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Question 1
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An active 58-year-old woman comes to the General Practitioner for a consultation. She has a history of asthma and atrial fibrillation (AF) and has been assessed by her Cardiologist, who has diagnosed her with permanent AF. The Cardiologist recommends rate control. Her resting heart rate is 120 bpm.
Which of the following is the correct statement about rate control in these circumstances?
Your Answer: Verapamil can be used for first-line rate control in asthmatic patients with AF
Explanation:Managing Atrial Fibrillation: Choosing the Right Medication
Patients with atrial fibrillation (AF) are at risk of stroke and require proper management. The initial approach to managing AF involves either rhythm or rate control, depending on the patient’s age, comorbidity, and the duration of AF.
According to the National Institute for Health and Care Excellence guidelines, rate-limiting calcium antagonists or β-blockers are recommended as first-line treatment for many patients requiring rate-control medication. However, β-blockers are contraindicated in patients with asthma.
Rate-limiting calcium channel blockers such as verapamil and diltiazem are alternative options. Digoxin is only recommended for very sedentary patients as a first-line medication, as it doesn’t control heart rate during exertion. However, it can be used in combination with a first-line drug if rate control is poor. The target for rate control should be a resting heart rate of less than 110 bpm, and lower if the patient remains symptomatic.
Choosing the right medication for managing AF is crucial in reducing the risk of stroke and improving the patient’s quality of life.
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This question is part of the following fields:
- Cardiovascular Health
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Question 2
Incorrect
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You have a scheduled telephone consultation with Mrs. O'Brien, a 55-year-old woman who has been undergoing BP monitoring with the health-care assistant. The health care assistant has arranged the appointment as her readings have been consistently around 150/90 mmHg. Upon reviewing her records, you see that she was prescribed amlodipine due to her Irish ethnicity, and she is taking 10 mg once a day. Her only other medication is atorvastatin 20 mg. The health care assistant has noted in the record that the patient confirms she takes her medications as directed.
As per NICE guidelines, what is the next step in managing hypertension in Mrs. O'Brien, taking into account her ethnic background?Your Answer: Angiotensin-converting enzyme inhibitor
Correct Answer: Angiotensin II receptor blocker
Explanation:For patients of black African or African–Caribbean origin who are taking a calcium channel blocker for hypertension and require a second medication, it is recommended to consider an angiotensin receptor blocker instead of an ACE inhibitor. An alpha-blocker is typically not a first-line option, while spironolactone may be considered as a fourth-line option. However, the 2019 update to the NICE guidelines on hypertension recommends an ARB as the preferred choice for this patient population.
Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.
Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.
Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.
The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.
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This question is part of the following fields:
- Cardiovascular Health
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Question 3
Incorrect
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What PEFR variation over a two-week period is indicative of asthma diagnosis?
Your Answer:
Correct Answer: Less than 10% variation or less than 30 litres per minute on any day
Explanation:Tests for Diagnosing Asthma
The diagnosis of asthma can be challenging, but there are several tests available to help healthcare professionals make an accurate diagnosis. One such test is peak expiratory flow (PEF) variability, which involves measuring PEF readings four or more times per day. A variation of more than 20% is highly suggestive of asthma, although some patients may have lower variability.
Other tests include fractional exhaled nitric oxide (FeNO), spirometry, and bronchodilator reversibility. FeNO levels of 40 parts per billion or more are considered positive for asthma in patients aged 17 and over. Obstructive spirometry, indicated by a forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio of less than 70%, is also a positive test. Bronchodilator reversibility is positive if there is an improvement in FEV1 of 12% or more and an increase in volume of 200 ml or more in patients aged 17 and over.
It is important to note that there are caveats and age limitations to these tests, and healthcare professionals should refer to the latest NICE guidance NG80 for more detailed information.
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This question is part of the following fields:
- Respiratory Health
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Question 4
Incorrect
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A 26-year-old male attends your morning surgery five days after an insect bite. He has presented today as the area surrounding the bite is becoming increasingly red and itchy.
On examination, you notice a 3-4 cm area of erythema surrounding the bite area and excoriation marks. The is some pus discharging from the bite mark. Observations are all within the normal range. You decide to prescribe antibiotics to cover for infection and arrange a repeat review in 48 hours.
On reviewing his medical records you note he is on isotretinoin for acne and has a penicillin allergy.
Which of the following antibiotics would you consider prescribing?Your Answer:
Correct Answer: Clindamycin
Explanation:Combining oral isotretinoin with tetracyclines is not recommended as it may lead to benign intracranial hypertension. Trimethoprim is not suitable for treating skin or soft tissue infections. Clindamycin, a lincomycin antibiotic, can be used for such infections, especially if the patient is allergic to penicillin. Co-amoxiclav doesn’t interact with isotretinoin, but it cannot be used in patients with penicillin allergy. Doxycycline, a tetracycline antibiotic, should be avoided when a patient is taking isotretinoin due to the risk of benign intracranial hypertension.
Understanding Isotretinoin and its Adverse Effects
Isotretinoin is a type of oral retinoid that is commonly used to treat severe acne. It has been found to be effective in providing long-term remission or cure for two-thirds of patients who undergo a course of treatment. However, it is important to note that isotretinoin also comes with several adverse effects that patients should be aware of.
One of the most significant adverse effects of isotretinoin is its teratogenicity, which means that it can cause birth defects in fetuses if taken during pregnancy. For this reason, females who are taking isotretinoin should ideally be using two forms of contraception to prevent pregnancy. Other common adverse effects of isotretinoin include dry skin, eyes, and lips/mouth, low mood, raised triglycerides, hair thinning, nosebleeds, and photosensitivity.
It is also worth noting that there is some controversy surrounding the potential link between isotretinoin and depression or other psychiatric problems. While these adverse effects are listed in the British National Formulary (BNF), further research is needed to fully understand the relationship between isotretinoin and mental health.
Overall, while isotretinoin can be an effective treatment for severe acne, patients should be aware of its potential adverse effects and discuss any concerns with their healthcare provider.
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This question is part of the following fields:
- Dermatology
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Question 5
Incorrect
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A woman aged 25 asks your practice nurse for advice on travel immunisations.
She is 16 weeks pregnant and is travelling to a rural part of Asia to visit her family as her father is very ill. She doesn't know what vaccinations she may have had as a child and the practice doesn't have any old records. The nurse wants to know if she can give the vaccines. Which vaccine should not be given to a pregnant woman?Your Answer:
Correct Answer: Cholera
Explanation:Vaccinations for Pregnant Women
It is important to consider the potential risks and benefits of vaccinations for pregnant women. Live virus vaccines, such as the yellow fever vaccine, should not be given to pregnant women due to the theoretical risk of the fetus contracting the infection. However, if travel to a high-risk area is unavoidable, the individual risk from the disease and vaccine should be assessed. Inactivated viral or bacterial vaccines and toxoids, such as those for hepatitis A and B, cholera, and tetanus, are generally safe for pregnant women and may be given when clinically indicated. It is important to consult with a healthcare provider to determine the best course of action for each individual case.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 6
Incorrect
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A 32-year-old woman presents to the clinic with sudden shortness of breath. An ambulance is called and a brief medical history is obtained. She is currently taking the combined oral contraceptive pill and had a laparoscopic cholecystectomy recently. The following are her vital signs:
- Blood pressure: 100/60 mmHg
- Respiratory rate: 28 breaths per minute
- Temperature: 36.8ºC
- Oxygen saturation: 92% on room air
While waiting for the ambulance, the patient is given oxygen through a face mask and an ECG is performed. Based on the likely diagnosis, what is the expected ECG finding?Your Answer:
Correct Answer: Sinus tachycardia
Explanation:Pulmonary embolism (PE) is a serious medical condition that can lead to a range of symptoms and complications. One of the most common signs of PE is an elevated heart rate, which can be caused by the increased demand on the right ventricle of the heart. This can lead to a range of other symptoms, including shortness of breath, chest pain, and coughing.
Another common sign of PE is the presence of S1Q3T3 on an electrocardiogram (ECG). This is characterized by a deep S-wave in lead I, a Q-wave in lead III, and an inverted T-wave in lead III. While this finding is associated with PE, it is not specific to the condition and may not be present in all cases.
T-wave inversions in leads V1-V4 can also be a sign of right ventricular strain, which can occur as a result of the increased demand on the heart caused by PE. However, this is not the most common finding in cases of PE.
Pulmonary embolism can be difficult to diagnose as it can present with a variety of cardiorespiratory symptoms and signs depending on its location and size. The PIOPED study in 2007 found that tachypnea, crackles, tachycardia, and fever were common clinical signs in patients diagnosed with pulmonary embolism. The Well’s criteria for diagnosing a PE use tachycardia rather than tachypnea. All patients with symptoms or signs suggestive of a PE should have a history taken, examination performed, and a chest x-ray to exclude other pathology.
To rule out a PE, the pulmonary embolism rule-out criteria (PERC) can be used. All criteria must be absent to have a negative PERC result, which reduces the probability of PE to less than 2%. If the suspicion of PE is greater than this, a 2-level PE Wells score should be performed. A score of more than 4 points indicates a likely PE, and an immediate computed tomography pulmonary angiogram (CTPA) should be arranged. If the CTPA is negative, patients do not need further investigations or treatment for PE.
CTPA is now the recommended initial lung-imaging modality for non-massive PE. V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease. D-dimer levels should be considered for patients over 50 years old. A chest x-ray is recommended for all patients to exclude other pathology, but it is typically normal in PE. The sensitivity of V/Q scanning is around 75%, while the specificity is 97%. Peripheral emboli affecting subsegmental arteries may be missed on CTPA.
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This question is part of the following fields:
- Respiratory Health
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Question 7
Incorrect
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A 28-year-old woman presents with 13 months of amenorrhoea. For the past few months she has been experiencing hot flashes, night sweats, mood changes and pain on intercourse. Follicular stimulating hormone (FSH) has been > 40 µIU/l on two separate occasions, and her serum oestradiol level is low. Thyroid-stimulating hormone (TSH) and prolactin are normal. Fasting blood glucose is normal. Pregnancy test is negative.
What is the most likely diagnosis?Your Answer:
Correct Answer: Premature ovarian insufficiency
Explanation:Premature Ovarian Insufficiency: Causes and Symptoms
Premature ovarian insufficiency (POI) is a condition that affects at least 1% of women under the age of 40 years. It is characterized by elevated follicle-stimulating hormone (FSH), low oestradiol, and prolonged amenorrhoea. In most cases, no underlying cause is identified, but familial history, autoimmune lymphocytic oophoritis, infections, and iatrogenic causes such as surgery, radiotherapy, and chemotherapy may contribute to the condition. Spontaneous recovery of fertility is unlikely.
Androgen-secreting adrenal tumour, hypopituitarism, polycystic ovarian syndrome (PCOS), and thyrotoxicosis are incorrect diagnoses for POI. Androgen-secreting adrenal tumour is rare and presents with hirsutism, acne, and clitoral enlargement. Hypopituitarism is caused by anterior pituitary tumours and may result in pressure features, ACTH deficiency, TSH deficiency, GH deficiency, ADH deficiency, and gonadotrophin deficiency. PCOS is unlikely due to the raised FSH and lack of hyperandrogenism. Thyrotoxicosis is ruled out by the normal TSH levels.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 8
Incorrect
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A 12-year-old girl presents with symptoms that meet the criteria for a diagnosis of mild attention-deficit hyperactivity disorder (ADHD). You are considering referring the child to the Child and Adolescent Mental Health Services (CAMHS). Her father would like information about managing this condition.
What is the most suitable advice to provide regarding the management of ADHD?Your Answer:
Correct Answer: You can arrange referral to a parent-training programme even before a formal diagnosis
Explanation:Managing Attention-Deficit Hyperactivity Disorder (ADHD): Myths and Facts
Attention-Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder that affects children and adults. Managing ADHD can be challenging, and there are many myths and misconceptions about the condition and its treatment. Here are some common myths and facts about managing ADHD:
Myth: Referral to a parent-training program should wait for a formal diagnosis.
Fact: If the problems are having an adverse impact on development or family life, a General Practitioner should consider referral to a parent-training and/or education program even before a formal diagnosis. The parent program may include skills to manage problem behavior and communicate with the child and help to understand the child’s emotions and behavior.Myth: Eliminating artificial coloring and additives from the diet is important.
Fact: NICE doesn’t recommend this unless there seems to be a link between deterioration in behavior and consumption of artificial additives.Myth: A food diary to seek a relationship between specific foods and symptoms is unhelpful.
Fact: The National Institute for Health and Care Excellence (NICE) advises that if there seems to be a clear relationship between specific foods and symptoms, parents should keep a diary recording food and drinks taken and behavior. If the diary supports a relationship, then referral to a dietician should be offered.Myth: Dietary fatty acid supplements (omega 3 and omega 6) are beneficial.
Fact: Many parents have experimented with these supplements, but according to NICE guidelines, these should not be routinely recommended.Myth: Methylphenidate (Ritalin®) can be prescribed immediately.
Fact: In more severe attention-deficit hyperactivity disorder or where other measures have not been successful, medication is usually recommended. Drug treatment should not be started in primary care. Methylphenidate (Ritalin®) is the most commonly used drug.In conclusion, managing ADHD requires a comprehensive approach that includes parent training, dietary changes, and medication when necessary. It is important to separate myths from facts to ensure that individuals with ADHD receive the best possible care.
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This question is part of the following fields:
- Children And Young People
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Question 9
Incorrect
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A 60-year-old man has a small-cell lung cancer. His serum sodium level is 128 mmol/l on routine testing (normal range 135–145 mmol/l).
What is the most probable reason for the biochemical abnormality observed in this case? Choose ONE option only.Your Answer:
Correct Answer: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Explanation:Understanding Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
SIADH is a condition where the release of antidiuretic hormone (ADH) from the posterior pituitary is not inhibited by a reduction in plasma osmolality on drinking water, causing water retention and extracellular fluid volume expansion without oedema or hypertension. This condition is commonly associated with small-cell lung cancer. Hyponatraemia and concentrated urine are the main laboratory findings, and severe cases may present with symptoms of cerebral oedema. Addison’s disease, diuretics, psychogenic polydipsia, and vomiting are not likely causes of hyponatraemia, although they may contribute to it in certain cases.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 10
Incorrect
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Which one of the following is not a key principle of the 2010 Mental Capacity Act?
Your Answer:
Correct Answer: A person's ability to make decisions must be reviewed on an annual basis
Explanation:The Mental Capacity Act was introduced in 2007 and applies to adults over the age of 16. It outlines who can make decisions on behalf of a patient who becomes incapacitated, such as after a stroke. Mental capacity includes the ability to make decisions about daily life, healthcare, and finances. The Act is based on five key principles, including assuming a person has capacity unless proven otherwise, taking all possible steps to help a person make decisions, and making decisions in the person’s best interests.
To assess whether a person lacks capacity, the Act provides a clear test that is decision-specific and time-specific. A person can only be considered unable to make a particular decision if they have an impairment or disturbance in the functioning of the mind or brain and are unable to understand, retain, use, or communicate information relevant to the decision. The Act also emphasizes that no individual can be labeled incapable based on their age, appearance, or any medical condition.
When assessing what is in someone’s best interests, the Act considers factors such as the likelihood of regaining capacity, the person’s wishes and beliefs, and the views of other relevant people. The Act also allows for the appointment of an attorney through a Lasting Power of Attorney (LPA) to act on behalf of a person who loses capacity. The LPA can cover property and financial affairs as well as health and welfare decisions, including life-sustaining treatment. Advance decisions can also be made by individuals with capacity to specify treatments they would not want if they lost capacity. These decisions must be written, signed, and witnessed if they refuse life-sustaining treatment.
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This question is part of the following fields:
- Mental Health
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