If a child has a palpable abdominal mass or an unexplained enlarged abdominal organ, it is important to refer them urgently (<48 hours) for specialist assessment to check for neuroblastoma and Wilms' tumour. The correct course of action would be to discuss the case with the on-call paediatric registrar. It is crucial to rule out malignancy as the cause of the mass, as neuroblastomas can metastasize quickly and are often diagnosed too late. While constipation may be a possible cause, it is important not to overlook the possibility of a neuroblastoma, which can even cause constipation. A 2-week review is not appropriate, and a routine referral would cause unnecessary delay. Paediatrics can arrange an abdominal ultrasound scan much quicker than primary care, and an abdominal x-ray is not recommended due to the high radiation exposure, especially for a young child. Understanding Neuroblastoma in Children Neuroblastoma is a type of cancer that affects children and is responsible for 7-8% of childhood malignancies. It develops from neural crest tissue found in the adrenal medulla and sympathetic nervous system. Typically, the disease is diagnosed in children around 20 months old and presents with a range of symptoms, including abdominal mass, weight loss, bone pain, and hepatomegaly. In some cases, paraplegia and proptosis may also occur. To diagnose neuroblastoma, doctors will typically look for raised levels of urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA). Additionally, calcification may be visible on an abdominal x-ray, and a biopsy may be necessary to confirm the diagnosis. Overall, neuroblastoma is a serious condition that requires prompt diagnosis and treatment. By understanding the symptoms and diagnostic process, parents and caregivers can work with healthcare providers to ensure that children receive the best possible care.

Dermatological Conditions: Granuloma Annulare, Necrobiosis Lipoidica, Fungal Infection, Scabies, and Erythema Multiforme

Granuloma Annulare is a skin condition that presents as groups of papules forming an arc or ring around a slightly depressed center. It is usually found on the dorsal surfaces of hands, feet, fingers, and extensor surfaces of arms and legs. The generalised form of this condition presents similar but bigger rings that are more widely disseminated. A subcutaneous form also exists that presents as nodules. Although an association with diabetes has been suggested, it is not always present. The local type is self-limiting and doesn’t require treatment, while a large number of treatments are described for the generalised form but have little evidence to support them.

Necrobiosis Lipoidica is another condition that occurs in patients with type 1 diabetes mellitus. It is characterised by firm, red-yellow plaques that occur over the shins. This condition may pre-date the development of diabetes by many years.

Fungal infections, such as tinea or ringworm, are epidermal conditions that produce scaling. On the other hand, scabies presents as crusted linear itchy lesions on the hands and web spaces, plus a generalised itchy nonspecific rash. Erythema Multiforme presents as multiple erythematous lesions with a darker or vesicular centre, particularly on the hands and feet.

In summary, these dermatological conditions have distinct presentations and require different treatments. It is important to seek medical advice for proper diagnosis and management.

The Psychological Effect of Placebos

A placebo is a substance or treatment that has no therapeutic effect but is given to a patient or participant in a clinical trial. When administered, it typically produces a psychological effect rather than a physical one. This means that the patient or participant may experience a perceived improvement in their symptoms or condition due to the belief that they are receiving a real treatment. The psychological effect of placebos is often referred to as the placebo effect and can be powerful enough to produce measurable changes in the body, such as a decrease in pain or an increase in dopamine levels. However, it is important to note that the placebo effect is not a substitute for real medical treatment and should not be relied upon as such.

Diabetic Amyotrophy: A Painful Proximal Motor Neuropathy

This patient exhibits several symptoms of diabetic amyotrophy, a painful asymmetrical proximal motor neuropathy that primarily affects the lower limbs. While it can occur bilaterally, it typically presents with pain in the thigh that progresses to proximal muscle wasting, loss of knee reflexes, and tender proximal muscles. While the plantars can become extensor, this is not a common occurrence.

The condition is believed to be caused by the occlusion of the vasa nervorum of the proximal lumbar plexus and/or femoral nerve. It is often associated with poor diabetic control, but it may improve with good control or resolve on its own over time.

Other conditions, such as osteomalacia, hyperthyroidism, and Cushing’s, are unlikely to cause a proximal myopathy involving the quadriceps and hamstrings, with preserved knee reflexes and pain not being a predominant feature. Vitamin B12 deficiency, on the other hand, initially causes peripheral neuropathy, with loss of vibration sense and position, followed by areflexia and weakness. If left untreated, it can lead to spasticity, Babinski plantars, and ataxia.

The RCGP curriculum includes Public Health as part of the statement on ‘Healthy People: promoting health and preventing disease,’ which are commonly encountered in Primary Care.

The nurse in this scenario is practicing health promotion, which is defined by the World Health Organisation as ‘the process of enabling people to increase control over, and to improve, their health.’

Health surveillance, as defined by WHO, involves the continuous and systematic collection, analysis, and interpretation of health-related data for public health practice. An example of this is the National Child Measurement Program, which collects data on childhood obesity.

Screening is the process of testing a population or selected subgroup for a disease in its early or pre-symptomatic stage to provide earlier treatment and improve outcomes. In the UK, examples of screening programs include breast screening, cervical screening, and bowel cancer screening. It is linked to the concept of secondary prevention, which aims to identify and treat a disease at an earlier stage to reduce morbidity and mortality.

Understanding Health Promotion and Surveillance

Health promotion refers to the process of empowering individuals to take control of their health and improve it. This is achieved through various means such as education, awareness campaigns, and access to healthcare services. The World Health Organisation defines health promotion as a continuous process that enables people to increase their control over their health.

On the other hand, health surveillance is the systematic collection, analysis, and interpretation of health-related data. This data is used to plan, implement, and evaluate public health practices. Health surveillance is crucial in identifying health trends and patterns, which can help in the prevention and control of diseases. An example of health surveillance is the National Child Measurement Program, which collects data on childhood obesity.

In summary, health promotion and surveillance are essential components of public health. Health promotion empowers individuals to take control of their health, while health surveillance provides valuable data that can be used to plan and implement effective public health interventions.

Different Roles in Healthcare: Patient Advocate, Carer, Chaperone, IMCA, and Attorney

In healthcare, there are various roles that individuals can take to support patients in different ways. One of these roles is that of a patient advocate, whose primary responsibility is to help patients communicate their views or decisions when they have difficulty doing so themselves. This role is independent and doesn’t involve making decisions on behalf of the patient.

Another role is that of a carer, who provides practical and emotional support to patients, often in a long-term capacity. A chaperone, on the other hand, acts as a witness during medical procedures to ensure the safety and comfort of both the patient and the practitioner.

An independent mental-capacity advocate (IMCA) is appointed to safeguard the rights of individuals who lack the capacity to make decisions for themselves. Finally, an attorney can be appointed by a patient to help them make decisions or make decisions on their behalf if they lack capacity.

Overall, these different roles play important and distinct functions in supporting patients in healthcare settings.

In this scenario, the BNF suggests administering half the usual oral dose of morphine.

When morphine is given through injection (subcutaneous, intramuscular, or intravenous), the recommended dose is approximately half of the oral dose. If the patient is no longer able to swallow, a continuous subcutaneous infusion of morphine is typically used.

Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects include nausea, drowsiness, and constipation, which are usually transient but may persist. Denosumab may be used to treat metastatic bone pain in addition to strong opioids, bisphosphonates, and radiotherapy.

Suspected Inflammatory Breast Cancer

This patient’s medical history raises concerns for inflammatory breast cancer, a rare but easily missed subtype of breast cancer. Despite accounting for only 1-5% of cases, inflammatory breast cancer can be difficult to diagnose and is often initially misdiagnosed as mastitis. The patient’s unilateral nipple retraction, which she attributes to breastfeeding, is also a suspicious sign. Therefore, it is crucial to have a high level of suspicion and refer the patient to a breast clinic urgently.

In this scenario, advising the patient to stop breastfeeding, massage the nipple, or use a breast shield would not be appropriate. Referring routinely without considering the severity of the potential diagnosis would also not be appropriate. It is essential to prioritize the patient’s health and well-being by taking swift and appropriate action.

Medications for Syringe Drivers

Not all medications can be used in syringe drivers for subcutaneous infusion due to the risk of injection site skin reactions. Diazepam, chlorpromazine, and prochlorperazine are contraindicated. Diamorphine is the most commonly used medication in syringe drivers, and it can be mixed with other medications such as cyclizine, dexamethasone, haloperidol, hyoscine butylbromide and hydrobromide, levomepromazine, metoclopramide, and midazolam. The British National Formulary (BNF) provides detailed information on mixing and compatibility of medications used in syringe drivers. It is important to note that phenobarbital and diclofenac are not compatible with diamorphine and should be given using a separate syringe driver. Understanding the appropriate medications for syringe drivers is crucial for healthcare professionals, and it is a common topic in the MRCGP examination.

Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

Genetic Syndromes and Infertility in Men

Tall stature, gynaecomastia, and infertility due to azoospermia are characteristic features of Klinefelter syndrome, a genetic disorder caused by an extra X chromosome in males. Other symptoms include reduced facial hair, obesity, and small testes. Cystic fibrosis, on the other hand, is unlikely to cause tall stature and is usually diagnosed in childhood due to recurrent chest infections and failure to thrive. Homocystinuria, a rare autosomal recessive disorder, causes tall stature, learning difficulties, lens dislocation, osteoporosis, and recurrent arterial thrombosis. Marfan syndrome, an autosomal dominant disorder, is characterized by tall stature, joint laxity, lens dislocation, aortic root dilatation, and skin striae. XYY syndrome, a condition where males have an extra Y chromosome, can cause tall stature, mild learning difficulties, and behavioral problems, but most men have normal fertility. It is important to consider genetic syndromes as a potential cause of infertility in men.

The case involves a boy with DMD, a common childhood-onset muscular dystrophy with X-linked recessive inheritance. Symptoms include developmental delay, inability to run, waddling gait, and wasting of leg muscles. DDH, BMD, cerebral palsy, and T1DM are ruled out as possible causes.

Different Study Designs for Evaluating a New Drug Intervention

When evaluating a new drug intervention, there are several study designs to consider. Each design has its own strengths and weaknesses, and the choice of design depends on the research question and the characteristics of the disease and population being studied.

Double-blind Crossover Randomised Controlled Trial (RCT)
This design is considered the gold standard for evaluating a new intervention. It involves randomly assigning participants to receive either the new drug or a placebo, and then switching the groups after a certain period of time. This design reduces the potential for bias and is more powerful than a parallel group design if the disease is chronic and stable.

Cohort Study
In a cohort study, a group of people who share a defining characteristic are sampled and followed over time to study incidences, causes, and prognosis. No intervention or treatment is administered to participants. This design is useful for studying long-term outcomes and identifying risk factors.

Case-control Study
A case-control study compares groups of people with an illness to control subjects to identify a causal factor. However, this design is unsuitable for evaluating a new drug intervention as it requires an existing group of patients who have potentially been exposed to the drug.

Double-blind Parallel Groups RCT
This design involves randomly assigning participants to receive either the new drug or a placebo, and then comparing the outcomes between the two groups. It is a suitable design for evaluating a new drug intervention, but a crossover trial may be more powerful.

Open-label Parallel Groups RCT
In an open-label study, both the health providers and the patients are aware of the drug or treatment being given. This design may increase the potential for bias and is not recommended for evaluating a new drug intervention.

Common Mistakes in AKT Exams

A common mistake made by candidates in RCGP AKT exams is making silly errors when performing simple calculations. This often results in incorrect answers. However, at onExamination, we have noticed that candidates also tend to misread questions, leading to incorrect answers.

For instance, in a dose conversion question, candidates were asked to convert mcg to IU, but some failed to notice this and divided the 10 mcg dose by 40, resulting in an incorrect answer of 0.25. The correct method would have been to multiply the 10 mcg dose by 40 to convert to IU, giving the correct answer of 400.

To avoid such errors, the RCGP advises candidates to do a reality check after their calculation. For example, if you are familiar with the CKS NICE recommended adult intake of Vitamin D (which is 400 IU), you should be able to recognize that 0.25 is not the correct answer and double-check your calculation. By paying attention to details and doing a reality check, candidates can avoid making common mistakes in AKT exams.

Common Causes of Elbow Pain

Elbow pain can be caused by a variety of conditions, each with their own characteristic features. Lateral epicondylitis, also known as tennis elbow, is characterized by pain and tenderness localized to the lateral epicondyle. Pain is worsened by resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended. Episodes typically last between 6 months and 2 years, with acute pain lasting for 6-12 weeks.

Medial epicondylitis, or golfer’s elbow, is characterized by pain and tenderness localized to the medial epicondyle. Pain is aggravated by wrist flexion and pronation, and symptoms may be accompanied by numbness or tingling in the 4th and 5th finger due to ulnar nerve involvement.

Radial tunnel syndrome is most commonly due to compression of the posterior interosseous branch of the radial nerve, and is thought to be a result of overuse. Symptoms are similar to lateral epicondylitis, but the pain tends to be around 4-5 cm distal to the lateral epicondyle. Symptoms may be worsened by extending the elbow and pronating the forearm.

Cubital tunnel syndrome is due to the compression of the ulnar nerve. Initially, patients may experience intermittent tingling in the 4th and 5th finger, which may be worse when the elbow is resting on a firm surface or flexed for extended periods. Later, numbness in the 4th and 5th finger with associated weakness may occur.

Olecranon bursitis is characterized by swelling over the posterior aspect of the elbow, with associated pain, warmth, and erythema. It typically affects middle-aged male patients.

When a patient presents with a Subconjunctival haemorrhage, which is characterised by a distinct area of bleeding in one eye, it is important to provide reassurance and check their blood pressure. This condition is often caused by coughing, constipation, or high blood pressure. Treatment may involve using lubricating eye drops for dry eyes, while infective conjunctivitis can be treated with options 3 and 4. Patients with conjunctivitis typically experience itchy eyes.

Subconjunctival haemorrhages occur when blood vessels in the subconjunctival space bleed. These vessels typically supply the conjunctiva or episclera. Trauma is the most common cause, followed by spontaneous idiopathic cases, Valsalva manoeuvres, and several systemic diseases. While subconjunctival haemorrhages can look alarming, they are rarely an indicator of anything serious. They are more common in women than men, and the risk increases with age. Newborns are also more susceptible. The incidence of both traumatic and non-traumatic subconjunctival haemorrhages is 2.6%.

Risk factors for subconjunctival haemorrhages include trauma, contact lens usage, idiopathic causes, Valsalva manoeuvres, hypertension, bleeding disorders, certain drugs, diabetes, arterial disease, and hyperlipidaemia. Symptoms include a red eye, usually unilateral, and mild irritation. Signs include a flat, red patch on the conjunctiva with well-defined edges and normal conjunctiva surrounding it. The patch’s size can vary depending on the size of the bleed and can involve the whole conjunctiva. Traumatic haemorrhages are most common in the temporal region, with the inferior conjunctiva as the next most commonly affected area. Vision should be normal, including acuity, visual fields, and range of eye movements. On examination, the fundus should be normal.

The diagnosis of a subconjunctival haemorrhage is clinical. If there is no obvious traumatic cause, check the patient’s blood pressure. If raised, refer the patient appropriately. If the patient is taking warfarin, check the INR. If raised, refer for appropriate adjustments to the dose to bring the INR back into the target range. If you cannot see the whole border of the haemorrhage, it may be associated with an intracranial bleed or an orbital roof fracture. Further appropriate investigations should then be done, including a full cranial nerve exam looking for neurological signs as well as a CT head, after discussion with a senior. Recurrent or spontaneous, bilateral subconjunctival haemorrhages warrant investigations for bleeding disorders or other pathology.

Reassure the patient that subconjunctival haemorrhages are a benign condition that will resolve on their own in 2 to 3 weeks.

The positive predictive value (PPV) is calculated by dividing the number of true positives by the total number of positive results. In this case, the total number of positive blood tests is 120, with 90 true positives. Therefore, the PPV is 0.75.
The sensitivity of the test is the proportion of patients with the condition who have a positive test result. In this scenario, out of the 150 people with the disease identified on CTPA, 90 have a positive blood result, resulting in a sensitivity of 0.6.
The negative predictive value (NPV) is the proportion of true negative results out of all negative results. In this case, there are 180 negative blood results, with 120 being truly negative as per the disease being absent on CTPA. Therefore, the NPV is 0.67.
The figure of 0.7 is not relevant to this scenario.

Precision refers to the consistency of a test in producing the same results when repeated multiple times. It is an important aspect of test reliability and can impact the accuracy of the results. In order to assess precision, multiple tests are performed on the same sample and the results are compared. A test with high precision will produce similar results each time it is performed, while a test with low precision will produce inconsistent results. It is important to consider precision when interpreting test results and making clinical decisions.

Care of Older Adults in General Practice

The Royal College of General Practitioners (RCGP) has emphasized that the care of older adults will be a significant part of a General Practitioner’s workload. It is crucial to consider issues such as comorbidity, communication difficulties, polypharmacy, and the need for support for increasingly dependent patients.

One important factor to keep in mind is that there is a reduced plasma protein binding of drugs with age. This can result in more drug availability, leading to side effects. Additionally, declining renal and hepatic function in the elderly can make them more susceptible to drug toxicity. Therefore, it may be necessary to prescribe lower doses than those given to a healthy adult.

As people age, their renal function tends to decline, and the rate of gastric emptying slows down. Hepatic mass and blood flow also decrease, and intestinal motility tends to decrease with age. These factors must be considered when prescribing medication to older adults.

The British National Formulary provides guidelines for prescribing medication to the elderly, and it is essential to follow these guidelines to ensure the safety and well-being of older patients.

Management of Benign Paroxysmal Positional Vertigo

This patient is exhibiting classic signs and symptoms of benign paroxysmal positional vertigo (BPPV). The Epley manoeuvre is a highly effective treatment option that can be taught to the patient to reduce or eliminate their symptoms. Vestibular sedatives are not recommended for the management of BPPV.

If the patient were experiencing unilateral deafness or tinnitus, an MRI would be necessary. However, at this stage, there is no indication for audiological or outpatient ENT assessment. It is important to note that early intervention and proper management can greatly improve the patient’s quality of life and prevent further complications.

Diagnosing Diabetes: Understanding the Criteria

Diagnosing diabetes is a common topic in the AKT exam, and it is important to understand the criteria for diagnosis. In an asymptomatic individual, a single sample alone is not sufficient for diagnosis. Instead, separate fasting samples must show above 7 mmol/L. The gold standard for diagnosis is still the oral glucose tolerance test (OGT), although fasting glucose can be used if an adequate fast is ensured.

It is important to note that there are new categories of glycaemia, including impaired fasting glycaemia and impaired glucose tolerance. Impaired fasting glycaemia is defined as a fasting glucose level above 6.1 but below 6.9, while impaired glucose tolerance is defined as glucose levels of 7.8-11.1 mmol/L. Understanding these categories and their criteria is essential for accurately diagnosing diabetes.