Télécharge MRCGP PAST QUESTIONS et plus Dissertation au format PDF de Sciences médico-sociales (SMS) sur Docsity uniquement!
Question 1 of 117 Next A 28-year-old woman is diagnosed with constipation predominant irritable bowel syndrome. She occasionally experiences spasms of pain in the left iliac fossa. Which one of the following is LEAST likely to help her symptoms? A. Mebeverine B. Ispaghula C. Methylcellulose D. Sterculia E. Lactulose Next question NICE recommend avoiding lactulose in the management of IBS Irritable bowel syndrome: management The management of irritable bowel syndrome (IBS) is often difficult and varies considerably between patients. NICE issued guidelines in 2008 First-line pharmacological treatment - according to predominant symptom pain: antispasmodic agents constipation: laxatives but avoid lactulose diarrhoea: loperamide is first-line Second-line pharmacological treatment low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
Other management options psychological interventions - if symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory IBS), consider referring for cognitive behavioural therapy, hypnotherapy or psychological therapy complementary and alternative medicines: 'do not encourage use of acupuncture or reflexology for the treatment of IBS' General dietary advice have regular meals and take time to eat avoid missing meals or leaving long gaps between eating drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas restrict tea and coffee to 3 cups per day reduce intake of alcohol and fizzy drinks consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice) reduce intake of 'resistant starch' often found in processed foods limit fresh fruit to 3 portions per day for diarrhoea, avoid sorbitol for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day). Question 2 of 117 Next You are asked to review a 78-year-old woman with a non-healing leg ulcer by the practice nurse. You notice she is very thin. What is the most appropriate tool to screen for malnutrition? A. GPMS B. MN- 10 C. MUST
Question 3 of 117 Next A 35-year-old man who is usually fit and well presents to his GP with a 2 month history of indigestion. His weight is stable and there is no history of dysphagia. Examination of the abdomen is unremarkable. Of the following options, what is the most suitable initial management? A. Urea breath testing and non-urgent referral for endoscopy B. H pylori eradication therapy and full-dose proton pump inhibitor for three months C. Full-dose Proton pump inhibitor and immediate referral for endoscopy D. Three month course of a standard-dose proton pump inhibitor E. One month course of a full-dose proton pump inhibitor Next question This question highlights the NICE guidelines for the management of dyspepsia. There is no evidence currently to suggest whether a one month course of a PPI or 'test and treat' strategy should be adopted first line. Many clinicians prefer to test for H pylori first as this cannot be done within 2 weeks of acid-suppression therapy, as false-negative results may occur Given the options available, only the answer is in line with current NICE guidelines Dyspepsia In 2014 NICE updated their guidelines for the management of dyspepsia. These take into account the age of the patient (whether younger or older than 55 years) and the presence or absence of 'alarm signs': chronic gastrointestinal bleeding progressive unintentional weight loss progressive difficulty swallowing persistent vomiting iron deficiency anaemia epigastric mass suspicious barium meal
Deciding whether urgent referral for endoscopy is needed Urgent referral (within 2 weeks) is indicated for patients with any alarm signs irrespective of age Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs is not necessary, however Patients aged 55 years and over should be referred urgently for endoscopy if dyspepsia symptoms are: recent in onset rather than recurrent and unexplained (e.g. New symptoms which cannot be explained by precipitants such as NSAIDs) and persistent: continuing beyond a period that would normally be associated with self-limiting problems (e.g. Up to four to six weeks, depending on the severity of signs and symptoms) Managing patients who do not meet referral criteria ('undiagnosed dyspepsia') This can be summarised at a step-wise approach 1. Review medications for possible causes of dyspepsia 2. Lifestyle advice 3. Trial of full-dose PPI for one month* 4. 'Test and treat' using carbon-13 urea breath test *it is unclear from studies whether a trial of a PPI or a 'test and treat' should be used first 1 / 3 Question 4-6 of 117 Next Theme: Hepatobiliary disease and related disorders A. Ascending cholangitis B. Duodenal ulcer C. Biliary colic
Hepatobiliary disease and related disorders The table below gives characteristic exam question features for conditions causing hepatobiliary disease and related disorders: Viral hepatitis Common symptoms^ include: nausea and vomiting, anorexia myalgia lethargy right upper quadrant (RUQ) pain Questions may point to risk factors such as foreign travel or intravenous drug use. Congestive hepatomegaly The liver only usually causes pain if stretched. One common way this can occur is as a consequence of congestive heart failure. In severe cases cirrhosis may occur. Biliary colic RUQ pain, intermittent, usually begins abruptly and subsides gradually. Attacks often occur after eating. Nausea is common. It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation. Acute cholecystitis Pain similar to biliary colic but more severe and persistent. The pain may radiate to the back or right shoulder. The patient may be pyrexial and Murphy's sign positive (arrest of inspiration on palpation of the RUQ) Ascending cholangitis An infection of the bile ducts commonly secondary to gallstones. Classically presents with a triad of: fever (rigors are common) RUQ pain jaundice Gallstone ileus This describes small bowel obstruction secondary to an impacted gallstone. It may develop if a fistula forms between a gangrenous gallbladder and the duodenum. Abdominal pain, distension and vomiting are seen.
Cholangiocarcinoma Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen Acute pancreatitis Usually due to alcohol or gallstones Severe epigastric pain Vomiting is common Examination may reveal tenderness, ileus and low-grade fever Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare Pancreatic cancer Painless jaundice is the classical presentation of pancreatic cancer. However pain is actually a relatively common presenting symptom of pancreatic cancer. Anorexia and weight loss are common Amoebic liver abscess Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon. Question 7 of 117 Next Which one of the following features is more common in Crohn's disease than ulcerative colitis? A. Abdominal mass palpable in the right iliac fossa B. Tenesmus C. Bloody diarrhoea D. Faecal incontinence E. Abdominal pain in the left lower quadrant Next question Inflammatory bowel disease: key differences
high sensitivity and specificity for examination of the terminal ileum strictures: 'Kantor's string sign' proximal bowel dilation 'rose thorn' ulcers fistulae loss of haustrations superficial ulceration, 'pseudopolyps' long standing disease: colon is narrow and short - 'drainpipe colon' *impaired bile acid rebsorption increases the loss calcium in the bile. Calcium normally binds oxalate. Question 8 of 117 Next A 30-year-old woman is admitted to hospital with abdominal pain and diarrhoea. She has no past medical history other than depression for which she takes citalopram. She smokes 20 cigarettes/day and drinks 20 units of alcohol per week. Ileocolonoscopy shows features consistent with Crohn's disease and she is treated successfully with glucocorticoid therapy. Which one of the following is the most important intervention to reduce the chance of further episodes? A. Infliximab B. Stop^ drinking C. Stop smoking D. Mesalazine E. Budesonide Next question Crohn's disease: management Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and
colon but may be seen anywhere from the mouth to anus. NICE published guidelines on the management of Crohn's disease in 2012. General points patients should be strongly advised to stop smoking some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy Inducing remission glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children) 5 - ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate metronidazole is often used for isolated peri-anal disease Maintaining remission as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) azathioprine or mercaptopurine is used first-line to maintain remission methotrexate is used second-line 5 - ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery Surgery around 80% of patients with Crohn's disease will eventually have surgery *assess thiopurine methyltransferase (TPMT) activity before offering azathioprine or mercaptopurine
minimum score = 0, maximum score = 16 the score for hazardous drinking is 3 or more with relation to the first question 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits if the answer to the first question is 'never' then the patient is not misusing alcohol if the response to the first question is 'Weekly' or 'Daily or almost daily' then the patient is a hazardous, harmful or dependent drinker. Over 50% of people will be classified using just this one question 1 MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? 2 How often during the last year have you been unable to remember what happened the night before because you had been drinking? 3 How often during the last year have you failed to do what was normally expected of you because of drinking? 4 In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? CAGE well known but recent research has questioned it's value as a screening test two or more positive answers is generally considered a 'positive' result C Have you ever felt you should C ut down on your drinking? A Have people A nnoyed you by criticising your drinking? G Have you ever felt bad or G uilty about your drinking? E Have you ever had a drink in the morning to get rid of a hangover ( E ye opener)? Diagnosis ICD-10 definition - 3 or more needed compulsion to drink
difficulties controlling alcohol consumption physiological withdrawal tolerance to alcohol neglect of alternative activities to drinking persistent use of alcohol despite evidence of harm Question 10 of 117 Next A 35-year-old female presents with abdominal pain associated with bloating for the past 6 months, Which one of the following symptoms is least associated with a diagnosis of irritable bowel syndrome? A. Feeling of incomplete stool evacuation B. Weight loss C. Back pain D. Lethargy E. Nausea Next question Weight loss is not a feature of IBS and underlying malignancy or inflammatory bowel disease needs to be excluded Irritable bowel syndrome: diagnosis NICE published clinical guidelines on the diagnosis and management of irritable bowel syndrome (IBS) in 2008 The diagnosis of IBS should be considered if the patient has had the following for at least 6 months: abdominal pain, and/or bloating, and/or change in bowel habit
Gamma glutamyl transferase (yGT) 529 u/l Which of the following antibiotics is she most likely to have received? A. Co-amoxiclav B. Gentamicin C. Ciprofloxacin D. Trimethoprim E. Ceftazidime Next question Co-amoxiclav is a well recognised cause of cholestasis Drug-induced liver disease Drug-induced liver disease is generally divided into hepatocellular, cholestatic or mixed. There is however considerable overlap, with some drugs causing a range of changes to the liver The following drugs tend to cause a hepatocellular picture: paracetamol sodium valproate, phenytoin MAOIs halothane anti-tuberculosis: isoniazid, rifampicin, pyrazinamide statins alcohol amiodarone methyldopa nitrofurantoin The following drugs tend to cause cholestasis (+/- hepatitis):
oral contraceptive pill antibiotics: flucloxacillin, co-amoxiclav, erythromycin* anabolic steroids, testosterones phenothiazines: chlorpromazine, prochlorperazine sulphonylureas fibrates rare reported causes: nifedipine Liver cirrhosis methotrexate methyldopa amiodarone *risk may be reduced with erythromycin stearate Question 12 of 117 Next A 22-year-old man presents with a three week history of diarrhoea. He says his bowels have not been right for the past few months and he frequently has to run to the toilet. These symptoms had seemed to be improving up until three weeks ago. For the past week he has also been passing some blood in the stool and reports the feeling of incomplete evacuation after going. He has lost no weight and has a good appetite. Examination of his abdomen demonstrates mild tenderness in the left lower quadrant but no guarding. What is the most likely diagnosis? A. Diverticulitis B. Colorectal cancer C. Crohn's disease D. Ulcerative colitis E. Infective diarrhoea Next question
neutrophils migrate through the walls of glands to form crypt abscesses depletion of goblet cells and mucin from gland epithelium granulomas are infrequent Barium enema loss of haustrations superficial ulceration, 'pseudopolyps' long standing disease: colon is narrow and short - 'drainpipe colon' Question 13 of 117 Next A 78-year-old woman develops profuse, offensive watery diarrhoea following a course of co- amoxiclav. A diagnosis of Clostridium difficile diarrhoea is made. On examination she is haemodynamically stable, apyrexial and has no abdominal signs. What is the most appropriate first- line therapy? A. Oral vancomycin for 7 days B. Oral metronidazole for 10-14 days C. Oral metronidazole + vancomycin for 10-14 days D. Oral metronidazole for 7 days E. Probiotic yoghurt for 14 days Next question Clostridium difficile Clostridium difficile is a Gram positive rod often encountered in hospital practice. It produces an
exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are suppressed by broad-spectrum antibiotics. Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile. Features diarrhoea abdominal pain a raised white blood cell count is characteristic if severe toxic megacolon may develop Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool Management first-line therapy is oral metronidazole for 10-14 days if severe or not responding to metronidazole then oral vancomycin may be used for life-threatening infections a combination of oral vancomycin and intravenous metronidazole should be used Question 14 of 117 Next A 42-year-old woman is investigated for lethargy and diarrhoea. Investigations reveal positive anti- endomysial antibodies. Each of the following food stuffs should be avoided, except: A. Beer B. Rye C. Maize D. Bread
