Qs Flashcards
A 52-year-old woman attends for a discussion regarding her recent diagnosis of bladder cancer. Her hospital discharge letter comments that histology has confirmed carcinoma in situ.
In addition to transurethral resection of bladder tumour (TURBT), what further treatment is the SINGLE MOST likely to be offered to this patient? Select ONE option only.
Select one: A.Intravesical Bacillus Calmette–Guérin (BCG) B.Intravesical chemotherapy C.No further treatment D.Radiotherapy E.Annual monitoring
ANS A.
Answer justification and feedback: Carcinoma in situ (CIS) is a superficial tumour, but it has strong potential to become muscle-invasive so is treated differently to less aggressive superficial tumours. Maintenance therapy with intravesical Bacillus Calmette–Guérin (BCG) should be considered to improve local control and reduce the incidence of progression.
Resource:
NICE.Bladder cancer: diagnosis and management(NG 2).2015.
The correct answer is: Intravesical Bacillus Calmette–Guérin (BCG)
A 78-year-old patient attends with a gift following your recent prompt referral for his acute myocardial infarction.
According to the NHS England Standard GMS Contract, what is the threshold at which gifts should be recorded in a register? Select ONE option only.
Select one: A.£10 B.£25 C.£100 D.£250 E.£50
Answer justification and feedback:This raises ethical issues around the impact of potential or actual gifts on the objectivity and professionalism of the doctor–patient relationship. The GMC’sGood Medial Practiceguidelines state that:
- You must not encourage patients to give, lend or bequeath money or gifts that will directly or indirectly benefit you
- You must not put pressure on patients or their families to make donations to other people or organisations.
The NHS England Standard GMS Contractrequires individual GPs and contractors to keep a register of gifts from patients or their relatives which have a value of £100 or more unless the gift is unconnected with the provision of services.
Resources:
BMA.Receiving gifts from patients.2020.
GMC.Good Medical Practice.2013 (updated 2014, 2019).
The correct answer is: £100
A 45-year-old man has a booked telephone consultation with you. He has already self-certified for the first week off work and asks for a ‘fit note’ stating that he is unfit to work, back-dated a week and for four months duration. He tells you that he sustained a nasty fracture of his leg a week ago and was told by the hospital consultant that he would not be fit to work for at least four months. You check his notes and find a discharge summary relating to this injury.
In these circumstances, which of the following actions would be the SINGLE MOST appropriate? Select ONE option only.
Select one:
A.
Issue a fit note back-dated to a week from the date of the injury for a period shorter than three months
B.
Issue a fit note from the date of your consultation for a period shorter than three months
C.
Refuse to issue a fit note on the basis that the man has not been seen by you following his injury
D.
Issue a fit note back-dated to the date of the injury for a period of four months
E.
Issue a fit note from the date of your consultation for four months duration
Answer justification and feedback:The Statement of Fitness to Work or ‘fit note’ gives medical evidence of an individual’s fitness to work. It is intended for periods of absence from work for more than seven days (including weekends). For shorter periods, workers can self-certify their incapacity.
Before a ‘fit note’ can be issued, some form of assessment of the patient by a healthcare professional must have taken place. Therefore, forward-dated fit notes should never be issued. The assessment can take the form of a GP consultation (face-to-face or telephone) but written reports from other healthcare professionals are also allowable.
So, if a patient who has had a viral illness for two weeks without consulting a healthcare professional calls the GP and asks for a back-dated fit note to cover that period, a fit note should not be issued as there is no independent corroborating evidence of the illness. In this case, a written report is available from the treating hospital. This provides corroborating evidence for the patient and therefore a back-dated fit note to the date of this hospital assessment can be issued.
In the first six months of a patient’s condition, a ‘fit note’ can cover a maximum of three months. If a condition has lasted longer than six months, a fit note can be for any clinically appropriate period up to ‘an indefinite period’. The dates are inclusive, so a fit note dated from 24May to 3June will no longer apply from 4June onwards.
In this case, depending on the work that the man does and his progress towards recovery from his injury, he might be fit to return to work with suitable workplace adaptations well before 4 months. Therefore, good practice would be to issue a fit note stating that this man is unfit to work now, backdated to the date of his injury, and for a duration of less than three months with an endorsement on the form to state that you need to assess the man again before return to work.
Of note, a person can return to work at any point that he or she feels able to, even if this is before the expiry date of a fit note. There is no requirement to see the GP in order to return to work or for the GP to issue a further fit note to that effect.
Resource:
DWP.Fit note: guidance for GPs.
The correct answer is: Issue a fit note back-dated to a week from the date of the injury for a period shorter than three months
You see a 42-year-old man who has been asked to attend your afternoon surgery by your practice nurse following a routine diabetic review. She is concerned that he may be depressed and has asked him to complete a patient health questionnaire (PHQ-9). He has no previous history of psychiatric illness. His PHQ-9 score is 6.
What is the SINGLE MOST appropriate management for this patient? Select ONE option only
Select one:
A.
St John’s wort
B.
Fluoxetine
C.
Routine referral to a psychiatrist
D.
Amitriptyline
E.
Computerised cognitive behavioural therapy (CCBT)
Answer justification and feedback:Depression severity can be graded using the PHQ-9 score:
0–4 None
5–9 mild
10–14 moderate
15–19 moderately severe
20–27 severe
Consider offering one or more of the following low-intensity psychosocial interventions to patients with persistent subthreshold depressive symptoms or mild to moderate depression, and to patients with subthreshold depressive symptoms that complicate the care of their chronic physical health problem:
A physical activity programme (modified for the particular physical health problem)
A peer support programme in a group of patients with a shared physical health problem
Individual guided self-help based on cognitive behavioural therapy (CBT) principles
Computerised cognitive behavioural therapy (CCBT)
Watchful waiting is an option as a management strategy in selected patients with mild depression.
Do not use antidepressants routinely to treat subthreshold depressive symptoms or mild depression, but consider them for patients with one of the following:
A past history of moderate or severe depression
Mild depression that complicates the care of the physical health problem
Initial presentation of subthreshold depressive symptoms present for at least two years
Subthreshold depressive symptoms
Mild depression persisting after other interventions
The correct answer is: Computerised cognitive behavioural therapy (CCBT)
A 19-year-old patient with recurrent sore throat requests antibiotics unnecessarily. The consultation becomes very difficult. You consider using a consultation model to help deal with the consultation.
Which option is the SINGLE MOST appropriate? Select ONE option only.
Select one:
A.
Cambridge–Calgary model
B.
Helman–Folk Model
C.
The FRAYED model
D.
Transactional analysis
E.
DR SAMOSA
ANS C.
Answer justification and feedback:The FRAYED consultation model is for situations when doctors deal with what might be considered unreasonable demands from difficult patients. One aim of this model is to preserve the GP’s emotional health for the rest of the day's work. It is represented by the mnemonic FRAYED. F– Fact-Finding R– Refuse Request A– Acceptable Alternative Y– Yield or don’t Yield E– End the Encounter D– Document Diligently
Resource:
Mirza D.The need for new GP consultation models.InnovAiT2018;12(1):33–37.
The correct answer is: The FRAYED model
Michael Balint was a psychologist whose work is still appreciated within general practice today.
What is an underlying principle in his work? Select ONE option only.
Select one:
A.A doctor’s behaviour and personality can impact on the doctor–patient relationship
B.Consultation is a ‘game’ of social interchange
C.Communication is initiated by the sender and interpreted by the receiver
D.Doctors are like drugs without side effects
E.Illness has a social meaning and is derived from a patient’s perspective
ANS A.
Answer justification and feedback:Balint introduced a pioneering approach to consulting in general practice. His work with other doctors highlighted the idea of the doctor as a ‘drug’ and suggested that doctors’ feelings have a function and can guide the direction of the consultation.
Resource:
Neighbour R.Challenging consultations.InnovAiT2018;12(1):24–29.
The correct answer is: A doctor’s behaviour and personality can impact on the doctor–patient relationship
Whilst practicing for the clinical skills assessment (CSA) it can be helpful to look at different consultation models.
Which of the following models adopts an evidence-based approach with a structure that includes information gathering, building the relationship and explanation/ planning?Select ONE option only.
Select one: A.Pendleton’s 1984 model B.Cambridge–Calgary model C.Roger Neighbour’s 1987 model D.Murtagh’s 1998 model E.Stott and Davies’s 1979 model
ANS B.
Answer justification and feedback:The Calgary–Cambridge system can be used to understand the structure of the consultation and also includes initiating the consultation, building the relationship and closing the consultation. Murtagh’s model introduces the concept of uncertainty about the diagnosis and what conditions might be missed. Pendleton’s model combines structure with a psychodynamic element introducing enquiry about ideas, concerns and expectations. Roger Neighbour’s model includes the concepts of summarising, safety-netting and housekeeping. Stott and Davies introduced four key consultation tasks including modification of health seeking behavior, management of continuing problems and opportunistic health promotion.
The correct answer is: Cambridge–Calgary model
A 38-year-old man has had low back pain for five years and investigations have been normal. He and his family have been attending joint consultations with a member of the mental health care team in order to find solutions to his problems. Which of the following BEST describes this therapeutic approach? Select ONE option only. Select one: A.Collaborative care B.Cognitive behavioural therapy C.Reattribution D.Psychodynamic therapy E.Brief intervention therapy
ANS A.
Answer justification and feedback:Collaborative care usually includes working with the patient and their family to define solutions to problems. Collaborative care studies have shown improvement both in symptoms and in health care utilisation costs for patients with medically unexplained symptoms (MUS).
Brief intervention therapy isdesigned to motivate individuals with unhealthy behaviours such as smoking, alcohol and substance misuse to alter their behaviour. It ofteninvolves using validated tools ( e.g theAlcohol Use Disorders Identification Test(AUDIT)) to screen and identify those at risk.
Cognitive behavioural therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression and anxiety.
Reattribution isa technique which tests the thoughts and assumptions by considering alternative causes of events. This particularly helps to challenge beliefs held by people who perceive themselves as the cause of problem events.
Psychodynamic therapy draws on theories and practices of analytical psychology and psychoanalysis. It is a therapeutic process which helps patients understand and resolve their problems,helping individuals to unravel, experience and understand their true, deep-rooted feelings in order to resolve them.
The correct answer is: Collaborative care
A 31-year-old female retail manager comes to your morning surgery complaining of tiredness for about six weeks. She says she has been promoted in her job and reports no stress in her family life. She used to smoke 2–3 cigarettes a day for ten years, but gave up two years ago. She does not think she has lost weight and cannot recall any recent infection, abnormal bleeding, regular periods, cough or dyspnoea. She considers herself fit and healthy but this continued fatigue is bothering her. Her physical examination is unremarkable: temperature 36.4°C, blood pressure 128/72 mmHg, pulse 76 beats/min and regular.
What is the SINGLE MOST appropriate next step? Select ONE option only.
Select one:
A.
Perform further investigations in primary care

B.
Arrange review in 2–3 weeks and investigate further if no better
C.
Tell the patient to come back in a month if no better
D.
Do not investigate further and reassure the patient
E.
Refer the patient to the local chronic fatigue specialist service.
Answer justification and feedback:It would be advisable to offer first-line investigation in this case to exclude any underlying causes especially as this woman’s symptoms have been present for more than a month. First-line tests would include blood tests for full blood count, erythrocyte sedimentation rate or C-reactive protein, liver function tests, renal function tests, thyroid function, random blood glucose/glycosylated haemoglobin (HbA1c) andimmunoglobulin A (IgA) tissue transglutaminase.
Depending on additional factors and the individual presentation, it may also be worthwhile to consider checking bone biochemistry, ferritin, vitamin D level,human immunodeficiency virus(HIV),hepatitis serology and a chest X-ray.
Resource:
NICE.Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (or Encephalopathy): diagnosis and management(CG53).2007.
The correct answer is: Perform further investigations in primary care
Answer justification and feedback:It would be advisable to offer first-line investigation in this case to exclude any underlying causes especially as this woman’s symptoms have been present for more than a month. First-line tests would include blood tests for full blood count, erythrocyte sedimentation rate or C-reactive protein, liver function tests, renal function tests, thyroid function, random blood glucose/glycosylated haemoglobin (HbA1c) andimmunoglobulin A (IgA) tissue transglutaminase.
Depending on additional factors and the individual presentation, it may also be worthwhile to consider checking bone biochemistry, ferritin, vitamin D level,human immunodeficiency virus(HIV),hepatitis serology and a chest X-ray.
Resource:
NICE.Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (or Encephalopathy): diagnosis and management(CG53).2007.
The correct answer is: Perform further investigations in primary care
https://rcgp.eaction.org.uk/GPactionplan
Which one of the following BEST describes the use of illness narratives in medically unexplained symptoms?
Select one option only.
A. Facilitates pt involvement in record keeping
B. Guides use of investigations
C. Helps prevent litigation
D. Links the cultural background to a patient’s presenting symptoms
E. Supports joint record keeping with the family
😉
Hmm
I chose C
But RCGP says D is correct answer
You’re working a weekend shift for OOH service and are called to visit a 51 year old woman who was found dead in her bed an hour ago.
The husband reports that she was seen by her own GP for an annual Diabetic check six months ago.
You confirm the death and speak to husband.
Single most appropriate next step?
A. Contact the Coroner’s office B. Contact the on call social worker C. Contact the funeral director D. Contact the police E. Call an ambulance
D
A 65 year old man attends your clinic complaining of a 4 month history of difficulty swallowing, episodes of staring and falls. What is the most likely diagnosis ? A. Wilson's B. Corticobasal ganglionic degeration C. Parkinson's D. Multiple System Atrophy E. Progressive Supranuclear Palsy
PSP (Steele-Richardson-Olszewski Syndrome)
- Early Dysphagia
- Gaze Palsy
- Recurrent falls.
So the age 25-65(ideally 24.5-64).
3 yearly for 25-49, 5yearly for 50-64.
If >/=65 can still be screened of recent prior test was positive.
Pregnant women should have smears delayed till 12 weeks post partum, but in them colposcopy should not be delayed.
If smear shows positive Hr HPV, and abnormal cytology then refer for colposcopy.
If HrHPV positive, but negative cytology , repeat in 12 months, if negative HrHPV , then can return to routine, if positive HrHPV then repeat in smear in another 12 months, if negative for HrHPV then return to routine If positive for HrHPV (i.e at 24 months) irrespective of cytology should be referred for colposcopy.
Hmmmmmm what else
Age is now 24.5 to 65
Yes pregnancy 12 weeks
The ‘Blue Badge scheme’ allows people with severe mobility problems to park for free. This means badge holders can park close to where they need to go.
Which ONE of the following patients would be eligible for a Blue Badge automatically without the need for a further assessment? Select ONE option only.
Select one:
A.A 69-year-old man who receives a war pensioner’s mobility supplement
B.A 67-year-old woman who receives attendance allowance
C.A 71-year-old woman who has heart failure
D.A 19-year-old man who has cerebral palsy
E.A 37-year-old woman who receives incapacity benefit
ANS A.
Answer justification and feedback:The Blue Badge scheme is to help disabled people who have severe mobility problems to access goods, services and other facilities by allowing them to park close to their destination.
People automatically qualify for a badge if they are over two years old and meet at least one of the following criteria:
• Receiving the Higher Rate of the Mobility Component of the Disability Living Allowance
• Receiving a Personal Independence Payment for being unable to walk further than 50 metres (a score of 8 points or more under the ‘moving around’ activity of the mobility component)
• Registered blind (severely sight impaired)
• Receiving a War Pensioner’s Mobility Supplement
• Has received a lump sum benefit within tariff levels 1-8 of the Armed Forces and Reserve Forces (Compensation) Scheme and has been certified as having a permanent and substantial disability which causes inability to walk or very considerable difficulty in walking.
Other conditionsmay also be eligible for a badge if those affected can demonstrate that they have a permanent and substantial disability which causes inability to walk or very considerable difficulty in walking.The local authority is responsible assessing eligibility and may ask those applying for a Blue Badge to undergo a mobility assessment with a medical professional such as a physiotherapist or occupational therapist.
Resource:
Department for Transport.Blue Badge scheme.
The correct answer is: A 69-year-old man who receives a war pensioner’s mobility supplement
…………………………….
A 60-year-old patient withchronic obstructive pulmonary disease(COPD) started smoking when he was 20 and smoked 60 cigarettes a day until he was 40. At that time the duty on cigarettes went up and he cut back to 30 cigarettes a day, a habit that he still follows.
How many pack years has he smoked? Select ONE option only.
Select one:
A.
40 pack years
B.
60 pack years
C.
75 pack years
D.
90 pack years
E.
100 pack years
Answer justification and feedback:Pack yearsare calculated by dividing the number of cigarettes smoked per day by 20, then multiply by the number of years smoked.
He smoked 60 cigarettes divided by 20 = 3. This is for 20 years = 60
Then he cut down to 30 daily, divided by 20= 1.5. This for 20 years= 30
Therefore the total pack years for this man is 90
An up-to-date smoking history, including pack years smoked, should be documented for everyone with COPD.
The correct answer is: 90 pack years
Which TWO of the following are the MOST APPROPRIATE first-line medications for the relief of muscle spasticity in multiple sclerosis (MS)? Select TWO options only. Select one or more: A.Baclofen B.Cannabis extract (sativex) C.Dantrolene D.Diazepam E.Gabapentin
ANS A and E
Answer justification and feedback: Either gabapentin or baclofen are recommended by the National Institute of Clinical Excellence (NICE) as first-line treatments. If neither are effective alone or in combination, then tizanidine or dantrolene as second-line choices and benzodiazepines are third-line. Sativex is not cost effective.
Resource:
NICE.Multiple sclerosis in adults: management.2014 (updated 2019)
The correct answers are: Baclofen, Gabapentin
.
A 55 year old Male has tried gabapentin, pregabalin, amitriptyline and capsaicin cream for DM neuropathic pain with no success. He has asked you to try a different medication today. Which one of the following is Most appropriate to try next ? A. Tramadol B. Nortryptiline C. Co-codamaol D. Naproxen E. Duloxetine
Yes E.
NB all the other medication they had tried in the stem question are liscenced for DM neuropathic pain
Which medication below is safe in a G6PD patient? A. Ciprofloxacin B. Primaquine C. Sulphasalazine D. Glicazide E. Phenoxymethylpenicillin
E.
All the others can trigger hemolysis in G6PD
A 74 year old long term smoker presents to his Gp with shortness of breath and haemptysis. On examination he is noted to have hyperpigmentation of his oral mucosa, palms and soles. Investigations reveal that he is diabetic and hypokalemic. What is the most likely diagnosis? A. Conn's syndrome B. Addison's C. Ectopic ACTH D. Pseudocushing's syndrome E. Hypothyroidism
ANS C. he’s got likely lung Ca
A 50 year old Male diagnosed with Cushing’s disease.
What is the most common cause of Cushing’s disease?
A. Pancreatic NET
B. Phaechromocttoma
C. Pituitary adenoma
D. Adrenal adenoma
E. Adrenal hyperplasia
C.
A 55 year old Male has tried gabapentin, pregabalin, amitriptyline and capsaicin cream for DM neuropathic pain with no success. He has asked you to try a different medication today. Which one of the following is Most appropriate to try next ? A. Tramadol B. Nortryptiline C. Co-codamaol D. Naproxen E. Duloxetine
Yes E.
NB all the other medication they had tried in the stem question are liscenced for DM neuropathic pain
Which medication below is safe in a G6PD patient? A. Ciprofloxacin B. Primaquine C. Sulphasalazine D. Glicazide E. Phenoxymethylpenicillin
E.
All the others can trigger hemolysis in G6PD
