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Question 1
Incorrect
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What is the correct definition of advanced decisions according to the Mental Capacity Act (2005)?
Your Answer: Expressed wishes to receive particular treatments have to be followed
Correct Answer: Decisions about life-sustaining treatment must be in writing
Explanation:Understanding Advance Decisions under the Mental Capacity Act
The Mental Capacity Act provides individuals with the right to make advance decisions, which replace advanced directives. These decisions allow a person to refuse certain medical treatments in specific circumstances, even if it may result in their death. However, to make an advance decision, the person must be 18 years or older (16 years in Scotland) and have mental capacity.
While any treatment can be refused, measures needed for comfort, such as warmth, shelter, and offering food or water by mouth, cannot be refused. A person may express a wish for particular treatments in advance, but these do not have to be followed. An advance decision has the same weight as decisions made by a person with capacity at the present time and must be followed, so the concept of patient’s best interests doesn’t apply.
Advance decisions about life-sustaining treatment must be in writing, signed, and witnessed, and include a statement that the decision applies even if life is at risk. Other decisions may be verbal but should be recorded in medical records. An advance decision becomes invalid if it is withdrawn or amended when capacity is still present or changed by someone with ‘lasting powers of attorney.’
An advance decision takes precedence over decisions made in a patient’s best interest by other people. In making a best interest decision, the Mental Capacity Act requires doctors to try to find out the individual’s views, including their past and present wishes and feelings, as well as any beliefs or values.
Ignoring an advance decision can result in claims for criminal charges of assault. In Scotland, advance directives are not legally enforceable under the Adults with Incapacity (Scotland) Act 2000, but the Act states that the wishes of the adult should be taken into consideration when acting or making a decision on their behalf.
Understanding Advance Decisions and the Mental Capacity Act
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This question is part of the following fields:
- End Of Life
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Question 2
Correct
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A 28-year-old man comes to his General Practitioner complaining of several episodes of haematospermia over the past few weeks. He denies any urinary symptoms or pain and reports no other unusual bleeding. He is generally healthy and not on any regular medications.
What is the most probable diagnosis? Choose ONE option only.Your Answer: Chlamydial infection
Explanation:Causes of Haematospermia in a Young Adult
Haematospermia, the presence of blood in semen, can be a distressing symptom for men. In those under 40 years of age, infections are the most common cause, with sexually transmitted infections (STIs) such as chlamydia being a likely culprit, especially in the absence of urinary symptoms. Haemophilia A, a genetic disorder that affects blood clotting, is unlikely to present with haematospermia as the first symptom, especially in a young adult. Malignant hypertension, a rare and severe form of high blood pressure, can cause end-organ damage but is an unusual cause of haematospermia. Prostate cancer, which is more common in older men, can also cause haematospermia, but is usually associated with urinary symptoms and erectile dysfunction. Prostatitis, an inflammation of the prostate gland, can cause haematospermia and other symptoms such as pain and fever, but is less common than UTIs or STIs. A thorough medical history, physical examination, and appropriate investigations can help identify the underlying cause of haematospermia and guide treatment.
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This question is part of the following fields:
- Kidney And Urology
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Question 3
Correct
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You observe a 35-year-old librarian who has been living with Crohn's disease for 18 years. She has been in remission for the past six years, but has been experiencing abdominal pain and passing bloody stools for the past week. She is seeking treatment.
She is generally healthy and takes the combined contraceptive pill and ibuprofen as needed for back pain. She smokes five cigarettes daily but doesn't consume alcohol.
What is the accurate statement regarding her condition?Your Answer: Smoking increases the risk of Crohn's disease relapse
Explanation:Crohn’s disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. The National Institute for Health and Care Excellence (NICE) has published guidelines for managing this condition. Patients are advised to quit smoking, as it can worsen Crohn’s disease. While some studies suggest that NSAIDs and the combined oral contraceptive pill may increase the risk of relapse, the evidence is not conclusive.
To induce remission, glucocorticoids are typically used, but budesonide may be an alternative for some patients. Enteral feeding with an elemental diet may also be used, especially in young children or when there are concerns about steroid side effects. Second-line options include 5-ASA drugs, such as mesalazine, and add-on medications like azathioprine or mercaptopurine. Infliximab is useful for refractory disease and fistulating Crohn’s, and metronidazole is often used for isolated peri-anal disease.
Maintaining remission involves stopping smoking and using azathioprine or mercaptopurine as first-line options. Methotrexate is a second-line option. Surgery is eventually required for around 80% of patients with Crohn’s disease, depending on the location and severity of the disease. Complications of Crohn’s disease include small bowel cancer, colorectal cancer, and osteoporosis. Before offering azathioprine or mercaptopurine, it is important to assess thiopurine methyltransferase (TPMT) activity.
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This question is part of the following fields:
- Gastroenterology
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Question 4
Incorrect
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A 28-year-old female, originally from Malta, presents with complaints of oral and genital ulcers. She has a history of recurrent ulcers and scarring from previous episodes. Other than the ulcers, she appears to be in good health. Upon reviewing her medical records, it is noted that she has a history of arthritis and anterior uveitis. What is the most probable diagnosis that connects all of these symptoms?
Your Answer: Reactive arthritis
Correct Answer: Behçet's disease
Explanation:Oral and Genital Ulceration: A Sign of Behçet’s Disease
Oral ulceration can be a symptom of various diseases, both local and systemic. However, when combined with genital ulceration, the differential diagnosis narrows down, and clinicians should consider potential systemic causes. One such disease is Behçet’s disease, a multisystem vasculitic disorder that typically presents with recurrent oral and genital ulcers. Patients with Behçet’s may also experience arthritis and uveitis. This disease is more common in individuals of Mediterranean and eastern backgrounds.
Inflammatory bowel disease is also a possible differential diagnosis, but it typically presents with gastrointestinal symptoms such as abdominal pain, blood/mucous in the stool, and altered bowel habits. Crohn’s disease can cause oral ulceration and perianal disease, while ulcerative colitis can cause aphthous ulcers in the mouth. Eye problems and arthritis are also associated with inflammatory bowel disease.
Reactive arthritis is characterized by a triad of arthritis, conjunctivitis, and urethritis, but ulceration is not a feature. Rheumatoid arthritis is another multisystem vasculitic disorder that can have various clinical manifestations, including eye problems, but recurrent oral and genital ulcers are not typical. Stevens-Johnson syndrome, on the other hand, is an acute problem characterized by blistering and mucous membrane erosions triggered by drugs, infections, or systemic illnesses, but it doesn’t involve arthritis or uveitis.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 5
Correct
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Mrs. Johnson, a 62-year-old woman, visits you to discuss cancer screening. She is concerned about the possibility of having a 'hidden' cancer after her friend was diagnosed with ovarian cancer at an advanced stage. Mrs. Johnson is up to date with her breast and cervical screening but did not send off her bowel cancer screening kit last year. She asks if she can have a blood test for ovarian cancer like her friend. Upon inquiry, she reports no weight loss, pelvic pain, bloating, urinary symptoms, or change in bowel habit. You perform an abdominal palpation and find no masses or ascites.
What would be your next course of action?Your Answer: Advise the blood test is not suitable for screening for ovarian cancer in asymptomatic patients
Explanation:Screening for ovarian cancer in asymptomatic women should not be done using Ca-125 due to its poor sensitivity and specificity. Even when used in symptomatic patients, there is a high false negative rate, so an ultrasound scan should be considered if symptoms persist. CEA is a tumour marker for colorectal cancer, but it is not recommended for screening and is only used to monitor disease activity. Ultrasound is also not advised for screening for ovarian cancer in asymptomatic patients. Private whole-body scans for the worried well are available, but they carry the risk of incidental findings, and CT scans have a significant radiation risk.
Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management
Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.
There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.
To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.
Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.
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This question is part of the following fields:
- Gynaecology And Breast
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Question 6
Incorrect
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A 19-year-old female presents to you with complaints of a sore throat. She reports feeling sick for the past three days with a high fever and painful throat. She has been self-medicating with an over-the-counter flu remedy containing paracetamol. Upon examination, she has a temperature of 37.1°C, tender anterior cervical lymphadenopathy, visible tonsillar exudate, and a dry cough. What is this patient's Centor score?
Your Answer: 1
Correct Answer: 3
Explanation:Understanding the Centor Score for Tonsillitis
The Centor score is a tool used by clinicians to differentiate between viral and bacterial tonsillitis, which helps guide the use of antibiotics. It consists of four criteria: the presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, a history of fever, and absence of cough. If at least three out of the four criteria are met, it suggests a bacterial infection and antibiotics may be beneficial. Conversely, if less than three criteria are met, antibiotics are unlikely to be needed. It’s important to note that the Centor score is based on a history of fever, not necessarily a fever at the time of being seen. The McIsaac modification adds a point for patients under 15 years old and deducts a point for those over 45 years old. The Centor score is a helpful tool, but it should not replace clinical judgement.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 7
Incorrect
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You have a White patient with cystic fibrosis. His 25-year-old brother, who doesn't have cystic fibrosis, comes to ask you about the chances of his future children having cystic fibrosis. They have the same parents.
What is the best advice you can provide them concerning genetic inheritance?Your Answer: She has a 1 in 4 chance of being a carrier of the cystic fibrosis gene
Correct Answer: Her White partner has a 1 in 25 chance of being a cystic fibrosis carrier
Explanation:Cystic fibrosis is a genetic disease that is inherited in an autosomal recessive manner. It is more common in people of White ethnicity, with a carrier frequency of 1 in 25. The most common mutation is DeltaF508, which can be screened for genetically. A clinical diagnosis of cystic fibrosis can only be made in someone who is homozygous. If one parent is a carrier, there is a 1 in 4 chance that their child will have the disease, a 2 in 4 chance of being a carrier, and a 1 in 4 chance of not being a carrier. Without further testing, it cannot be determined if someone is a carrier or not, but in this case, the woman has a 2 in 3 chance of being a carrier.
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This question is part of the following fields:
- Genomic Medicine
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Question 8
Correct
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A 5-year-old boy has been experiencing frequent urination and complaining to his father of abdominal pain. His father reports that he has been acting differently for the past 2-3 days. The boy has no abdominal or flank tenderness.
His temperature is 37.4 degrees Celsius, pulse 110 beats per minute, and capillary refill time is less than 2 seconds. He appears to be in good health. A urine sample shows positive results for leukocytes and nitrites on dipstick testing.
The correct dose of trimethoprim is prescribed based on his weight. What is the appropriate duration of treatment?Your Answer: 3 days
Explanation:It is important to distinguish between upper and lower urinary tract infections as the choice and duration of antibiotic treatment differ. Localising symptoms can guide treatment in primary care. In young children with confirmed UTI, clinicians may be tempted to treat for 5 or 7 days simply because of their age, but there are clear guidelines on this. A urine specimen should be collected for culture and sensitivity testing before starting antibacterial therapy, especially in children under 3 years of age, those with suspected upper urinary-tract infection, complicated infection, or recurrent infection, and pregnant women. Treatment should not be delayed while waiting for results, and the chosen antibacterial should reflect current local bacterial sensitivity. Uncomplicated lower urinary tract infections in children over 3 months of age can be treated with various antibiotics for 3 days, while acute pyelonephritis in children over 3 months of age can be treated with a first-generation cephalosporin or co-amoxiclav for 7-10 days. Children under 3 months of age should be transferred to hospital and treated initially with intravenous antibacterials until the infection responds.
Urinary Tract Infection in Children: Symptoms, Diagnosis, and Treatment
Urinary tract infections (UTIs) are more common in boys until 3 months of age, after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood. The presentation of UTIs in childhood depends on age. Infants may experience poor feeding, vomiting, and irritability, while younger children may have abdominal pain, fever, and dysuria. Older children may experience dysuria, frequency, and haematuria. Features that may suggest an upper UTI include a temperature of over 38ºC and loin pain or tenderness.
According to NICE guidelines, a urine sample should be checked in a child if there are any symptoms or signs suggestive of a UTI, with unexplained fever of 38°C or higher (test urine after 24 hours at the latest), or with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest). A clean catch is the preferable method for urine collection. If not possible, urine collection pads should be used. Invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible.
Infants less than 3 months old should be referred immediately to a paediatrician. Children aged more than 3 months old with an upper UTI should be considered for admission to the hospital. If not admitted, oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days. Children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin, or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours. Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs.
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This question is part of the following fields:
- Children And Young People
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Question 9
Incorrect
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A 6-year-old girl has started soiling her pants. She was apparently toilet-trained prior to this happening.
Which of these features is MOST COMMONLY found in children with faecal incontinence?Your Answer: Passage of stools in inappropriate places
Correct Answer: History of painful defaecation
Explanation:Understanding Functional Incontinence in Children
Functional incontinence in children is often associated with a history of constipation or painful defecation. This may have been caused by an anal fissure, which can lead to ongoing issues with bowel movements. Children with functional incontinence may exhibit retentive posturing and withholding behavior, but any behavioral difficulties associated with soiling are likely a result of the incontinence rather than its cause.
Symptoms of functional incontinence include frequent low-volume solid stools, which can be so large that they block the toilet. Children may also be aware of soiling but deny the urge to defecate associated with their episodes. In some cases, they may be unable to differentiate between passing gas and passing feces. On examination, stools may be palpable in the abdomen or rectum.
Non-retentive fecal incontinence is a less common form of functional incontinence, typically seen in children over 4 years old with no evidence of constipation. In this form, stools are more likely to be passed in inappropriate places. There may be an associated oppositional defiant disorder or conduct disorder.
Overall, understanding the symptoms and causes of functional incontinence in children can help parents and healthcare providers address the issue and provide appropriate treatment.
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This question is part of the following fields:
- Children And Young People
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Question 10
Correct
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A 16-year-old girl comes to see you and requests the contraceptive pill. She has come to the surgery alone. You attempt to discuss the request in more detail but she seems nervous and fidgety, not making eye contact with you. You ask her if she would like someone else present for the discussion.
She says she wants to start taking the pill as she is in a relationship and wants to be safe. She appears to be listening but is not asking any questions.
You explain to her that you need to make a thorough assessment if you are to prescribe, and you need to make sure she understands the implications of using contraception and becoming sexually active. You ask her if she has any questions or concerns, and she asks a few questions but seems hesitant to discuss further.
What is the most appropriate approach?Your Answer: Arrange to review her or refer her to a specialist young person's clinic
Explanation:Fraser Guidelines and Young People’s Competence to Consent to Contraceptive Advice or Treatment
The Fraser guidelines provide a framework for assessing young people’s competence to consent to contraceptive advice or treatment. According to these guidelines, a young person is considered competent if they understand the doctor’s advice, cannot be persuaded to inform their parents, are likely to start or continue having sexual intercourse with or without contraceptive treatment, are at risk of physical or mental harm without treatment, and require advice or treatment in their best interests without parental consent.
However, there can be considerable differences in the maturity of teenagers seeking contraception, and it is important to consider whether the failure of the consultation is due to the doctor’s communication skills or the young person’s anxiety. For instance, a young person who is not sexually active may not understand the importance of contraception and may need education or counselling to help them make informed decisions about their sexual health.
In such cases, a specialist young people’s service may be able to provide the necessary support, such as counselling, education, or youth work interventions, to help the young person understand the risks and benefits of contraception and make an informed decision about their sexual health. By providing young people with the information and support they need, healthcare professionals can help them make responsible choices about their sexual health and reduce the risk of physical and mental harm.
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This question is part of the following fields:
- Children And Young People
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Question 11
Correct
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A 32-year-old woman will visit her general practice surgery next week for her annual learning disability health check. She has a diagnosis of mild learning disability and lives in supported accommodation. She has a carer who can support her with communication. The patient works part-time in a library and is in good physical health, with no regularly prescribed medications.
What is the most appropriate adaptation to the standard consultation that needs to be made to carry out this check?Your Answer: Providing the patient with a health check action plan following the consultation
Explanation:Modifications for Conducting a Learning Disability Health Check
How to Modify Health Check for Patients with Learning Disabilities
Providing a health check for patients with learning disabilities requires modifications to ensure that the patient’s needs are met. The following are some modifications that can be made to conduct a successful learning disability health check.
Sending an Invite to the Patient and Carer
The patient and carer should be invited to the health check in the most acceptable way. The carer should be involved in the health check where required. Extra time should be allowed for consultation. A pre-health check questionnaire should be sent to the patient/carer for completion before the appointment.
Ensuring the Carer Attends with the Patient
Patients with learning disabilities may have varying degrees of capacity. Some patients may have full capacity and wish to attend the appointment unaccompanied. However, carers should be invited and welcomed to appointments, if required, and with the patient’s consent whenever possible.
Sending the Invite to the Carer
Patients should be involved in their own healthcare needs, and so should be sent an invite. If appropriate, an invite may also need to be sent to the carer. It should not be assumed that lacking capacity in one area means that patients should be excluded from any decisions or discussion.
Sending the Pre-Health Check Questionnaire to the Carer for Completion
The questionnaire should be completed by the patient with input/support from the carer if required. Depending on the severity of the learning disability, the carer may need to complete the whole questionnaire.
Allocating Thirty Minutes for the Appointment
Consultations will need to be longer for a learning disability health check as time may need to be taken to explain things in a way that the patient can understand. The time for the appointment will need to be decided on an individual basis, depending on the severity of the learning disability.
In conclusion, modifications are necessary to conduct a successful learning disability health check. By following the above modifications, healthcare providers can ensure that patients with learning disabilities receive the care they need.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 12
Correct
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A 32-year-old woman has come for her regular appointment at your GP surgery and has just discovered that she is 6 weeks pregnant. She is seeking assistance with quitting smoking during her pregnancy and wants to discuss treatment options. At present, she smokes 10 cigarettes per day and due to her hectic schedule, she believes that she won't be able to attend frequent meetings.
What is the most suitable smoking cessation therapy to suggest to her?Your Answer: Nicotine replacement therapy
Explanation:Pregnant women who smoke should be offered nicotine replacement therapy, but varenicline and bupropion should not be given as they are not safe for them.
Although referring the patient to a stop smoking clinic would be appropriate, it may not be feasible for her to attend regular meetings.
While the effects of e-cigarette vapour on the foetus are unknown, NICE advises against discouraging pregnant women who are already using e-cigarettes to quit smoking.
Nicotine replacement therapy is the only approved treatment for smoking cessation during pregnancy.
Smoking cessation is the process of quitting smoking. In 2008, NICE released guidance on how to manage smoking cessation. The guidance recommends that patients should be offered nicotine replacement therapy (NRT), varenicline or bupropion, and that clinicians should not favour one medication over another. These medications should be prescribed as part of a commitment to stop smoking on or before a particular date, and the prescription should only last until 2 weeks after the target stop date. If unsuccessful, a repeat prescription should not be offered within 6 months unless special circumstances have intervened. NRT can cause adverse effects such as nausea and vomiting, headaches, and flu-like symptoms. NICE recommends offering a combination of nicotine patches and another form of NRT to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past.
Varenicline is a nicotinic receptor partial agonist that should be started 1 week before the patient’s target date to stop. The recommended course of treatment is 12 weeks, but patients should be monitored regularly and treatment only continued if not smoking. Varenicline has been shown in studies to be more effective than bupropion, but it should be used with caution in patients with a history of depression or self-harm. Nausea is the most common adverse effect, and varenicline is contraindicated in pregnancy and breastfeeding.
Bupropion is a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist that should be started 1 to 2 weeks before the patient’s target date to stop. There is a small risk of seizures, and bupropion is contraindicated in epilepsy, pregnancy, and breastfeeding. Having an eating disorder is a relative contraindication.
In 2010, NICE recommended that all pregnant women should be tested for smoking using carbon monoxide detectors. All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services. The first-line interventions in pregnancy should be cognitive behaviour therapy, motivational interviewing, or structured self-help and support from NHS Stop Smoking Services. The evidence for the use of NRT in pregnancy is mixed, but it is often used if the above measures fail. There is no evidence that it affects the child’s birthweight. Pregnant women
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 13
Correct
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A 65-year-old woman with longstanding rheumatoid arthritis presents with fatigue and loss of appetite of recent origin. Her serum creatinine is 230 µmol/l (50-120 µmol/l) and urea is 13.5 mmol/l (2.5-6.5 mmol/l). She has taken diclofenac for pain relief for several years.
Select from the list the single correct statement about this side-effect of diclofenac.Your Answer: It is likely to be reversible if the drug is stopped
Explanation:The Renal Risks of NSAIDs
One of the most common renal problems is sodium retention, which leads to water retention and oedema. This issue is particularly concerning for patients with pre-existing heart failure, as it can worsen their condition. Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs) can cause hyperkalaemia by inhibiting aldosterone, especially in patients with diabetes, heart failure, or multiple myeloma. If the patient is taking potassium-sparing diuretics or ACE inhibitors, the hyperkalaemia may be more severe.
NSAIDs can cause two types of acute renal failure. The first is haemodynamically mediated, where inhibition of prostaglandin synthesis can lead to reversible renal ischemia, a fall in GFR, and acute renal failure. The second is direct toxic effects on the kidney, such as acute tubular necrosis and acute interstitial nephritis. Adverse renal effects are generally reversible upon discontinuation of NSAID treatment. Glomerulosclerosis, typically caused by diabetes, can also be caused by drug-induced glomerular disease, including that caused by NSAIDs.
High-dose NSAID use may significantly increase the risk of accelerated renal function decline in patients with chronic kidney disease. Therefore, caution should always be exercised when using NSAIDs, and they should be given at the lowest effective dose.
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This question is part of the following fields:
- Kidney And Urology
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Question 14
Correct
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A 30-year-old gentleman presents with a small non-tender lump in the natal cleft. He reports no discharge from the lump. You suspect this to be a pilonidal sinus.
What is the SINGLE MOST appropriate NEXT management step? Choose ONE option only.Your Answer: Refer to general surgeons
Explanation:Management of Asymptomatic Pilonidal Sinus Disease
A watch and wait approach is recommended for individuals with asymptomatic pilonidal sinus disease. It is important for patients to maintain good perianal hygiene through regular bathing or showering. However, there is no evidence to support the removal of buttock hair in these patients. If cellulitis is suspected, antibiotic treatment should be considered. Referral to a surgical team may be necessary if the pilonidal sinus is discharging or if an acute pilonidal abscess requires incision and drainage.
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This question is part of the following fields:
- Dermatology
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Question 15
Incorrect
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A 6-year-old girl is brought in for a follow-up appointment regarding her asthma. She has been using inhaled treatment for the past 12 months and is currently taking salbutamol as needed and a very low dose of inhaled corticosteroids (ICS) daily. She has been using the very low dose ICS at the current dose for the past six months. Her parents report that she still needs to use her salbutamol on most days of the week, but never more than once a day. On clinical examination, her chest is clear and there are no focal cardiorespiratory findings. Her inhaler technique is good and there are no issues with compliance. Based on BTS/SIGN guidelines, what is the most appropriate plan for her current management?
Your Answer: Add in an inhaled long-acting beta2 agonist
Correct Answer: Increase the inhaled corticosteroids to a low daily dose
Explanation:Treatment Ladder for Asthma in Children
Here we have a 7-year-old child who is currently on a regular inhaled very low dose corticosteroid and salbutamol PRN for asthma. However, despite the regular inhaled steroid, the child still requires salbutamol most days, indicating suboptimal control and the need for treatment escalation.
To guide treatment titration, the British Thoracic Society treatment ladder is the most well-recognized guideline in the UK. Based on this, the next step should be to add in an inhaled long-acting beta2 agonist or an LTRA (Leukotriene receptor antagonist) if over 5 years old. If the child was under 5 years old, then an LTRA alone would be added.
It is important to note that higher inhaled corticosteroid doses are treatment options further up the ladder, and theophylline would not normally feature in the primary care setting. Continuing the same treatment with review in 12 months is not appropriate as the child’s current disease control is suboptimal.
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This question is part of the following fields:
- Children And Young People
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Question 16
Incorrect
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A 65-year-old lady comes to see you about her husband. He suffers with Alzheimer's dementia and she is finding it difficult to cope. She says that she doesn't drive and has had to resort to employing private carers to allow her time to do the shopping. She says that they are both in receipt of generous pensions but her sister has suggested that she applies for any benefits that are applicable.
What can you tell her about the Attendance Allowance (AA)?Your Answer: Patients who are not terminally ill must have needed help for twelve months
Correct Answer: To qualify for Attendance Allowance patients must be State Pension age or over
Explanation:Attendance Allowance – A Guide for GPs
Attendance Allowance is a tax-free benefit that provides financial assistance to individuals who are State Pension age or older and have a disability that requires additional help with personal care. This benefit is not affected by income or employment status. To qualify, the individual must have required assistance for at least six months, unless they are terminally ill. There are two levels of Attendance Allowance – lower and higher.
As a GP, you may be asked to complete a statement at the end of the Attendance Allowance claim form by your patient. If the decision maker cannot determine benefit entitlement without further evidence, they may request that you complete a medical report based on your medical records and knowledge of the patient.
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This question is part of the following fields:
- Mental Health
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Question 17
Correct
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A 45-year-old male presents at your clinic following a recent admission at the cardiac unit of the local general hospital. He suffered a myocardial (MI) infarction three weeks ago and has been recovering well physically, but he cries a lot of the time.
You find evidence of low mood, anhedonia and sleep disturbance.
The man feels hopeless about the future and has fleeting thoughts of suicide. He has suffered from depression in the past which responded well to antidepressant treatment.
Which antidepressant would you choose from the following based on its demonstrated safety post-myocardial infarction?Your Answer: Sertraline
Explanation:Sertraline for Depression in Patients with Recent MI or Unstable Angina
Sertraline is a medication that is both effective and well-tolerated for treating depression in patients who have recently experienced a myocardial infarction (MI) or unstable angina. In addition to its antidepressant properties, sertraline has been found to inhibit platelet aggregation. This makes it a valuable treatment option for patients who are at risk for blood clots and other cardiovascular complications. With its dual benefits, sertraline can help improve both the mental and physical health of patients who have experienced a cardiac event.
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This question is part of the following fields:
- Cardiovascular Health
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Question 18
Incorrect
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You are conducting an interview with a 35-year-old man who has increased his alcohol consumption after a recent breakup. According to NICE recommendations, what is the most suitable method to screen for alcohol dependence and harmful drinking?
Your Answer: CAGE questionnaire
Correct Answer: AUDIT questionnaire
Explanation:According to the Clinical Knowledge Summaries from NICE, it is recommended to utilize formal assessment tools to evaluate the extent and seriousness of alcohol misuse. This includes utilizing the AUDIT (Alcohol Use Disorders Identification Test) as a routine measure for identification purposes. This can assist in determining whether a brief intervention is necessary and, if so, what type of intervention is appropriate. In situations where time is limited, it is recommended to use a shortened version of the AUDIT, such as the AUDIT-C (AUDIT-Consumption), and then follow up with the complete questionnaire if problem drinking is indicated.
Alcohol Problem Drinking: Detection and Assessment
Alcohol problem drinking can have serious consequences on an individual’s health and well-being. Therefore, it is important to detect and assess alcohol consumption to identify those who may need intervention. Screening tools such as AUDIT, FAST, and CAGE can be used to identify hazardous or harmful alcohol consumption and alcohol dependence.
AUDIT is a 10-item questionnaire that takes about 2-3 minutes to complete. It has been shown to be superior to CAGE and biochemical markers for predicting alcohol problems. A score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of hazardous or harmful alcohol consumption. A score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol dependence. AUDIT-C is an abbreviated form consisting of 3 questions.
FAST is a 4-item questionnaire that can quickly identify hazardous drinking. The score for hazardous drinking is 3 or more. Over 50% of people will be classified using just the first question, which asks how often the individual has had eight or more drinks on one occasion (six or more for women).
CAGE is a well-known screening tool, but recent research has questioned its value. Two or more positive answers are generally considered a ‘positive’ result. The questions ask about feeling the need to cut down on drinking, being annoyed by criticism of drinking, feeling guilty about drinking, and having a drink in the morning to get rid of a hangover.
To diagnose alcohol dependence, the ICD-10 definition requires three or more of the following: compulsion to drink, difficulties controlling alcohol consumption, physiological withdrawal, tolerance to alcohol, neglect of alternative activities to drinking, and persistent use of alcohol despite evidence of harm.
Overall, screening and assessment tools can help identify individuals who may need intervention for alcohol problem drinking. It is important to use these tools to promote early detection and intervention to prevent further harm.
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This question is part of the following fields:
- Smoking, Alcohol And Substance Misuse
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Question 19
Correct
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Sophie is a 65-year-old woman who has recently been diagnosed with atrial fibrillation after experiencing some palpitations. She has no other medical history and only takes atorvastatin for high cholesterol. She has no symptoms currently and her observations are stable with a heart rate of 75 beats per minute. Her CHA2DS2-VASc score is 0.
What would be the appropriate next step in managing Sophie's condition?Your Answer: Arrange for an echocardiogram
Explanation:When a patient with atrial fibrillation has a CHA2DS2-VASc score that suggests they do not need anticoagulation, it is recommended to perform a transthoracic echo to rule out valvular heart disease. The CHA2DS2-VASc score is used to assess the risk of stroke in AF patients, and anticoagulant treatment is generally indicated for those with a score of two or more. Rivaroxaban is an anticoagulant that can be used in AF, but it is not necessary in this scenario. Aspirin should not be used to prevent stroke in AF patients. If a patient requires rate control for fast AF, beta-blockers are the first line of treatment. Digoxin is only used for patients with a more sedentary lifestyle and doesn’t protect against stroke. It is important to perform a transthoracic echo in AF patients, especially if it may change their management or refine their risk of stroke and need for anticoagulation.
Atrial fibrillation (AF) is a condition that requires careful management, including the use of anticoagulation therapy. The latest guidelines from NICE recommend assessing the need for anticoagulation in all patients with a history of AF, regardless of whether they are currently experiencing symptoms. The CHA2DS2-VASc scoring system is used to determine the most appropriate anticoagulation strategy, with a score of 2 or more indicating the need for anticoagulation. However, it is important to ensure a transthoracic echocardiogram has been done to exclude valvular heart disease, which is an absolute indication for anticoagulation.
When considering anticoagulation therapy, doctors must also assess the patient’s bleeding risk. NICE recommends using the ORBIT scoring system to formalize this risk assessment, taking into account factors such as haemoglobin levels, age, bleeding history, renal impairment, and treatment with antiplatelet agents. While there are no formal rules on how to act on the ORBIT score, individual patient factors should be considered. The risk of bleeding increases with a higher ORBIT score, with a score of 4-7 indicating a high risk of bleeding.
For many years, warfarin was the anticoagulant of choice for AF. However, the development of direct oral anticoagulants (DOACs) has changed this. DOACs have the advantage of not requiring regular blood tests to check the INR and are now recommended as the first-line anticoagulant for patients with AF. The recommended DOACs for reducing stroke risk in AF are apixaban, dabigatran, edoxaban, and rivaroxaban. Warfarin is now used second-line, in patients where a DOAC is contraindicated or not tolerated. Aspirin is not recommended for reducing stroke risk in patients with AF.
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This question is part of the following fields:
- Cardiovascular Health
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Question 20
Correct
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A 54-year-old woman visits your clinic with a complaint of continuous ringing in her ears. She had previously sought medical attention for her lower back pain and was prescribed naproxen and paracetamol. However, the paracetamol was later substituted with co-codamol and then with co-dydramol. Which medication is the probable cause of her recent symptom?
Your Answer: Naproxen
Explanation:High doses of aspirin and other NSAIDs can lead to tinnitus, although the frequency of this side effect is unknown. Co-codamol and co-dydramol are not known to cause tinnitus, but they can cause other side effects such as drowsiness, respiratory depression, and addiction. Melatonin is generally well-tolerated, but it can cause side effects such as changes in behavior, headaches, and sleep disturbances. It is important to be aware of the potential side effects of these medications and to consult with a healthcare professional if any concerns arise.
Tinnitus is a condition where a person perceives sounds in their ears or head that do not come from an external source. It affects approximately 1 in 10 people at some point in their lives and can be distressing for patients. While it is sometimes considered a minor symptom, it can also be a sign of a serious underlying condition. The causes of tinnitus can vary, with some patients having no identifiable underlying cause. Other causes may include Meniere’s disease, otosclerosis, conductive deafness, positive family history, sudden onset sensorineural hearing loss, acoustic neuroma, hearing loss, drugs, and impacted earwax.
To assess tinnitus, an audiologist may perform an audiological assessment to detect any underlying hearing loss. Imaging may also be necessary, with non-pulsatile tinnitus generally not requiring imaging unless it is unilateral or there are other neurological or ontological signs. Pulsatile tinnitus, on the other hand, often requires imaging as there may be an underlying vascular cause. Management of tinnitus may involve investigating and treating any underlying cause, using amplification devices if associated with hearing loss, and psychological therapy such as cognitive behavioural therapy or joining tinnitus support groups.
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This question is part of the following fields:
- Ear, Nose And Throat, Speech And Hearing
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Question 21
Incorrect
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A 35-year-old gentleman has come to discuss the result of a routine annual blood test at work. He is otherwise well with no symptoms reported.
He was found to have a serum phosphate of 0.7.
Other tests done include FBC, U+Es, LFTs, Calcium and PTH which were all normal.
Serum phosphate normal range (0-8-1.4 mmol/L)
What is the most appropriate next step in management?Your Answer: Repeat blood test in 1 month with vitamin D and magnesium
Correct Answer: Ultrasound neck
Explanation:Management of Mild Hypophosphataemia
In cases of mild hypophosphataemia, monitoring is often sufficient. It may be helpful to check vitamin D levels as it can affect phosphate uptake and renal excretion, along with parathyroid hormone (PTH). If there is a concurrent low magnesium level, it may indicate dietary deficiencies.
An ultrasound of the neck is not necessary unless there are signs of enlarged parathyroid glands. Oral phosphate is typically reserved for preventing refeeding syndrome in cases of anorexia, starvation, or alcoholism. Mild hypophosphataemia usually resolves on its own.
Parenteral phosphate may be considered in acute situations but requires inpatient monitoring of calcium, phosphate, and other electrolytes. Referral should only be considered if the patient is symptomatic, has short stature or skeletal deformities consistent with rickets, or if the hypophosphataemia is chronic or severe.
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This question is part of the following fields:
- Cardiovascular Health
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Question 22
Correct
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A 3-year-old girl presents with weight loss at her health check, having dropped from the 75th centile weight at birth to the 9th. She was born abroad; the results of any neonatal screening are unavailable. Since her arrival in this country, she has been prescribed antibiotics for several chest infections. Between attacks, she is well. The mother worries that she might have asthma. There is no family history of note.
What is the most likely diagnosis?Your Answer: Cystic fibrosis
Explanation:Differential diagnosis of a child with faltering growth and respiratory symptoms
Cystic fibrosis, coeliac disease, α1-antitrypsin deficiency, asthma, and hypothyroidism are among the possible conditions that may cause faltering growth and respiratory symptoms in children. In the case of cystic fibrosis, dysfunction of the exocrine glands affects multiple organs, leading to chronic respiratory infection, pancreatic enzyme insufficiency, and related complications. The diagnosis of cystic fibrosis is often made in infancy, but can vary in age and may involve meconium ileus or recurrent chest infections. Coeliac disease, on the other hand, typically develops after weaning onto cereals that contain gluten, and may cause faltering growth but not respiratory symptoms. α1-Antitrypsin deficiency, which can lead to chronic obstructive pulmonary disease later in life, is less likely in a young child. Asthma, a common condition that affects the airways and causes wheeze or recurrent nocturnal cough, usually doesn’t affect growth. Hypothyroidism, a disorder of thyroid hormone deficiency, is screened for in newborns but doesn’t cause respiratory symptoms after birth. Therefore, based on the combination of faltering growth and respiratory symptoms, cystic fibrosis is the most likely diagnosis in this scenario.
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This question is part of the following fields:
- Children And Young People
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Question 23
Correct
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A 60-year-old man has been diagnosed with heart failure and his cardiologist recommends starting a beta-blocker along with other medications. He is currently stable hemodynamically. What is the most suitable beta-blocker to use in this case?
Your Answer: Bisoprolol
Explanation:Beta-Blockers for Heart Failure: Medications and Contraindications
Heart failure is a serious condition that requires proper management to reduce mortality. Beta-blockers are a class of medications that have been shown to be effective in treating heart failure. Despite some relative contraindications, beta-blockers can be safely initiated in general practice. However, there are still absolute contraindications that should be considered before prescribing beta-blockers, such as asthma, second or third-degree heart block, sick sinus syndrome (without pacemaker), and sinus bradycardia (<50 bpm). Bisoprolol, carvedilol, and nebivolol are all licensed for the treatment of heart failure in the United Kingdom. Among these medications, bisoprolol is the recommended choice and should be started at a low dose of 1.25 mg daily and gradually increased to the maximum tolerated dose (up to 10 mg). Other beta-blockers such as labetalol, atenolol, propranolol, and sotalol have different indications and are not licensed for the treatment of heart failure. Labetalol is mainly used for hypertension in pregnancy, while atenolol is used for arrhythmias, angina, and hypertension. Propranolol is indicated for tachycardia linked to thyrotoxicosis, anxiety, migraine prophylaxis, and benign essential tremor. Sotalol is commonly used to treat atrial and ventricular arrhythmias, particularly atrial fibrillation. In summary, beta-blockers are an important class of medications for the treatment of heart failure. However, careful consideration of contraindications and appropriate medication selection is crucial for optimal patient outcomes.
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This question is part of the following fields:
- Cardiovascular Health
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Question 24
Correct
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A 38-year-old man with learning disabilities presents to his General Practitioner for review. He is accompanied by a carer from his residential home, who is new to the home and doesn't know him very well. He was recently discharged from hospital. He has his annual review and blood tests are attempted but rebooked when he becomes distressed.
Which of the following is most likely to be true of this patient, compared to an age-matched population?
Your Answer: Inactive lifestyle
Explanation:The Health Risks and Inequalities Faced by People with Learning Disabilities
People with learning disabilities often live in residential care homes or supported living, leading to an inactive lifestyle. This, along with a greater risk of health problems, can lead to a higher incidence of mental health issues, which are often undiagnosed due to communication difficulties. Additionally, social inequality and poverty can exacerbate health problems, including a higher risk of cardiovascular disease and premature death. It is important to address these health risks and inequalities faced by people with learning disabilities.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 25
Incorrect
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A 48-year-old man comes to your GP clinic complaining of feeling generally unwell and lethargic. His wife notes that he has been eating less than usual and gets tired easily. He has a history of hypertension but no other significant medical history. He drinks alcohol socially and has a stressful job as a banker, which led him to start smoking 15 cigarettes a day for the past 13 years. He believes that work stress is the cause of his symptoms and asks for a recommendation for a counselor to help him manage it. What should be the next step?
Your Answer: Refer to counselling services
Correct Answer: Refer for an urgent Chest X-Ray
Explanation:If a person aged 40 or over has appetite loss and is a smoker, an urgent chest X-ray should be offered within two weeks, according to the updated 2015 NICE guidelines. This is because appetite loss is now considered a potential symptom of lung cancer. While counseling, smoking cessation, and a career change may be helpful, investigating the possibility of lung cancer is the most urgent action required. It is important to address each issue separately, as trying to tackle all three at once could be overwhelming for the patient.
Referral Guidelines for Lung Cancer
Lung cancer is a serious condition that requires prompt diagnosis and treatment. The 2015 NICE cancer referral guidelines provide clear advice on when to refer patients for suspected lung cancer. According to these guidelines, patients should be referred using a suspected cancer pathway referral for an appointment within 2 weeks if they have chest x-ray findings that suggest lung cancer or are aged 40 and over with unexplained haemoptysis.
For patients aged 40 and over who have 2 or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, an urgent chest x-ray should be offered within 2 weeks to assess for lung cancer. This recommendation also applies to patients who have ever smoked and have 1 or more of these unexplained symptoms.
In addition, patients aged 40 and over with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be considered for an urgent chest x-ray within 2 weeks to assess for lung cancer.
Overall, these guidelines provide clear and specific recommendations for healthcare professionals to identify and refer patients with suspected lung cancer for prompt diagnosis and treatment.
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This question is part of the following fields:
- Cardiovascular Health
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Question 26
Incorrect
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A 10-month old baby is brought in for a developmental review by his parents. He is able to sit without support, crawl, and pull himself up to stand. He shows a preference for using his left hand for most activities. He has a weak pincer grip and can point at objects.
However, he is unable to walk without support, even with one hand. He has not yet said mama or dada but does understand the word no. He also doesn't respond to his own name.
Which of these findings is the most concerning?Your Answer: Inability to respond to his name
Correct Answer: Left-handedness
Explanation:Having a hand preference before the age of 12 months is not normal and could be a sign of cerebral palsy. The child’s left-handedness is not a concern, but their early hand preference is. By 12 months, children should be able to walk with support from one parent and respond to their name. They should only be able to walk independently between 13-15 months. While 9-month old babies can typically say mama and dada, it is too early to worry about this in the child’s case.
Common Developmental Problems and Their Causes
Developmental problems can manifest in various ways, including referral points, fine motor skill problems, gross motor problems, and speech and language problems. Referral points may include a lack of smiling at 10 weeks, inability to sit unsupported at 12 months, and inability to walk at 18 months. Fine motor skill problems may be indicated by abnormal hand preference before 12 months, which could be a sign of cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, but other causes may include environmental deprivation and general developmental delay. It is important to identify and address these developmental problems early on to ensure the best possible outcomes for the child’s future.
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This question is part of the following fields:
- Children And Young People
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Question 27
Correct
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A 30-year-old female presents for annual review.
She developed diabetes mellitus at the age of 20 and currently is treated with human mixed insulin twice daily. Over the last one year she has been aware of episodes of dysuria and has received treatment with trimethoprim on four separate occasions for cystitis.
Examination reveals no specific abnormality except for two dot haemorrhages bilaterally on fundal examination. Her blood pressure is 116/76 mmHg.
Investigations show:
HbA1c 75 mmol/mol (20-46)
9% (3.8-6.4)
Fasting plasma glucose 12.1 mmol/L (3.0-6.0)
Serum sodium 138 mmol/L (137-144)
Serum potassium 3.6 mmol/L (3.5-4.9)
Serum urea 4.5 mmol/L (2.5-7.5)
Serum creatinine 90 µmol/L (60-110)
Urinalysis Glucose +
24 hour urine protein 220 mg/24 hrs (<200)
What would be the best therapeutic option to prevent progression of renal disease?Your Answer: Improve glycaemic control with insulin
Explanation:Treatment Options for Diabetic Nephropathy
Diabetic nephropathy is a common complication of diabetes, affecting up to 40% of patients with type 1 diabetes and 5-40% of patients with type 2 diabetes. Without intervention, it can lead to end-stage renal disease. In the case of a patient with microalbuminuria and poor glycaemic control but normal blood pressure, the recommended treatment options include ACE inhibitors, low dietary protein, and improved glycaemic control.
While good glycaemic control has not shown clear benefits in treating microalbuminuria in patients with type 1 diabetes, meta-analyses have shown that ACE inhibitors can reduce albumin excretion rates by 50% in treated patients compared to untreated patients. Low protein diets have been proven effective for overt proteinuria but not for microalbuminuria.
It is important to note that the absence of urinary tract infection is crucial in determining the appropriate treatment plan. In addition to the recommended interventions, any infections that may arise should also be treated promptly. Overall, a combination of ACE inhibitors, low dietary protein, and improved glycaemic control can help prevent the progression of diabetic nephropathy and improve renal function.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 28
Incorrect
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A 30-year-old builder presents with a two week history of deteriorating pain in both feet that feels as though he is walking on gravel, and a sore lower back.
He returned from a holiday in Spain two months ago and had been aware of a transient urethral discharge for which he has received no treatment.Your Answer: Gonococcal arthritis
Correct Answer: Reactive arthritis
Explanation:Understanding Reactive Arthritis
Reactive arthritis, previously known as Reiter’s syndrome, is a condition characterized by a triad of symptoms. These include sero-negative arthritis, urethritis, and conjunctivitis. The painful feet reflect a plantar fasciitis, while sacroiliitis is often present.
Reactive arthritis is known to occur after gastrointestinal infections with Shigella or Salmonella. It can also occur following a nonspecific urethritis. On the other hand, gonococcal arthritis tends to occur in patients who are systemically unwell and have features of septic arthritis.
In summary, understanding the symptoms and causes of reactive arthritis is crucial in its diagnosis and management. Proper identification and treatment of the underlying infection can help alleviate the symptoms and prevent complications.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 29
Incorrect
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A 17-year-old male with uncontrolled asthma on beta agonist therapy is started on a steroid inhaler.
What is the most probable side effect?Your Answer: Dysphonia
Correct Answer: Dental abscess
Explanation:Inhaled Corticosteroids vs Oral Corticosteroids
Inhaled corticosteroids are a preferred treatment option for respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) due to their fewer systemic effects. Unlike oral corticosteroids, inhaled corticosteroids do not cause ulceration and glucose intolerance. However, they may cause local adverse effects such as dysphonia, which is a hoarse or raspy voice. It is important to weigh the benefits and risks of each type of corticosteroid and work with a healthcare provider to determine the best treatment plan for individual needs.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 30
Correct
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A 79-year-old man is being seen in the hypertension clinic. What is the recommended target blood pressure for him once he starts treatment?
Your Answer: 150/90 mmHg
Explanation:Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.
Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.
Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.
The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.
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This question is part of the following fields:
- Cardiovascular Health
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