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 MRCGP MCQ Discusion-1

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PostSubject: MRCGP MCQ Discusion-1   Mon Apr 22, 2013 1:13 pm

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In this topic we will introduce some MRCGP MCQs and correct answer for discusion from all,so let us start by this Question:
You
are giving dietary advice to an obese patient who has been diagnosed with type 2
diabetes mellitus. Following recent NICE guidelines, which one of the following
should not be encouraged?
ia
A.A
Food products specifically targeted at diabeticsia

B.A
Initial weight loss of  5-10%ia

C.A
Limited substitution of sucrose-containing foods for other carbohydratesia

D.A
High-fibre, low glycaemic index carbohydratesia

E.A
Low-fat dairy productsia
what the correct answer? why?
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PostSubject: Re: MRCGP MCQ Discusion-1   Mon Apr 22, 2013 1:17 pm

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The correct answer:
A:Food products
specifically targeted at diabetics

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PostSubject: Re: MRCGP MCQ Discusion-1   Mon Apr 22, 2013 1:20 pm

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NICE
suggest that the consumption of foods marketed specifically at diabetics should
be discouraged.


Diabetes mellitus: management
of type 2


NICE
updated its guidance on the management of type 2 diabetes mellitus (T2DM) in
2009. Key points are listed below:

Dietary advice

  • encourage
    high fibre, low glycaemic index sources of carbohydrates
  • include low-fat dairy products and oily fish
  • control the intake of foods containing saturated fats and trans fatty acids
  • limited substitution of sucrose-containing foods for other carbohydrates is allowable,
    but care should be taken to avoid excess energy intake
  • discourage use of foods marketed specifically at people with diabetes
  • initial target weight loss in an overweight person is 5-10%

HbA1c

  • the general target for patients is 6.5%. HbA1c levels below 6.5% should not be pursued
  • however, individual targets should be agreed with patients to encourage motivation
  • HbA1c should be checked every 2-6 months until stable, then 6 monthly

Blood
pressure


  • target
    is < 140/80 mmHg (or < 130/80 mmHg if end-organ damage is present)
  • ACE inhibitors are first-line

The NICE treatment algorithm has become much more complicated following the introduction of new therapies for type 2 diabetes. We suggest reviewing this using the link provided. Below is a very selected group of points from the algorithm:

  • NICE still suggest a trial of lifestyle interventions first*
  • usually metformin is first-line, followed by a sulfonylurea if the HbA1c remains > 6.5%
  • if the patient is at risk from hypoglycaemia (or the consequences of) then a DPP-4 inhibitor or thiazolidinedione should be considered rather than a
    sulfonylurea
  • meglitinides (insulin secretagogues) should be considered for patients with an erratic lifestyle
  • if HbA1c > 7.5% then consider human insulin
  • metformin treatment should be continued after starting insulin
  • exenatide should be used only when insulin would otherwise be started, obesity is a
    problem (BMI > 35 kg/m^2) and the need for high dose insulin is likely.
    Continue only if beneficial response occurs and is maintained (> 1.0 percentage point HbA1c reduction in 6 months and weight loss > 5% at 1 year)

Starting
insulin

  • usually commenced if HbA1c > 7.5%
  • NICE recommend starting with human NPH insulin (isophane, intermediate acting) taken
    at bed-time or twice daily according to need

Other
risk factor modification

  • aspirin
    to all patients > 50 years and to younger patients with other significant risk factors
  • the management of blood lipids in T2DM has changed slightly. Previously all patients
    with T2DM > 40-years-old were prescribed statins. Now patients > 40-years-old who have no obvious cardiovascular risk (e.g. Non-smoker, not
    obese, normotensive etc) and have a cardiovascular risk < 20%/10 years do not need to be given a statin. We suggest reviewing the NICE T2DM guidelines for
    further information.
  • if serum cholesterol target not reach consider increasing simvastatin to 80mg on
  • if target still not reached consider using a more effective statin (e.g. Atorvastatin) or adding ezetimibe
  • target total cholesterol is < 4.0 mmol/l
  • if serum triglyceride levels are > 4.5 mmol/l prescribe
    fenofibrate

*many local protocols now recommend starting metformin upon diagnosis

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PostSubject: Re: MRCGP MCQ Discusion-1   Mon Apr 22, 2013 1:22 pm

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PostSubject: Re: MRCGP MCQ Discusion-1   Mon Apr 22, 2013 1:27 pm

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correct answer:
D.AClopidogrel
NB:
sqweqwesf erwrewfsdfs adasd dhe
Induction usually
requires prolonged exposure to the inducing drug, as opposed to P450 inhibitors,
where effects are often seen rapidly

Inducers of the P450 system
include

  • antiepileptics: phenytoin, carbamazepine
  • barbiturates: phenobarbitone
  • rifampicin
  • St John's Wort
  • chronic alcohol intake
  • griseofulvin
  • smoking (affects CYP1A2, reason why smokers require more
    aminophylline)
Inhibitors of the P450 system include

  • antibiotics: ciprofloxacin, erythromycin
  • isoniazid
  • cimetidine, omeprazole
  • amiodarone
  • allopurinol
  • imidazoles: ketoconazole, fluconazole
  • SSRIs: fluoxetine, sertraline
  • ritonavir
  • sodium valproate
  • acute alcohol intake
  • quinupristin

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PostSubject: Re: MRCGP MCQ Discusion-1   Tue Apr 23, 2013 3:01 am

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Q3:
A 64-year-old woman with metastatic breast cancer is brought in by her husband. Over the past two days she has developed increasingly severe back pain. Her husband reports that her legs are weak and she is having difficulty walking. On examination she has reduced power in both legs and increased tone associated with brisk knee and ankle reflexes. There is some sensory loss in the lower limbs and feet but perianal sensation
is normal.
What is the most likely diagnosis?ia
A:Spinal cord compression at T10
B: Cauda equina syndrome
C:
Guillain Barre syndrome
D:
Hypercalcaemiaia
E:
Paraneoplastic peripheral neuropathy

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PostSubject: Re: MRCGP MCQ Discusion-1   Tue Apr 23, 2013 3:05 am

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Correct Answer:
Spinal cord compression at T10i

why?

The upper motor neuron signs point towards a diagnosis of spinal cord compression above L1, rather than cauda equina syndrome.
=================================
Spinal cord compression

Spinal cord compression is an oncological emergency and affects up to
5% of cancer patients. Extradural compression accounts for the marjority of cases, usually due to vertebral body metastases. It is more common in patients with lung, breast and prostate cancer

Features:

  • back pain - the earliest and most common symptom - may be worse on lying down and coughing
  • lower limb weakness
  • sensory changes: sensory loss and numbness
  • neurological
    signs depend on the level of the lesion. Lesions above L1 usually
    result in upper motor neuron signs in the legs and a sensory level.
    Lesions below L1 usually cause lower motor neuron signs in the legs and
    perianal numbness. Tendon reflexes tend to be increased below the level
    of the lesion and absent at the level of the lesion.
Management

  • high-dose oral dexamethasone
  • urgent oncological assessment for consideration of radiotherapy or surgery

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PostSubject: Re: MRCGP MCQ Discusion-1   Tue Apr 23, 2013 9:20 am

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Thanks john
Regards

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PostSubject: Re: MRCGP MCQ Discusion-1   Wed Apr 24, 2013 10:22 am

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Q4:
Which one of the following prescriptions is contraindicated in pregnancy?

A.Methyldopa for hypertension
B.Topical clindamycin for bacterial vaginosis
C.Doxycycline for malarial prophylaxisia
D.Metoclopramide for vomiting
E.Prednisolone for an asthma exacerbation




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PostSubject: Re: MRCGP MCQ Discusion-1   Wed Apr 24, 2013 10:25 am

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Correct Answer:
C.Doxycycline for malarial prophylaxis

===========================
All tetracyclines should be avoided in pregnancy.

It should be noted
that the above prescriptions are not necessarily the recommended first-line
treatments

Very few drugs are known
to be completely safe in pregnancy. The list below largely comprises of those
known to be harmful. Some countries have developed a grading system

Antibiotics

  • tetracyclines
  • aminoglycosides
  • sulphonamides and trimethoprim
  • quinolones: the BNF advises to avoid due to arthropathy in some animal
    studies

Other drugs

  • ACE inhibitors, angiotensin II receptor antagonists
  • statins
  • warfarin
  • sulfonylureas
  • retinoids (including topical)
  • cytotoxic agents

The majority of antiepileptics including
valproate, carbamazepine and phenytoin are known to be potentially harmful. The
decision to stop such treatments however is difficult as uncontrolled epilepsy
is also a risk

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PostSubject: Re: MRCGP MCQ Discusion-1   Sun Apr 28, 2013 12:15 pm

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Q5:
A 57-year-old female presents due to problems with urine leakage over the past
six months. She describes frequent voiding and not always being able to get to
the toilet in time. She denies losing urine when coughing or sneezing. What is
the most appropriate initial treatment?ia
A.Trial of oxybutynin
B.Bladder retraining
C.Regular toileting
D.Topical oestrogen cream
E.Pelvic floor muscle training

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PostSubject: Re: MRCGP MCQ Discusion-1   Sun Apr 28, 2013 12:17 pm

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Correct Answer:
B.Bladder retraining
Urinary incontinence - first-line treatment:

  • urge incontinence: bladder retraining
  • stress incontinence: pelvic floor muscle training
sqweqwesf erwrewfsdfs adasd dhe
Urinary incontinence
(UI) is a common problem, affecting around 4-5% of the UK population. It is more
common in elderly females. NICE released guidance on the management of UI in
2006

Causes

  • overactive bladder (OAB)/urge incontinence: due to detrusor over activity
  • stress incontinence: leaking small amounts when coughing or laughing
  • mixed incontinence: both urge and stress
  • overflow incontinence: due to bladder outlet obstruction, e.g. due to
    prostate enlargement

Initial investigation

  • bladder diaries should be completed for a minimum of 3 days
  • urine dipstick and culture

Management depends on whether urge
or stress UI is the predominant picture. If urge incontinence is
predominant:

  • bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually
    increase the intervals between voiding)
  • bladder stabilising drugs: immediate release oxybutynin is first-line
  • surgical management: e.g. sacral nerve stimulation

If stress
incontinence is predominant:

  • pelvic floor muscle training (for a minimum of 3 months)
  • surgical procedures: e.g. retropubic mid-urethral tape procedures

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PostSubject: Re: MRCGP MCQ Discusion-1   Sun Apr 28, 2013 12:35 pm

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Q6:
A 5-year-old girl is brought to surgery due to a high temperature. On
examination she is noted to have an evolving purpuric rash. What is the most
appropriate course of action?
A.
IM benzylpenicillin 150mg
B.IM benzylpenicillin 300mg
C.IM benzylpenicillin 600mg
D.IM benzylpenicillin 900mg
E.IM benzylpenicillin 1200mg

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PostSubject: Re: MRCGP MCQ Discusion-1   Sun Apr 28, 2013 12:36 pm

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Correct Answer:
C.IM benzylpenicillin 600mg
The RCGP have previously fed back that doctors are expected to be familiar with
emergency drug doses, and have mentioned suspected meningococcal septicaemia in
particular
The current BNF should always be consulted prior to prescribing drugs you are
unfamiliar with, the following is just a guide

IM benzylpenicillin for
suspected meningococcal septicaemia in the community


< 1 year300 mg
1 - 10 years600 mg
> 10 years1200 mg

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PostSubject: Re: MRCGP MCQ Discusion-1   Fri May 03, 2013 3:56 am

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Q7:
A 17-year-old female presents requesting advice as she forgot to take her
Microgynon 30 pills on a weekend away. She is normally very good at remembering
her pill but has missed days 10, 11 and 12 of her packet and it is now day 13.
Although she took the day 13 pill this morning she is concerned she may become
pregnant and she had unprotected sexual intercourse whilst away. What is the
most appropriate management?
A.
No action needed
B.No action needed but omit pill break at end of pack

C.Offer emergency contraception - hormonal D.Offer emergency contraception - intrauterine device
E.
No action needed but use condoms for next 7 days


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PostSubject: Re: MRCGP MCQ Discusion-1   Fri May 03, 2013 4:03 am

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Correct Answet:
No action needed but use condoms for next 7 days
Tough question. As the patient had taken the pill for 7 days in a row previously
she is protected for the next 7 days. The FFPRHC guidelines state: "after seven
consecutive pills have been taken there is no need for emergency contraception"
- please consult the link. The guidelines also recommend in this situation using
condoms for the next 7 days

Combined oral contraceptive pill: missed pill :
The advice from the Faculty of Family Planning and Reproductive Health Care has
changed over recent years. The following recommendations are now made for women
taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of
ethinylestradiol

If 1 or 2 pills missed (at any time in the cycle)

  • take a pill as soon as possible and then continue taking pills daily, one
    each day
  • no additional contraceptive protection needed

If 3 or more
pills missed


  • take a pill as soon as possible and then continue taking pills daily, one
    each day
  • the women should use condoms or abstain from sex until she has taken pills
    for 7 days in a row
  • if pills are missed in week 1 (Days 1-7): emergency contraception should be
    considered if she had unprotected sex in the pill-free interval or in week 1
  • if pills are missed in week 2 (Days 8-14): after seven consecutive days of
    taking the COC there is no need for emergency contraception*
  • if pills are missed in week 3 (Days 15-21): she should finish the pills in
    her current pack and start a new pack the next day; thus omitting the pill free
    interval
*theoretically women would be protected if they took the
COC in a pattern of 7 days on, 7 days off

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PostSubject: Re: MRCGP MCQ Discusion-1   Fri May 03, 2013 4:07 am

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Q8:
A pregnant woman presents for review. She is 24 weeks pregnant. What would be
the expected symphysis-fundal height?
A.
13 - 15 cm
B.
15 - 17 cm
C.
17 - 19 cm
D.
18 - 22 cm
E.
22 - 26 cm

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PostSubject: Re: MRCGP MCQ Discusion-1   Fri May 03, 2013 4:09 am

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Correct Answer:
E.22 - 26 cm
After 20 weeks, symphysis-fundal height in cm = gestation in weeks

The symphysis-fundal height (SFH) is measured from the top of the pubic bone to
the top of the uterus in centimetres
It should match the gestational age
in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH =
22 to 26 cm


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PostSubject: Re: MRCGP MCQ Discusion-1   Fri May 03, 2013 4:20 am

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Q9:
You are counselling a 26-year-old man who has recently had a positive HIV test.
His most recent CD4 count is 650 cells/mm^3. Which one of the following
vaccinations is contraindicated?
A.
Oral poliomyelitis
B.Yellow fever
C.Pneumococcus
D.Parenteral poliomyelitis
E.Measles, Mumps, Rubella

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PostSubject: Re: MRCGP MCQ Discusion-1   Fri May 03, 2013 4:26 am

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Correct Answer:
A.Oral poliomyelitis
HIV: immunisation :
The Department of Health 'Greenbook' on immunisation defers to the British HIV
Association for guidelines relating to immunisation of HIV-infected adults.
A:Vaccines that can be used in all HIV-infected adults:

Hepatitis A
Hepatitis B
Haemophilus influenzae B (Hib)

Influenza-parenteral
Japanese encephalitis
Meningococcus-MenC

Meningococcus-ACWY I
Pneumococcus-PPV23
Poliomyelitis-parenteral
(IPV)
Rabies
Tetanus-Diphtheria (Td)
B:
Vaccines that can be used if CD4 > 200
Measles, Mumps, Rubella (MMR)
Varicella
Yellow Fever
D:Contraindicated in HIV-infected adults

Cholera CVD103-HgR
Influenza-intranasal
Poliomyelitis-oral
(OPV)
Tuberculosis (BCG)

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PostSubject: Re: MRCGP MCQ Discusion-1   Fri May 03, 2013 4:34 am

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Q10:
A 60-year-old man who is currently receiving chemotherapy for non-small cell
lung cancer presents for review. He is currently being treated with oral calcium
supplements as hypocalcaemia was detected during a recent admission. Bloods
taken two days ago reveal the following:

Calcium2.01 mmol/l
Which one of the
following tests may help determine why his calcium level remains low despite
calcium supplementation?
A.Vitamin D
B.Parathyroid hormone
C.Phosphate
D.Alkaline phosphatase
E.Magnesium

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PostSubject: Re: MRCGP MCQ Discusion-1   Fri May 03, 2013 4:38 am

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Correct Answer:
E.Magnesium

Cisplatin, often used in the management of non-small cell lung cancer, is a well
known cause of magnesium deficiency. Without first correcting magnesium levels
it is difficult to reverse hypocalcaemia

sqweqwesf erwrewfsdfs adasd dhe
The clinical history
combined with parathyroid hormone levels will reveal the cause of hypocalcaemia
in the majority of cases

Causes

  • vitamin D deficiency (osteomalacia)
  • chronic renal failure
  • hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
  • pseudohypoparathyroidism (target cells insensitive to PTH)
  • rhabdomyolysis (initial stages)
  • magnesium deficiency (due to end organ PTH resistance)
Acute
pancreatitis may also cause
hypocalcaemia. Contamination of blood samples with
EDTA may also give falsely low calcium levels

Management

  • acute management of severe hypocalcaemia is with intravenous replacement.
    The preferred method is with intravenous calcium gluconate, 10ml of 10% solution
    over 10 minutes
  • intravenous calcium chloride is more likely to cause local irritation
  • ECG monitoring is recommended
  • further management depends on the underlying cause

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