Questions Flashcards

1
Q

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

A

b. 14
Number Needed To Treat = 1/ARR
ARR = CER-EER ARR 0.1 -0.17= 0.07 1/0.07 = 14

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2
Q

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

A

b. Bblocker
Beta blockers are indicated for all those with left ventricular dysfunction regardless of whether symptoms are present or not.

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3
Q

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

A

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.

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4
Q

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

A

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

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5
Q

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

A

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.

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6
Q

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

A

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.

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7
Q

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

A

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.

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8
Q

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

A

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

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9
Q

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

A

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.

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10
Q

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

A

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.

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11
Q

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

A

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.

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12
Q

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

A

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.

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13
Q

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

A

d. Start Eltroxin 25mcg od
This patient’s blood results show subclinical hypothyroidism. She complains of subfertility, a trial of thyroxin replacement is appropriate

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14
Q

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

A

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.

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15
Q

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

A

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.

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16
Q

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

A

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.

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17
Q

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

A

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.

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18
Q

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

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.

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19
Q

A 13-year-old girl presents with height and weight above the 99.6th centile. She has some abdominal striae but has not noted any changes in her skin or hair. She denies constipation. She has normal pubertal changes consistent with her age. The rest of the family are not overweight.
What is the most likely cause for her obesity?
Select one:
a. Hypothyroidism
b. Prader-Willi syndrome
c. Family history
d. Simple obesity
e. Type 2 diabetes

A

d. Simple obesity
Abdominal striae are signs of obesity and do not indicate any particular cause.
Prader Wili syndrome is a rare genetic condition which is associated with obesity and usually diagnosed in early childhood
Hypothyroidism juvenile onset may be associated with increased weight, coarse hair, sallow skin, constipation. There may be growth retardation, delayed skeletal maturation and pubertal development.
Family history or genetic susceptibility accounts for <5% of childhood obesity and is not relevant in this patient’s case.
Type 2 Diabetes does not cause obesity but may be a complication of it.

20
Q

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

A

d. 3
Centor score: 3 points: 1 for each of Exudative tonsils
Cervical lymphadenopathy
History of fever
0 points for presence of cough

21
Q

Which of the following is correct regarding Domestic violence?

a.
Affects 1 in 3 women during their lifetime

b.
80% of reported cases of domestic violence is against women by male partners

c.
Victims disclose the abuse readily to their General Practitioner

A

b OHGP p 8

Domestic violence is a common and serious problem. According to the Irish National Study on Domestic Abuse 15% of women and 6% of men reported experiencing severe abuse.

DV affects about 1 in 4 women in their lifetime and is the most common form of interpersonal crime. OHGP p 86

22
Q

Which of the following is correct regarding abuse?

a.
Does not affect young people in a relationship

b.
Abuse between parents is the most frequently reported form of trauma for children

c.
Patients do not face any barriers to disclosing abuse

A

b

23
Q

What is the legal age to consent to medical treatment in Ireland?

a.
18 years

b.
16 years

c.
14 year

A

b

24
Q

Which of the following correctly represents the HARK questionnaire when asking a patient about domestic violence?

a.
Hate, Annoy, Rate, Kidnap

b.
Halt, Aggravate, Rude, Knock

c.
Humiliate, Afraid, Rape, Kicked

A

c

25
Q

What proportion of men aged between 40 and 70 years experience erectile dysfunction?
Select one:

a. 50%
b. 25%
c. 5%
d. 20%
e. 1%

A

Erectile dysfunction (ED) is defined as the persistent inability to achieve and/or maintain a penile erection sufficient to permit satisfactory sexual performance. It is very common with estimates that at least 50% of men will experience it at some stage in their life time. Up to 90% of men are too embarrassed to seek help. OHGP p. 754
The correct answer is: 50%

26
Q

Which of the following are associated with erectile dysfunction. Tick all that apply.

a.Relationship problems

b.Cardiovascular disease

c.Smoking

d.Use of a selective serotonin re-uptake inhibitor

e.Diabetes mellitus

A

Erectile dysfunction (ED) is strongly associated with organic disease, especially cardiovascular disease. Loss of early morning erections points more towards an organic cause. However there is also a psychogenic component whereby anxiety about the symptoms can potentiate the problem. ED can be entirely psychogenic in origin. This is more likely in younger patients and in those with a sudden onset as opposed to gradual onset of symptoms.

The correct answers are: Cardiovascular disease, Diabetes mellitus, Smoking, Relationship problems, Use of a selective serotonin re-uptake inhibitor

27
Q

In 2012, in Ireland roughly what proportion of people aged 65 years and older were on 5 or more regular medicines?
Select one:

a.20%

b. 40%

c. 60%

d. 5%

e. 10%

A

Due to advances in healthcare there are more and more older people living with multiple chronic illnesses or multimorbidity. Polypharmacy is often necessary and appropriate in people with multimorbidity but it is also the biggest risk factor for potentially inappropriate prescribing (PIP). PIP is a term used to describe sub-optimal prescribing where the risks of treatment generally outweigh the benefits. There are various tools that can be used to screen for PIP. An example is the STOPP (Screening Tool of Older Person’s Prescriptions) criteria.
Appropriate polypharmacy is a term that can used to to describe a situation where the benefits from treatment have been maximised, the risks minimised and patient choices and preferences respected. In order to ensure that people with multimorbidity are on appropriate treatment it is important that they have regular medication reviews.
The correct answer is: 60%

28
Q

Mary is a 72 year old patient of your practice who has attended you for a repeat prescription. She has a history of COPD, osteoarthritis, hypertension and severe depression. She has been well lately and had routine bloods including a renal profile taken two months ago which was normal.
Here is her list of medicines:
Salbutamol MDI 200mcg PRN, started 5 years ago
Tiotropium dry powder inhaler 18mcg OD, started 4 years ago
Paracetamol 1g QDS, started 2 years ago
Ramipril 2.5mg OD, started 1 year ago
Amlodipine 10mg OD, started 10 years ago
Zopiclone 7.5mg OD, started 6 years ago
Citalopram 20mg OD, started 8 years ago
Which of the above medications is potentially inappropriate?
Select one:

a. Citalopram
b. Ramipril
c. Tiotropium
d. Zopiclone
e. Amlodipin

A

Benzodiazepines and z drugs are often used to treat insomnia. However they are associated with tolerance and dependence. Tolerance describes a situation where a higher dose of a medicine is needed to give the same effect. Dependence describes a situation where the person feels they cannot stop the medicine or they will get withdrawal symptoms. This is why benzodiazepines and z drugs should not be used for prolonged periods wherever possible. These medicines are particularly risky in older adults and are associated with reduced cognition and falls.
If a benzodiazepine or z drug is to be discontinued after prolonged use this should be done very gradually to prevent withdrawal symptoms of anxiety and insomnia.
OHGP p. 169

The correct answer is: Zopiclone

29
Q

What proportion of all cancer deaths are associated with cigarette smoking?
Select one:

a. 10%
b. 50%
c. 30%
d. 5%
e. 75%

A

Smoking is the greatest single cause of illness and mortality. Simple advice from a GP can result in between 2 and 5% of smokers quitting.
OHGP p. 156

The correct answer is: 30%

30
Q

Phosphodiesterase type 5 (PDE5) inhibitors are contraindicated if the patient is co-prescribed which of the following medicines?

Select one:

a. Metformin 850mg BD

b. Isosorbide mononitrate 60mg OD

c. Bisoprolol 7.5mg OD

d. Sumatriptan 50mg PRN

e. Citalopram 20mg OD

A

Phosphodiesterase inhibitors such as sildenafil are a very effective treatment for erectile dysfunction. Some are short acting and others longer acting. They are generally prescribed PRN and taken prior to planned sexual activity.

Contraindications include recent stroke or MI, systolic BP < 90 mmHg and co-prescription of a nitrate or nicorandil as this combination can cause profound hypotension.

The correct answer is: Isosorbide mononitrate 60mg OD

31
Q

Peter is a 72 year old man who has attended you to discuss his recent blood results. He is feeling well. He has a history of hypertension and hypercholesterolaemia and was recently commenced on atorvastatin 10mg. He is also prescribed amlodipine 10mg and ramipril 5mg.

His Alkphos is in normal range, AST, ALT and GGT are all raised.
All lipid profiles are raised.

With respect to his LFTs, what may be the cause of the raised AST and ALT?

a. Gallstones
b. Atorvastatin
c. Viral infection
d. Non alcoholic fatty liver disease
e. Alcohol liver diseas

A

There are many causes of raised liver transaminases. Examples of drug causes are: penicillins, anti-epileptics, statins, antifungals and NSAIDs. Fatty liver disease is another cause and can be associated with either alcohol or the metabolic syndrome. Other causes include: iron overload (eg from HH), viral infection (including the hepatitis viruses) and autoimmune hepatitis. OHGP p. 390

The correct answers are: Viral infection, Atorvastatin, Non alcoholic fatty liver disease, Alcohol liver disease

32
Q

Peter is a 72 year old man who has attended you to discuss his recent blood results. He is feeling well. He has a history of hypertension and hypercholesterolaemia and was recently commenced on atorvastatin 10mg. He is also prescribed amlodipine 10mg and ramipril 5mg.

With respect to his U&E, what is the most likely cause of the raised potassium?

Select one:

a. Haemolysed specimen

b. Excessive alcohol consumption

c. Atorvastatin

d. Addison’s disease

e. Ramipril

A

ACE inhibitors are commonly prescribed medicines for hypertension and diabetic nephropathy. Common side effects include a dry cough, GI upset, orthostatic hypotension and electrolyte imbalances.

The correct answer is: Ramipril

33
Q
A

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.

34
Q

This ECG shows: ______

These are all features of _____.

What should you do next?

A

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.

35
Q

most appropriate initial management for Lime disease?

A

Oral doxycycline as the first-line management.

If oral doxycycline cannot be given to a patient due to contraindications, such as allergy or pregnancy, oral amoxicillin can be used as an alternative.

36
Q

ABX for UTI

A

nitrofuratonin (CI if eGFR <45)
trimethoprim

37
Q

The patient is prescribed trimethoprim.

Which of the following laboratory abnormalities is most likely to be seen in patients taking this medication?

A

Trimethoprim is a commonly used medication for the management of urinary tract infections (UTI) in non-pregnant women. A three-day course is typically prescribed for an uncomplicated UTI. Notable side effects of trimethoprim include hyperkalaemia, nausea/ vomiting and skin rashes. Other medications that cause hyperkalaemia include potassium-sparing diuretics (e.g. spironolactone, eplerenone, triamterene and amiloride), angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and heparin derivatives.

38
Q

Drug classes that can lead to hyperkalaemia?

A

potassium-sparing diuretics (e.g. spironolactone, eplerenone, triamterene and amiloride)

angiotensin-converting enzyme inhibitors (ACEi)

angiotensin II receptor blockers

heparin derivatives

Trimethoprim (ABX for cystitis)

39
Q

drug classes that can cause hyperprolactinaemia?

A

antipsychotics

bowel motility agents (metoclopramide)

histamine-2 receptor blockers

40
Q

Drugs that can lead to hypokalaemia

A

Hypokalaemia is a common electrolyte abnormality seen in patients using

salbutamol,
insulin or
polystyrene sulfonate.

41
Q

________are associated with chronic proton pump inhibitor use and loop diuretic use.

A

Hypomagnesaemia

42
Q

_____can cause hypovolaemiac hypernatraemia.

A

Loop diuretics (e.g. furosemide)

43
Q

A 55-year old man presents to the GP for his annual health check as the has some symptoms of urinary frequency. The doctor does some beside tests and orders some blood tests.

Results:

HR 72 beats per minute
BP 138/86 mmHg
Urea 5.5 mmol/l
Creatinine 110 mmol/l
Cholesterol 7.4 mmol/l
LDL cholesterol 4.8 mmol/l
HBA1c 51 mmol/l
The GP counsels the patient regarding his cholesterol and commences a statin.

What is the most appropriate next step for this patient?

  1. Metformin
  2. Gliclazide
  3. Amlodipine
  4. Bisoprolol
  5. Ramipril
A

Metformin is the correct answer. This patient is presenting with a HBA1c result indicative of diabetes. Diabetes is diagnosed with an HBA1c result over 48mmol/L, with the pre-diabetic range being 42-47mmol/l. It is important to control his blood sugar promptly as he has other risk factors (high cholesterol) which make him at risk of cardiovascular events such as a myocardial infarction or a stroke. As the patient is symptomatic (polyuria), a single abnormal HbA1c can be used to diagnose diabetes.

In the UK, the National Institute for Health and Care Excellence (NICE) recommends supporting the patient to to aim for an HbA1c level of 48 mmol/mol (6.5%) if they manage their type 2 diabetes either with lifestyle and diet, or with lifestyle and diet combined with a single drug not associated with hypoglycaemia.
Ramipril is incorrect. If this patient had high blood pressure, Ramipril would be prescribed, as ACE-inhibitors or angiotensin receptor blockers (ARBs) are now recommended first-line for blood pressure control in patients with type 2 diabetes irrespective of age. Home blood pressure monitoring for one week is considered for clinic blood pressure over 140/90 mmHg. If the home blood pressure is over 135/85 mmHg, an antihypertensive is commenced.

Amlodipine is incorrect. Calcium channel blockers are first-line antihypertensives in patients over 55-years-old or in black-African or Afro-Caribbean patients. However, this patient’s clinic blood pressure is just below the cut-off for home blood pressure monitoring, so it is not relevant in this case.

Gliclazide is incorrect. This patient does not have hyperglycaemia symptoms that would require rescue therapy with hypoglycaemics with review treatment when blood glucose control has been achieved. Long-term control is usually with metformin (on top of or instead of anti-hypoglycaemics).

Bisoprolol is incorrect. Indications for beta-blockers are tachycardia, secondary prevention of cardiovascular events (usually begun post-MI), heart failure, or resistant hypertension.

44
Q

A 43-year-old Caucasian patient presents to the GP after noticing increasing ankle swelling that has been worsening over the past few days. He had assumed that it was due to the hot weather and sitting down for prolonged periods at his office job, but the swelling appears to be worsening. He denies shortness of breath, fatigue, chest pain or orthopnoea, and has been previously well, with his only past medical history being amblyopia that was treated as a child. He takes no regular medication.

Examination reveals pitting oedema up to the mid-calf bilaterally. Cardiac and respiratory examinations are both normal, and the patient’s pulse, respiratory rate and blood pressure are all within normal limits. The GP asks the patient to provide a urine sample and performs dipstick testing, this shows +++ protein, with no blood, leucocytes or nitrites.

The GP orders a set of routine blood tests and refers the patient to hospital, informing him that he may require several medications and some dietary changes to help to control his symptoms.

Which of the following is most likely to form part of the management plan in this patient?
1. Midodrine
2. Amlodipine
3. Fludrocortisone
4. Atorvastatin
5. Propranolol

A

Rifampicin - renal failure, liver toxicity, red-orange body secretions
Ethambutol - colour blindness, optic neuritis, pruritis, thrombocytopenia
Pyrazinamide - nausea, vomiting, arthralgia, hepatotoxicity
Isoniazid - peripheral neuropathy, hepatitis, psychosis

45
Q

important features of Kawasaki’s disease

Treatment?

A

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

46
Q

Teenage patient with bilateral anterior knee pain and tenderness at the tibial tuberosity - what could it be?

Tx?

A

Osgood-Schlatter disease (OSD)

Tx supportive