by work-related exposure to chemicals or biological irritants. According to the Health and Safety Executive (HSE), dermatitis is reportable when associated with exposure to any chemical or biological irritant or sensitizing agent. This includes chemicals with warnings such as may cause sensitization by skin contact or irritating to the skin. Common causes of dermatitis include epoxy resins, latex, rubber chemicals, soaps and cleaners, metalworking fluids, cement, wet work, enzymes, and wood. Corrosive and irritating chemicals can also lead to dermatitis.
Various industries are associated with dermatitis, including construction work, health service work, rubber making, printing, paint spraying, agriculture, horticulture, electroplating, cleaning, catering, hairdressing, and floristry. However, dermatitis can also be caused by exposure to common agents found outside the workplace. If there is good evidence that the condition has been caused solely by such exposure rather than by exposure to an agent at work, it is not reportable.
It is important to note that arranging patch testing, referral, and prescribing are considerations for the patient’s own doctor and not their employer. While most questions in the AKT exam relate to a doctor’s duties to their patients, it is essential to have a basic understanding of employment law and health and safety regulations to ensure the safety and well-being of employees in the workplace.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 27
Correct
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A research facility is attempting to create a new test to screen for prostate cancer compared to current methods which include a prostate-specific antigen (PSA) blood test. From initial findings, the new screening test seems to be more effective at detecting early-stage cancers. However, when comparing both tests, there doesn't seem to be a noticeable difference in survival rates.
What is this an instance of?Your Answer: Lead-time bias
Explanation:Lead-time bias is when a comparison is made between two tests for a disease, and the new test diagnosis the disease earlier, but there is no impact on the disease’s outcome. This can result in the survival times appearing more favorable for the new test.
Late-look bias is a type of selection bias that occurs when information is collected at an inappropriate time. For instance, studying a fatal disease many years after patients have passed away.
Publication bias happens when negative or uninteresting results from valid studies are not published.
Recall bias is particularly relevant for case-control studies, where there is a difference in the accuracy of the memories retrieved by participants.
Understanding Bias in Clinical Trials
Bias refers to the systematic favoring of one outcome over another in a clinical trial. There are various types of bias, including selection bias, recall bias, publication bias, work-up bias, expectation bias, Hawthorne effect, late-look bias, procedure bias, and lead-time bias. Selection bias occurs when individuals are assigned to groups in a way that may influence the outcome. Sampling bias, volunteer bias, and non-responder bias are subtypes of selection bias. Recall bias refers to the difference in accuracy of recollections retrieved by study participants, which may be influenced by whether they have a disorder or not. Publication bias occurs when valid studies are not published, often because they showed negative or uninteresting results. Work-up bias is an issue in studies comparing new diagnostic tests with gold standard tests, where clinicians may be reluctant to order the gold standard test unless the new test is positive. Expectation bias occurs when observers subconsciously measure or report data in a way that favors the expected study outcome. The Hawthorne effect describes a group changing its behavior due to the knowledge that it is being studied. Late-look bias occurs when information is gathered at an inappropriate time, and procedure bias occurs when subjects in different groups receive different treatment. Finally, lead-time bias occurs when two tests for a disease are compared, and the new test diagnosis the disease earlier, but there is no effect on the outcome of the disease. Understanding these types of bias is crucial in designing and interpreting clinical trials.
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This question is part of the following fields:
- Evidence Based Practice, Research And Sharing Knowledge
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Question 28
Correct
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A 32-year-old woman has been experiencing abdominal pain and intermittent bloody diarrhoea for the past 4 months. She has a history of perianal abscess. Her blood test shows hypochromic, microcytic anaemia and mild hypokalaemia. Although her liver function tests are normal, her albumin is reduced. Barium imaging reveals a small bowel stricture with evidence of mucosal ulceration extending into the colon, interspersed with normal looking mucosa ‘skipping’. What is the most likely diagnosis?
Your Answer: Crohn's disease
Explanation:Understanding Crohn’s Disease: Symptoms, Diagnosis, and Differential Diagnosis
Crohn’s disease is a chronic inflammatory condition that can affect any part of the gastrointestinal tract. The most commonly affected sites are the ileocecal region and the colon. Patients with Crohn’s disease experience relapses and remissions, with symptoms including low-grade fever, prolonged diarrhea, right lower quadrant or periumbilical pain, weight loss, and fatigue. Perianal disease may also occur, with symptoms such as perirectal pain, malodorous discharge, and fistula formation. Extra-intestinal manifestations may include arthritis, erythema nodosum, and primary sclerosing cholangitis.
To establish a diagnosis of Crohn’s disease, ileocolonoscopy and biopsies from affected areas are first-line procedures. A cobblestone-like appearance is often seen, representing areas of ulceration separated by narrow areas of healthy tissue. Barium follow-through examination is useful for looking for inflammation and narrowing of the small bowel.
Differential diagnosis for Crohn’s disease include coeliac disease, small bowel lymphoma, tropical sprue, and ulcerative colitis. Coeliac disease presents as a malabsorption syndrome with weight loss and steatorrhoea, while small bowel lymphoma is rare and presents with nonspecific symptoms such as abdominal pain and weight loss. Tropical sprue is a post-infectious malabsorption syndrome that occurs in tropical areas, and ulcerative colitis may be clinically indistinguishable from colonic Crohn’s disease but lacks the small bowel involvement and skip lesions seen in Crohn’s disease.
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This question is part of the following fields:
- Gastroenterology
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Question 29
Correct
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You are recommending hormone replacement therapy (HRT) for a 50-year-old woman who is healthy but is suffering from severe menopausal symptoms. She is curious about the advantages and disadvantages of various types of HRT.
What is the accurate response concerning the risk of cancer associated with different HRT formulations?Your Answer: Combined HRT increases the risk of breast cancer
Explanation:The addition of progestogen to HRT has been found to increase the risk of breast cancer. However, this risk is dependent on the duration of treatment and decreases after discontinuing HRT. It is important to note that this increased risk doesn’t affect the likelihood of dying from breast cancer. HRT with oestrogen alone may have no or reduced risk of coronary heart disease, while combined HRT has little to no increase in the risk of CHD. It is worth noting that there is no HRT available that contains progestogen only. Although NICE doesn’t provide specific risk analysis for ovarian cancer in women taking HRT, a meta-analysis suggests an increased risk for both oestrogen-only and combined HRT preparations.
Adverse Effects of Hormone Replacement Therapy
Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.
Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.
Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.
In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 30
Incorrect
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A 75-year-old woman has just been released from the hospital after suffering a stroke. She is visiting from France and wants to return home on the next flight to be with her family. As a temporary patient, she seeks your advice on flying. After reviewing the guidelines of the Civil Aviation Authority (CAA), what would be the most suitable advice to give her?
Your Answer: Patients should not fly for 2 months following a cerebrovascular accident, and will require a medical chaperone if flying within 3 months of the event. He should also contact his airline directly
Correct Answer: Patients should not fly for 10 days following a cerebrovascular accident. He should also contact his airline directly
Explanation:According to the guidance provided by the Civil Aviation Authority (CAA), individuals with a history of cerebrovascular accident should refrain from air travel for a period of 10 days. However, if the patient’s condition is stable, they may be allowed to fly within 3 days of the event. It is important to note that patients should also consult their insurance and airline providers before making any travel arrangements. The CAA doesn’t provide a clear definition of what constitutes a stable condition, so it is advisable to seek advice from a healthcare professional before considering air travel within the 10-day period.
The CAA has issued guidelines on air travel for people with medical conditions. Patients with certain cardiovascular diseases, uncomplicated myocardial infarction, coronary artery bypass graft, and percutaneous coronary intervention may fly after a certain period of time. Patients with respiratory diseases should be clinically improved with no residual infection before flying. Pregnant women may not be allowed to travel after a certain number of weeks and may require a certificate confirming the pregnancy is progressing normally. Patients who have had surgery should avoid flying for a certain period of time depending on the type of surgery. Patients with haematological disorders may travel without problems if their haemoglobin is greater than 8 g/dl and there are no coexisting conditions.
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This question is part of the following fields:
- Equality, Diversity And Inclusion
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