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Question 1
Incorrect
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A 5-year-old girl presents with intermittent leg pains, which have been occurring for four weeks. They occur at night and wake her from sleep. The pain is relieved when her mother rubs her legs. The girl is otherwise well and examination is normal.
What is the most likely diagnosis?Your Answer: Perthes’ disease
Correct Answer: Growing pains
Explanation:Understanding Childhood Musculoskeletal Conditions: Differential Diagnosis
Childhood musculoskeletal conditions can present with a variety of symptoms, making it important to differentiate between them for proper diagnosis and treatment. One common condition is growing pains, which are episodic muscular pains that typically affect the legs and wake children from sleep. Another condition, Henoch-Schönlein purpura (HSP), can cause joint pain, abdominal pain, and a purpuric rash on the legs and buttocks, as well as renal involvement. Acute lymphoblastic leukaemia may also cause bone and joint pain, but patients usually deteriorate rapidly and become unwell. Juvenile idiopathic arthritis is characterized by joint inflammation persisting for at least six weeks. Perthes’ disease, on the other hand, presents with pain in the hip and limited movement. Understanding the differences between these conditions can aid in accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Children And Young People
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Question 2
Correct
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A 16-year-old girl with a learning disability has been exhibiting aggressive behavior without any identifiable physical, psychological, or environmental triggers. Despite attempts at behavioral interventions, there has been no improvement. Recently, she attacked one of her caregivers, causing concern for their safety. The caregivers are considering medication as a possible solution. Which medication would be the most suitable option?
Your Answer: Olanzapine
Explanation:Antipsychotic and Melatonin Medications for People with Learning Disabilities and Autism
Concerns about the overuse of antipsychotic and antidepressant medications in people with learning disabilities and/or autism have been raised. Instead, a full assessment of physical, psychological, and environmental factors should be conducted when a person presents with challenging behavior. Psychological and behavioral interventions should be considered first.
The National Institute for Health and Care Excellence recommends that antipsychotic medication should only be used if other interventions do not produce change within an agreed time, treatment for coexisting mental or physical health problems has not led to a reduction in behavior, or the risk to the person or others is severe. Olanzapine is the only antipsychotic medication offered in the option list, but other antipsychotic drugs may also be appropriate. Antipsychotic medication should only be offered in combination with psychological or other interventions and initiated by a specialist.
Melatonin, a pineal hormone that affects sleep patterns, may be of value for treating sleep-onset insomnia and delayed sleep phase syndrome in children with conditions such as visual impairment, cerebral palsy, attention deficit hyperactivity disorder, autism, and learning difficulties if behavioral measures fail. Clinical experience supports this use.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 3
Correct
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A 32-year-old man comes to the clinic after getting cement in his eye while working on a construction site. He is experiencing severe pain in the eye, sensitivity to light, and is having difficulty with examination due to intense blepharospasm. What is the most suitable initial course of action in this scenario?
Your Answer: Irrigate the eye with saline for 15–20 minutes
Explanation:First Aid Treatment for Chemical Eye Burns
Chemical eye burns require immediate first aid treatment before history-taking or examination. The priority is to remove the substance causing the burn. Copious irrigation with normal saline or non-sterile water is crucial for 15-30 minutes, checking the pH every five minutes if possible. If a topical anaesthetic is needed, add a drop every five minutes. Contact lenses should be removed, and the patient’s head tilted back over the sink. Referral to the nearest eye hospital should be made after initial management due to the high risk of corneal scarring.
Alkali substances are particularly dangerous as they penetrate rapidly and can cause irreversible damage at a pH value above 11.5. There is no need to use a burr to remove any foreign body, as this may cause further damage.
Administering chloramphenicol ointment is not indicated for chemical eye burns. Instead, the patient should be advised to attend the local Ophthalmology Department for review.
If only water is available, it should be used to irrigate the eye. However, if saline is an option, it would be the preferred choice as it helps to neutralize the acid. Remember, prompt first aid treatment is crucial to prevent long-term damage to the eye.
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This question is part of the following fields:
- Eyes And Vision
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Question 4
Incorrect
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A 54-year-old car driver seeks guidance. He's an insulin-dependent diabetic who frequently drives long distances. He monitors his blood sugars regularly while driving but needs advice on when to take action. In the absence of hypoglycemia symptoms, what is the minimum blood glucose level for safe driving?
Your Answer: 5 mmol/litre
Correct Answer: 7 mmol/litre
Explanation:DVLA Guidance for Drivers with Diabetes
The DVLA provides guidance for drivers with diabetes, which is summarized by the BNF. For insulin-treated drivers, it is recommended to check blood glucose levels every two hours while driving. If the blood glucose level is 5 mmol/litre or less, a snack should be taken. However, if the level is less than 4 mmol/litre, driving should be stopped. After the blood sugar level has returned to normal, drivers should wait at least 45 minutes before driving again. It is crucial for insulin-treated drivers to carry a supply of fast-acting carbohydrate with them at all times.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 5
Correct
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A 5-year-old boy has had a limp for several weeks. His parents do not recall any injury or recent ill health. His left ankle is swollen and cannot be moved, although it is not especially painful. His symptoms are particularly bad in the mornings, but his gait improves during the day. He has not had any other symptoms.
Which of the following is the most likely diagnosis?Your Answer: Juvenile idiopathic arthritis
Explanation:Understanding Juvenile Idiopathic Arthritis: Classification and Differential Diagnosis
Juvenile idiopathic arthritis (JIA), also known as juvenile rheumatoid arthritis, is a chronic rheumatologic disease that affects children and is one of the most common chronic diseases of childhood. It is an autoimmune, non-infective, inflammatory joint disease that is defined as joint inflammation presenting in children under the age of 16 years and persisting for at least six weeks, with other causes excluded.
There are seven subsets of JIA with differing clinical courses, classified by the International League of Associations for Rheumatology criteria. Oligoarticular JIA affects young girls and usually presents with asymmetrical joint involvement, while polyarticular JIA can be RF-negative or RF-positive and affects young or older girls with symmetrical stiffness, swelling, and pain in several joints. Systemic-onset JIA presents with arthritis in one or more joints, daily high spiking fevers, and a salmon-colored rash, while enthesitis-related JIA affects boys over the age of 6 years with asymmetrical arthritis, enthesitis, and sacro-iliac joint involvement. Psoriatic JIA presents with arthritis and a history of psoriasis, nail changes, and/or dactylitis, while undifferentiated JIA may present with features of more than one subtype.
Other conditions, such as acute lymphoblastic leukemia, septic arthritis, reactive arthritis, and rheumatic fever, should be included in the differential diagnosis of JIA. It is important to understand the classification and differential diagnosis of JIA to provide appropriate management and treatment for affected children.
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This question is part of the following fields:
- Children And Young People
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Question 6
Incorrect
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A 56-year-old man with a history of a learning disability, hypertension, ischaemic heart disease, and chronic obstructive pulmonary disease (COPD) is admitted to hospital and subsequently dies.
What is the most common cause of death in people with a learning disability?Your Answer: Respiratory disease
Correct Answer: Circulatory disease
Explanation:Common Causes of Death in People with Learning Disabilities
People with learning disabilities are at a higher risk of premature death compared to the general population. The most common cause of death in this group is circulatory or cardiovascular disease, accounting for 22.9% of deaths. Regular health check-ups can help promote long-term health and prevent such diseases.
Cancer is another major cause of death, responsible for 13.1% of deaths in people with learning disabilities. While it is a significant cause of death, it is not the most common.
Aspiration pneumonitis, a potentially preventable cause of death, accounts for 3.6% of deaths in people with learning disabilities. It is important to be aware of this cause of death and take necessary precautions to prevent it.
Epilepsy is responsible for 3.9% of deaths in people with learning disabilities. Like aspiration pneumonitis, it is a preventable cause of death, and awareness can help reduce the risk.
Respiratory disease is the second most common cause of death in people with learning disabilities, accounting for 17.1% of deaths. It is crucial to monitor and manage respiratory conditions in this population to prevent premature deaths.
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This question is part of the following fields:
- Neurodevelopmental Disorders, Intellectual And Social Disability
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Question 7
Incorrect
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A 12-month-old girl comes in with a unilateral purulent nasal discharge and worsening bad breath over the past few days. However, she doesn't exhibit any systemic symptoms. What is the probable diagnosis?
Your Answer: Sinusitis
Correct Answer: Allergic rhinitis
Explanation:Unilateral Discharge in Children: A Possible Sign of Foreign Body
The occurrence of unilateral discharge in an otherwise healthy child may indicate the presence of a foreign body, especially in this age group. It is important to consider the child’s history to determine the possible cause of the discharge. If a foreign body is suspected, prompt removal is necessary to prevent further complications. Fortunately, removal of the foreign body is usually curative and can alleviate the symptoms.
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This question is part of the following fields:
- Children And Young People
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Question 8
Correct
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A 50-year-old woman has been referred to the hospital with several asymmetrically distributed patches of what was thought to be eczema on the buttocks and trunk. However, there was only minimal improvement with potent topical corticosteroids. The diagnosis after a biopsy is mycosis fungoides.
Which of the following best describes mycosis fungoides?Your Answer: Cutaneous T-cell lymphoma
Explanation:Understanding Mycosis Fungoides: A Type of Cutaneous T-Cell Lymphoma
Mycosis fungoides, also known as cutaneous T-cell lymphoma, is a type of lymphoma that primarily affects the skin. It is the most common form of cutaneous lymphoma and typically presents with eczematous or dermatitis skin lesions that can persist for years before a diagnosis is confirmed.
This disease is more common in men and black people, with a median age of onset around 50 years. The lymphoma first appears as superficial skin lesions that thicken and eventually ulcerate. In advanced stages, it can involve lymph nodes and other organs.
Patients with stage IA disease who undergo treatment have a normal life expectancy. However, the median survival is 11 years for patients with more extensive patch and/or plaque (stage IB or IIA) and less for those with advanced disease.
It is important to note that mycosis fungoides is not a fungal infection, despite its misleading name. It is also distinct from cutaneous B-cell lymphoma, which has a different growth pattern and presentation.
Overall, understanding mycosis fungoides is crucial for early diagnosis and effective treatment of this type of cutaneous T-cell lymphoma.
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This question is part of the following fields:
- Haematology
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Question 9
Incorrect
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A 4-year-old girl is brought to an evening surgery after swallowing a battery from a watch. On examination, she is well, with no drooling, respiratory symptoms or abdominal tenderness.
What is the most appropriate management option?Your Answer: Refer for an abdominal X-ray on the next day
Correct Answer: Arrange immediate admission for investigation and possible endoscopy
Explanation:The Dangers of Swallowing Button Batteries: Why Immediate Action is Necessary
Button batteries are small, but they can cause serious harm if swallowed. These batteries contain metals and concentrated solutions of caustic electrolytes, which can damage the oesophageal wall if left stuck for even just two hours. Therefore, it is essential to arrange immediate admission for investigation and possible endoscopy if a child has swallowed a button battery.
Prescribing laxatives and taking no further action is not appropriate for a high-risk foreign body like a button battery. Similarly, asking the mother to collect all stools and return in 48 hours if the battery doesn’t pass is not recommended. Instead, it may be appropriate to observe asymptomatic children for the passage of the battery in the stool, but only if certain conditions are met.
Reassuring the mother that no action is necessary is also not appropriate, as symptoms may still develop even if the child is asymptomatic. Referring for an abdominal X-ray on the next day is also not recommended, as urgent chest and abdominal X-rays will be carried out in the hospital.
In conclusion, immediate action is necessary when a child swallows a button battery. Delaying treatment can lead to serious harm, and it is important to seek medical attention as soon as possible.
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This question is part of the following fields:
- Children And Young People
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Question 10
Incorrect
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A 46-year-old woman visits the clinic with a history of chronic migraines. She experiences 2 or more attacks every month. After maintaining a headache diary, no triggering factors were identified. She has previously tried topiramate and amitriptyline, but her symptoms did not improve. She has a history of severe asthma.
Her cranial nerve examination, including fundoscopy, is normal, and her blood pressure is 130/75 mmHg.
Based on the current NICE CKS guidance, what is the most appropriate management option?Your Answer: Daily propranolol and review the patient in 2-3 weeks to check response
Correct Answer: Offer 10-sessions of acupuncture over 5-8 weeks and review the patient in 2-3 weeks to check response
Explanation:For patients who experience frequent and severe migraines, preventive treatment should be considered if acute treatments are ineffective or not suitable, or if there is a risk of medication-overuse headaches. Propranolol is the first-line prophylactic treatment, but if it is not suitable, alternative treatments such as topiramate or amitriptyline may be considered. Gabapentin should not be used for migraine prophylaxis. Non-pharmacological therapies such as acupuncture, relaxation techniques, or cognitive behavioural therapy can also be used as an alternative or adjunct to pharmacological therapy. Daily riboflavin may also be helpful in reducing migraine frequency and intensity. It is important to advise patients to limit their use of acute medication to a maximum of 2 days per week to avoid medication-overuse headaches. Referral for same-day neurology assessment is not necessary unless there are red-flag features. If the patient doesn’t respond to acupuncture, a neurology referral may be indicated.
Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the management of migraines.
For acute treatment, a combination of an oral triptan and an NSAID or paracetamol is recommended as first-line therapy. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective or not tolerated, a non-oral preparation of metoclopramide or prochlorperazine may be offered, along with a non-oral NSAID or triptan.
Prophylaxis should be considered if patients are experiencing two or more attacks per month. NICE recommends either topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity.
For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be used as a type of mini-prophylaxis. Specialists may also consider candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, such as erenumab. However, pizotifen is no longer recommended due to common adverse effects such as weight gain and drowsiness.
It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering the various treatment options available, migraines can be effectively managed and their impact on daily life reduced.
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This question is part of the following fields:
- Neurology
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Question 11
Incorrect
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A 28-year-old diabetic woman would like to discuss a copper IUCD device. She is a nulliparous lady who has had fertility problems and endometriosis in the past, but would like a reliable form of contraception after a recent divorce.
One week before seeing you, she mentioned to the nurse that she had been getting some intermenstrual bleeding and it was suggested that she makes an appointment to see you. You note that she had pelvic inflammatory disease when she was 20, but this was successfully treated as an inpatient.
Which one of the conditions given in the history is a contraindication to having a copper IUCD fitted?Your Answer: Unexplained uterine bleeding
Correct Answer: Endometriosis
Explanation:Contraception Contraindications and Cautions
Contraception questions are commonly featured in the MRCGP exam, and it is essential to have a good understanding of the contraindications and cautions listed in the British National Formulary (BNF). In the BNF, unexplained uterine bleeding is listed as a contraindication, while the other items mentioned in the history are listed as cautions. It is important to note that there are other contraindications not mentioned in the history, such as pregnancy, current sexually transmitted infection, current pelvic inflammatory disease, and distorted uterine cavity. Familiarizing oneself with these contraindications and cautions is crucial in providing safe and effective contraception to patients.
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This question is part of the following fields:
- Sexual Health
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Question 12
Incorrect
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You see a 45-year-old gentleman that presents with a 3-week history of neck pain. He reports occasional shooting pains in his right arm. The symptoms have been improving since they first started. He reports no weight loss, gait disturbance, clumsiness, loss of sexual, bladder or bowel function. On examination, no neurological signs are noted.
According to NICE, what would be the next appropriate step in his management?Your Answer: Routine MRI
Correct Answer: Reassurance, encourage activity, analgesia
Explanation:Management of Cervical Radiculopathy
Cervical radiculopathy is a condition that affects the nerves in the neck, causing pain, weakness, and numbness in the arms. For patients with this condition that has been present for less than 4-6 weeks and no objective neurological signs present, NICE advises conservative management. This includes reassurance, encouragement of activity, and analgesia. The long-term prognosis for patients with radiculopathy is good, and most cases improve without surgery.
However, clinicians should be aware of red flags that warrant an urgent referral. These include patients who are younger than 20 years or older than 55 years, severe or increasing pain, weakness involving more than one myotome, signs and symptoms suggestive of compression of the spinal cord, signs and symptoms suggestive of cancer, infection or inflammation, and signs and symptoms suggestive of severe trauma or skeletal injury. It is important to identify these red flags to ensure prompt and appropriate management of cervical radiculopathy.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 13
Incorrect
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A 30-year-old man comes to you with a bothersome skin rash. He has been experiencing this for a few weeks now and has not found relief with an emollient cream. The itching is described as 'severe' and has caused him difficulty sleeping. Upon examination, you observe a mixture of papules and vesicles on his buttocks and the extensor surface of his knees and elbows. What is the probable diagnosis?
Your Answer: Scabies
Correct Answer: Dermatitis herpetiformis
Explanation:Understanding Dermatitis Herpetiformis
Dermatitis herpetiformis is a skin disorder that is linked to coeliac disease and is caused by the deposition of IgA in the dermis. It is characterized by itchy, vesicular skin lesions that appear on the extensor surfaces such as the elbows, knees, and buttocks.
To diagnose dermatitis herpetiformis, a skin biopsy is performed, and direct immunofluorescence is used to show the deposition of IgA in a granular pattern in the upper dermis.
The management of dermatitis herpetiformis involves a gluten-free diet and the use of dapsone. By adhering to a gluten-free diet, patients can reduce the severity of their symptoms and prevent further damage to their skin. Dapsone is a medication that can help to alleviate the symptoms of dermatitis herpetiformis by reducing inflammation and suppressing the immune system.
In summary, dermatitis herpetiformis is a skin disorder that is associated with coeliac disease and is caused by the deposition of IgA in the dermis. It is characterized by itchy, vesicular skin lesions and can be managed through a gluten-free diet and the use of dapsone.
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This question is part of the following fields:
- Dermatology
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Question 14
Incorrect
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A 9-year-old boy is brought in to your clinic by his father. His father is worried because two days ago he had been playing in the same room as a child who was subsequently diagnosed with Chickenpox.
He is completely asymptomatic and has no other significant illnesses or allergies. His father declined the varicella vaccine when he was a baby having assumed that it could not be given because one of his grandparents had a history of shingles and a distant relative was undergoing investigation for possible autoimmune disease.
How would you handle this situation?Your Answer: Tell the mother to inform you if she develops a rash so that you can notify the HPA
Correct Answer: Reassure that no further action necessary
Explanation:Measles and MMR Vaccination Guidelines
Significant contact with measles is defined as being in the same room as an infected individual for 15 minutes or more. If an individual has not been fully immunised or has not previously had laboratory confirmed measles, it is assumed that they lack immunity. This is important to note for children who have not received the MMR vaccination for no good reason, as family history of epilepsy or autism is not a contraindication.
Ideally, the MMR vaccine should be given within three days of contact with a possible case of measles. A repeat MMR vaccine should be given after at least a month. The first dose of MMR should be given between 12 and 13 months of age, within a month of the first birthday. Immunisation before one year of age provides earlier protection in localities where the risk of measles is higher, but residual maternal antibodies may reduce the response rate to the vaccine. The optimal age chosen for scheduling children is therefore a compromise between risk of disease and level of protection.
If a dose of MMR is given before the first birthday, either because of travel to an endemic country or because of a local outbreak, then this dose should be ignored, and two further doses given at the recommended times between 12 and 13 months of age and at three years four months to five years of age. During the 2012-13 outbreak in Wales, a recommendation was made about the possibility of withdrawal from educational establishments for unvaccinated close contacts.
It is important to follow these guidelines to prevent the spread of measles and protect individuals who may be at risk.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 15
Correct
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Samantha, a 50-year-old woman, visits her doctor complaining of feeling fatigued, experiencing a low mood, and losing interest in activities she typically enjoys for the past two weeks. As per ICD-10 guidelines, how long must Samantha's symptoms persist to be diagnosed with a depressive episode?
Your Answer: 2 weeks
Explanation:The criteria for diagnosing depressive illness according to ICD-10 include a depressed mood, loss of interest in activities that were once enjoyable, and decreased energy levels. Other common symptoms include reduced concentration, low self-esteem, feelings of guilt, pessimistic views of the future, and thoughts or actions of self-harm or suicide. Disturbed sleep, diminished appetite, psychomotor agitation or retardation, and loss of libido are also common.
To diagnose a mild depressive episode, at least two of the main three symptoms and two of the other symptoms should be present, but none of the symptoms should be intense. The episode should last for a minimum of two weeks, and individuals should still be able to function socially and at work, despite being distressed by the symptoms.
For a moderate depressive episode, at least two of the main three symptoms and three or four of the other symptoms should be present for a minimum of two weeks. Individuals will likely have difficulty continuing with normal work and social functioning.
A severe depressive episode is diagnosed when all three typical symptoms are present, along with at least four other symptoms, some of which should be severe. The episode should last for a minimum of two weeks, but an early diagnosis may be appropriate if the symptoms are particularly severe. Individuals may also experience psychotic symptoms and show severe distress or agitation.
Screening and Assessment of Depression
Depression is a common mental health condition that affects many people worldwide. Screening and assessment are important steps in identifying and managing depression. The screening process involves asking two simple questions to determine if a person is experiencing symptoms of depression. If the answer is yes to either question, a more in-depth assessment is necessary.
Assessment tools such as the Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9) are commonly used to assess the severity of depression. The HAD scale consists of 14 questions, seven for anxiety and seven for depression. Each item is scored from 0-3, producing a score out of 21 for both anxiety and depression. The PHQ-9 asks patients about nine different problems they may have experienced in the last two weeks, which can then be scored from 0-3. This tool also includes questions about thoughts of self-harm.
The DSM-IV criteria are used by NICE to grade depression. This criteria includes nine different symptoms, such as depressed mood, diminished interest or pleasure in activities, and feelings of worthlessness or guilt. The severity of depression can range from subthreshold depressive symptoms to severe depression with or without psychotic symptoms.
In conclusion, screening and assessment are crucial steps in identifying and managing depression. By using tools such as the HAD scale and PHQ-9, healthcare professionals can accurately assess the severity of depression and provide appropriate treatment.
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This question is part of the following fields:
- Mental Health
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Question 16
Correct
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A 50-year-old female has a history of aggressive, erosive rheumatoid arthritis over three years.
It remains poorly controlled despite good compliance with therapy (NSAIDs and methotrexate). She is now complaining of severe fatigue.
FBC shows:
Haemoglobin 72 g/L (120-160)
White cell count 1.4 Ă—109/L (4-11)
Platelet count 44 Ă—109/L (150-400)
What is the most likely cause of her pancytopenia?Your Answer: Methotrexate
Explanation:Pancytopenia in a Patient with Erosive Rheumatoid Arthritis
This patient is presenting with pancytopenia, which can be attributed to her history of erosive rheumatoid arthritis over the past three years. It is likely that she has been on immunosuppressive therapy, which can lead to this type of hematological condition.
There are several medications used in immunosuppressive therapy that can cause pancytopenia, including methotrexate, sulfasalazine, penicillamine, and gold. It is important to monitor patients on these medications for any signs of hematological abnormalities and adjust treatment accordingly.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 17
Correct
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A 27-year-old woman presents to the GP clinic with complaints of abdominal pain. She missed her last menstrual period and had unprotected sexual intercourse 8 weeks ago. She denies any vaginal discharge or bleeding and has no urinary symptoms.
During the examination, her abdomen is soft, but there is mild tenderness in the suprapubic region. Her heart rate is 72 beats per minute, blood pressure is 118/78 mmHg, and she has no fever. A pregnancy test is performed, and it comes back positive.
As per the current NICE CKS guidelines, what would be the most appropriate next step in management?Your Answer: Arrange immediate referral to the early pregnancy assessment unit
Explanation:Women with a positive pregnancy test and abdominal, pelvic or cervical motion tenderness should be immediately referred for assessment to exclude ectopic pregnancy, which could be fatal. Referral should be made even if an ultrasound cannot be arranged immediately, as the patient may require monitoring in hospital. Serial hCG measurements should not be done in secondary care, and referral to a sexual health clinic alone is not appropriate.
Bleeding in the First Trimester: Causes and Management
Bleeding in the first trimester of pregnancy is a common concern for women, often leading them to seek medical attention. The main causes of bleeding during this time include miscarriage, ectopic pregnancy, implantation bleeding, cervical ectropion, vaginitis, trauma, and polyps. Of these causes, ectopic pregnancy is the most important to rule out as it can be life-threatening if missed.
To manage early bleeding, the National Institute for Health and Care Excellence (NICE) released guidelines in 2019. If a woman has a positive pregnancy test and experiences pain, abdominal or pelvic tenderness, or cervical motion tenderness, she should be referred immediately to an early pregnancy assessment service. If the pregnancy is over six weeks gestation or of uncertain gestation and the woman experiences bleeding, she should also be referred to an early pregnancy assessment service. A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.
For pregnancies under six weeks gestation and no pain or risk factors for ectopic pregnancy, expectant management is appropriate. Women should be advised to return if bleeding continues or pain develops, to repeat a urine pregnancy test after 7-10 days and to return if it is positive. A negative pregnancy test indicates a miscarriage. By following these guidelines, healthcare providers can effectively manage bleeding in the first trimester and ensure the safety of both the mother and the developing fetus.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 18
Incorrect
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A 67-year old man with a history of osteoarthritis and prior cervical laminectomy for degenerative cervical myelopathy reports a 2-month progression of gait instability and urinary urgency. What is the most probable cause of his symptoms?
Your Answer: Spinal metastases
Correct Answer: Recurrent degenerative cervical myelopathy
Explanation:Patients who have undergone decompressive surgery for cervical myelopathy need to be closely monitored postoperatively as there is a risk of adjacent segment disease, where pathology can recur at spinal levels that were not treated during the initial surgery. Additionally, spinal dynamics can be altered by surgery, increasing the likelihood of other levels being affected and causing mal-alignment of the spine, such as kyphosis and spondylolisthesis, which can also impact the spinal cord. If patients experience recurrent symptoms, they should be urgently evaluated by specialist spinal services.
Transverse myelitis typically presents more suddenly than in this case, with a sensory level and upper motor neuron signs below the affected level. It is often seen in patients with multiple sclerosis or Devics disease (neuromyelitis optica), who may also experience optic neuritis.
On the other hand, the patient’s symptoms are more consistent with recurrent cervical myelopathy, given his medical history and subacute presentation. Cauda equina syndrome, which results from compression of the cauda equina and typically includes leg weakness, saddle anesthesia, and sphincter disturbance, is less likely in this case.
Degenerative cervical myelopathy (DCM) is a condition that has several risk factors, including smoking, genetics, and certain occupations that expose individuals to high axial loading. The symptoms of DCM can vary in severity and may include pain, loss of motor function, loss of sensory function, and loss of autonomic function. Early symptoms may be subtle and difficult to detect, but as the condition progresses, symptoms may worsen or new symptoms may appear. An MRI of the cervical spine is the gold standard test for diagnosing cervical myelopathy. All patients with DCM should be urgently referred to specialist spinal services for assessment and treatment. Decompressive surgery is currently the only effective treatment for DCM, and early treatment offers the best chance of a full recovery. Physiotherapy should only be initiated by specialist services to prevent further spinal cord damage.
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This question is part of the following fields:
- Musculoskeletal Health
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Question 19
Correct
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A 68-year-old man with type 2 diabetic attends annual review at the GP practice.
His current treatment consists of: aspirin 75 mg OD, ramipril 10 mg OD, simvastatin 40 mg ON, metformin 1g BD, pioglitazone 45 mg OD and glibenclamide 15 mg OD.
He complains of episodes of blurred vision and feeling lightheaded. He has taken his blood sugar during one of these episodes and it was 2.3.
Which one of his medicines is the most likely cause of his symptoms?Your Answer: Glibenclamide
Explanation:Understanding Hypoglycaemic Episodes and Sulphonylureas
This gentleman is experiencing hypoglycaemic episodes that are causing symptoms of blurred vision and lightheadedness. The most likely cause of these episodes is the sulphonylurea he is taking. Sulphonylureas stimulate insulin secretion, which can cause significant problems with hypoglycaemia. On the other hand, metformin increases insulin sensitivity and reduces hepatic gluconeogenesis, while pioglitazone reduces insulin resistance. Hypoglycaemia is uncommon with pioglitazone, and metformin doesn’t cause it.
Glibenclamide is a long-acting sulphonylurea that is associated with a greater risk of hypoglycaemia. It should be avoided in the elderly, and shorter-acting alternatives, such as gliclazide, are more appropriate. The above patient is also on the maximum dose, which increases the risk of hypoglycaemia further. Therefore, glibenclamide is the correct answer. Understanding the relationship between hypoglycaemic episodes and sulphonylureas is crucial in managing diabetes and preventing complications.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 20
Incorrect
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What is the accurate statement about the connection between IUDs and PID?
Your Answer: Overall increased risk throughout lifetime of IUD
Correct Answer: Increased risk in first 20 days then returns to normal
Explanation:New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 21
Incorrect
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A 20-year-old traveller presents to the GP casualty unit with a five-inch dirty wound on his shin after mucking out horses. The wound is cleaned and sutured, but the patient is unsure of his vaccination status.
What is the most suitable recommendation for tetanus treatment?Your Answer: Give him tetanus immunoglobulin
Correct Answer: Give him tetanus immunoglobulin and a course of five tetanus vaccinations
Explanation:Treatment for High-Risk Wounds
This man’s wound poses a high risk of contamination from horse manure, and we do not know his vaccination status. Immediate action is necessary to prevent tetanus infection. Tetanus immunoglobulin can provide short-term protection, but it takes several months to achieve long-term immunity after the first dose of tetanus vaccine and up to a week after a booster. Therefore, the patient should receive both tetanus immunoglobulin and a full course of five tetanus vaccinations, with intervals of at least four weeks between doses. The standard dose of tetanus immunoglobulin is 250 IU IM, but if the wound is heavily contaminated, or if there is a delay in seeking treatment, a dose of 500 IU is recommended.
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This question is part of the following fields:
- Population Health
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Question 22
Incorrect
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A 72-year-old male patient requests a house call because he has been feeling unwell. Upon arrival, he reports experiencing double vision and difficulty with balance.
During the physical examination, you observe nystagmus, significant ataxia, and slurred speech.
The patient mentions that he was recently prescribed a new medication by his hospital specialist, but he is unsure about the correct dosage.
What medication has he been prescribed?Your Answer: Donepezil
Correct Answer: Methotrexate
Explanation:Side-Effects of Phenytoin
Phenytoin is a medication used to treat seizures and epilepsy. However, it can have various undesirable side-effects, both in the long-term and with excessive dosage.
Acute phenytoin overdose can cause nystagmus, diplopia, slurred speech, ataxia, confusion, and hyperglycaemia. On the other hand, common side-effects not related to acute intoxication include tremors, paraesthesia, gingival hypertrophy, rashes, acne, hirsutism, and coarse facies.
In rare cases, serious haematological and neurological side-effects can occur with regular usage. Haematological side-effects include megaloblastic anaemia, aplastic anaemia, thrombocytopaenia, and agranulocytosis. Meanwhile, neurological side-effects include peripheral neuropathy and dyskinaesias.
It is important to monitor the dosage and usage of phenytoin to avoid these side-effects and ensure the patient’s safety.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 23
Incorrect
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A 35-year-old woman presents to the clinic with her husband. They are concerned because she has become increasingly fixated on cleaning, which is interfering with her other responsibilities and straining their relationship.
She has installed a nail brush in the downstairs bathroom to scrub her skin after using the toilet and has prohibited guests from using any of the upstairs bathrooms. She also requires visitors to remove their shoes outside and has banned eating from any area outside the kitchen. Most recently, she has begun waking up at 5:30 am every day to clean.
What is the most appropriate initial treatment for her?Your Answer: Cognitive behavioural therapy (CBT)
Correct Answer: Counselling
Explanation:Treating OCD with CBT and SSRIs
CBT and SSRIs are the main treatments for obsessive-compulsive disorder (OCD). CBT involves challenging the ritualistic behavior of OCD through exposure and response prevention, which exposes the patient to stimuli that usually provoke their behavior and challenges their irrational thinking. On the other hand, SSRIs are the main pharmacological therapy for OCD. Counseling alone is not usually focused enough to provide significant impact on symptoms. A comprehensive treatment plan that includes CBT and SSRIs can help individuals with OCD manage their symptoms and improve their quality of life.
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This question is part of the following fields:
- Mental Health
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Question 24
Correct
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A 30-year-old woman is worried about experiencing hair loss. Her family has a history of premature hair loss, and upon examination, she has diffuse hair loss over her scalp, which appears normal. She is curious if medication can assist her in this situation.
What is the most effective licensed medication she can use?Your Answer: Minoxidil (topical)
Explanation:Treatment Options for Female-Pattern Hair Loss
Female-pattern hair loss, also known as androgenic alopecia, is a common cause of hair loss in women. While there is no cure for this condition, there are several treatment options available. One such option is topical minoxidil, which can stimulate limited hair growth in some adults. It comes in 2% and 5% solutions, with the 2% strength recommended for women. Cyproterone acetate and spironolactone are anti-androgens that may have a role in treatment, but should only be used under specialist guidance and are not licensed for this purpose. Finasteride is not licensed for use in women of childbearing age due to the potential for fetal abnormalities. Topical ketoconazole is indicated for seborrhoiec dermatitis of the scalp, which is not typically associated with female-pattern hair loss. Overall, treatment options for female-pattern hair loss should be discussed with a healthcare professional.
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This question is part of the following fields:
- Dermatology
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Question 25
Incorrect
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You are cleaning out your medicine cabinet and you come across some expired ampoules of diamorphine. You want to dispose of them.
Who among the following individuals could witness their destruction?Your Answer: Any GP partner
Correct Answer: Any practice manager
Explanation:Destruction and Disposal of Controlled Drugs
Destruction and disposal of controlled drugs are strictly regulated and require an authorized witness to observe and counter-sign the controlled drugs register to confirm destruction has taken place, even after the drugs have expired. It is important to note that not everyone is allowed to witness the destruction of controlled drugs. The list of authorized witnesses includes any Police Constable, Inspectors of the General Pharmaceutical Council, CCG chief pharmacist or pharmaceutical prescribing adviser who reports directly to the chief executive or to a director of the CCG, a registered medical practitioner who has been appointed to the CCG Professional Executive Committee or equivalent, the CCG board executive member with responsibility for clinical governance or risk management, and the medical director of a CCG.
It is crucial to understand that practice nurses or GP partners are not allowed to witness the destruction of controlled drugs. While any Police Constable or CCG Medical Directors may witness the destruction of CDs, there are also other possible authorized witnesses. However, in practice, it is not practical for CCG Medical Directors to visit practices solely for the purpose of witnessing the destruction of CDs, and regions will have their own protocols in place for the collection and/or destruction of CDs. It is also important to note that patient-held CDs returned to community pharmacies or dispensing doctors’ practices do not require an authorized witness to be present for them to be destroyed. This distinction is essential to remember, especially when being tested on it in the AKT exam.
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This question is part of the following fields:
- Improving Quality, Safety And Prescribing
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Question 26
Incorrect
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A 25-year-old woman had blood tests taken at her 12-week booking appointment with the midwife. This is her first pregnancy and she has no significant medical history. The results of her full blood count (FBC) are as follows:
- Hb: 110 g/L
- Platelets: 340 10^9/L
- WBC: 7.2 10^9/L
What would be the most appropriate course of action based on these findings?Your Answer: Give dietary advice to increase iron intake
Correct Answer: Start oral iron replacement therapy
Explanation:To determine if iron supplementation is necessary, a cut-off of 110 g/L should be applied during the first trimester.
During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually at 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a woman requires oral iron therapy. For the first trimester, the cut-off is less than 110 g/L, for the second and third trimesters, it is less than 105 g/L, and for the postpartum period, it is less than 100 g/L. If a woman falls below these levels, she should receive oral ferrous sulfate or ferrous fumarate. Treatment should continue for three months after iron deficiency is corrected to allow for the replenishment of iron stores.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 27
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: It is only indicated in at-risk immunosuppressed people
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 28
Incorrect
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Which drug, prescribed for the treatment of type 2 diabetes mellitus, has been cautioned by the Medicines and Healthcare products Regulatory Agency for its potential to cause severe pancreatitis and renal impairment?
Your Answer: Acarbose
Correct Answer: Exenatide
Explanation:Diabetes mellitus is a condition that has seen the development of several drugs in recent years. One hormone that has been the focus of much research is glucagon-like peptide-1 (GLP-1), which is released by the small intestine in response to an oral glucose load. In type 2 diabetes mellitus (T2DM), insulin resistance and insufficient B-cell compensation occur, and the incretin effect, which is largely mediated by GLP-1, is decreased. GLP-1 mimetics, such as exenatide and liraglutide, increase insulin secretion and inhibit glucagon secretion, resulting in weight loss, unlike other medications. They are sometimes used in combination with insulin in T2DM to minimize weight gain. Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as vildagliptin and sitagliptin, increase levels of incretins by decreasing their peripheral breakdown, are taken orally, and do not cause weight gain. Nausea and vomiting are the major adverse effects of GLP-1 mimetics, and the Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that it has been linked to severe pancreatitis in some patients. NICE guidelines suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated, or the person has had a poor response to a thiazolidinedione.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 29
Correct
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A 28-year-old woman contacts the clinic seeking guidance. She has missed taking her Cerazette contraceptive pill yesterday. Based on your calculation, it has been approximately 48 hours since she last took a Cerazette pill. She is typically diligent in taking her pills and has not missed any other pills in the last half-year. Her last sexual activity was eight days ago. What is the best advice to provide her?
Your Answer: Take two pills now + use condoms for 2 days
Explanation:Cerazette has a wider time frame for taking the pill than traditional progestogen only pills, but if a pill is missed, the user should take two pills immediately and use additional contraception for two days.
The progestogen only pill (POP) has simpler rules for missed pills compared to the combined oral contraceptive pill. It is important to not confuse the two. For traditional POPs such as Micronor, Noriday, Norgeston, and Femulen, as well as Cerazette (desogestrel), if a pill is less than 3 hours late, no action is required and pill taking can continue as normal. However, if a pill is more than 3 hours late (i.e. more than 27 hours since the last pill was taken), action is needed. If a pill is less than 12 hours late, no action is required. But if a pill is more than 12 hours late (i.e. more than 36 hours since the last pill was taken), action is needed.
If action is needed, the missed pill should be taken as soon as possible. If more than one pill has been missed, only one pill should be taken. The next pill should be taken at the usual time, which may mean taking two pills in one day. Pill taking should continue with the rest of the pack. Extra precautions, such as using condoms, should be taken until pill taking has been re-established for 48 hours.
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This question is part of the following fields:
- Maternity And Reproductive Health
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Question 30
Correct
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Sophie is a 32 year old woman who has been experiencing symptoms of irritability, anxiety, lethargy, poor concentration and disturbed sleep for a week before her periods. These symptoms disappear after her period starts. Do you think she may have premenstrual syndrome? If so, what are some possible treatment options?
Your Answer: Low dose SSRI (selective serotonin reuptake inhibitor) during luteal phase
Explanation:The only recognized treatment option for premenstrual syndrome among the given choices is a low dose SSRI during the luteal phase. According to the NICE Clinical Knowledge Summary on Premenstrual Syndrome, lifestyle advice should be given to women with severe PMS, and treatment options for moderate PMS include a new-generation combined oral contraceptive, analgesics, or cognitive behavioral therapy. Additionally, an SSRI can be taken continuously or during the luteal phase (days 15-28 of the menstrual cycle, depending on its length).
Understanding Premenstrual Syndrome (PMS)
Premenstrual syndrome (PMS) is a condition that affects women during the luteal phase of their menstrual cycle. It is characterized by emotional and physical symptoms that can range from mild to severe. PMS only occurs in women who have ovulatory menstrual cycles and doesn’t occur before puberty, during pregnancy, or after menopause.
Emotional symptoms of PMS include anxiety, stress, fatigue, and mood swings. Physical symptoms may include bloating and breast pain. The severity of symptoms varies from woman to woman, and management options depend on the severity of symptoms.
Mild symptoms can be managed with lifestyle advice, such as getting enough sleep, exercising regularly, and avoiding smoking and alcohol. Specific advice includes eating regular, frequent, small, balanced meals that are rich in complex carbohydrates.
Moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP), such as Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg). Severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI), which can be taken continuously or just during the luteal phase of the menstrual cycle (for example, days 15-28, depending on the length of the cycle). Understanding PMS and its management options can help women better cope with this condition.
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This question is part of the following fields:
- Gynaecology And Breast
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