Questions Flashcards
Nicotine replacement therapy for smoking cessation’ is the title of a Cochrane review to determine the effect of nicotine replacement therapy (NRT) compared to placebo in aiding smoking cessation. The review included 150 studies enrolling over 50,000 subjects comparing NRT to placebo. Overall, NRT increased successful cessation rates from 10 to 17%.
According to this review how many people would have to be prescribed NRT to successfully stop one person smoking?
Select one:
a. 7
b. 14
c. 140
d. 700
e. Not possible to calculate from these figures
b. 14
Number Needed To Treat = 1/ARR
ARR = CER-EER ARR 0.1 -0.17= 0.07 1/0.07 = 14
An 82 year old lady with stable heart failure NYHA I comes to see you for her repeat prescription. She has hypertension, hypercholestrolaemia and ischemic heart disease. She takes an antiplatelet agent, a statin, an ACE-inhibitor and a loop diuretic. Her Bp is 145/70 hr 90 regular.
What further medication should she be taking for management of heart failure?
Select one:
a. Clopidogrel
b. Bblocker
c. Warfarin
d. Thiazide diuretic
e. Calcium channel blocker
b. Bblocker
Beta blockers are indicated for all those with left ventricular dysfunction regardless of whether symptoms are present or not.
An 82 year old lady is complaining of lower back pain for the last 2 days. She has pain on movement and is finding it difficult to sleep at night. She has no incontinence of urine and no saddle anaesthesia. She has a past history of breast cancer. On examination, there is pain on straight leg raising and her knee and ankle reflexes are intact.
What would be the most appropriate management?
Select one:
a. Analgesia and bed rest
b. Analgesia, mobilisation and back exercises
c. Analgesia and refer for X ray of the lumbar sacral spine
d. Analgesia and refer for urgent MRI
e. Refer immediately to neurosurgery
c. Analgesia and refer for X ray of the lumbar sacral spine
Xray is indicated in this patient as she has a history of breast cancer and metastatic disease needs to be outruled. Osteoporotic crush fracture is another possible cause that could be outruled by Xray.
Analgesia is also appropriate. Bed rest is rarely appropriate for back pain.
There is no immediate need to refer to neurosurgery at this point given that she has no neurological signs suggestive of spinal cord compression or cauda equina.
A mother attends with her 4 year old child who has become increasingly drowsy. She had been unwell earlier that day with high temperature and a runny nose. On examination the child is lethargic.Her temperature of 38.3°C with cold peripheries. You notice a couple of small purpuric spots on the legs. She has no known drug allergies. You call reception and ask them to call 999 for a ‘blue light’ ambulance; the nearest hospital is five minutes away.
What is the most appropriate treatment to institute acutely in the community?
Select one:
a. Adrenaline intramuscular
b. Benzylpenicillin intramuscular
c. Ceftriaxone intramuscular
d. Chloramphenicol intramuscular
e. No antibiotic treatment, urgent hospital transfer only
b. Benzylpenicillin intramuscular
Adrenaline is a sympathomimetic it increases heart rate and contractility, it is indicated in acute anaphylaxis, angioedema and in cardio- pulmonary arrest.
Benzylpenicillin 600mg IM is indicate
A 77 year old patient of the practice is receiving palliative care at home for advanced metastatic lung cancer. No further active treatment has been planned and she has requested to be managed at home. She is not eating or drinking due to lack of appetite. She is getting relief for her nausea with domperidone, her pain is under control and she is not constipated.
What would the most appropriate next step in management of her anorexia?
Select one:
a. Nutritional supplements
b. Refer for PEG feeding
c. Cyclizine
d. Prednisolone 15mg bd
e. Arrange for home care to assist with feeding
d. Prednisolone 15mg bd
Nutritional supplements do not improve appetite but may reverse cachexia. ONS are often poorly tolerated.
PEG feeding would not be appropriate at this point as no further active treatment has been planned.
Cyclizine is effective in the treatment of nausea but is not an appetite stimulant. This lady is already receiving domperidone for nausea
Steroids e.g. Prednisolone or dexamethasone may improve appetite.
A 75 year old lady with newly diagnosed atrial fibrillation on ECG attends your practice. She has a history of diabetes. She is feeling well and has no symptoms. On examination her heart rate is 80 beats per minute and irregularly irregular. Her blood pressure is 130/80mmHg. She has no history of stroke or transient ischaemic attack (TIA) and does not have heart failure.
What is the most appropriate type of medication to commence?
Select one:
a. Antiarrythmics
b. Anticoagulation
c. Antiplatelet therapy
d. Antihypertensive
e. Statin therapy
b. Anticoagulation
Antiarrhythmic not appropriate at this point as the duration of atrial fibrillation is not known and the patient is systemically stable.
Antiplatelet therapy would not reduce the risk of stroke sufficiently given this patient has a CHA2DS2-VASc score of 4
Antihypertensive and statins do not directly prevent thrombo-embolism, which is the main concern in the management of atrial fibrillation in this patient.
The correct answer is Anticoagulation due to CHA2DS2-VASc score of 4.
A 72-year-old farmer presents with a small red lesion on his left cheek. It has grown slowly over several months and it now has a central ulcer.
What is the most likely nature of this lesion?
Select one:
a. Amelanotic malignant melanoma
b. Basal cell carcinoma
c. Basal cell papilloma
d. Cowpox
e. Squamous cell carcinoma
b. Basal cell carcinoma
BCC are a type of slow-growing, locally invasive malignant tumour of the epidermal keratinocytes normally in older individuals, only rarely metastasises.
Amelanotic melanoma is a type of invasive malignant tumour of the epidermal melanocytes, which has the potential to metastasise
Basal cell papilloma also called senile wart or seborrheic wart is a warty nodule usually pigmented with a stuck on appearance.
Cowpox ( viral infection) appear as one or a small number of pus like lesions on the hands or face, which ulcerate and form a black scab before healing.
SCC is a locally invasive malignant tumour of the epidermal keratinocytes or its appendages, which has the potential to metastasise.
A 70 year old woman attends the surgery after a recent hospital admission for a radial fracture sustained after a fall from a chair. She has no previous medical history. She does not take any regular medications and is a non smoker. Her alcohol intake is minimal. A Dual Energy X-ray Absorptiometry (DEXA) scan performed during her admission shows osteoporosis. According to the National Institute for Health and Clinical Excellence (NICE) guidelines, what would be the recommended first line pharmacological treatment for this lady?
Select one:
a. Vitamin D and Calcium
b. Alendronate
c. Hormone Replacement Therapy (HRT) d. Denosumab
e. Strontium ranelate
b. Alendronate
Bisphosphonates, such as alendronate, are the mainstay of treatment of osteoporosis. Those at risk of osteoporosis should maintain adequate vitamin D and calcium intake.
HRT is not a first line treatment for osteoporosis in those >51 years because of side effect profile. Denosumab is indicated for severe osteoporosis where bisphosphonates are contraindicated
Strontium ranelate is indicated for severe osteoporosis where bisphosphonates are contraindicated. It is associated with an increased risk of severe cardiovascular disease
A 64-year-old woman with type 2 diabetes mellitus attends for review. She had microalbuminuria on her last examination and a repeat sample continues to show microalbuminuria. She is taking metformin 500mg twice daily. She feels well and is on no other medication.On examination her BP 122/76 and HbA1c < 6.1% (3.8-6.4)
Which is the next most appropriate step in management for this patient?
Select one:
a. Add diamicron
b. Add ramipril
c. Avoid excessive exercise
d. Restriction of dietary protein
e. Add insulin
b. Add ramipril
The correct answer is to add ramipril which is an ACE inhibitor and the recommended management for patients with Diabetes Mellitus with microalbuminuria.
Which of the following drugs would be the most appropriate treatment to prevent the symptoms of alcohol withdrawal, for example, delirium tremens or seizures?
Select one:
a. Acamprosate
b. Buprenorphine
c. Bupropion
d. Chlordiazepoxide
e. Temazepam
d. Chlordiazepoxide
Chlordiazepoxide is a benzodiazepine that is indicated for short term use in alcohol withdrawal to prevent symptoms such as delirium tremens.
Acamprosate is used in the maintenance of abstinence in alcohol dependent patients. It is not indicated for acute withdrawal.
Buprenorphine is used as substitution therapy in opioid dependent patients
Buproprion is used to aid smoking cessation
Temazepam is a hypnotic indicated for short term use in insomnia and for peri-operative sedation.
A 4 year old boy attends the surgery for a review of his asthma. He takes Budesonide (Pulmicort) 200mcg twice daily and requires Salbutamol (Ventolin) on a daily basis. You are satisfied with compliance, technique and that the inhaler device and spacer are all appropriate.
According to the British Thoracic Society Guidelines, which would be the most appropriate next step in drug management?
Select one:
a. Add in a long acting beta 2 agonist e.g. Salmeterol (Serevent)
b. Add in a leukotriene receptor antagonist e.g. Montelukast (Singulair)
c. Add in ipratropium bromide
d. Increase budesonide (Pulmicort) to 400mcg twice daily
e. Add in a short course of oral steroids
b. Add in a leukotriene receptor antagonist e.g. Montelukast (Singulair)
See BTS guidelines/BNFc management of chronic asthma.
Step 3: inhaled short acting beta agonist as required plus regular standard dose inhaled corticosteroid plus leukotriene receptor antagonist.
Standard dose inhaled corticosteroid <12 years -budesonide 100-200mcg bd.
A 38 year old female presents with tiredness which is getting worse in the last 6 weeks. She says she goes to bed early and sleeps all night. However she is still tired the next day. She has no other significant symptoms and examination is normal.
What is the most appropriate management at this stage?
Select one:
a. Reassure and review in one month if no improvement
b. Advise sleep hygiene
c. Check bloods for anaemia and hypothyroid and review
d. Prescribe oral iron
e. Refer for polysomnography
c. Check bloods for anaemia and hypothyroid and review
Symptoms are persisting for 6 weeks it is reasonable to check a blood test. if normal reassure. 75% of TATT are due to emotional distress, 9% due to physical causes.
Sleep hygiene advice not appropriate as patient enjoys good sleep pattern Check FBC and iron studies before prescribing iron
Patient does not have any signs of a sleep disorder so polysomnography unlikely to be useful at this point.
A 28 year old female attends the surgery. She has been trying to conceive for 6 months. She has requested a hormone profile to out rule any cause for infertility. She feels well and has no specific symptoms. She has never had any abdominal surgery or pelvic infection. Clinical examination is normal. Blood tests reveal the following:
TSH 7 (normal range 0.35-6.20 milli-international units/L)
T4 13 (normal range 9.00-23.12 picomol/L [0.7 to 1.8 nanograms/dL])
FSH, LH and Day 21 progesterone - All within normal range What is the most appropriate management for this lady?
Select one:
a. Reassure and advise her to have regular intercourse
b. Reassure and repeat hormone profile in 6 months
c. Reassure and advise that she will need to start eltroxin when she conceives
d. Start Eltroxin 25mcg od
e. Refer to a fertility specialist
d. Start Eltroxin 25mcg od
This patient’s blood results show subclinical hypothyroidism. She complains of subfertility, a trial of thyroxin replacement is appropriate
A 25 year old lady attends 6 weeks post cesarean section to discuss contraception. She had a deep vein thrombosis during pregnancy and is currently on warfarin. She will stop warfarin in 6 months time and would ideally like to conceive again in the next 3 years.
Which of the following types of contraception would be the most suitable for this lady?
Select one:
a. Combined oral contraceptive pill
b. Combined contraceptive patch
c. Progesterone only pill
d. Depot Medroxyprogesterone Acetate (DMPA)
e. Intra-uterine device
c. Progesterone only pill
Combined oral contraceptives ( pill or patch) containing oestrogen are contraindicated in patients with a history of VTE.
Medroxyprogesterone acetate (depot) reduces warfarin clearance, which may result in an increase in its effects.
Intrauterine system e.g. Mirena is a long acting contraceptive and duration of use is usually 5 years.
A 24 year old lady attends your Practice. She tells you that her father died suddenly of an MI one year previously.Her main complaint is that of worsening sleep pattern and loss of appetite for the last year. She misses her father greatly and also cries for prolonged periods on a daily basis.On further questioning she admits to significant loss of interest and enjoys little or nothing. She has missed one months work from her job as a secretary. She has a very negative outlook on her future. She has had fleeting ideas of self harm, but assures you she would not do anything to herself. Objectively, she is quite withdrawn, with reduced eye contact and motor activity.
Which one of the following is the most likely diagnosis in this case?
Select one:
a. Adjustment reaction
b. Depressive illness of moderate severity
c. Generalised anxiety disorder
d. Mild depression
e. Normal grief reaction
b. Depressive illness of moderate severity
This lady demonstrates symptoms of depression including prolonged sadness on a daily basis, a negative outlook on life, poor sleep pattern, loss of appetite and anhedonia. Her symptoms have a negative impact on her functional ability to work indicating depression of a moderate severity.
A 19-year-old farmer attends the surgery having cut his leg while cleaning the cow shed. On examination he has a dirty wound approximately five inches in length on his shin. You clean it up and suture it. He does not know what vaccinations he has had in the past.
Which of the following is the most appropriate advice with respect to treatment for tetanus?
Select one:
a. Give him a course of three tetanus vaccinations
b. Give him one tetanus booster vaccination
c. Give him tetanus immunoglobulin
d. Give him tetanus immunoglobulin and a course of three tetanus vaccinations
e. Give him tetanus immunoglobulin and one tetanus booster vaccination
d. Give him tetanus immunoglobulin and a course of three tetanus vaccinations
This is a tetanus prone wound - open wound in contact with manure - see page 1107 of Oxford handbook of general practice for management.
A 16-year-old girl who presents with a two year history of worsening central abdominal pain. She is very upset about her symptoms and is now starting to miss school because of the pain. The pain is associated with intermittent diarrhea and is relieved by defecation. She was recently admitted to hospital and thorough investigations including OGD, colonoscopy, abdominal ultrasound and blood tests were all normal. On examination she is of normal height and weight. Her mother is concerned that there must be something wrong.
What is the most likely diagnosis?
Select one:
a. Meckels diverticulum
b. Abdominal migraine
c. Functional dyspepsia
d. Irritable bowel syndrome
e. Crohns disease
d. Irritable bowel syndrome
IBS is a diagnosis of exclusion, it is a common chronic relapsing remitting condition of unknown cause. It can appear and any age and is more common in women.
Meckels diverticulum is usually diagnosed in early childhood and may cause appendicitis like symptoms
Abdominal migraine presents as stereotypical attacks in which nausea, vomiting and headache can accompany abdominal pain.
Dyspepsia is an upper GI symptom characterized by heartburn, reflux, fullness, nausea with or without epigastric pain.
Crohn’s disease is a chronic inflammatory condition associated with abdominal pain, diarrhea weight loss. Blood and colonoscopy results are likely to show signs of inflammation.
A 14-year-old girl attends the practice with her mother. She has been stung by a bee. Her hand is red and swollen where she was stung. She looks unwell and has swelling around her eyes and lips. She is starting to have difficulty breathing and is beginning to feel faint.
What would be the most appropriate first medication to administer?
Select one:
a. 0.5ml of 1 in 1000 adrenaline intramuscularly
b. Chlorphenaramine 5mg intramuscularly
c. Hydrocortisone 200mg by slow intravenous injection
d. Nebulised salbutamol
e. Nebulised adrenaline
a. 0.5ml of 1 in 1000 adrenaline intramuscularly
This patient is showing signs of anaphylaxis.
Adrenaline is indicated for immediate resuscitation.
Chlorphenamine 10mg IM and hydrocortisone 200mg are indicated after giving adrenaline.
A 10 year old girl presents with a history of high fever and painful throat. Her mother has been giving her paracetamol for the last 3 days. On examination she has a temperature of 38.1°C, there is tender anterior cervical lymphadenopathy, tonsillar exudate is visible and she has a dry cough.
What is this patient’s ‘Centor’ score?
Select one: a. 0
b. 1
c. 2
d. 3
e. 4
d. 3
Centor score: 3 points: 1 for each of Exudative tonsils
Cervical lymphadenopathy
History of fever
0 points for presence of cough
Iron deficiency can cause a microcytic hypochromic anaemia. Causes of iron deficiency are blood loss, malabsorption and reduced dietary intake. Blood loss from menstruation is the most common cause. A detailed menstrual history is important including past obstetric and gynaecology history and current contraceptive needs, as these considerations will help determine the most appropriate management.
The correct answer is: Take detailed menstrual history.
This ECG shows: ______
These are all features of _____.
What should you do next?
Absent P waves and tall tented T waves. shows feature of hyperkalaemia;
This patient could be at risk of a fatal arrhythmia and should be referred to the emergency department immediately.
important features of Kawasaki’s disease
Treatment?
Kawasaki’s disease, a vasculitis affecting medium-sized vessels that can give a number of systemic features.
‘CRASH and BURN (‘Burn’ referring to the prolonged fever):
Conjunctivitis
Rash
Adenopathy
Strawberry tongue (also seen in scarlet fever)
Hand and foot desquamation
A prolonged fever (greater than 5 days)
Tx Aspirin
