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Question 1
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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: 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 2
Correct
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A 5-year-old boy is brought by his mother into 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 around 30 minutes ago, and quickly developed facial flushing, with swelling of the lips and face. He has become wheezy and is now unable to talk in complete sentences.
You suspect anaphylaxis.
What is the most appropriate immediate management option?
Your Answer: Administer 300 µg 1 : 1000 adrenaline IM
Explanation:Managing Anaphylaxis: Correct Doses and Emergency Treatment
Anaphylaxis is a potentially life-threatening allergic reaction that requires immediate drug management. Adrenaline 1 : 1000 is the correct immediate management choice, with doses varying depending on the patient’s age. For a 7-year-old child, the correct dose is 300 µg IM.
In addition to adrenaline, other emergency drugs may be necessary, and it is important to attend the nearest emergency department for further treatment. Chlorphenamine is a sedating antihistamine that may be administered, but only after initial stabilisation and not as a first-line intervention. Non-sedating oral antihistamines may be given following initial stabilisation, especially in patients with persisting skin symptoms.
It is crucial to administer the correct dose of adrenaline, as an overdose can be dangerous. The adult dose is 500 µg, while the dose for children aged between six and 12 years is 300 µg. A 1000 µg dose is twice the recommended dose for adults and should not be given to a 7-year-old child.
In summary, managing anaphylaxis requires prompt and appropriate drug management, with correct doses of adrenaline and other emergency drugs. It is also important to seek further treatment at the nearest emergency department.
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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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In which scenario will skin-prick allergy testing be most valuable?
Your 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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Question 4
Incorrect
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What is a contraindication for pregnant women receiving the pertussis vaccination to protect their unborn infants?
Your Answer: Feverish illness at the time of administration
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 5
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: Skin-prick tests will confirm the diagnosis
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 6
Incorrect
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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: Banana food allergy
Correct 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 7
Incorrect
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A 75-year-old woman arrives at the Emergency Department feeling fatigued and short of breath. During the examination, her haemoglobin level is measured at 70 g/l (normal range: 115–155 g/l), and her serum vitamin B12 level is found to be 95 ng/l (normal range: 130–700 ng/l). Which of the following positive tests would suggest that pernicious anaemia is the likely cause of her vitamin B12 deficiency?
Your Answer: Gastric anti-parietal cell (GPC) antibody
Correct Answer: Intrinsic factor (IF) antibody
Explanation:Autoantibodies in the Diagnosis of Pernicious Anaemia
Pernicious anaemia is a type of megaloblastic anaemia caused by impaired absorption of vitamin B12 due to autoimmune destruction of gastric glands and loss of intrinsic factor (IF). IF antibodies, specifically type I and type II, are present in 50% of patients with pernicious anaemia and are specific to this disorder. Therefore, they can be used to confirm the diagnosis.
Other autoantibodies, such as antinuclear antibodies (ANA) and gastric anti-parietal cell (GPC) antibodies, are not specific to pernicious anaemia but may be present in some patients. ANA is used in the diagnosis of systemic lupus erythematosus and other autoimmune diseases, while GPC antibodies occur in 90% of patients with pernicious anaemia but are also positive in 10% of normal individuals.
Tests such as the Coombs test, which detect antibodies that attack red blood cells, are not used in the investigation of pernicious anaemia. Similarly, the immunoglobulin A tissue transglutaminase measurement is not diagnostic of pernicious anaemia but is used as the first-choice test for suspected coeliac disease in young people and adults.
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This question is part of the following fields:
- Allergy And Immunology
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Question 8
Incorrect
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A mother brings her two-year-old daughter in to the General Practice Surgery for review, as she is concerned about her frequent ear and chest infections. She was born full term with no complications. Her mother reports that she tried to breastfeed but ended up converting to formula as she was failing to thrive, and she still often brings food up through her nose.
On examination, she has low-set ears, hypertelorism (wide-set eyes) and hooded eyelids. She makes some babbling noises but doesn't say any words yet. A set of blood tests reveal low calcium. There is no family history of recurrent infections.
What is the most likely diagnosis?Your Answer: Bruton's agammaglobulinaemia
Correct Answer: DiGeorge syndrome
Explanation:Differentiating between immunodeficiency disorders in a pediatric patient
This patient presents with symptoms of immunodeficiency, including hypocalcaemia, developmental delay, facial dysmorphism, and feeding difficulties. The differential diagnosis includes DiGeorge syndrome, selective immunoglobulin A (IgA) deficiency, Bruton’s agammaglobulinaemia, common variable immunodeficiency (CVID), and physiological hypogammaglobulinaemia of infancy.
DiGeorge syndrome, also known as 22q11.2 deletion syndrome, is a genetic syndrome that commonly presents with mild immunodeficiency due to reduced thymus function or absence of a thymus. Facial dysmorphism, such as low-set ears, hypertelorism, and hooded eyelids, is also common.
Selective IgA deficiency is the most common primary antibody deficiency and may be associated with autoimmune disease or allergies. It is not associated with characteristic facies or low calcium.
Bruton’s agammaglobulinaemia is an X-linked immunodeficiency that presents with severe respiratory tract infections in male infants. It is unlikely in this case as the patient is female with a different clinical picture.
CVID is the most common primary immunodeficiency in adults and presents with recurrent bacterial infections. It is not associated with the characteristic facies described here or developmental delay, feeding difficulties, or hypocalcaemia.
Physiological hypogammaglobulinaemia of infancy is a common phenomenon where babies gradually lose their mother’s immunoglobulin G and replace it with their own. It is not associated with any additional facial features, blood abnormalities, or developmental or feeding delay.
Therefore, a thorough evaluation and testing are necessary to differentiate between these immunodeficiency disorders in this pediatric patient.
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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 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: 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 10
Correct
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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: 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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