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Question 1
Correct
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A 31-year-old woman reports that she recently had anaphylaxis due to a peanut allergy. She asks you about immunotherapy for anaphylaxis.
Which of the following pieces of information about immunotherapy for anaphylaxis is correct?Your Answer: Gradually increasing amounts of allergen are injected
Explanation:Hyposensitisation: Gradual Exposure to Allergens for Allergy Treatment
Hyposensitisation, also known as immunotherapy, is a treatment that involves gradually exposing a patient to increasing amounts of an allergen to reduce or eliminate their allergic response. The British National Formulary recommends this treatment for seasonal allergic hay fever and hypersensitivity to wasp and bee venoms that have not responded to anti-allergic drugs. However, it should be used with caution in patients with asthma.
The treatment typically lasts four weeks and can be administered through different dosing schedules, including conventional, modified rush, and rush. In a conventional schedule, injections are given weekly for 12 weeks, with the interval increasing stepwise to two, three, then four weeks. Maintenance treatment is then continued four weekly for at least three years.
Immunotherapy is recommended for patients with a history of severe systemic reactions or moderate systemic reactions with additional risk factors, such as a high serum tryptase or a high risk of stings, or whose quality of life is reduced by fear of venom allergy. Skin testing can be done, and measuring allergen-specific immunoglobulin E (IgE) antibodies is less sensitive.
Patients need referral to an immunotherapy specialist, and injections can be self-administered at home. However, a healthcare professional who can recognize and treat anaphylaxis should be present at the time of injection, and cardiopulmonary resuscitation facilities should be available. The patient should be observed for one hour after injection, and any symptoms, even if mild, need to be monitored until they resolve.
While local or systemic reactions may occur, including anaphylaxis, major side-effects are not a significant risk. However, risks are higher in people with asthma. Overall, hyposensitisation can be an effective treatment for allergies that have not responded to other therapies.
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This question is part of the following fields:
- Allergy And Immunology
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Question 2
Correct
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A 50-year-old woman had a renal transplant three months ago. She presents with fatigue, fever, sweating (especially at night), aching joints and headaches. On examination, there are no focal signs.
Which is the MOST LIKELY diagnosis?Your Answer: Cytomegalovirus (CMV) infection
Explanation:Common Infections in Kidney Transplant Patients
Kidney transplant patients are at a higher risk of infections due to immunosuppression. In the first month post-transplant, infections are similar to those in non-immunosuppressed individuals. However, in the one-month to six-month period, immunomodulating viruses like Cytomegalovirus (CMV), herpes simplex viruses, Epstein–Barr virus, and human herpesvirus-6, hepatitis A, B and C viruses, and human immunodeficiency virus (HIV) are most problematic. influenza can also cause respiratory symptoms, but routine annual administration of the injectable inactivated vaccine is recommended. Herpes simplex virus can cause severe lesions and even disseminated or visceral disease. Pneumonia and urinary infections are also common, and patients should receive appropriate immunisation and prophylactic antibiotics and antiviral drugs for a few months after transplantation. A small group of patients may experience persistence of viral infections and are at risk of opportunistic infections like cryptococcus, pneumocystis, listeria, and nocardia.
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This question is part of the following fields:
- Allergy And Immunology
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Question 3
Correct
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A 28-year-old woman presents to her General Practitioner with a 6-month history of progressive tiredness. She has been working alternative night and day shifts for many months. In the last two months she has experienced intermittent constipation. She reports that her diet is not great because of these awkward shift patterns but that she doesn't restrict it. She thinks she may have lost a small amount of weight over this period. Her legs ache after a long shift and that the tan she obtained in the summer seems to have lingered.
She has no significant previous illness and doesn't take any regular medications.
Investigations:
Investigation Result Normal values
Haemoglobin (Hb) 130 g/l 115–155 g/l
White cell count (WCC) 4.5 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 222 × 109/l 150–400 × 109/l
Sodium (Na+) 128 mmol/l 135–145 mmol/l
Potassium (K+) 5.3 mmol/l 3.5–5.0 mmol/l
Urea 4.8 mmol/l 2.5–7.8 mmol/l
Creatinine (Cr) 56 µmol/l 45–84 µmol/l
Free thyroxine (T4) 12 pmol/l 9–24 pmol/l
Thyroid-stimulating hormone (TSH) 2.2 mU/l 0.4–4.0 mU/l
Haemoglobin A1c (HbA1c) 39 mmol/mol < 41 mmol/mol
Ferritin 50 ng/ml 10–300 ng/ml
Glucose 5.2 mmol/l 3.9–7.1 mmol/l
What is the most likely diagnosis?Your Answer: Addison's disease
Explanation:Differential diagnosis for a patient with fatigue, weight loss, and electrolyte abnormalities
Addison’s disease: The most likely diagnosis for this patient is Addison’s disease, an autoimmune disorder that affects the adrenal glands and leads to a deficiency of cortisol and aldosterone. The gradual onset of symptoms, including fatigue, weight loss, muscle aches, constipation, and hyperpigmentation, along with mild hyponatremia and hyperkalemia, are consistent with this diagnosis.
Subclinical hypothyroidism: Although the patient has some symptoms that could be attributed to low thyroid hormone levels, her thyroid function tests are normal, making this diagnosis less likely.
Dietary related hyponatremia: Mild hyponatremia in a young person is unlikely to be caused by dietary differences or deficiency, suggesting a pathological process.
Renal disease: While electrolyte abnormalities could be a sign of renal insufficiency, the patient’s normal urea and creatinine levels make this diagnosis less likely.
Cushing’s disease: Although some symptoms, such as fatigue and muscle weakness, could be attributed to excess cortisol, other expected symptoms, such as weight gain and high blood sugar, are not present in this patient.
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This question is part of the following fields:
- Allergy And Immunology
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Question 4
Correct
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A 30-year-old woman visits her General Practitioner during the summer. She has suffered from mild asthma for many years, controlled with an inhaled short-acting beta-agonist (SABA). She has started working at a construction site and has noticed that her asthma is much worse, with daily symptoms. She has to use her current inhaler several times a day.
On examination, her chest is clear. Her best peak expiratory flow rate (PEFR) is 480 l/min. Today, her PEFR is 430 l/min.
What is the most appropriate next step in this patient's management?Your Answer: Start an inhaled corticosteroid
Explanation:Managing Worsening Asthma Symptoms: Starting Inhaled Corticosteroids
This patient’s asthma symptoms have worsened, likely due to exposure to allergens at the stable. While her chest is clear and her PEFR has only mildly dropped, her daily symptoms and use of SABA indicate poorly controlled asthma. The first step in managing her symptoms is to start an inhaled corticosteroid as part of the stepwise approach to asthma management. Urgent allergy testing or a home allergy testing kit are not necessary at this stage, and oral steroids are not yet indicated. Instead, allergen avoidance measures can be discussed. It is not necessary for the patient to stop working at the stable at this time.
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This question is part of the following fields:
- Allergy And Immunology
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Question 5
Correct
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A 5-year-old boy is brought by his mother to the Out-of-hours (OOH) walk-in centre. She reports that he is thought to have an allergy to peanuts and is waiting for an Allergy Clinic outpatient appointment. He has eaten a piece of birthday cake at a party about 30 minutes ago and has quickly developed facial flushing, with swelling of the lips and face. He has become wheezy and is now unable to talk in complete sentences.
What is the most appropriate management option?Your Answer: Administer 300 µg 1: 1000 adrenaline IM
Explanation:Correct and Incorrect Management Options for Anaphylaxis
Anaphylaxis is a potentially life-threatening allergic reaction that requires immediate management. The correct management options include administering adrenaline 1:1000 intramuscularly (IM) at appropriate doses based on the patient’s age and weight. However, there are also incorrect management options that can be harmful to the patient.
One incorrect option is administering chlorphenamine IM. While it is a sedating antihistamine, it should not be used as a first-line intervention for airway, breathing, or circulation problems during initial emergency treatment. Non-sedating oral antihistamines may be given following initial stabilisation.
Another incorrect option is advising the patient to go to the nearest Emergency Department instead of administering immediate drug management. Out-of-hours centres should have access to emergency drugs, including adrenaline, and GPs working in these settings should be capable of administering doses in emergencies.
It is also important to administer the correct dose of adrenaline based on the patient’s age and weight. Administering a dose that is too high, such as 1000 µg for a 7-year-old child, can be harmful.
In summary, the correct management options for anaphylaxis include administering adrenaline at appropriate doses and avoiding incorrect options such as administering chlorphenamine IM or advising the patient to go to the nearest Emergency Department without administering immediate drug management.
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This question is part of the following fields:
- Allergy And Immunology
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Question 6
Correct
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A 47-year-old woman with rheumatoid arthritis is being evaluated in the clinic as she has not responded well to methotrexate. The possibility of starting sulfasalazine is being considered. However, if she has an allergy to which of the following drugs, it may not be advisable to prescribe sulfasalazine?
Your Answer: Aspirin
Explanation:Sulfasalazine may cause a reaction in patients who are allergic to aspirin.
Sulfasalazine: A DMARD for Inflammatory Arthritis and Bowel Disease
Sulfasalazine is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage inflammatory arthritis, particularly rheumatoid arthritis, as well as inflammatory bowel disease. This medication is a prodrug for 5-ASA, which works by reducing neutrophil chemotaxis and suppressing the proliferation of lymphocytes and pro-inflammatory cytokines.
However, caution should be taken when using sulfasalazine in patients with G6PD deficiency or those who are allergic to aspirin or sulphonamides due to the risk of cross-sensitivity. Adverse effects of sulfasalazine may include oligospermia, Stevens-Johnson syndrome, pneumonitis/lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, and the potential to color tears and stain contact lenses.
Despite these potential side effects, sulfasalazine is considered safe to use during pregnancy and breastfeeding, making it a viable option for women who require treatment for inflammatory arthritis or bowel disease.
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This question is part of the following fields:
- Allergy And Immunology
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Question 7
Correct
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Jacob is a 27-year-old man with asthma, eczema, hayfever, type 1 diabetes and coeliac disease. He also suffers from oral allergy syndrome and reacts to banana, carrots and kiwifruit.
Among Jacob's health conditions, which one is most closely linked to oral allergy syndrome?Your Answer: Hayfever
Explanation:Seasonal variation is a common feature of oral allergy syndrome, which is closely associated with pollen allergies such as hayfever.
Understanding Oral Allergy Syndrome
Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.
It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.
OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.
In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.
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This question is part of the following fields:
- Allergy And Immunology
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Question 8
Correct
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A 25-year-old woman comes to her General Practitioner complaining of bilateral erythematous palms. She reports itching and the presence of some vesicles. She has observed this developing quickly at work, where she has just begun a new job as a hairdresser.
What is the most probable diagnosis?Your Answer: Allergic contact dermatitis
Explanation:Skin Conditions: Allergic Contact Dermatitis, Atopic Eczema, Scabies, Hand, Foot and Mouth Disease, and Ringworm
Skin conditions can vary in their causes and symptoms. Allergic contact dermatitis is a delayed hypersensitivity reaction that occurs upon contact with an allergen, such as nickel, hair dyes, bleaches, perfumes, fragrances, and rubber antioxidants in gloves. Atopic eczema is a chronic skin condition that presents with red, itchy skin localized to the flexor surfaces and doesn’t normally develop vesicles. Scabies is a contagious skin condition caused by exposure to mites, which is very itchy and often starts between the fingers, but it would not normally flare up while at work. Hand, foot and mouth disease is a common childhood condition caused by the Coxsackievirus, characterized by a vesicular rash on the hands, feet, and mouth. Ringworm is a fungal skin infection that is usually circular with a silver scale and can be itchy, but it would be unlikely to cause bilateral hand symptoms and doesn’t cause the vesicular rash described here.
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This question is part of the following fields:
- Allergy And Immunology
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Question 9
Correct
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A 45-year-old man presents to his General Practitioner complaining of persistent urticaria, which he has experienced over the last six months. He obtains relief by taking antihistamine tablets. He takes no other medications and has restricted his diet to fresh food in an attempt to reduce the histamine exposure in his diet. He has not been in contact with any new chemicals or materials.
What is the most likely underlying cause of this patient's presentation?Your Answer: An autoimmune response
Explanation:Understanding the Different Causes of Urticaria
Urticaria, commonly known as hives, can be caused by a variety of factors. It can be idiopathic, immunological, or non-immunological. Chronic urticaria is diagnosed when a patient experiences daily or episodic wheals for at least six weeks. Histamine-releasing autoantibodies are present in at least 30% of patients with chronic urticaria. Contact urticaria is a rapid, localised reaction to certain triggering substances. Pseudoallergens, such as certain drugs or food additives, can aggravate wheals in any form of urticaria. Type I hypersensitivity reactions, which are immunoglobulin E mediated, can cause acute urticaria. Type IV hypersensitivity and contact irritant effects are seen in contact allergic dermatitis and contact irritant dermatitis. Understanding the different causes of urticaria can help in its diagnosis and management.
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This question is part of the following fields:
- Allergy And Immunology
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Question 10
Correct
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A 7-year-old boy comes to the doctor's office with his mother complaining of recurrent episodes of mouth, tongue, and lip itchiness shortly after eating bananas. The symptoms usually subside within half an hour. The child has a history of asthma and allergic rhinitis. He has undergone allergy testing before, which revealed a positive result for birch pollen.
What is the probable diagnosis?Your Answer: Oral allergy syndrome
Explanation:Angioedema can be triggered by drug-induced reactions or, in rare cases, other factors.
Understanding Oral Allergy Syndrome
Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.
It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.
OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.
In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.
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This question is part of the following fields:
- Allergy And Immunology
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Question 11
Incorrect
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A father is worried that his 7-year-old daughter has a food allergy. She has been experiencing occasional itchy rashes. He decided to eliminate all nuts from her diet and the rashes have disappeared. However, she recently had an episode of vomiting, so he also removed milk from her diet. He has been giving her antihistamines regularly. He is curious if she can undergo a blood test for allergies.
What is the most suitable advice you can provide him?Your Answer: Evidence of sensitisation to an allergen by means of this test is synonymous with clinically relevant disease
Correct Answer: It is indicated for a child who has a suspected allergic reaction after consuming peanuts
Explanation:Understanding IgE Immunoassay Testing for Peanut Allergies
IgE immunoassay testing is a diagnostic tool used to evaluate hypersensitivity to various allergens, including peanuts. This test is particularly useful for children who have a suspected allergic reaction after consuming peanuts. IgE produced by B cells in response to specific antigens binds to receptors on mast cells, triggering an immediate (type I) response that can lead to anaphylaxis, urticaria, bronchospasm, and other symptoms.
Compared to skin-prick testing, IgE immunoassay testing is more sensitive and doesn’t carry the risk of anaphylaxis. However, it can give false-negative results in patients who have true IgE-mediated disease, as confirmed by skin testing or allergen challenge. Therefore, it should be used in conjunction with the patient’s clinical history and not for screening purposes.
A positive IgE immunoassay test indicates past sensitization to an allergen, but it doesn’t necessarily mean that the patient has clinically relevant disease. Some patients may show positive results but no symptoms associated with that allergen. Therefore, the history is more important in making a diagnosis.
It is important to note that IgE immunoassay testing cannot be used if a patient is taking antihistamines. However, it is a useful diagnostic tool for patients on long-term corticosteroids, although data are conflicting.
In summary, IgE immunoassay testing is a valuable diagnostic tool for peanut allergies, but it should be used in conjunction with the patient’s clinical history and not for screening purposes. A positive test supports the diagnosis of peanut allergy, but the history is more important.
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This question is part of the following fields:
- Allergy And Immunology
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Question 12
Incorrect
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A 65-year-old woman comes to talk about shingles vaccine. She says she has had shingles before – although there is no record of this in her notes – and she doesn't want it again, as she has heard it is more severe if you get it when you are older. Which of the following is it most important to make her aware of?
Your Answer:
Correct Answer: He should postpone vaccination until he is 70-years old
Explanation:Shingles Vaccination: Who Should Get It and When?
The national shingles immunisation programme aims to reduce the incidence and severity of shingles in older people. The vaccine is recommended for routine administration to those aged 70 years, but can be given up until the 80th birthday. Vaccination is most effective and cost-effective in this age group, as the burden of shingles disease is generally more severe in older ages. The vaccine is not routinely offered below 70 years of age, as the duration of protection is not known to last more than ten years and the need for a second dose is not known.
Zostavax® is the only shingles vaccine available in the UK, and is contraindicated in immunosuppressed individuals. Previous shingles is also a contraindication, as there is a natural boosting of antibody levels after an attack of shingles.
Clinical trials have shown that the vaccine reduces the incidence of shingles and post-herpetic neuralgia in those aged 60 and 70 years and older. However, it is important to note that the vaccine is only effective in reducing neuralgia.
In summary, the shingles vaccine is recommended for routine administration to those aged 70 years, but can be given up until the 80th birthday. It is contraindicated in immunosuppressed individuals and those with a history of shingles. While the vaccine is effective in reducing neuralgia, it is not a guarantee against shingles.
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This question is part of the following fields:
- Allergy And Immunology
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Question 13
Incorrect
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A 67-year-old man presents for his first seasonal influenza vaccination. He reports a history of anaphylaxis and carries an epipen. What would be a contraindication to administering the vaccine?
Your Answer:
Correct Answer: Food allergy to egg
Explanation:Being mindful of contraindications for the influenza vaccine is crucial. The presence of ovalbumin, an egg protein, in the regular influenza vaccine may lead to anaphylaxis in individuals with a severe egg allergy. To address this concern, egg protein-free vaccines such as Optaflu are accessible for these patients.
influenza vaccination is recommended in the UK between September and early November, as the influenza season typically starts in the middle of November. There are three types of influenza virus, with types A and B accounting for the majority of clinical disease. Prior to 2013, flu vaccination was only offered to the elderly and at-risk groups. However, a new NHS influenza vaccination programme for children was announced in 2013, with the children’s vaccine given intranasally and annually after the first dose at 2-3 years. It is important to note that the type of vaccine given to children and the one given to the elderly and at-risk groups is different, which explains the different contraindications.
For adults and at-risk groups, current vaccines are trivalent and consist of two subtypes of influenza A and one subtype of influenza B. The Department of Health recommends annual influenza vaccination for all people older than 65 years and those older than 6 months with chronic respiratory, heart, kidney, liver, neurological disease, diabetes mellitus, immunosuppression, asplenia or splenic dysfunction, or a body mass index >= 40 kg/m². Other at-risk individuals include health and social care staff, those living in long-stay residential care homes, and carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill.
The influenza vaccine is an inactivated vaccine that cannot cause influenza, but a minority of patients may develop fever and malaise that lasts 1-2 days. It should be stored between +2 and +8ºC and shielded from light, and contraindications include hypersensitivity to egg protein. In adults, the vaccination is around 75% effective, although this figure decreases in the elderly. It takes around 10-14 days after immunisation before antibody levels are at protective levels.
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This question is part of the following fields:
- Allergy And Immunology
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Question 14
Incorrect
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A 54-year-old man comes to the general practice clinic to discuss his aftercare: he was discharged from hospital six weeks ago after a successful liver transplant. He is being treated by the local liver unit and has a medical history of hypertension, hyperlipidaemia, and liver cirrhosis caused by alcohol consumption. He is also a smoker. He has some concerns about his ongoing care and would like some guidance on lifestyle issues and managing his blood pressure. What is the best advice to give this patient?
Your Answer:
Correct Answer: The use of nicotine patches is safe post liver transplant
Explanation:Post-Liver Transplant Patient Care: Important Considerations
Liver transplant patients require specialized care to ensure optimal outcomes. Here are some important considerations:
Encourage smoking cessation: Smoking can promote fibrosis and increase the risk of hepatoma development. Nicotine replacement therapy is a safe option.
Limit alcohol intake: For non-alcohol indications, maintaining alcohol intake below 14 units/week is appropriate to prevent significant relapse and graft damage.
Encourage exercise: Exercise can provide cardiovascular benefits and reduce the risk of osteoporosis. Strenuous exercise should be avoided for the first 12 months after transplant.
Consider statins: Pravastatin and atorvastatin are safe and effective for managing hypertriglyceridaemia following a liver transplant.
Use calcium channel blockers for hypertension: These drugs have minimal side effects and do not interact with calcineurin inhibitors like tacrolimus.
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This question is part of the following fields:
- Allergy And Immunology
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Question 15
Incorrect
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A 30-year-old patient presents to your GP clinic with a spider bite that occurred 7 days ago. The patient reports experiencing pruritus, urticarial rash, erythema, lip swelling, abdominal pain, and vomiting shortly after being bitten. The patient has been taking cetirizine daily from a home supply for the past week, which has resolved all symptoms.
What is the recommended follow-up plan for this patient?Your Answer:
Correct Answer: Referral to an allergy specialist
Explanation:If someone experiences a systemic reaction to an insect bite, it is important to refer them to an allergy specialist. In this case, the patient’s moderate reaction suggests the need for further evaluation by a specialist who can determine if an adrenaline auto-injector and medical identification bracelet are necessary. However, since the bite occurred 7 days ago and the patient is currently stable, there is no need to refer them to the emergency department or medical team at this time. Additionally, late-onset reactions typically occur within a few hours of the bite, so a follow-up appointment at the 2-week mark is not necessary.
Venom allergy can cause local or systemic reactions, including anaphylaxis. Acute management is supportive, with anaphylaxis treated with adrenaline, steroids, and antihistamines. Referral to an allergy specialist is recommended for those with systemic reactions or suspected venom allergy. Venom immunotherapy may be recommended for those with a history of systemic reactions and raised levels of venom-specific IgE, but should not be performed in those without demonstrable venom-specific IgE or recent anaphylaxis. VIT has a high success rate in preventing systemic reactions and improving quality of life.
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This question is part of the following fields:
- Allergy And Immunology
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Question 16
Incorrect
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A 25-year-old woman is treated in the Emergency Department (ED) following an anaphylactic reaction to a wasp sting. She presents to her General Practitioner (GP) a few days later as she is worried about the possibility of this happening again and is seeking advice on what she should do if it does.
What is the most appropriate initial self-management advice for this patient?Your Answer:
Correct Answer: Self-administer an intramuscular (IM) injection of adrenaline
Explanation:How to Self-Administer an Intramuscular Injection of Adrenaline for Anaphylaxis
Anaphylaxis is a severe and potentially life-threatening allergic reaction that requires immediate treatment. The most effective treatment for anaphylaxis is intramuscular (IM) adrenaline, which can be self-administered using adrenaline auto-injectors (AAIs) such as EpiPen® and Jext®.
Before using an AAI, patients should receive proper training on their use. The recommended dose of adrenaline for adults is 0.3 mg, while for children up to 25-30 kg, it is 0.15 mg. Patients should carry two doses with them at all times, as the dose may need to be repeated after 5-15 minutes.
It is important to note that a cold compress is not an effective treatment for anaphylaxis, as it is a systemic reaction. Similarly, taking an oral antihistamine should not delay treatment with IM adrenaline.
If experiencing anaphylaxis, it is crucial to administer the IM adrenaline injection immediately and then seek medical attention. Contacting emergency services is recommended, but should not delay self-administration of the injection. Additionally, if stung by a bee, the sting should be scraped out rather than plucked to avoid squeezing more venom into the skin.
In summary, knowing how to self-administer an IM injection of adrenaline is crucial for those at risk of anaphylaxis. Proper training and carrying two doses of the medication at all times can help ensure prompt and effective treatment in case of an emergency.
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This question is part of the following fields:
- Allergy And Immunology
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Question 17
Incorrect
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A father brings his eight-year-old daughter to an emergency appointment at the Duty Doctor Clinic after she sustained a needlestick injury that day on her way home from school. He explains that he picked her up from school by car, and he then parked in the underground car park where they have an allocated space next to their flat.
Unfortunately, rough sleepers have been using the car park as shelter, and on getting out of the car his daughter found a needle on the floor which she picked up but accidentally pricked her finger in doing so. His dad is very concerned about her risk of human immunodeficiency virus (HIV) and wants to know if she should be tested.
What is the most appropriate advice to give him, regarding immediate management of this needlestick injury?Your Answer:
Correct Answer: The risk of hepatitis from a contaminated needle is greater than the risk of HIV
Explanation:Managing a Needlestick Injury: Important Considerations
A needlestick injury can be a stressful and potentially dangerous situation. Here are some important considerations to keep in mind when managing such an injury:
– The risk of hepatitis from a contaminated needle is greater than the risk of HIV. However, post-exposure prophylaxis (PEP) should still be considered for HIV prevention.
– If the individual has not been vaccinated against hepatitis B, an accelerated course of hepatitis B should be offered following the injury.
– Blood tests should be arranged as soon as possible for baseline virology and liver function tests. These should be repeated at three and six months.
– First aid for a needlestick injury includes encouraging bleeding and washing with soap and running water. However, there is no need to re-open the wound to encourage further bleeding.
– HIV self-test kits are available through online request platforms, but they are generally not appropriate for individuals who do not belong to a high-risk group and have had a single needlestick injury in the community.By keeping these considerations in mind, individuals can take appropriate steps to manage a needlestick injury and reduce the risk of infection.
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This question is part of the following fields:
- Allergy And Immunology
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Question 18
Incorrect
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A mother has brought her 10-year-old daughter to see the GP regarding a rash that developed after being bitten by a horsefly on her left arm while playing in the garden. The child developed multiple red rashes on her body and limbs within fifteen minutes, which were itchy and uncomfortable. The mother promptly gave her daughter cetirizine syrup, and the rash went down by the evening. The child has no history of allergies or any other symptoms.
During examination, the child's observations are normal, and there is only a small area of localised redness measuring 1 cm in diameter where she was bitten. There is no sign of infection. The mother shows a picture of the rash on her phone, which appears to be an urticarial rash, affecting the trunk, upper and lower limbs.
What is the most appropriate management plan for this 10-year-old girl?Your Answer:
Correct Answer: Referral to allergy clinic
Explanation:People who have experienced a systemic reaction to an insect bite or sting should be referred to an allergy clinic, according to NICE guidelines. This is particularly important if the individual has a history of such reactions or if their symptoms suggest a systemic reaction, such as widespread urticarial rash and pruritus. Immediate admission to the emergency department is necessary if there are signs of a systemic reaction. Treatment for large local reactions to insect bites or stings may involve oral antihistamines and/or corticosteroids, although evidence to support this is limited. Testing for serum levels of complement C1 inhibitor may be necessary in cases of suspected hereditary angioedema, which is characterized by recurrent oedema in various parts of the body. However, there are no indications of this in the case at hand.
Venom allergy can cause local or systemic reactions, including anaphylaxis. Acute management is supportive, with anaphylaxis treated with adrenaline, steroids, and antihistamines. Referral to an allergy specialist is recommended for those with systemic reactions or suspected venom allergy. Venom immunotherapy may be recommended for those with a history of systemic reactions and raised levels of venom-specific IgE, but should not be performed in those without demonstrable venom-specific IgE or recent anaphylaxis. VIT has a high success rate in preventing systemic reactions and improving quality of life.
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This question is part of the following fields:
- Allergy And Immunology
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Question 19
Incorrect
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A 35-year-old woman has recently developed symmetrical polyarthritis affecting the small joints of the hands and feet.
Which of the following tests is most likely to contribute to a definitive diagnosis in this patient?
Your Answer:
Correct Answer: Rheumatoid factor
Explanation:Autoantibodies and their Association with Autoimmune Diseases
Autoantibodies are antibodies that target the body’s own tissues and cells. They are often associated with autoimmune diseases, which occur when the immune system mistakenly attacks healthy cells and tissues. Here are some common autoantibodies and their association with autoimmune diseases:
1. Rheumatoid factor: This autoantibody is found in 60-70% of patients with rheumatoid arthritis (RA) and in 5% of the general population. It may also be elevated in other autoimmune diseases. Testing for rheumatoid factor is recommended in people with suspected RA who have synovitis on clinical examination.
2. Antinuclear antibody: This autoantibody binds to the contents of the cell nucleus. It is present in almost all people with systemic lupus erythematosus and is also found in patients with other autoimmune diseases such as rheumatoid arthritis, scleroderma, Sjögren’s syndrome, polymyositis, and certain forms of chronic active hepatitis.
3. Antimitochondrial antibody: This autoantibody is present in 90-95% of patients with autoimmune liver disease, primary biliary cholangitis, and also in 0.5% of the general population. It is also found in about 35% of patients with primary biliary cirrhosis.
4. Antiphospholipid antibodies: These autoantibodies are associated with antiphospholipid syndrome, an autoimmune, hypercoagulable state that can cause arterial and venous thrombosis as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, and severe preeclampsia.
5. HLA-B27 antigen: This antigen is strongly associated with ankylosing spondylitis, as well as other diseases such as psoriasis, reactive arthritis, and inflammatory bowel disease. Its prevalence varies in the general population according to racial type.
In conclusion, autoantibodies can provide important diagnostic and prognostic information in autoimmune diseases. Testing for these antibodies can help healthcare providers make accurate diagnoses and develop effective treatment plans.
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This question is part of the following fields:
- Allergy And Immunology
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Question 20
Incorrect
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A 35-year-old homeless Romanian man presents to his General Practitioner with a persistent cough that has lasted for the last four weeks, with breathlessness at rest. He sometimes does casual work as a labourer, but he is finding that he is unable to keep up with this work due to his breathlessness and generally feels fatigued and 'not well'.
On further questioning, he reports night sweats and weight loss over the past 4-6 weeks. He is a non-smoker and is not on regular medication. He requests a course of antibiotics to make his cough better so he can get back to work.
What is the most likely underlying diagnosis?Your Answer:
Correct Answer: Tuberculosis (TB)
Explanation:Diagnosing Respiratory Conditions: Differential Diagnosis of a Persistent Cough
A persistent cough can be a symptom of various respiratory conditions, making it important to consider a differential diagnosis. In the case of a homeless patient from Romania, the most likely diagnosis is pulmonary tuberculosis (TB), given the patient’s risk factors and symptoms of weight loss, night sweats, malaise, and breathlessness. To investigate this, three sputum samples and a chest X-ray should be arranged.
While lung cancer can also present with similar symptoms, the patient’s young age and non-smoking status make this less likely. Asthma is unlikely given the absence of environmental triggers and the presence of additional symptoms. Bronchiectasis is also an unlikely diagnosis, as it is characterized by copious mucopurulent sputum production, which is not described in this case. Pulmonary fibrosis is rare in patients under 50 years old and doesn’t typically present with night sweats.
In summary, a persistent cough can be indicative of various respiratory conditions, and a thorough differential diagnosis is necessary to determine the most likely diagnosis and appropriate treatment plan.
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This question is part of the following fields:
- Allergy And Immunology
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Question 21
Incorrect
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Individuals with primary antibody deficiencies often experience repeated infections. What is the most common symptom observed in these individuals?
Your Answer:
Correct Answer: Respiratory infection
Explanation:Understanding Primary Antibody Deficiencies: Causes, Symptoms, and Diagnosis
Primary antibody deficiencies refer to a group of rare disorders that affect the body’s ability to produce effective antibodies against pathogens. These disorders may be caused by a mutation in a single gene or by multiple genetic factors, similar to diabetes. While primary antibody deficiencies are the most common forms of primary immune deficiency, other primary immune deficiencies involve defects in cellular immunity, phagocyte defects, and complement defects. It is important to distinguish primary antibody deficiencies from secondary immune deficiencies caused by factors such as malignancy, malnutrition, or immunosuppressive therapy.
Clinical history is crucial in identifying primary antibody deficiencies. Patients of any age who experience recurrent infections, particularly in the respiratory tract, should be investigated if the frequency or severity of infection is unusual or out of context. While most patients are under 20 years old, common variable immunodeficiency typically peaks in the second or third decade of life. A systematic review has found that respiratory and sinus infections are the most common presenting symptoms, followed by gastrointestinal and cutaneous infections. Meningitis, septic arthritis/osteomyelitis, and ophthalmic infections are much less common.
In summary, understanding primary antibody deficiencies is essential in diagnosing and managing patients with recurrent infections. Clinical history plays a crucial role in identifying these disorders, which can be caused by genetic factors and affect the body’s ability to produce effective antibodies against pathogens.
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This question is part of the following fields:
- Allergy And Immunology
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Question 22
Incorrect
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A 5-year-old girl is brought to the General Practitioner because of atopic eczema. Her patents enquire about the possible role of food allergy in her condition.
Which of the following features is most suggestive of a food allergen exacerbating the eczema of this patient?
Your Answer:
Correct Answer: Eczema not controlled by optimum management
Explanation:Understanding Food Allergies and Atopic Eczema in Children
Atopic eczema is a common skin condition that affects many children. While it can be managed with proper treatment, some cases may not respond to standard therapies. In these situations, food allergies should be considered as a possible contributing factor. According to the National Institute for Health and Care Excellence, children with moderate to severe atopic eczema that has not been controlled with optimum management, particularly if associated with gut dysmotility or failure to thrive, should be evaluated for food allergies.
Elevated levels of immunoglobulin E (IgE) are often associated with atopic eczema and may indicate allergies to food or environmental allergens. However, these allergies may not be directly related to the eczema. While exclusive breastfeeding has been recommended to prevent the development of atopic eczema in susceptible infants, there is no evidence to support this claim.
Allergy tests, such as prick tests and radioallergosorbent tests (RAST), may be used to identify potential allergens. However, false positives are common in individuals with atopic eczema due to the skin’s excessive sensitivity. If a true allergy is identified and exposure to the allergen worsens the eczema, removing the allergen may improve the condition.
In summary, understanding the relationship between food allergies and atopic eczema is important for managing this common condition in children. Proper evaluation and treatment can help improve symptoms and quality of life.
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This question is part of the following fields:
- Allergy And Immunology
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Question 23
Incorrect
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A 25-year-old woman presents to the General Practice Surgery where she has recently registered. She is experiencing sneezing, an itchy nose, and itchy, watery eyes. She suspects that her symptoms are due to allergies and would like to undergo comprehensive allergy testing to inform her workplace and make necessary adjustments. She also wonders if she should carry an EpiPen.
What is the most probable cause of this patient's allergy?Your Answer:
Correct Answer: Seasonal rhinitis
Explanation:Common Allergic and Non-Allergic Conditions: Causes and Differences
Seasonal rhinitis, atopic eczema, chronic urticaria, lactose intolerance, and coeliac disease are common conditions that can cause discomfort and distress. Understanding their causes and differences is important for proper diagnosis and treatment.
Seasonal rhinitis, also known as hay fever, is caused by allergens such as tree pollen, grass, mould spores, and weeds. It is an IgE-mediated reaction that occurs at certain times of the year.
Atopic eczema can be aggravated by dietary factors in some children, but less frequently in adults. Food allergy should be suspected in children who have immediate reactions to food or infants with moderate or severe eczema that is not well-controlled.
Chronic urticaria may have an immunological or autoimmune cause, but can also be idiopathic or caused by physical factors, drugs, or dietary pseudo allergens. It presents with a rash.
Lactose intolerance is due to an enzyme deficiency and is different from milk allergy, which is IgE-mediated. It can occur following gastroenteritis.
Coeliac disease is an autoimmune condition that affects the small intestine in response to gluten exposure. It is not a gluten allergy.
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This question is part of the following fields:
- Allergy And Immunology
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Question 24
Incorrect
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A 32-year-old man has an ‘allergic condition’ and wants to know if desensitising injections can help him overcome it.
Which of the following ‘allergic conditions’ is the one for which allergen immunotherapy (desensitising vaccines) is most commonly recommended?Your Answer:
Correct Answer: Hypersensitivity to bee and wasp stings
Explanation:Allergy Treatment Options for Different Types of Allergies
Bee and Wasp Sting Hypersensitivity:
Patients who have a systemic reaction to bee or wasp stings should be referred to an allergy specialist. The first line of investigation is to demonstrate specific IgE by skin testing to both bee and wasp venom. Serum tryptase should also be measured to indicate the risk of future severe reactions. Patients should receive a written emergency management plan, an adrenaline auto-injector, and be educated in its use. Venom immunotherapy is effective in treating this type of allergy.Peanut Allergy:
Desensitization is not widely used to treat food allergy because of the risk of anaphylaxis. The British National Formulary approves its use only for bee and wasp venom and pollen allergy.Allergic Rhinitis:
Desensitization is available for severe seasonal rhinitis that has not responded to drugs. Sublingual or subcutaneous administration can be used, but it is recommended that only specialists use them due to concerns about the safety of desensitizing vaccines.Chronic Urticaria:
Chronic urticaria doesn’t normally have an allergic cause. Chronic spontaneous urticaria may be autoimmune, while chronic inducible urticaria is due to physical stimuli such as heat, cold, pressure, and sweating.Contact Allergic Dermatitis:
This type of allergy is not IgE-mediated but rather a delayed hypersensitivity reaction. In contrast, bee and wasp venom and pollen allergies are IgE-mediated immediate hypersensitivity reactions. -
This question is part of the following fields:
- Allergy And Immunology
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Question 25
Incorrect
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A 25-year-old man has had recurrent chest and sinus infections. He was originally thought to be asthmatic, but his response to treatment has been poor. He does respond to antibiotics, but the courses he has had in the previous 12 months have totalled 2 months. Primary immunodeficiency is suspected.
Which of the following is the most appropriate test?Your Answer:
Correct Answer: Immunoglobulin assay
Explanation:Understanding Common Variable Immunodeficiency: Prevalence, Diagnosis, and Delayed Treatment
Common variable immunodeficiency (CVID) is the most prevalent primary antibody deficiency, affecting approximately 1 in 25,000 individuals. However, due to its rarity, only a small fraction of healthcare professionals will encounter a patient with CVID during their career. This, coupled with a delay in diagnosis, increases the risk of irreversible lung damage and bronchiectasis.
Defects in humoral immunity account for 50% of primary immunodeficiencies, with combined humoral and cellular deficiencies making up 20-30% of cases. Inherited single-gene disorders are the most common cause of primary immune deficiencies. While many of these defects present in infancy and childhood, CVID typically presents after the age of five, with a peak in the second or third decade of life.
A diagnosis of CVID is based on defective functional antibody formation, accompanied by decreased serum immunoglobulin levels (IgG and IgA), generally decreased serum IgM, and exclusion of other known causes of antibody deficiency. Identifying defective functional antibody formation may involve measuring the response to a vaccine such as the pneumococcal vaccine.
Overall, understanding the prevalence, diagnosis, and delayed treatment of CVID is crucial in providing appropriate care for individuals with this rare but potentially debilitating condition.
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This question is part of the following fields:
- Allergy And Immunology
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Question 26
Incorrect
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A father has called to report that his preteen son is experiencing breathlessness and swelling about ten minutes after being stung by a bee. The boy's condition has worsened since the sting and he is now having increased difficulty breathing, although he can still speak in complete sentences. Currently, he is lying on the couch and appears to be unwell. An initial diagnosis of anaphylaxis is suspected. They reside in the same town as your clinic, and the father has transportation and is willing to bring his son to the clinic. How would you handle this situation?
Your Answer:
Correct Answer: An emergency ambulance should be called
Explanation:Managing Anaphylaxis: The Importance of Immediate Medical Attention
Anaphylaxis is a medical emergency that requires immediate attention. If a patient presents with symptoms of anaphylaxis, such as difficulty breathing, swelling, and hives, it is crucial to call for an ambulance right away. Basic life support and possible cardiopulmonary resuscitation (CPR) may be necessary.
Transporting the patient in a personal vehicle should only be considered if there are no other options. In most cases, an emergency ambulance will be quicker at responding. If the patient presents at a medical facility, adrenalin should be administered intramuscularly, along with antihistamines and steroids. Adrenalin can be repeated after five minutes if the patient is not responding.
While the use of auto-inject pens is debated, some GPs trained in this area do prescribe them. It is important to remember that anaphylaxis is a life-threatening condition that requires immediate medical attention. Delaying treatment can have serious consequences.
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This question is part of the following fields:
- Allergy And Immunology
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Question 27
Incorrect
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A 12-year-old girl has recently arrived from Lithuania and registered with your practice. Lithuania is a country with an incidence of more than 40 per 100000 of tuberculosis. Mantoux testing has been carried out to screen for latent tuberculosis. It is unclear if she has ever had BCG immunisation and there are no scars suggestive of this. After 3 days the diameter of induration is 10 mm.
Select from the list the single most correct management option.Your Answer:
Correct Answer: Interferon γ (IGT) blood test
Explanation:Detecting latent tuberculosis is crucial in controlling the disease, as up to 15% of adults with latent tuberculosis may develop active disease, and the risk may be even higher in children. In immunocompromised individuals, such as those who are HIV positive, the chance of developing active disease within 5 years of latent infection is up to 50%. The Mantoux test is a method of detecting previous exposure to the tuberculosis organism or BCG vaccination by causing a cell-mediated immune reaction. The interpretation of the test depends on factors such as BCG vaccination history, immune status, and concurrent viral infection. While a negative test in HIV-positive patients doesn’t exclude tuberculosis, a positive test at certain thresholds can indicate the need for treatment of latent tuberculosis. Indeterminate results may require further evaluation by a specialist. The use of IGT as a surrogate marker of infection can be useful in evaluating latent tuberculosis in BCG-vaccinated individuals, but it cannot distinguish between latent infection and active disease. NICE recommends different testing strategies based on age and risk factors, but the benefits of IGT over the Mantoux test in determining the need for treatment of latent tuberculosis are not certain. In children under 5 years, a positive test requires referral to a specialist to exclude active disease and consideration of treatment of latent tuberculosis.
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This question is part of the following fields:
- Allergy And Immunology
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Question 28
Incorrect
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A 27-year-old male patient complains of bloating and changes in his bowel movements. He has been maintaining a food diary and suspects that his symptoms may be due to a food allergy. Laboratory results reveal normal full blood count, ESR, and thyroid function tests. Anti-endomysial antibodies are negative. What is the most appropriate test to explore the possibility of a food allergy?
Your Answer:
Correct Answer: Skin prick test
Explanation:Skin prick testing is the preferred initial approach as it is cost-effective and can assess a wide range of allergens. Although IgE testing is useful in food allergy, it is specific IgE antibodies that are measured rather than total IgE levels.
Types of Allergy Tests
Allergy tests are used to determine the specific allergens that trigger an individual’s allergic reactions. There are several types of allergy tests available, each with its own advantages and limitations. The most commonly used test is the skin prick test, which is easy to perform and inexpensive. Drops of diluted allergen are placed on the skin, and a needle is used to pierce the skin. If a patient has an allergy, a wheal will typically develop. This test is useful for food allergies and pollen allergies.
Another type of allergy test is the radioallergosorbent test (RAST), which determines the amount of IgE that reacts specifically with suspected or known allergens. Results are given in grades from 0 (negative) to 6 (strongly positive). This test is useful for food allergies, inhaled allergens (such as pollen), and wasp/bee venom.
Skin patch testing is another type of allergy test that is useful for contact dermatitis. Around 30-40 allergens are placed on the back, and irritants may also be tested for. The patches are removed 48 hours later, and the results are read by a dermatologist after a further 48 hours.
Blood tests may be used when skin prick tests are not suitable, for example if there is extensive eczema or if the patient is taking antihistamines. Overall, the choice of allergy test depends on the individual’s specific needs and circumstances.
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This question is part of the following fields:
- Allergy And Immunology
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Question 29
Incorrect
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A 45-year-old man visits his GP for a medication review after undergoing a renal transplant three months ago. The GP notes that the patient's medication was changed following the transplant, with the addition of immunosuppressant medication. What is the most probable immunosuppressive drug regimen for this patient?
Your Answer:
Correct Answer: Mycophenolatemofetil (MMF), prednisolone, tacrolimus
Explanation:After a renal transplant, patients require immunosuppressive drugs to prevent rejection. There are four classes of maintenance drugs: calcineurin inhibitors, antiproliferative agents, mammalian target of rapamycin inhibitors, and steroids. Mycophenolate mofetil is a cost-efficient antiproliferative agent that reduces the risk of acute rejection by 50%. Prednisolone is a steroid that is typically used in low doses and gradually reduced over several months. Azathioprine may also be used in initial therapy, but a calcineurin inhibitor is necessary. Basiliximab may be used for induction therapy within four days of the transplant. Ciclosporin and prednisolone are both used for maintenance immunosuppression, but require an antiproliferative agent to complete the regimen. Sirolimus may be used with a corticosteroid in patients intolerant of calcineurin inhibitors, according to National Institute for Health and Care Excellence guidelines.
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This question is part of the following fields:
- Allergy And Immunology
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Question 30
Incorrect
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A 42-year-old man presents to his General Practitioner with a 4-week history of a persistent dry cough, gradually worsening breathlessness on exertion and fevers. He usually easily walks for fifteen minutes to the park, but is now unable to walk there as he gets too breathless.
On examination, he has difficulty taking a full breath due to painful inspiration, and has fine bilateral crackles on auscultation. Oxygen saturations drop from 96% to 90% on walking around the consulting room. He is a non-smoker with no significant past medical history but has had multiple prescriptions for bacterial skin infections and athlete's foot over the years with increasing frequency more recently.
What is the most likely diagnosis?Your Answer:
Correct Answer: Pneumocystis pneumonia (PCP)
Explanation:Differential Diagnosis for a Respiratory Presentation: A Case Study
Possible diagnoses for a respiratory presentation can be numerous and varied. In this case study, the patient presents with a persistent dry cough, fever, increasing exertional dyspnoea, decreasing exercise tolerance, chest discomfort, and difficulty in taking a deep breath. The following are the possible diagnoses and their respective likelihoods:
Pneumocystis pneumonia (PCP): This is the most likely diagnosis, given the patient’s symptoms and history of recurrent fungal infections. PCP is an opportunistic respiratory infection associated with HIV infection and can be fatal if diagnosed late.
Pulmonary embolism (PE): Although this is a potentially fatal medical emergency, it is unlikely in this case as the patient has no suspicion of DVT, tachycardia, recent immobilisation, past history of DVT/PE, haemoptysis, or history of malignancy.
Bronchiectasis: This is less likely as the patient’s persistent dry cough is not typical of bronchiectasis.
Chronic obstructive pulmonary disease (COPD): This is also less likely as the patient is a non-smoker and has a shorter history of respiratory symptoms.
Idiopathic pulmonary fibrosis (IPF): This is a possibility, but the onset would generally be over a longer time course, and pleuritic chest pain is not a typical feature.
In conclusion, PCP is the most likely diagnosis in this case, and the patient needs acute medical assessment and treatment. Other possible diagnoses should also be considered and ruled out.
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This question is part of the following fields:
- Allergy And Immunology
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Question 31
Incorrect
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A 48-year-old woman with known breast cancer is undergoing chemotherapy at the local hospital. She has been feeling tired and emotional throughout her course of chemotherapy so far, but presents to the Duty Clinic as today, she is feeling more tired than usual, with no appetite and she has been feeling hot and cold at home and struggling to get comfortable.
On examination, you find she has a temperature of 38.5 oC, but no focal symptoms, and her respiratory and pulse rates and blood pressure are all within normal limits.
What is the most appropriate course of action?Your Answer:
Correct Answer: Emergency transfer to a local hospital for medical review
Explanation:Emergency Management of Neutropenic Sepsis in a Chemotherapy Patient
Neutropenic sepsis is a potentially life-threatening complication of neutropenia, commonly seen in patients undergoing chemotherapy. In a patient with fever and neutropenia, neutropenic sepsis should be suspected, and emergency transfer to a local hospital for medical review is necessary. Prescribing broad-spectrum antibiotics or offering emotional support is not the appropriate management in this situation. The patient requires inpatient monitoring and treatment, as per the ‘sepsis six’ bundle of care, to avoid the risk of sudden deterioration. It is crucial to recognize the urgency of this situation and act promptly to ensure the best possible outcome for the patient.
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This question is part of the following fields:
- Allergy And Immunology
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Question 32
Incorrect
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A 36-year-old woman comes to the clinic with facial swelling that started 6 hours ago. She is a busy lawyer and has important court cases this week. During the examination, her lips are found to be swollen. Her blood pressure is 118/72 mmHg and her pulse rate is 80 beats per minute. She reports no breathing difficulties or stridor.
What is the most suitable course of treatment for this patient?Your Answer:
Correct Answer: Loratadine
Explanation:The symptoms and signs exhibited by this woman suggest the presence of angioedema, which is a condition characterized by swelling of the connective tissue beneath the skin in response to a trigger. Unlike anaphylaxis, angioedema doesn’t affect breathing or vital signs. antihistamines are effective in treating this condition, while adrenaline is not necessary as it is primarily used to treat anaphylaxis. Hydrocortisone is also used to treat anaphylaxis, but it is not recommended for angioedema. Furosemide is typically prescribed for leg swelling caused by heart failure and is not suitable for treating angioedema. Chlorphenamine and loratadine are both effective in reducing swelling caused by angioedema, but since the woman has an important job that requires full concentration, loratadine would be the better option as it is a non-sedating antihistamine.
Understanding Angioedema: Causes and Treatment
Angioedema is a condition characterized by swelling beneath the skin, which can be caused by different allergens. The treatment for this condition varies depending on the underlying cause, but it often involves the use of antihistamines. Angioedema can be triggered by a variety of factors, including food allergies, insect bites, medication reactions, and genetic factors. The swelling can occur in different parts of the body, such as the face, lips, tongue, throat, and hands. In some cases, angioedema can be life-threatening, especially if it affects the airways and causes difficulty breathing.
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This question is part of the following fields:
- Allergy And Immunology
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Question 33
Incorrect
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What is a contraindication for pregnant women receiving the pertussis vaccination to protect their unborn infants?
Your Answer:
Correct Answer: Anaphylactic reaction to neomycin
Explanation:Pertussis Vaccine Information
Most combined vaccine formulations for pertussis contain neomycin. However, the only reason an individual cannot receive the vaccine is if they have an anaphylactic reaction. Boostrix-IPV is an inactivated vaccine that will not be affected by anti-D treatment. Even if a pregnant woman has a feverish illness or suspected whooping cough, the pertussis vaccine should still be offered to provide optimal antibody levels for the baby. Evidence shows that immunization during pregnancy can increase pertussis antibodies in breast milk, potentially protecting the baby from the illness. However, this doesn’t replace the need for the infant to complete the recommended primary immunization schedule.
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This question is part of the following fields:
- Allergy And Immunology
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Question 34
Incorrect
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You see a 6-month-old boy who you suspect has non-IgE-mediated cow's' milk protein allergy. He is exclusively breastfed. You would like to do a trial elimination of cows' milk from his diet.
What would you advise the mother to achieve this trial elimination?Your Answer:
Correct Answer: Exclude cows' milk protein from her diet for 4 weeks
Explanation:Managing Non-IgE-Mediated Cow’s’ Milk Protein Allergy in Infants
When dealing with a breastfed infant suspected of having non-IgE-mediated cows’ milk protein allergy, it is recommended to advise the mother to exclude cows’ milk from her diet for 2-6 weeks. During this period, calcium and vitamin D supplements may be prescribed to ensure the infant’s nutritional needs are met. After the exclusion period, reintroducing cows’ milk is advised to determine if it is the cause of the infant’s symptoms. If there is no improvement or the symptoms worsen, a referral to secondary care may be necessary.
For formula-fed or mixed-fed infants, replacing cow’s milk-based formula with hypoallergenic infant formulas is recommended. Extensively hydrolysed formulas (eHF) are typically the first option, and amino acid formulas are an alternative if the infant cannot tolerate eHFs or has severe symptoms. It is important to note that parents should not switch to soy-based formulas without consulting a healthcare professional, as some infants with cow’s’ milk protein allergy may also be allergic to soy.
In cases where there is faltering growth, acute systemic reactions, severe delayed reactions, significant atopic eczema with multiple food allergies suspected, or persistent parental concern, a referral to secondary care should be considered. With proper management and guidance, infants with non-IgE-mediated cow’s’ milk protein allergy can still receive adequate nutrition and thrive.
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This question is part of the following fields:
- Allergy And Immunology
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Question 35
Incorrect
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A 30-year-old man with a known history of peanut allergy comes to the clinic with facial swelling. Upon examination, his blood pressure is 85/60 mmHg, pulse is 120 bpm, and he has a bilateral expiratory wheeze. What type of adrenaline should be administered?
Your Answer:
Correct Answer: 0.5ml 1:1,000 IM
Explanation:Please find below the recommended doses of adrenaline for Adult Life Support (ALS) in different scenarios:
– Anaphylaxis: 0.5mg or 0.5ml of 1:1,000 adrenaline should be administered intramuscularly.
– Cardiac arrest: For intravenous administration, 1 mg or 10ml of 1:10,000 adrenaline or 1 ml of 1:1000 adrenaline is recommended.Understanding Adrenaline and Its Effects on the Body
Adrenaline is a hormone that is responsible for the body’s fight or flight response. It is released by the adrenal glands and acts on both alpha and beta adrenergic receptors. Adrenaline has various effects on the body, including increasing cardiac output and total peripheral resistance, causing vasoconstriction in the skin and kidneys, and stimulating glycogenolysis and glycolysis in the liver and muscle.
Adrenaline also has different actions on alpha and beta adrenergic receptors. It inhibits insulin secretion by the pancreas and stimulates glycogenolysis in the liver and muscle through alpha receptors. On the other hand, it stimulates glucagon secretion in the pancreas, ACTH, and lipolysis by adipose tissue through beta receptors. Adrenaline also acts on beta 2 receptors in skeletal muscle vessels, causing vasodilation.
Adrenaline is used in emergency situations such as anaphylaxis and cardiac arrest. The recommended adult life support adrenaline doses for anaphylaxis are 0.5ml 1:1,000 IM, while for cardiac arrest, it is 10ml 1:10,000 IV or 1 ml of 1:1000 IV. However, accidental injection of adrenaline can occur, and in such cases, local infiltration of phentolamine is recommended.
In conclusion, adrenaline is a hormone that plays a crucial role in the body’s response to stress. It has various effects on the body, including increasing cardiac output and total peripheral resistance, causing vasoconstriction in the skin and kidneys, and stimulating glycogenolysis and glycolysis in the liver and muscle. Adrenaline is used in emergency situations such as anaphylaxis and cardiac arrest, and accidental injection can be managed through local infiltration of phentolamine.
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This question is part of the following fields:
- Allergy And Immunology
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Question 36
Incorrect
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A 35-year-old man presents with chronic diarrhoea, unexplained weight loss, and low levels of iron in his blood. You suspect coeliac disease and want to investigate further.
Choose from the options below the immunoglobulin that may be deficient in individuals with coeliac disease.Your Answer:
Correct Answer: IgA
Explanation:Coeliac Disease and Selective IgA Deficiency
Coeliac disease is more common in individuals with selective IgA deficiency, which affects 0.4% of the general population and 2.6% of coeliac disease patients. Diagnosis of coeliac disease relies on detecting IgA antibodies to transglutaminase or anti-endomysial antibody. However, it is crucial to check total serum IgA levels before ruling out the diagnosis based on serology. For those with confirmed IgA deficiency, IgG tTGA and/or IgG EMA are the appropriate serological tests.
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This question is part of the following fields:
- Allergy And Immunology
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Question 37
Incorrect
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A 26-year-old woman comes for follow-up after experiencing a systemic reaction to a wasp sting during a picnic at the park. She reports swelling and redness at the site of the sting that had begun to spread to her face.
What is the best course of action for long-term management?Your Answer:
Correct Answer: Refer for venom immunotherapy and dispense an adrenaline auto-injector (AAI, e.g. EpiPen®)
Explanation:Venom allergy can cause local or systemic reactions, including anaphylaxis. Acute management is supportive, with anaphylaxis treated with adrenaline, steroids, and antihistamines. Referral to an allergy specialist is recommended for those with systemic reactions or suspected venom allergy. Venom immunotherapy may be recommended for those with a history of systemic reactions and raised levels of venom-specific IgE, but should not be performed in those without demonstrable venom-specific IgE or recent anaphylaxis. VIT has a high success rate in preventing systemic reactions and improving quality of life.
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This question is part of the following fields:
- Allergy And Immunology
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Question 38
Incorrect
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A 35-year-old man visits the General Practitioner for a check-up after undergoing a corneal transplant. What is the most indicative sign of graft rejection?
Your Answer:
Correct Answer: Red eye, corneal clouding and decreased visual acuity
Explanation:postoperative Complications Following Corneal Transplant Surgery
Corneal transplant surgery is a common procedure used to treat various eye conditions. However, like any surgery, it can have complications. Here are some postoperative complications that may occur following corneal transplant surgery:
1. Corneal Graft Rejection: This occurs when the body’s immune system attacks the transplanted cornea. Symptoms include a red eye, corneal clouding, with or without uveitis, and decreased visual acuity. Treatment involves urgent referral and the use of topical and systemic steroids.
2. Early Graft Failure: This is usually due to defective donor endothelium or operative trauma. Symptoms include a red eye and decreased visual acuity.
3. Positive Seidel’s Test: This test is used to identify a penetrating injury. A positive test would show a wound leak after transplant surgery. Treatment involves urgent referral and surgical intervention.
4. Corneal Abrasion: Epithelial defects giving symptoms and signs of a corneal abrasion (pain and fluorescein staining) may occur in the postoperative period.
5. Protruding Sutures: A red eye with an associated foreign body sensation in the postoperative period might be produced by protruding sutures.
6. Watery Discharge: A watery discharge on its own doesn’t suggest graft rejection.
In conclusion, it is important to be aware of these potential complications and seek medical attention if any symptoms arise. Early detection and treatment can improve the chances of a successful outcome.
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This question is part of the following fields:
- Allergy And Immunology
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Question 39
Incorrect
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A 10-year-old severely atopic boy is brought to the practice by his father. The father produces drugs from his bag and wants to ‘sort them out and get a repeat prescription’. He says the child is currently reasonably well. Among the items are:
an empty packet of prednisolone 5 mg tablets (30 tablets) dated 10 months ago, take six tablets daily for five days
budesonide dry powder inhaler 200 µg, use two puffs twice a day
hydrocortisone cream 1%, apply twice a day to inflamed skin (30 g tube)
loratadine syrup (5 mg/5 ml), take one 5 ml dose daily
sodium cromoglicate eye drops use in both eyes four times a day.
Which item seems the MOST SIGNIFICANT in importance in the first instance to discuss with the father?Your Answer:
Correct Answer: Budesonide
Explanation:Medication Review for an Atopic Child with Asthma
When reviewing the medication of an atopic child with asthma, it is important to consider the dosage of inhaled corticosteroids, the potency of topical corticosteroids, and the effectiveness of antihistamines and rescue courses of prednisolone. In this case, the child is using a medium dose of budesonide, which suggests the need for specialist care. The use of mild hydrocortisone for atopic eczema may not be sufficient, and a larger tube may be needed. Loratadine is an effective non-sedating antihistamine for allergic rhinitis and conjunctivitis, and repeat prescriptions are appropriate. Short courses of prednisolone may be necessary for acute exacerbations, and sodium cromoglicate can be used intermittently for allergic conjunctivitis. Overall, careful consideration of medication is crucial for managing the symptoms of an atopic child with asthma.
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This question is part of the following fields:
- Allergy And Immunology
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Question 40
Incorrect
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A 50-year-old man comes to the emergency department with facial swelling that he has had for 2 hours. He started taking a new medication yesterday. During the examination, his lips are found to be swollen. His blood pressure is 128/76 mmHg and his pulse is 70 beats per minute. He reports no breathing difficulties or stridor.
What medication could be responsible for this reaction?Your Answer:
Correct Answer: Valsartan
Explanation:Angioedema, a condition characterized by swelling under the skin, can be caused by various allergens as well as certain medications such as ACE inhibitors and NSAIDs. antihistamines are a common treatment option depending on the underlying cause. However, the medications listed other than ACE inhibitors and NSAIDs are not known to cause angioedema.
Understanding Angioedema: Causes and Treatment
Angioedema is a condition characterized by swelling beneath the skin, which can be caused by different allergens. The treatment for this condition varies depending on the underlying cause, but it often involves the use of antihistamines. Angioedema can be triggered by a variety of factors, including food allergies, insect bites, medication reactions, and genetic factors. The swelling can occur in different parts of the body, such as the face, lips, tongue, throat, and hands. In some cases, angioedema can be life-threatening, especially if it affects the airways and causes difficulty breathing.
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This question is part of the following fields:
- Allergy And Immunology
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Question 41
Incorrect
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A 50-year-old woman had a renal transplant three months ago. She presents with fatigue, fever, sweating (especially at night), aching joints and headaches. On examination, there are no focal signs.
What is the most likely diagnosis?Your Answer:
Correct Answer: Cytomegalovirus (CMV) infection
Explanation:Infections after Renal Transplantation: Common Types and Risks
Renal transplant patients are at high risk of infections, with over 50% experiencing at least one infection in the first year. In the first month, the risk is similar to that of non-immunosuppressed individuals, with common infections such as postoperative pneumonias and wound infections. However, in the one to six-month period, immunomodulating viruses like Cytomegalovirus (CMV), herpes simplex viruses, Epstein–Barr virus, and human herpesvirus-6 become more problematic.
Herpes simplex virus can cause severe lesions, including disseminated mucocutaneous disease, oesophagitis, hepatitis, and pneumonitis. influenza can also cause respiratory symptoms, but the injectable inactivated vaccine is safe for kidney transplant recipients. Pneumonia and urinary tract infections are common in the general population, and patients should receive appropriate immunisation.
A small group of patients may experience persistent viral infections, and those who require additional immunosuppression are at risk of opportunistic infections like cryptococcus, pneumocystis, listeria, and nocardia. Urinary infections are the most common after renal transplantation, and patients usually receive prophylactic antibiotics and antiviral drugs for a few months after the procedure.
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This question is part of the following fields:
- Allergy And Immunology
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Question 42
Incorrect
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A 25-year-old healthcare worker presents to her General Practitioner with an itchy rash on her hands. She reports that the rash develops quickly while she is wearing gloves at work and is diagnosed with a latex allergy. She also mentions experiencing similar symptoms related to food. Which of the following foods is she most likely allergic to?
Your Answer:
Correct Answer: Banana
Explanation:Latex-Fruit Syndrome: Allergies to Certain Fruits and Vegetables
Latex allergies are immediate hypersensitivity reactions that can cause itching, urticaria, angioedema, anaphylaxis, and other symptoms. Latex-fruit syndrome occurs when there is a co-existing allergy to latex and certain fruits or vegetables due to cross-reactivity. The most common fruits associated with this syndrome are bananas, chestnuts, kiwi fruit, avocado, and tomato. Melon, apple, papaya, and potato are less commonly associated with this syndrome. It is believed that the resemblance of these fruits and vegetables to a latex protein component is responsible for the cross-reactivity. If you have a latex allergy, it is important to be aware of the potential for cross-reactivity with certain fruits and vegetables.
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This question is part of the following fields:
- Allergy And Immunology
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Question 43
Incorrect
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A 32-year-old woman is experiencing perennial rhinitis and has found relief from antihistamines and an intranasal corticosteroid. She is seeking a refill and has questions about her condition, including why she doesn't only experience symptoms in the summer like some of her acquaintances. She is also curious about the possibility of testing. What is the most suitable explanation?
Your Answer:
Correct Answer: Mainly adults have this condition
Explanation:Understanding Perennial Rhinitis: Causes and Diagnosis
Perennial rhinitis is a condition that occurs throughout the year, and it is more common in adults than in children. While seasonal rhinitis is more likely to affect older children and adolescents, perennial rhinitis is persistent and can be caused by various allergens, including house-dust mites, feathers, animal dander, or allergens at work.
Skin-prick testing is the most sensitive way to investigate the condition, as it measures specific IgE antibodies in the blood. However, it may not always be sensitive enough, and other tests, such as patch testing, may be indicated.
It is important to note that not all cases of perennial rhinitis have an allergic cause, but the response to medication can often provide clues. If an allergic cause is suspected, avoidance measures may be considered to manage symptoms.
Overall, understanding the causes and diagnosis of perennial rhinitis can help individuals manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Allergy And Immunology
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Question 44
Incorrect
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A 56-year-old man visits his General Practice Surgery, requesting travel vaccinations at short notice. His daughter has been taken ill on her gap year and is in hospital in Thailand, and he wants to travel over there within a few days. He is on interferon and ribavirin for chronic asymptomatic hepatitis C infection, which was diagnosed six months ago. He was fully immunised as a child and was given some additional vaccinations on diagnosis with hepatitis C. He wants to know whether there is time to have any travel vaccinations before he travels.
Which of the following is the most appropriate vaccination to offer, which can be given up to the day of travel?Your Answer:
Correct Answer: Diphtheria, tetanus and pertussis (DTP)
Explanation:The patient is planning to travel to Borneo and needs to know which vaccinations are appropriate to receive before departure. The DTP vaccine, which protects against diphtheria, tetanus, and pertussis, is recommended and can be given up to the day of travel. Rabies vaccination is also advised for those visiting areas where the disease is endemic, but it requires a course of three injections over 28 days and cannot be given within days of travel. Hepatitis A is a common disease in many parts of the world and can be contracted through contaminated food and water, but the patient’s known diagnosis of hepatitis C means that she has likely already been vaccinated against hepatitis A and B. Hepatitis B is generally given as a course of injections over six months, which is not feasible for the patient’s short timeline. Japanese Encephalitis is rare in travelers and requires two separate injections a month apart, which doesn’t fit with the patient’s schedule.
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This question is part of the following fields:
- Allergy And Immunology
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Question 45
Incorrect
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A 6-year-old girl presents with her father with a history of tingling lips and mouth within minutes of eating kiwi. There are no other symptoms. It has occurred on a number of occasions over the past few weeks but only after eating kiwi. Her past medical history includes a diagnosis of eczema. The pediatrician suspects the diagnosis is oral allergy syndrome.
What other condition is the girl likely to have been diagnosed with?Your Answer:
Correct Answer: Birch pollen allergy
Explanation:Understanding Oral Allergy Syndrome
Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.
It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.
OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.
In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.
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This question is part of the following fields:
- Allergy And Immunology
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Question 46
Incorrect
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You are instructing a woman on the proper use of an EpiPen. What is the most suitable guidance regarding the injection site?
Your Answer:
Correct Answer: Anterolateral aspect of the middle third of the thigh
Explanation:The anterolateral aspect of the middle third of the thigh is the recommended site for injecting IM adrenaline.
Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically develop suddenly and progress rapidly, affecting the airway, breathing, and circulation. Swelling of the throat and tongue, hoarse voice, and stridor are common airway problems, while respiratory wheeze and dyspnea are common breathing problems. Hypotension and tachycardia are common circulation problems. Skin and mucosal changes, such as generalized pruritus and widespread erythematous or urticarial rash, are also present in around 80-90% of patients.
The most important drug in the management of anaphylaxis is intramuscular adrenaline, which should be administered as soon as possible. The recommended doses of adrenaline vary depending on the patient’s age, with the highest dose being 500 micrograms for adults and children over 12 years old. Adrenaline can be repeated every 5 minutes if necessary. If the patient’s respiratory and/or cardiovascular problems persist despite two doses of IM adrenaline, IV fluids should be given for shock, and expert help should be sought for consideration of an IV adrenaline infusion.
Following stabilisation, non-sedating oral antihistamines may be given to patients with persisting skin symptoms. Patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic, and an adrenaline injector should be given as an interim measure before the specialist allergy assessment. Patients should be prescribed two adrenaline auto-injectors, and training should be provided on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and have been given an adrenaline auto-injector and trained how to use it. Patients who require two doses of IM adrenaline or have had a previous biphasic reaction should be observed for a minimum of 6 hours after symptom resolution, while those who have had a severe reaction requiring more than two doses of IM adrenaline or have severe asthma should be observed for a minimum of 12 hours after symptom resolution. Patients who present late at night or in areas where access to emergency care may be difficult should also be observed for a minimum of 12
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This question is part of the following fields:
- Allergy And Immunology
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Question 47
Incorrect
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What is the most common identified trigger of anaphylaxis in adolescents?
Your Answer:
Correct Answer: Food
Explanation:Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically develop suddenly and progress rapidly, affecting the airway, breathing, and circulation. Swelling of the throat and tongue, hoarse voice, and stridor are common airway problems, while respiratory wheeze and dyspnea are common breathing problems. Hypotension and tachycardia are common circulation problems. Skin and mucosal changes, such as generalized pruritus and widespread erythematous or urticarial rash, are also present in around 80-90% of patients.
The most important drug in the management of anaphylaxis is intramuscular adrenaline, which should be administered as soon as possible. The recommended doses of adrenaline vary depending on the patient’s age, with the highest dose being 500 micrograms for adults and children over 12 years old. Adrenaline can be repeated every 5 minutes if necessary. If the patient’s respiratory and/or cardiovascular problems persist despite two doses of IM adrenaline, IV fluids should be given for shock, and expert help should be sought for consideration of an IV adrenaline infusion.
Following stabilisation, non-sedating oral antihistamines may be given to patients with persisting skin symptoms. Patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic, and an adrenaline injector should be given as an interim measure before the specialist allergy assessment. Patients should be prescribed two adrenaline auto-injectors, and training should be provided on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and have been given an adrenaline auto-injector and trained how to use it. Patients who require two doses of IM adrenaline or have had a previous biphasic reaction should be observed for a minimum of 6 hours after symptom resolution, while those who have had a severe reaction requiring more than two doses of IM adrenaline or have severe asthma should be observed for a minimum of 12 hours after symptom resolution. Patients who present late at night or in areas where access to emergency care may be difficult should also be observed for a minimum of 12
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This question is part of the following fields:
- Allergy And Immunology
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Question 48
Incorrect
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Antihistamine drugs are commonly prescribed for skin disorders. Which of the following conditions are they most likely to be effective in treating?
Your Answer:
Correct Answer: Acute urticaria
Explanation:Understanding Skin Conditions: Causes and Mechanisms
Skin conditions can have various causes and mechanisms. Urticaria, for instance, is triggered by the release of histamine and other mediators from mast cells in the skin. While IgE-mediated type I hypersensitivity reactions are a common cause of urticaria, other immunological and non-immunological factors can also play a role.
In atopic eczema, antihistamines are not recommended as a routine treatment. However, a non-sedating antihistamine may be prescribed for a month to children with severe atopic eczema or those with mild or moderate eczema who experience severe itching or urticaria. It’s worth noting that allergies to food or environmental allergens may not be responsible for the symptoms of atopic eczema.
Contact allergic dermatitis and erythema multiforme are examples of cell-mediated immunity, and their symptoms are not caused by histamine release. On the other hand, bullous pemphigoid is an autoimmune disorder that occurs when the immune system attacks a protein that forms the junction between the epidermis and the basement membrane of the dermis.
Understanding the causes and mechanisms of different skin conditions can help in their diagnosis and treatment.
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This question is part of the following fields:
- Allergy And Immunology
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Question 49
Incorrect
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A 35-year-old woman has had a renal transplant six months ago. Other than chronic kidney disease and her subsequent transplant, she has no significant medical history or family history. There is a shared-care protocol between the Transplant Unit and the General Practitioner.
Which of the following is this patient most likely to receive as part of this protocol?
Your Answer:
Correct Answer: Depot medroxyprogesterone acetate
Explanation:Managing Women’s Health after Renal Transplant: Contraception, Cancer Screening, and Vaccinations
Women who have undergone renal transplant and are of childbearing age should use effective contraception to prevent unintended pregnancy. The most effective methods include intrauterine contraceptive devices, etonogestrel implants, and depot medroxyprogesterone acetate. The latter is particularly suitable as it doesn’t interact with immunosuppressive drugs commonly used in transplant patients. While pregnancy is possible after a renal transplant, it is recommended to wait for at least a year and plan it carefully. Women should also manage their cardiovascular risk factors and keep up-to-date with vaccinations and cancer screening.
Renal transplant recipients have a higher incidence of cancer than the general population, so regular cancer screening is essential. Breast screening typically starts at 50 years, while cervical screening may not require additional tests. Warfarin is unlikely to be prescribed after a renal transplant, but if necessary, careful monitoring is required. Live vaccines, including Zostavax® shingles vaccine, should be avoided due to the risk of lower efficacy and immunosuppression. Instead, Shingrix® vaccine can be used where indicated.
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This question is part of the following fields:
- Allergy And Immunology
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Question 50
Incorrect
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A 65-year-old man has become ill while at a family gathering. He feels itchy and has red blotchy skin and swollen lips and eyelids. He has an inspiratory stridor and wheeze, and an apex beat of 120/minute. He feels faint on standing and his blood pressure is 90/50 mmHg.
Select from the list the single most important immediate management option.Your Answer:
Correct Answer: Adrenaline intramuscular injection
Explanation:Understanding Anaphylactic Reactions and Emergency Treatment
Anaphylactic reactions occur when an allergen triggers specific IgE antibodies on mast cells and basophils, leading to the rapid release of histamine and other mediators. This can cause capillary leakage, mucosal edema, shock, and asphyxia. The severity and rate of progression of anaphylactic reactions can vary, and there may be a history of previous sensitivity to an allergen or recent exposure to a drug.
Prompt administration of adrenaline and resuscitation measures are crucial in treating anaphylaxis. Antihistamines are now considered a third-line intervention and should not be used to treat Airway/Breathing/Circulation problems during initial emergency treatment. Non-sedating oral antihistamines may be given following initial stabilization, especially in patients with persisting skin symptoms. Corticosteroids are no longer advised for the routine emergency treatment of anaphylaxis.
The incidence of anaphylaxis is increasing, and it is not always recognized. It is important to understand the causes and emergency treatment of anaphylactic reactions to ensure prompt and effective care.
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This question is part of the following fields:
- Allergy And Immunology
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Question 51
Incorrect
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A father thinks his 4-year-old daughter may have a peanut allergy. Twice, recently, she has complained of an itchy mouth after eating a peanut butter sandwich. On the second occasion, her mouth became swollen and her father stopped her eating the sandwich and the symptoms gradually resolved. He wonders what he should do and has come to ask your advice.
What is the most appropriate advice you can give him regarding peanut allergy?Your Answer:
Correct Answer: The only treatment is to avoid peanuts
Explanation:Understanding Peanut Allergy: Myths and Facts
Peanut allergy is a serious condition that affects a significant number of people, especially children. However, there are many misconceptions about this allergy that can lead to dangerous situations. Here are some myths and facts about peanut allergy:
Myth: Most children with peanut allergy will outgrow the condition by school age.
Fact: While some children may outgrow their peanut allergy, only about 20% do so by the time they reach school age. Even if they seem to have outgrown it, the allergy may still recur.Myth: Only peanuts should be implicated.
Fact: About half of patients with peanut allergy are also allergic to other nuts, with almond being the most frequently cross-reacting nut.Myth: Skin-prick tests will confirm the diagnosis.
Fact: While skin-prick testing can be done, it is positive in only 50-70% of those with confirmed nut allergy. It is useful in excluding allergy but less so in confirming it. The RAST test is less sensitive and may not confirm clinical allergy. Oral food challenge is potentially risky.Myth: They need only be concerned about visible pieces of nut.
Fact: For some people with peanut allergy, even small amounts of peanuts can cause a serious reaction. Food that is exposed to peanuts during processing or handling can also be problematic. Aerosols or dust containing peanuts may give symptoms, as can direct skin contact.The only treatment for peanut allergy is to avoid peanuts. It is important to take this allergy seriously and to educate oneself and others about the risks and precautions necessary to prevent a potentially life-threatening reaction.
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This question is part of the following fields:
- Allergy And Immunology
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Question 52
Incorrect
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A worried mother brings her 10-year-old son to the general practice clinic with complaints of nasal congestion, itchy eyes and throat irritation that usually occur during the spring months. What is the best guidance to offer this mother regarding the management of her son's symptoms?
Your Answer:
Correct Answer: Avoid drying washing outdoors when pollen count is high
Explanation:Managing Seasonal Allergic Rhinitis: Tips for Reducing Pollen Exposure
Seasonal allergic rhinitis is a condition where the nasal mucosa becomes sensitized to allergens, such as pollen, causing inflammation and symptoms like sneezing, runny nose, and itchy eyes. To reduce pollen exposure, the National Institute for Health and Care Excellence (NICE) recommends avoiding drying laundry outdoors when pollen counts are high. Showering and washing hair after potential exposure can also help alleviate symptoms. While the tree pollen season can start as early as March, there is no need to eat locally produced honey or resort to ineffective nasal irrigation with saline. By following these simple tips, individuals with seasonal allergic rhinitis can better manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Allergy And Immunology
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Question 53
Incorrect
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What is the only true statement about allergy from the given list?
Your Answer:
Correct Answer: Allergy is more common in developed areas than rural areas
Explanation:Understanding the Causes and Patterns of Allergies
Allergies have become increasingly prevalent in recent years, affecting up to 30-35% of people at some point in their lives. This rise is seen not only in developed countries but also in those undergoing development. The causes of allergies are multifactorial, with both environmental and genetic factors playing a role. Outdoor pollution, particularly diesel exhaust particles, has been linked to an increase in respiratory allergies. The hygiene hypothesis suggests that inadequate exposure to environmental micro-organisms during childhood may result in a tendency towards allergy. This is supported by studies showing that children with regular contact with farm animals have a lower incidence of allergy. The pattern of allergy is also changing, with a significant increase in food allergies, particularly among children. Immunotherapy for allergies should only be carried out in hospital where facilities for resuscitation are immediately available.
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This question is part of the following fields:
- Allergy And Immunology
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Question 54
Incorrect
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A 42-year-old female presents to rheumatology with complaints of fatigue and joint pain in her fingers. She has a history of mild asthma, which is managed with a salbutamol inhaler, and a known allergy to co-trimoxazole. Her blood tests reveal a positive rheumatoid factor and an anti-CCP antibody level of 150u/ml (normal range < 20u/ml). Which medication could potentially trigger an allergic reaction in this patient?
Your Answer:
Correct Answer: Sulfasalazine
Explanation:If a patient has a known allergy to a sulfa drug like co-trimoxazole, they should avoid taking sulfasalazine. However, hydroxychloroquine, leflunomide, and methotrexate are all viable options for first-line disease-modifying anti-rheumatic drugs for rheumatoid arthritis in this patient. Sarilumab may also be considered, but only if the patient has not responded well to other medications and has a disease activity score of over 5.1.
Sulfasalazine: A DMARD for Inflammatory Arthritis and Bowel Disease
Sulfasalazine is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage inflammatory arthritis, particularly rheumatoid arthritis, as well as inflammatory bowel disease. This medication is a prodrug for 5-ASA, which works by reducing neutrophil chemotaxis and suppressing the proliferation of lymphocytes and pro-inflammatory cytokines.
However, caution should be taken when using sulfasalazine in patients with G6PD deficiency or those who are allergic to aspirin or sulphonamides due to the risk of cross-sensitivity. Adverse effects of sulfasalazine may include oligospermia, Stevens-Johnson syndrome, pneumonitis/lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, and the potential to color tears and stain contact lenses.
Despite these potential side effects, sulfasalazine is considered safe to use during pregnancy and breastfeeding, making it a viable option for women who require treatment for inflammatory arthritis or bowel disease.
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This question is part of the following fields:
- Allergy And Immunology
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Question 55
Incorrect
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A 12-year-old boy, who has a known severe allergy to peanuts, comes to the emergency room after accidentally eating a peanut butter sandwich. He reports feeling itchy all over and his lips are starting to swell. He is having difficulty breathing and feels like he might pass out. His mother is in a panic, saying that she remembers a similar incident when he was younger.
What is the initial treatment option that should be considered in this case?Your Answer:
Correct Answer: Administer 0.5 ml of 1 in 1000 adrenaline by IM injection
Explanation:Anaphylaxis in General Practice: Importance of Emergency Knowledge
There are few life-threatening situations that GPs encounter in their daily practice, but anaphylaxis is one of them. The RCGP emphasizes the need for examination candidates to be proficient in their knowledge of life-threatening emergencies such as this. An example of anaphylaxis could be a bee sting, medicine, or immunization reaction.
Prompt injection of adrenaline is of paramount importance, and the preferred route of administration should be intramuscular. Other treatments may be supplemented, but adrenaline is the preferred first-line treatment. Chlorphenamine could be given by slow intravenous injection as an adjunctive treatment, as would be inhaled bronchodilators. Intravenous hydrocortisone is of secondary value because the onset of action is too slow compared to adrenaline.
To issue a prescription for anything would be wholly inappropriate. This patient needs immediate treatment. Oral treatments are too slow in their action. Although we have not tested your wider knowledge of her management in this question, it is important to remember your basic resuscitation skills.
It is crucial to carry emergency drugs in your doctor’s bag and know the correct dose of adrenaline to administer. Most vials of adrenaline come as 1 in 1000, but a 1 in 10,000 ampoule is available and this could lead to errors. It is essential to check the drug bag and ensure that all medications are within date. In case of an anaphylactic reaction to an immunization in a baby, the correct dose of adrenaline should be known.
In conclusion, anaphylaxis is a life-threatening emergency that requires prompt and appropriate treatment. GPs should be proficient in their knowledge of emergency management and carry emergency drugs in their doctor’s bag.
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This question is part of the following fields:
- Allergy And Immunology
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Question 56
Incorrect
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A 28-year-old woman arrived as an immigrant in the UK two years ago, and it is not clear what vaccines she has received in her own country. You enquire about her immune status relating to measles.
What is the minimum requirement to satisfy you that she is immune to measles?Your Answer:
Correct Answer: Rubella-virus-specific immunoglobulin G (IgG) antibodies in the serum
Explanation:Understanding Rubella Immunity: Factors to Consider
Rubella, also known as German measles, is a viral infection that can have serious consequences for pregnant women and their unborn babies. To prevent maternal infection and congenital rubella syndrome, it is important to ensure immunity through vaccination or past infection. Here are some factors to consider when assessing rubella immunity:
– MMR Vaccine: The MMR vaccine is recommended for children and adults, with a two-dose schedule providing the best protection. A single dose can still offer high levels of immunity, but a booster may be necessary.
– Immunisation History: Individuals who have received rubella-containing vaccines in their country of origin may have some level of immunity, but it is important to verify their vaccination status. Those without a reliable history of immunisation should be assumed as unimmunised.
– Childhood History: A history of rubella in childhood may indicate immunity, but it can be difficult to diagnose. Other viral exanthems can have similar symptoms, so a clinical diagnosis may not be reliable.
– Rubella Antibodies: The presence of rubella-virus-specific IgG antibodies in the serum indicates immunity from past infection or immunisation. However, immunity can wear off over time, so it is important to check immunity levels before every pregnancy. Rubella-virus-specific IgM antibodies in the serum can indicate recent or current infection, but these antibodies can persist for up to 12 months after infection or immunisation.By considering these factors, healthcare providers can help ensure that individuals are protected against rubella and its potential complications.
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This question is part of the following fields:
- Allergy And Immunology
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Question 57
Incorrect
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A 27-year-old female complains of mild mouth swelling and itching after consuming raw spinach, apple, and strawberries, which subsides within 15 minutes. She has a history of birch pollen allergy but no other medical conditions.
What is the probable diagnosis?Your Answer:
Correct Answer: Oral allergy syndrome
Explanation:Urticarial reactions can be caused by various factors, including drug-induced angioedema or C1-esterase inhibitor deficiency. Contact irritant dermatitis is usually the result of prolonged exposure to a mild irritant, but it doesn’t typically produce a rapid and predictable response that resolves quickly. Lip licking dermatitis is a form of skin inflammation that occurs when saliva from repeated lip licking causes redness, scaling, and dryness of the lips.
Understanding Oral Allergy Syndrome
Oral allergy syndrome, also known as pollen-food allergy, is a type of hypersensitivity reaction that occurs when a person with a pollen allergy eats certain raw, plant-based foods. This reaction is caused by cross-reaction with a non-food allergen, most commonly birch pollen, where the protein in the food is similar but not identical in structure to the original allergen. As a result, OAS is strongly linked with pollen allergies and presents with seasonal variation. Symptoms of OAS typically include mild tingling or itching of the lips, tongue, and mouth.
It is important to note that OAS is different from food allergies, which are caused by direct sensitivity to a protein present in food. Non-plant foods do not cause OAS because there are no cross-reactive allergens in pollen that would be structurally similar to meat. Food allergies may be caused by plant or non-plant foods and can lead to systemic symptoms such as vomiting and diarrhea, and even anaphylaxis.
OAS is a clinical diagnosis, but further tests can be used to rule out other diagnoses and confirm the diagnosis when the history is unclear. Treatment for OAS involves avoiding the culprit foods and taking oral antihistamines if symptoms develop. In severe cases, an ambulance should be called, and intramuscular adrenaline may be required.
In conclusion, understanding oral allergy syndrome is important for individuals with pollen allergies who may experience symptoms after eating certain raw, plant-based foods. By avoiding the culprit foods and seeking appropriate medical care when necessary, individuals with OAS can manage their symptoms effectively.
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This question is part of the following fields:
- Allergy And Immunology
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Question 58
Incorrect
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A father visits you in general practice with concerns about his 2-year-old daughter who has biliary atresia. He has been informed by the paediatric gastroenterologist that her condition has deteriorated and she requires a liver transplant. The father is feeling anxious and upset and is seeking further information about the procedure. As his GP, what is the best advice you can provide him regarding liver transplantation?
Your Answer:
Correct Answer: The donor must be tested for hepatitis B and C
Explanation:Myth-busting Facts about Pediatric Liver Transplantation
Pediatric liver transplantation is a complex medical procedure that involves replacing a diseased liver with a healthy one from a donor. However, there are several misconceptions surrounding this life-saving surgery. Here are some myth-busting facts about pediatric liver transplantation:
– The donor must be tested for hepatitis B and C: A potential living donor with antibodies to hepatitis B and C would usually be ruled out as a donor.
– HLA matching is necessary for kidney, heart, and lung transplants, but not for liver transplants: Blood-group compatibility is necessary, and a relative is more likely to be a match.
– Immunosuppression is usually required for life, not just 12 months after transplant: While the regimen can be reduced with time, complete withdrawal is only successful in a small number of individuals.
– Prednisolone is not the only immunosuppressant needed after transplant: A combination of drugs, including prednisolone, ciclosporin, tacrolimus, mycophenolate mofetil, azathioprine, and sirolimus, are commonly used.
– Survival at one year after liver transplantation is higher than 50% in children: One-year survival is 80% for all children transplanted and may reach 90% for children with biliary atresia.It is important to dispel these myths and provide accurate information about pediatric liver transplantation to help families make informed decisions about their child’s health.
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This question is part of the following fields:
- Allergy And Immunology
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Question 59
Incorrect
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A 32-year-old woman visits her doctor to discuss the results of some recent blood tests she had done due to ongoing symptoms of chronic fatigue. She has a previous diagnosis of irritable bowel syndrome (IBS) from a few years ago, but is otherwise healthy and has never had her blood checked before. She reports experiencing intermittent abdominal bloating, constipation, and abdominal pains. She is not taking any medications, her weight is stable, and her blood tests show microcytic anemia with low ferritin levels. Which of the following tests is most likely to lead to an accurate diagnosis? Choose only ONE option.
Your Answer:
Correct Answer: Tissue transglutaminase (TTG)
Explanation:Diagnostic Tests for a Patient with Gastrointestinal Symptoms: A Case Study
A 28-year-old female patient presents with intermittent abdominal bloating, constipation, abdominal pains, and persistent fatigue. She has never had any blood tests before. The following diagnostic tests are available:
Tissue Transglutaminase (TTG) Test: This test is used to diagnose coeliac disease, an immune-mediated disorder triggered by exposure to dietary gluten. The patient’s symptoms and history suggest coeliac disease, and a TTG test should be requested. If the result suggests possible coeliac disease, the patient should be referred to gastroenterology for endoscopic intestinal biopsy.
Faecal Immunochemical Testing (FIT): FIT testing can be used to look for occult faecal blood if colorectal cancer is suspected. However, the patient’s young age and stable weight make colorectal cancer less likely.
Cancer-Antigen 125 (CA-125) Test: This test is used to diagnose ovarian cancer, which is difficult to diagnose due to nonspecific symptoms. However, the patient’s age makes ovarian cancer less likely than other options.
Faecal Calprotectin Test: This test is used to distinguish between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). However, the patient’s symptoms do not suggest IBD, and faecal calprotectin may not be the most likely test to lead to the correct diagnosis.
Haemochromatosis Gene (HFE) Testing: This test is used to detect hereditary haemochromatosis, which presents with iron overload rather than deficiency. The patient’s symptoms suggest iron-deficiency anaemia, and HFE testing may not be necessary.
In conclusion, based on the patient’s symptoms and history, a TTG test for coeliac disease is the most appropriate diagnostic test to request.
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This question is part of the following fields:
- Allergy And Immunology
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Question 60
Incorrect
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In which scenario will skin-prick allergy testing be most valuable?
Your Answer:
Correct Answer: A 2-year-old boy whose mother says he is allergic to milk, eggs and fish.
Explanation:Diagnosing Food Allergies and Intolerances: Importance of Symptom History and Testing
When dealing with a potential case of food allergy or intolerance, it is crucial to gather a detailed symptom history to identify possible allergens and determine if the reaction is IgE-mediated, which could lead to anaphylaxis. Symptoms such as acute urticaria, nausea, vomiting, abdominal colic, rhinorrhea, itchy eyes, or bronchospasm with a temporal relationship to the offending item may suggest an IgE-mediated reaction. However, it is important to note that many people attribute symptoms to food that are not actually caused by it.
To support or refute the mother’s suspicions, a skin-prick test and/or blood tests for specific IgE antibodies to the suspected foods can be performed in conjunction with the symptom history. However, it is essential to remember that there have been cases of systemic reactions and anaphylaxis in food allergen skin testing, so referral is necessary in most cases.
Hay fever is typically diagnosed clinically, so a skin-prick test is unnecessary. Acute urticaria usually resolves within six weeks, so testing is also unnecessary unless the patient can identify a possible trigger. Skin-prick testing is not typically performed on asthmatics unless there is a likely precipitant that could be eliminated. For hairdressers, who are prone to both irritant and allergic contact dermatitis, patch testing would be appropriate for diagnosing delayed hypersensitivity.
Diagnosing Food Allergies and Intolerances: Importance of Symptom History and Testing
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This question is part of the following fields:
- Allergy And Immunology
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