The Complete GPVTS Stage 2 Preparation Guide E-Book

Saba Khan

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 331

Veröffentlichungsjahr: 2011

Beschreibung

Ease the pressure of the GP Vocational Training Scheme Stage 2 exams, and ensure your progress to Stage 3, with this complete preparation guide

Featuring all question types from the exam, including SBAs, EMQs and Professional Dilemmas, and covering a range of medical and surgical specialties, this invaluable guide not only tests appropriate application of clinical knowledge, but encourages doctors to think logically and ethically - vital in recognising appropriate behaviour in professional dilemmas. The opening section provides handy advice on how to prepare for the exam and explains what the question setters are looking for - the key to success in Stage 2. 

Based on the contributors’ own experience of typical problems and dilemmas, and including thorough explanations for each answer, this book is not just an exam crammer, but a valuable learning tool.

Leseprobe

Contents

Contributors

The Complete GPVTS Stage 2 Preparation Guide

How to Use This Book

Exam Technique

Part 1 Clinical Problem Solving Questions: SBAs and EMQs

1 Cardiology

2 Dermatology

3 Ear, Nose and Throat

4 Endocrinology and Metabolic Disease

5 Gastroenterology and Nutrition

6 Genetics

7 Haematology

8 Immunology

9 Infectious Diseases

10 Musculoskeletal Disorders

11 Neurology

12 Ophthalmology

13 Paediatrics

14 Psychiatry

15 Renal Medicine

16 Reproductive Health

17 Respiratory Medicine

18 Urology

Part 2 Professional Dilemmas

19 Ranking Questions

20 Multiple Best Answer Questions

Index

This edition first published 2012 © 2012 by John Wiley & Sons, Ltd.

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Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

Library of Congress Cataloging-in-Publication Data

Khan, Saba.The complete GPVTS stage 2 preparation guide : questions and professional dilemmas / edited by Saba Khan with Neel Sharma.p. ; cm.Includes bibliographical references and index.

ISBN-13: 978-0-470-65490-3 (pbk. : alk. paper)ISBN-10: 0-470-65490-2 (pbk. : alk. paper)I. Sharma, Neel. II. Title.[DNLM: 1. General Practice–education–Great Britain–Examination Questions.2. General Practitioners–education–Great Britain–Examination Questions. WB 18.2]LC classification not assigned610.76–dc23

2011029725

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781119959854; ePub 9781119959861; Mobi 9781119959878

Contributors

Safia DebarMSc, MBBS, DCH, DRCOG, nMRCGP, DipOccMedGP, NIHR In-practice FellowOunali JafferFRCR, MRCP, MBBSRadiologistKings College Hospital LondonNeman S KhanMRCGP, DFFP, DRCOG, MBBSGP Principle and Trainer, WorkingSaba KhanMBBS, DFFP, DRCOG, MRCGP (Distinction), MScGP and Programme Director, Chertsey GPVTS, KSS DeaneryDonna PilkingtonBSc, MBChBGPST1 TraineeNeel SharmaBSc (Hons), MBChB, MScCore Medical Trainee Year One, Lewisham Healthcare NHS Trust and Honorary Clinical Lecturer in Medical Education, Barts and the London School of Medicine and Dentistry

The Complete GPVTS Stage 2 Preparation Guide

This book has been written with the aspiring GP in mind, and it should contain enough information for you to be able to feel confident about taking and passing the Stage 2 entrance exam.

The entrance process is made up of four parts. This book is a guide for the second part of this process and should help you gain enough practice to feel more able to pass this stage comfortably.

Stage 1

The first stage is essentially completion of your application form, and producing evidence that you have completed training competently to then be able to apply for further specialty training.

The National Person Specification is a document that outlines all of the qualifications and attributes necessary to apply successfully for GP specialty training. It is worth being aware of the GMC Good Medical Practice guide as eligibility is based on these seven criteria. There are also six criteria under the Personal Skills section that are worth reading through that should be covered within your answers on the application form. The person specification also covers health and probity. There are standardised pieces of evidence that need to be provided at this stage of the process and details of this are on the National Recruitment Office (NRO) website (www.gprecruitment.org.uk).

As an applicant in this process you also need to clearly show evidence of having reached Foundation Competency through approved training posts. Those applicants who have come from other specialties or who have had gaps in training will need to present evidence of competency in line with GMC Standards.

The application form is submitted online, and once completed cannot be altered unless there are very specific reasons for a change to your preferred choice of deanery. When applying it is important to look at the geographical areas covered by each deanery, as your ranking of four preferred deanery choices will influence where you are offered a place.

Stage 2

The second stage is a computer-based assessment that will determine shortlisting and allocation for Stage 3 of the selection process. Candidates will complete this computer-based exam at various Pearson Vue centres around the UK. The Pearson Vue website can be used to book the test and also as a resource for a practical tutorial on how to record your answers on the day.

The paper is made up of two parts: a Professional Dilemma section followed by a Clinical Problem Solving section.

From previous papers, it is best to allow at least two hours for the Professional Dilemma and approximately one hour for the Clinical Problem Solving.

The Professional Dilemma section contains two types of question. The first is a ranking question, where the candidate is given a scenario and asked to rank the five options in order of most suitable response down to least appropriate. This is an exercise in decision making and rationalisation.

The second type of question sets out a scenario and asks the candidate to typically select three options from a list of answers, in any order, as their management plan or best response.

These questions are not negatively marked and in fact have a ‘most right answer’ which is judged as the best possible response for a competent doctor at F2 level. If the candidate selects a different but still reasonable response, marks will still be awarded. It is therefore advisable to attempt all questions as there are marks available even if the ideal answer is not chosen.

The second part of the assessment is made up of the Clinical Problem Solving section. This exam tests your ability to apply your clinical knowledge to various clinical scenarios. It does not expect a working knowledge of general practice but rather a competent approach and knowledge level appropriate to a foundation stage doctor, regardless of the patient presentation.

The answer totals are collated into four bands which are based on a range of scores, so those with the highest scores fall into the highest band and those with the lowest scores fall into the lowest band. The scores that trainees attain in this assessment will influence the allocation of their preferred deanery post, because the deaneries with higher demand for training posts will award rotations to candidates with higher scores first. Unfortunately those trainees that fall into the lowest band are not shortlisted.

Scoring for previous exams can be accessed on the NRO website.

Stage 3

The results from Stage 2 are used to allocate and rank candidates to their preferred deanery. The candidates are then assigned to a selection centre for Stage 3 assessment. The deanery assigned to each candidate will be more likely to be their first choice, the higher their score in the second stage. Those candidates with lower scores will be given their second choice and so on, dependent on available places. If none of the four choices can be met, vacant rotations in any deanery could be offered.

The Stage 3 assessment requires three references from recent educational and clinical supervisors, which should be recorded on the structured reference forms available on the NRO website. Along with these references a number of personal documents will also be required.

The Stage 3 assessment consists of two components: a simulation exercise and a written exercise.

The simulation exercise is made up of three 10-minute scenarios, designed to test the main attributes outlined in the National Person Specification.

The 10-minute scenarios are with a simulator who will act the part of a relative/carer, a patient and also a non-medical colleague. The role play is designed to test skills such as communication, empathy and problem solving. Clinical skills or knowledge are not tested in this process as it is the more difficult skills of patient and doctor interaction that are being assessed.

The written exercise will last approximately 30 minutes and will require the candidate to prioritise and justify their response to a dilemma presented to them. This exercise, again, is not designed to test clinical knowledge but to assess decision-making skills.

This part of the assessment is more focused on professionalism and rationalisation, hence it is best to try and use best judgement and common sense rather than relying on textbook answers.

Stage 4

Stage 4 of the assessment process involves the collation of results from Stage 2 and Stage 3. Once these results are collated all candidates are ranked in order, and those with the highest ranking are offered their first choice of deanery. Candidates are then offered their remaining choices of deanery if their first choice is unavailable. Following this, those candidates who are not given an offer may be offered a place in a different deanery to those on their preferred list, through local and then national clearing.

How to Use This Book

This book is designed to help you tease out where your strengths and possible learning gaps are. It is a useful aid at the beginning of your exam preparation to help guide learning or toward the end of your revision to make sure that you have all areas covered.

In our experience exam preparation is a balance between how much you know and how much you can apply what you know. The questions in this book are designed to test how much you know and the explanations will help you to test whether you are applying this knowledge correctly.

One of the most challenging aspects to the Stage 2 exam is the time pressure, which in itself is a key skill to becoming a good General Practitioner. The papers are written to test how you work under pressure as opposed to making subject matter unfairly difficult. Much of the skill of developing as a generalist lies in your ability to negotiate a large amount of work in a relatively small amount of time. This is an essential skill that is worth paying attention to prior to this process.

It would be helpful to use different chapters under timed conditions to see how you cope with this aspect of the exam.

The exam is designed to test Foundation level knowledge and does not expect you to have a working knowledge of General Practice. However the topics that you come across in the questions are commonly seen in General Practice. Much of your knowledge will come from learning that you have already done during your clinical posts as well as more structured teaching opportunities that you may have had. To support this we recommend standard clinical texts that cover general medicine, surgery and the specialties. However, this should be selective learning, based on where you find your learning needs are, after covering some of the subject matter in this book.

The chapters have been divided by subject to help you find where you need to focus your learning, with explanations to aid this. We have used authors with both experience and expertise in each subject area to make the questions as fair as possible.

The Professional Dilemma section is not a knowledge-based exercise. The scenarios are designed to assess the candidate’s ability to make clear and sound judgements, in difficult ethical or professional situations. These are real issues that could easily arise in one’s own practice. For revision purposes, a useful resource is the GMC’s Good Medical Practice Guide. It is worth spending time looking over this document to be aware of the domains that could be covered.

The questions are written with options with a most correct answer moving down to a least correct answer, there are still marks awarded if answers are not in the key response order but are almost correct. In these scenarios it is best to use standards such as the GMC guidance as your best plan of action.

Exam Technique

The Professional Dilemma paper for 2010 contained 60 questions, which were made up of ranking 4–5 options or selecting 2–3 responses for an answer stem. We recommend that for the ranking questions it is best to put the most suitable answer first, the least suitable answer last, and then arrange the remaining responses. These questions are more focused on your ability as a practitioner to sensibly deal with more difficult scenarios commonly faced by medical professionals. These questions are not designed to trip you up or to be difficult, they are purely a test of your decision-making ability. This is something that all clinicians do on a day-to-day basis regardless of their specialty field. However, in General Practice it is done at a much faster rate and under very specific time limits and this skill is tested in this paper.

It is good exam technique to try and answer as many questions as possible as each question has equal weighting; rather than spending too long on a few questions it is best to answer as many as possible. This is the main difficulty of this paper and we recommend working on the dilemma section of this book under timed conditions to help you develop this skill.

There is no negative marking in this paper so reasonable attempts at all questions should be made.

For the Clinical Problem Solving paper, there were 105 questions. The majority of the questions are based on general medicine with a smaller proportion allocated to the specialties. With the use of this book, you can focus your learning into areas where you may have more knowledge gaps, and focus your revision into these areas. However this exam is not designed to be difficult but is specifically aimed at Foundation level competency.

One of the most challenging aspects to this exam is the time pressure involved in the completion of each paper. It is worth attempting questions under timed conditions for this section also, to assess your own ability in this area.

We also recommend picking questions that you know you can answer quickly and then moving to the ones that are more difficult for you to do later in the exam. However, this requires you to look through the paper before starting, and some candidates would prefer to just start working and push through in order not to waste time. It is worth looking at which technique works for you and how you work best.

The Stage 3 assessment is much more about professionalism, and requires each candidate to demonstrate good judgement in an empathic and clear way. It is worth spending some time looking through the GMC website, as there are some excellent learning resources that will help focus your learning. The National Person Specification is also important for this part of your revision as much of this entire process is based on these principles. It is also helpful to practise different scenarios with colleagues to help you develop your skills.

Again, this stage is about how you demonstrate your professionalism in a pressurised situation. The examiners will be looking for candidates to remain focused and to give clear, considered judgements. The decisions expected to be made by each candidate are those that should fall within the realms of what is considered safe and reasonable for doctors at Foundation level competency. It is best to be natural and make sure you can justify the decisions that you make.

In summary, this exam is designed to ensure that those opting for General Practice are suited to the process and possess the necessary qualities to progress through training.

This book will, it is hoped, help guide your revision and ensure that you have a successful outcome!

Part 1

Clinical Problem Solving Questions: SBAs and EMQs

1 Cardiology

Single best answer questions

For each question below, what is the most likely answer?

Select ONE option only from the answers supplied.

1. A 76-year-old man presents to his GP. He complains of breathlessness which is made worse on exertion. He denies any history of chest pain or a cough. He has a past medical history of asthma which was diagnosed as a child. On examination you note a blood pressure of 123/77 mmHg, pulse rate of 67 beats per minute and a temperature of 36.7°C. Cardiovascular examination reveals a low-pitched diastolic murmur over the apex. Respiratory examination proves unremarkable. What is the most likely diagnosis?

a) Mitral regurgitation

b) Aortic stenosis

c) Pulmonary stenosis

d) Mitral stenosis

e) Aortic regurgitation

2. A 52-year-old Bengali man is referred to the cardiology outpatient department by his GP due to concerns with his blood pressure. A blood pressure diary reveals readings over 160/100 mmHg over a 2-week period. Fundoscopy examination proves unremarkable. What is the most suitable management option?

a) Watch and wait

b) Repeat blood pressure measurement in one week

c) Commence amlodipine

d) Commence ramipril

e) Commence bendroflumethiazide

3. A 79-year-old woman presents to the Emergency Department. She complains of central chest pain which came on at rest. Background medical history includes type 2 diabetes and hypercholesterolaemia. You note that she is quite short of breath with a pulse rate of 115 beats per minute and blood pressure of 95/45 mmHg. What is the single most important investigation in this case?

a) ECHO

b) ECG

c) Chest X-ray

d) Serum troponin

e) Arterial blood gas

4. A 46-year-old man attends the Emergency Department. He complains of central chest pain which is worse on inspiration. An ECG demonstrates evidence of diffuse concave ST elevation. What is the most likely diagnosis?

a) Myocardial infarction

b) Costochondritis

c) Pericarditis

d) Pulmonary embolism

e) Gastro-oesophageal reflux disease

5. A 23-year-old male hockey player collapses suddenly during a match and is rushed to the Emergency Department. He is noted to be in asystole on arrival and despite the best efforts of the resuscitation doctors is pronounced dead. No trauma was sustained during the match. What is the most likely cause of death?

a) Hypertrophic cardiomyopathy

b) Myocardial infarction

c) Pulmonary embolism

d) Aortic dissection

e) Commotio cordis

6. A 42-year-old man presents to the Emergency Department. He complains of left-sided chest discomfort and generalised weakness. He has a background history of hypertension and type 2 diabetes. An ECG demonstrates evidence of a shortened PR interval and a slow rise of the initial upstroke of the QRS complex. What is the most likely diagnosis?

a) Hypertrophic cardiomyopathy

b) Vasovagal syncope

c) First-degree heart block

d) Atrial fibrillation

e) Wolff-Parkinson-White syndrome

7. Which of the following is NOT a contraindication to exercise stress testing?

a) Left main coronary artery stenosis

b) Severe mitral regurgitation

c) Aortic dissection

d) Severe aortic stenosis

e) Severe osteoarthritis

8. You are the F2 doctor on call and are asked to see a 63-year-old woman. On arrival the nurse informs you that the patient has a strong cardiac history. An ECG demonstrates a narrow QRS complex and a regular rhythm. Which of the following is the most appropriate initial treatment?

a) Adenosine

b) Atropine

c) DC cardioversion

d) Adrenaline

e) Amiodarone

9. An 82-year-old woman presents to the Emergency Department. Routine observations reveal a blood pressure of 85/45 mmHg and pulse rate of 162 beats per minute. Which of the following is the most appropriate initial treatment?

a) Valsalva manoeuvre

b) Adenosine

c) Amiodarone

d) DC cardioversion

e) Bisoprolol

10. A 69-year-old man is reviewed by his GP. He complains of chest pain which is worse on inspiration, as well as a fever. He has recently been discharged from hospital following a myocardial infarction 7 weeks prior. On examination you note a pulse rate of 72 beats per minute and blood pressure of 124/75 mmHg. Cardiovascular examination reveals evidence of a rub over the left lower sternal edge. What is the most likely diagnosis?

a) Dressler’s syndrome

b) Pneumonia

c) Pulmonary embolism

d) Cardiac tamponade

e) Pericarditis

11. A 63-year-old woman is admitted to hospital with central chest pain, radiating to her left arm. She has a background history of hypertension. On examination her heart sounds are normal with no audible murmurs. Routine observations demonstrate a pulse rate of 96 beats per minute and blood pressure of 142/93 mmHg. An ECG demonstrates evidence of ST depression. Which one of the following is the most suitable initial management?

a) Aspirin 75 mg

b) Aspirin 75 mg and clopidogrel 75 mg

c) Bisoprolol 5 mg

d) Aspirin 300 mg, clopidogrel 300 mg, enoxaparin 1 mg/kg

e) Aspirin 300 mg, clopidogrel 300 mg, enoxaparin 1 mg/kg and bisoprolol 5 mg

12. A 45-year-old man is admitted to the Emergency Department. He complains of a 2-hour history of sudden-onset central crushing chest pain. An ECG demonstrates evidence of ST elevation in anterior leads. Which of the following is the most suitable management option?

a) Aspirin 75 mg

b) Clopidogrel 75 mg

c) Dobutamine stress echo

d) Exercise treadmill test

e) Coronary angiography

13. A 78-year-old woman is reviewed by her GP for a routine check-up. She has a strong cardiac history and required some urgent blood tests. Results demonstrate a serum sodium of 128 mmol/L, a potassium of 5.9 mmol/L, urea of 3.2 mmol/L and a creatinine of 88 mmol/L. Which of the following drugs is the most likely cause for her blood results?

a) Spironolactone

b) Bumetanide

c) Furosemide

d) Bendroflumethiazide

e) Atenolol

14. A 28-year-old woman presents to her GP following an episode of syncope. She has a background history of schizophrenia which was recently diagnosed. She was commenced on risperidone orally and has been compliant with her medication. Full system examination proves unremarkable. What is the most likely diagnosis?

a) Vasovagal syncope

b) Postural hypotension

c) Hypertrophic cardiomyopathy

d) Sick sinus syndrome

e) Long QT syndrome

15. A 54-year-old woman presents to her GP. She complains of generalised abdominal discomfort over a 2-week period. On examination you note evidence of a white discoloration of her retina and hepatosplenomegaly. What is the most likely diagnosis?

a) Type I hyperlipoproteinaemia

b) Type II hyperlipoproteinaemia

c) Type III hyperlipoproteinaemia

d) Type IV hyperlipoproteinaemia

e) Type V hyperlipoproteinaemia

Extended matching questions

Question 1

a) Furosemide

b) Atenolol

c) Ramipril

d) Spironolactone

e) Amlodipine

f) Bendroflumethiazide

g) Bisoprolol

h) Amiodarone

For each patient below, what is the most likely cause?

Select ONE option only from the list above.

Each option may be selected once, more than once or not at all.

1. A 62-year-old woman with a background history of hypertension and increased ankle swelling.

2. A 78-year-old man presenting with shortness of breath and visual disturbances. On examination you note a blue-grey discoloration of his skin.

3. An 83-year-old man with a history of hypertension presents with a dry cough. Routine blood investigations demonstrate a potassium of 6 mmol/L.

4. A 59-year-old woman with a history of hypertension presents to the GP for a routine blood test. Results demonstrate a sodium of 129 mmol/L and a potassium of 6.3 mmol/L.

5. A 45-year-old man recently commenced on an antihypertensive presents with a hot swollen right toe.

Question 2

a) Lisinopril

b) Candesartan

c) Amlodipine

d) Amiodarone

e) Glyceryl trinitrate (GTN)

f) Atenolol

g) Bisoprolol

h) Isosorbide mononitrate

i) Nicorandil

For each patient below, what is the most appropriate treatment option?

Select ONE option only from the list above.

Each option may be selected once, more than once or not at all.

1. A 43-year-old man with congestive cardiac failure presents with shortness of breath. A chest X-ray on arrival demonstrates evidence of an enlarged heart and pulmonary congestion. He is given 80 mg furosemide intravenously. An hour later his breathing becomes more laboured. Routine observations reveal a pulse rate of 105 beats per minute and a blood pressure of 110/75 mmHg.

2. A 62-year-old Caucasian man is reviewed by his GP. His blood pressure is 192/75 mmHg on three separate readings. Current medication includes aspirin 75 mg and bendroflumethiazide 2.5 mg.

3. A 53-year-old Caucasian woman presents to her GP for a routine check-up. Her blood pressure is noted to be 165/94 mmHg on three separate readings. Current medication includes aspirin 75 mg.

4. A 45-year-old woman presents with a dry cough. She has a background history of hypertension and is currently on ramipril 5 mg.

5. A 78-year-old man presents to his GP for a routine check-up. He has a background history of hypertension. Current medication includes bendroflumethiazide and ramipril. His blood pressure is still elevated at 175/105 mmHg.

Question 3

a) Lisinopril

b) Indapamide

c) Minoxidil

d) Clonidine

e) Losartan

f) Felodipine

g) Propranolol

h) Hydralazine

i) Doxazosin

For each patient below, what is the most likely cause?

Select ONE option only from the list above.

Each option may be selected once, more than once or not at all.

1. A 72-year-old woman is admitted to the Emergency Department with gradual-onset swelling of her eyes and lips. She is a known hypertensive patient and has been started on a new medication recently.

2. A 63-year-old man presents with soreness of his gums. He has a history of high blood pressure. On examination you note evidence of gingival hyperplasia.

3. A 69-year-old man presents with generalised joint pains. On examination you note evidence of an erythematous rash on his face which he comments gets worse in sunlight.

4. A 62-year-old woman registers at her local GP practice. She is a known hypertensive and undergoes a medication review. During the consultation you note evidence of fine, dark-coloured hair on her face and arms.

5. A 56-year-old man with a background history of chronic obstructive pulmonary disease (COPD) has been recently started on a new tablet for his blood pressure. He is admitted to the Emergency Department with increasing shortness of breath. He denies any cough or fever.

Answers

Single best answer questions

Q1 d.

Mitral stenosis has several causes including rheumatic fever, systemic lupus erythematosus and rheumatoid arthritis. Symptoms include exertional dyspnoea, orthopnoea and, in severe cases, pulmonary oedema. The murmur is classically heard as a low-pitched rumbling diastolic murmur over the apex. Mitral regurgitation results in a high-pitched blowing murmur over the apex which may radiate to the left axilla. Aortic stenosis results in an ejection systolic murmur in the second right intercostal space that radiates to the carotids. Pulmonary stenosis is associated with a systolic ejection murmur in the left upper sternal border that increases with inspiration. Aortic regurgitation is a diastolic murmur that is high-pitched and loudest at the left sternal border.

Q2 d.

In accordance with NICE guidelines, hypertensive patients aged 55 or over or Afro-Caribbean patients should be commenced on a calcium channel blocker or thiazide diuretic. Those younger than 55 should be commenced on an angiotensin converting enzyme (ACE) inhibitor or an angiotensin II receptor antagonist if an ACE inhibitor is not tolerated.

Q3 b.

From the history and cardiac risk factors the most likely diagnosis is an acute coronary syndrome. Hence an ECG as a first-line investigation is paramount. The other investigations are all of relevance but would not be deemed as the most important in this scenario. Patients presenting with cardiac-sounding chest pain should be ‘TIMI’ (thrombolysis in myocardial infarction) scored to assess their mortality risk. The score comprises the following criteria:

Age > 65 years

> 3 risk factors for coronary artery disease

Known coronary artery disease > 50% stenosis

ASA use in past 7 days

Severe angina

ST changes > 0.5 mm

Positive cardiac marker

Q4 c.

Pericarditis is associated with inflammation of the pericardium. It presents with chest pain which may be sharp or dull and exacerbated during inspiration and when lying flat. Concave ST elevation is diagnostic of the condition. Examination findings may include a pericardial rub which is scratching in character. Causes of pericarditis are numerous and include tuberculosis, systemic lupus erythematosus, rheumatoid arthritis, renal failure, hypothyroidism, streptococcus and coxsackievirus B. The management of pericarditis includes NSAIDs in the main.

Q5 a.

Hypertrophic cardiomyopathy is a genetic autosomal dominant condition associated typically with hypertrophy of the left ventricle and resulting in blood flow obstruction. It can result in sudden cardiac death, dyspnoea, syncope and presyncope. Pulmonary embolism results typically in pleuritic chest pain, shortness of breath and haemoptysis. Significant risk factors include a previous history of venous thromboembolism, recent surgery, oestrogen use, cancer and reduced mobility. Aortic dissection is associated with tearing type chest pain which can radiate to the back. Blood pressure may vary inter-arm in up to 30% of cases. Commotio cordis is sudden cardiac death that occurs following a non-penetrating blow to the chest. Studies have shown that an impact typically over the left ventricle may result in ventricular fibrillation and subsequent death.

Q6 e.

These are the classic ECG findings of Wolff-Parkinson-White syndrome. Treatment of choice includes adenosine or procainamide. Vasovagal syncope presents with dizzy spells, palpitations, nausea and sweating. It is typically cardiac, orthostatic or neurological in nature. First-degree heart block is associated with a prolonged PR interval on the ECG. Atrial fibrillation is associated with an irregular ventricular rate and absent P waves.

Q7 b.

Contraindications from the American College of Cardiology/American Heart Association include:

Myocardial infarction

Unstable angina

Aortic stenosis

Heart failure

Pulmonary embolism

Myocarditis

Aortic dissection

Left main coronary artery stenosis

Electrolyte abnormalities

Hypertrophic cardiomyopathy

Mental or physical impairment

Q8 a.

The ECG is most likely a supraventricular tachycardia (SVT) which is best treated with adenosine. An irregular narrow complex tachycardia is most likely atrial fibrillation which would require a beta-blocker or diltiazem for rate control.

Q9 d.

In accordance with advanced life support (ALS) guidelines a tachycardia with adverse features such as shock, syncope, myocardial ischaemia and heart failure is best treated by a synchronised DC shock. At least three attempts are made, followed by amiodarone intravenously.

Q10 a.

Dressler’s syndrome is a form of pericarditis that is seen following a myocardial infarction. Treatment of choice includes NSAIDs. Pneumonia typically presents with shortness of breath, productive cough and a fever. Cardiac tamponade is associated with chest pain and fatigue. Examination findings include an increased jugular venous pressure, hypotension and diminished heart sounds (Beck’s triad).

Q11 e.

Acute coronary syndrome is treated with aspirin 300 mg, clopidogrel 300 mg, enoxaparin 1 mg/kg and bisoprolol 5 mg. A statin, typically atorvastatin, is also of importance.

Q12 e.

An urgent coronary angiography would be most suitable as it would help to localise cardiac vessel stenosis which would be amenable to stenting. An acute coronary syndrome is a contraindication to exercise treadmill testing. A dobutamine stress echo is utilised when individuals are unable to exercise on a treadmill and require assessment of cardiac function.

Q13 a.

Spironolactone is a potassium-sparing diuretic. Side effects include a high potassium and low sodium. Additional side effects include gastrointestinal bleeding, gynaecomastia and ataxia. Bumetanide and furosemide are loop diuretics and result in a low serum sodium and potassium. Bendroflumethiazide results in hyperuricaemia, hypokalaemia, hypophosphataemia and hypomagnesaemia.

Q14 e.

Risperidone is an antipsychotic that can precipitate long QT syndrome. It presents as syncope and in severe cases cardiac arrest. Sick sinus syndrome is associated with dizziness, syncope and palpitations. An ECG is likely to demonstrate sinus bradycardia with sinus pauses.

Q15 a.

Type I hyperlipoproteinaemia presents with abdominal pain secondary to pancreatitis. The white discoloration of the retina is termed lipemia retinalis. Xanthomas and hepatosplenomegaly are common. The treatment of choice is dietary control. The condition is associated with increased chylomicrons and decreased lipoprotein lipase.

Extended matching questions

Question 1

Q1 e.

Amlodipine is a calcium channel antagonist, commonly associated with ankle swelling. Additional side effects include sweating, a dry mouth, headaches, hot flushes and palpitations.

Q2 h.

Amiodarone commonly causes pulmonary fibrosis. In addition it can lead to corneal microdeposits and a disorder of thyroid function. Patients may complain of seeing a bluish halo, and a blue-grey skin discoloration.

Q3 c.

Ramipril is an ACE inhibitor that can result in renal impairment. A dry cough is common as well as hypoglycaemia, nausea and a yellow discoloration of the skin or eyes.

Q4 d.

Spironolactone is an aldosterone antagonist which results in a low sodium and high potassium. Additional side effects include muscle weakness, bradycardia and breast enlargement commonly in men.

Q5 f.

Bendroflumethiazide is a thiazide diuretic. It can result in hyperuricaemia and subsequently gout. Additional side effects include dizziness and abdominal discomfort.

Question 2

Q1 e.

Worsening heart failure that is not responding to furosemide should be treated with a trial of glyceryl trinitrate (GTN) infusion to help offload the heart as long as the blood pressure remains stable.

Q2 a.

In accordance with NICE guidelines, patients aged 55 or more or black patients of any age should be commenced on a calcium channel blocker or thiazide diuretic. If there is no improvement in blood pressure while on the latter, an ACE inhibitor should be added.

Q3 a.

In accordance with NICE guidelines, patients younger than 55 years of age should be commenced on an ACE inhibitor if hypertensive.

Q4 b.

ACE inhibitors are associated with a dry cough due to inhibition of bradykinin metabolism. An alternative therapy therefore is an angiotensin II receptor antagonist such as candesartan which does not result in a cough.

Q5 c.

In accordance with NICE guidelines, patients with hypertension over the age of 55 or who are of black descent should be commenced on a calcium channel blocker or thiazide diuretic initially. If the patient fails to respond, an ACE inhibitor is added. If there is no response to both an ACE inhibitor and thiazide diuretic then a calcium channel blocker is added.

Question 3

Q1 a.

ACE inhibitors are known to cause a dry cough, renal impairment and angioedema.

Q2 f.

Calcium channel blockers are commonly associated with gum hyperplasia and hypertrophy.

Q3 h.

Hydralazine can induce lupus erythematosus. Additional side effects include diarrhoea, a compensatory tachycardia, headaches and depression.

Q4 c.

Minoxidil is commonly associated with excessive hair growth. It is a potassium channel activator and has been used for the treatment of hypertension. Additional side effects include visual disturbance, chest pain and pseudoacromegaly.

Q5 g.

Beta-blockers are associated with bronchospasm and hence should be avoided in those with COPD and asthma.

2 Dermatology

Single best answer questions

For each question below, what is the most likely answer?

Select ONE option only from the answers supplied.

1. You are an F2 doctor and have been called to the Emergency Department to see a 4-year-old girl with a diffuse rash all over her body; the rash is erythematous and non-blanching with discrete lesions. She has a high fever and appears drowsy. What is the most likely diagnosis?

a) Meningococcal infection

b) Henoch–Schönlein purpura

c) Varicella zoster

d) Herpes simplex

e) Rubella

2. You are working in a rheumatology post and you are asked to see a 42-year-old woman with rheumatoid arthritis. Which one of these conditions is commonly associated with rheumatoid arthritis?

a) Violacious rash

b) Sclerodactyly

c) Butterfly rash

d) Raynaud syndrome

e) Erythema nodosum

3. A 37-year-old woman is diagnosed with sarcoidosis. What skin manifestation might you expect to see?

a) Erythema marginatum

b) Erythema chronicum migrans

c) Erythema multiforme

d) Erythema nodosum

4. A 72-year-old man presents with shingles (Herpes zoster) in the Emergency Department. When are antivirals recommended?

a) Within 2 weeks

b) Within 72 hours

c) Within 10 days

d) Within 48 hours

e) Within 24 hours

5. You are an F2 doctor in general practice, and are asked to see a 15-year-old boy with mild acne. What is the first-line treatment option?

a) Oral isotretinoin

b) Topical isotretinoin

c) Oral cyproterone acetate

d) Oral tetracycline

e) Topical benzoyl peroxide + clindamycin

6. You are asked to see an 18-year-old girl with genital warts in the genitourinary medicine (GUM) clinic. What are the two most common treatment options?

a) Imiquimod cream

b) Cryotherapy with/without podophyllin

c) Intralesional interferon

d) Topical steroids

e) Griseofulvin

7. A 22-year-old man presents with a round, scaly, itchy lesion with an inflamed edge and central sparing on his torso. What is the most likely diagnosis?

a) Pityriasis rosea

b) Pityriasis alba

c) Pityriasis versicolor

d) Tinea

e) Psoriasis

8. An 18-year-old girl presents with a widespread erythematous discrete blanching rash over her torso and back, with a ‘christmas-tree distribution’. What is the most likely diagnosis?

a) Pityriasis alba

b) Pityriasis rosea

c) Pityriasis versicolor

d) Pityriasis rubra pilaris

e) Pityriasis lichenoides

9. Which one of the following conditions does NOT cause generalised itching?

a) Hyper/hypothyroidism

b) Chronic renal failure

c) Chronic liver disease

d) Chronic heart failure

e) Lymphoma

10. Which of these is NOT premalignant?

a) Lentigo maligna

b) Halo naevus

c) Actinic keratosis

d) Bowen disease

11. Which one of these conditions is NOT associated with systemic lupus erythematosus?

a) Butterfly rash

b) Discoid rash

c) Photosensitivity

d) Oral ulcers

e) Lupus pernio

12. Which of these is NOT associated with sarcoidosis?

a) Erythema nodosum

b) Lupus pernio

c) Subcutaneous nodules

d) Conjunctivitis

e) Erythema migrans

13. Which two of the following causes scarring alopecia?

a) Iron/zinc deficiency

b) Childbirth

c) Lichen planus

d) Alopecia areata

e) Discoid lupus erythematosus

14. Which one of the following is NOT a common cause of urticaria?

a) Shellfish

b) Strawberries

c) Rice

d) Eggs

e) Chocolates

15. Which one of the following is NOT a common skin manifestation of HIV?

a) Molluscum contagiosum

b) Varicella zoster

c) Scabies

d) Pityriasis rosea

e) Oral hairy leukoplakia

Extended matching questions

Question 1

a) Necrobiosis lipoidica

b) Erythema nodosum

c) Target lesions

d) Dermatitis herpetiformis

e) Butterfly rash

f) Lupus pernio

g) Sclerodactyly

h) Alopecia

i) Heliotrope rash

j) Acanthosis nigricans

k) Pyoderma gangrenosum

l) Angular chelitis

m) Folliculitis

n) Neurofibroma

1. Which one of the above conditions is most likely to present in a 21-year-old female with insulin-dependent diabetes?

2. Which two skin manifestations are found in patients with systemic lupus erythematosus?

3. A 64-year-old man is diagnosed with advanced stomach cancer. Which one of these skin manifestations could his condition most likely to be associated with?

Question 2

a) Basal cell carcinoma (BCC)

b) Squamous cell carcinoma (SCC)

c) Bowen disease

d) Actinic keratoses

e) Malignant melanoma

f) Mycosis fungoides

g) Paget disease

h) Pyoderma gangrenosum

i) Lichen planus

j) Hypertrichosis lanuginosa

k) Telangiectasia

l) Lentigo maligna

m) Granuloma annulare

1. Which one of the above conditions follows a benign, self-limiting course?

2. Which one of these conditions requires urgent referral to a breast surgeon?

3. Which two of the above conditions would need urgent referral to a dermatologist?

Question 3

a) Tar

b) Vitamin D analogues (calcipotriol)

c) Hydrocortisone 1%

d) Betamethasone

e) Fusidic acid

f) Methotrexate

g) Phototherapy

h) Infliximab

i) Emollients

j) Tacrolimus

k) Terbinafine

l) Selenium sulfide shampoo

m) Imidazole cream

n) Education

o) Metronidazole gel

1.