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 MRCGP MCQ Discusion-2

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PostSubject: MRCGP MCQ Discusion-2   Sun May 26, 2013 5:41 am

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We will continue our medicine examination and learning of MRCGP and we hope that you will start sharing with us
MRCGP is easy to pass but you must know how you can pass MRCGP.
MCQs of MRCGP is the only way to pass.

Question -1
A76-year-old woman with a history of atrial fibrillation presents with abdominal pain and bloody diarrhoea. On examination her temperature is
37.8ºC, pulse 102 / min and respiratory rate 30 / min. Her abdomen is
tender with generalised guarding. Blood tests reveal the following:
Hb10.9 g/dl
MCV76 fl
Plt348 * 109/l
WBC23.4 * 109/l
Na+141 mmol/l
K+5.0 mmol/l
Bicarbonate14 mmol/l
Urea8.0 mmol/l
Creatinine118 µmol/l
What is the most likely diagnosis?
A-Diverticulitisi
B-
Mesenteric ischaemiai
C-
Campylobacter infection
D-Ruptured abdominal aortic aneurysm
E-Ulcerative colitis

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PostSubject: Re: MRCGP MCQ Discusion-2   Sun May 26, 2013 5:44 am

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Answer
B-Mesenteric ischaemia
The low bicarbonate points to a metabolic acidosis - highly suggestive of mesenteric ischaemia.

Mesenteric ischaemia:
Mesenteric ischaemia is primarily caused by arterial embolism resulting
in infarction of the colon. It is more likely to occur in areas such as
the splenic flexure that are located at the borders of the territory
supplied by the superior and inferior mesenteric arteries.

Predisposing factors

  • increasing age
  • atrial fibrillation
  • other causes of emboli: endocarditis
  • cardiovascular disease risk factors: smoking, hypertension, diabetes

Features

  • abdominal pain
  • rectal bleeding
  • diarrhoea
  • fever
  • bloods typically show an elevated WBC associated with acidosis

Management

  • supportive care
  • laparotomy and bowel resection
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PostSubject: Re: MRCGP MCQ Discusion-2   Sun May 26, 2013 5:46 am

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Question -2
A 31-year-old female is admitted to the Emergency Department following a paracetamol overdose. The paracetamol level comes back as elevated but the doctor is unsure which treatment line to use. Which one of the following features in the medical history would classify the patient as high risk?
A-Hypothyroidism
B-Anorexia nervosa
C-Previous paracetamol overdosei
D-
Combined overdose with codeine
E-
Long-term sodium valproate use

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PostSubject: Re: MRCGP MCQ Discusion-2   Sun May 26, 2013 5:48 am

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Answer:
B-Anorexia nervosa
Paracetamol overdose - high risk if chronic alcohol, HIV, anorexia or P450 inducers

Paracetamol overdose: risk factors:

The following groups of patients are at an increased risk of developing hepatotoxicity following a paracetamol overdose:

  • chronic alcohol excess
  • patients on P450 enzyme inducers (rifampicin, phenytoin, carbamazepine)
  • anorexia nervosa: decreased glutathione stores
  • HIV
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PostSubject: Re: MRCGP MCQ Discusion-2   Sun May 26, 2013 5:52 am

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Question -3
Which one of the following is true regarding bacterial exotoxins?i
A-
They are mainly produced by Gram positive bacteria
B-Cholera toxin inhibits cAMP release in intestinal cells
C-Diphtheria toxin necrosis is limited to the pharynx, nasopharynx and tonsils
D-Staph. aureus exotoxins are not known to cause gastroenteritis
E-'Lockjaw' seen in tetanus is secondary to blockade of the neuromuscular junction by Botulinus toxin

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PostSubject: Re: MRCGP MCQ Discusion-2   Sun May 26, 2013 5:55 am

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Answer:
A-They are mainly produced by Gram positive bacteria
Exotoxins:
Exotoxins are generally released by Gram positive bacteria with the notable exceptions of Vibrio cholerae and some strains of E. coli

Diphtheria toxin commonly causes a 'diphtheric membrane' on tonsils caused by necrotic mucosal cells. Systemic distribution may produce necrosis of
myocardial, neural and renal tissue.

Staph. aureus exotoxins lead to acute gastroenteritis, toxic shock syndrome and Staphylococcal scalded skin syndrome

Lockjaw is caused by Clostridium tetani neurotoxin (tetanospasmin)

Cholera toxin causes activation of adenylate cyclase leading to increases in cAMP levels, which in turn leads to increased chloride secretion.

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PostSubject: Re: MRCGP MCQ Discusion-2   Sun May 26, 2013 5:58 am

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Question -4
A 44-year-old man is diagnosed with a duodenal ulcer. CLO testing performed during the gastroscopy is positive for Helicobacter pylori. What is the most appropriate management to eradicate Helicobacter pylori?
A-
Lansoprazole + clindamycin + metronidazole
B-
Lansoprazole + amoxicillin + clindamycin
C-
Lansoprazole + amoxicillin + clarithromycin
D-Omeprazole + amoxicillin + clindamycin
E-Omeprazole + penicillin + metronidazole

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PostSubject: Re: MRCGP MCQ Discusion-2   Sun May 26, 2013 6:02 am

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Answer:
C-Lansoprazole + amoxicillin + clarithromycin
H. pylori eradication:


  • PPI + amoxicillin + clarithromycin, or
  • PPI + metronidazole + clarithromycin
The BNF recommends a regimen containing amoxicillin and clarithromycin as first-line therapy.


Helicobacter pylori:

Helicobacter pylori is a Gram negative bacteria associated with a variety of gastrointestinal problems, principally peptic ulcer disease Associations


  • peptic ulcer disease (95% of duodenal ulcers, 75% of gastric ulcers)
  • gastric cancer
  • B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients)
  • atrophic gastritis

The role of H pylori in Gastro-oesophageal reflux disease (GORD) is unclear
- there is currently no role in GORD for the eradication of H pylori

Management - eradication may be achieved with a 7 day course of

  • a proton pump inhibitor + amoxicillin + clarithromycin, or
  • a proton pump inhibitor + metronidazole + clarithromycin
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PostSubject: Re: MRCGP MCQ Discusion-2   Mon Jun 17, 2013 5:06 pm

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Question -5

A 33-year-old woman is prescribed varenicline to help her quit smoking. What is the mechanism of action of varenicline?
A-Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
B-Dopamine agonist
C-Dopamine antagonist
D-Selective serotonin reuptake inhibitor
E-Nicotinic receptor partial agonist

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PostSubject: Re: MRCGP MCQ Discusion-2   Mon Jun 17, 2013 5:08 pm

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The Answer
E-Nicotinic receptor partial agonist

Smoking cessation

NICE released guidance in 2008 on the management of smoking cessation. General points include:

  • patients should be offered nicotine replacement therapy (NRT), varenicline or bupropion - NICE state that clinicians should not favour one medication over another
  • NRT, varenicline or bupropion should normally be prescribed as part of a commitment to stop smoking on or before a particular date (target stop date)
  • prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date. Normally, this will be after 2 weeks of NRT therapy, and 3-4 weeks for varenicline and bupropion, to allow for the different methods of administration and mode of action. Further prescriptions should be given only to people who have demonstrated that their quit attempt is continuing
  • if unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months unless special circumstances have intervened
  • do not offer NRT, varenicline or bupropion in any combination


Nicotine replacement therapy

  • adverse effects include nausea & vomiting, headaches and flu-like symptoms
  • NICE recommend offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past

Varenicline

  • a nicotinic receptor partial agonist
  • should be started 1 week before the patients target date to stop
  • the recommended course of treatment is 12 weeks (but patients should be monitored regularly and treatment only continued if not smoking)
  • has been shown in studies to be more effective than bupropion
  • nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams
  • varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline
  • contraindicated in pregnancy and breast feeding


Bupropion

  • a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
  • should be started 1 to 2 weeks before the patients target date to stop
  • small risk of seizures (1 in 1,000)
  • contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication


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PostSubject: Re: MRCGP MCQ Discusion-2   Mon Jun 17, 2013 5:15 pm

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Question -6

Which of the following is not known to cause acute pancreatitis?
A-Hypocalcaemia
B-Hypothermia
C-Mumps
D-Hypertriglyceridaemia
E-Steroids

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PostSubject: Re: MRCGP MCQ Discusion-2   Mon Jun 17, 2013 5:20 pm

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Answer:
A-Hypocalcaemia

Hypercalcaemia, not hypocalcaemia is a recognised cause of acute pancreatitis

Acute pancreatitis: causes

The vast majority of cases in the UK are caused by gallstones and alcohol

Popular mnemonic is GET SMASHED

  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps (other viruses include Coxsackie B)
  • Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
  • Scorpion venom
  • Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
  • ERCP
  • Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)


*pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazin

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PostSubject: Re: MRCGP MCQ Discusion-2   Mon Jun 17, 2013 5:38 pm

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Question -7
What is the most appropriate time to take blood samples for therapeutic monitoring of digoxin levels?
A-At any time
B-At least 6 hours after last dose
C-At least 2 hours after last dose
D-Immediately after last dose
E-
At least 4 hours after last dose

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PostSubject: Re: MRCGP MCQ Discusion-2   Mon Jun 17, 2013 5:39 pm

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The answer:
B-At least 6 hours after last dose


Lithium

  • range = 0.4 - 1.0 mmol/l
  • take 12 hrs post-dose


Ciclosporin

  • trough levels immediately before dose


Digoxin

  • at least 6 hrs post-dose


Phenytoin

  • trough levels immediately before dose


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PostSubject: Re: MRCGP MCQ Discusion-2   Sat Jun 29, 2013 10:14 am

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Question -8
A 54-year-old female presents with fatigue and xerostomia. Bloods tests reveal the following:
Hb   13.9 g/dl   WBC   6.1 *109/l     Platelets     246 *109/l   Bilirubin   33 µmol/l   ALP   292 u/l   ALT   47 u/l
What is the most likely diagnosis?  
A. Systemic lupus erythematous
B. Infectious mononucleosis
C. Primary biliary cirrhosis
D. Autoimmune hepatitis
E. Sjogren's syndrome

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PostSubject: Re: MRCGP MCQ Discusion-2   Sat Jun 29, 2013 10:18 am

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Primary biliary cirrhosis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
The dry mouth is this patient is due to sicca syndrome, which occurs in 70% of cases of primary biliary cirrhosis. The cholestatic liver function tests point towards primary biliary cirrhosis rather than Sjogren's syndrome
Primary biliary cirrhosis is chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis, which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman
Clinical features
early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
cholestatic jaundice
hyperpigmentation, especially over pressure points
xanthelasmas, xanthomata
also: clubbing, hepatosplenomegaly
late: may progress to liver failure
Complications
malabsorption: osteomalacia, coagulopathy
sicca syndrome occurs in 70% of cases
portal hypertension: ascites, variceal haemorrhage
hepatocellular cancer (20-fold increased risk)


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