Dementia
A 78-year-old man presents to his GP with a 6-month history of worsening memory and concentration difficulties.
His wife reports that his symptoms have worsened in a stepwise fashion, with sudden deteriorations in his ability to carry out daily activities. He also has a history of hypertension and a stroke two years ago.
On examination, he shows difficulty with attention and some gait disturbance.
What is the most likely diagnosis?
A. Alzheimer’s disease
B. Frontotemporal dementia
C. Lewy body dementia
D. Normal pressure hydrocephalus
E. Vascular dementia
E- stepwise progression with vasculopath hx.
The breakthrough dose for a patient's morphine should be what fraction of their prescribed morphine?
A. 1/2
B. 1/4
C. 1/5
D. 1/6
E. 1/8
D- Breakthrough dose for pain relief (usually morphine) should be 1/6 of their daily prescribed.
A 58-year-old Asian man attends for his annual diabetic review. At this appointment his blood pressure is found to be 158/94 mmHg.
Over the next week, he undergoes ambulatory blood pressure monitoring. The average of these readings is found to be 152/95 mmHg.
What is the first-line management for this patient?
A. Amlodipine
B. Doxazosin
C. Indapamide
D. Lifestyle advice only
E. Ramipril
E- ACEi/ARBs are 1st line for HTN in all diabetics regardless of age.
A 35-year-old woman presents to the GP with a three-month history of worsening muscle weakness. She reports that her symptoms are worse towards the end of the day, especially after physical activity, and improve with rest. She also notes occasional double vision. On examination, there is ptosis and weakness in her neck muscles.
What is the most likely underlying cause of this patient's symptoms?
A. Antibodies against acetylcholine receptors
B. Antibodies against muscle-specific tyrosine kinase
C. Autoimmune destruction of myelin
D. Immune-mediated attack on voltage-gated calcium channels
E. Thymoma-related immune response
A- Classic MG.
A 78-year-old woman presents to the memory clinic with a 12-month history of progressive short-term memory loss and difficulty with word-finding.
Her family reports that she has become increasingly forgetful. She is otherwise healthy with no significant psychiatric or neurological history. A Mini-Mental State Examination (MMSE) reveals a score of 22/30.
Physical examination is unremarkable. Blood tests, including vitamin B12, thyroid function, and metabolic panel, are normal.
What is the most appropriate next step in confirming the diagnosis of dementia?
A. Diagnose dementia based on the MMSE score and clinical history
B. Initiate a trial of donepezil based on clinical assessment
C. Order neuroimaging to exclude other causes of cognitive decline
D. Perform cerebrospinal fluid (CSF) analysis
E. Refer for further neuropsychological testing
C- need neuroimaging to rule out hydrocephalus, strokes, tumours etc.
A 47-year-old man is on the ward recovering after a cholecystectomy. An examination is unremarkable and there is nothing of concern and it is decided to prescribe pain relief.
He has been suffering from nausea and has been unable to keep down food or fluid in the last hour.
His drug chart shows maintenance fluids and having taken eight 500mg tablets of paracetamol so far today. There are no recorded allergies and he weighs 75 kg.
What form of analgesia is most appropriate to be offered?
A. 1g paracetamol IV over 15 minutes
B. 30mg oral codeine maximum 4-hourly as required
C. 400mg oral ibuprofen 3 times a day + 20mg omeprazole once daily
D. IV morphine controlled by patient-controlled analgesia (PCA)
E. Two 500mg oral tablets of paracetamol STAT
D- Can use PCA in post-operative period as struggling to keep oral products down + already had maximum paracetamol for the day.
You are reviewing a 74-year-old man with hypertension, type 2 diabetes and osteoarthritis. He takes 10mg of ramipril once a day, 10mg of amlodipine once a day, indapamide 2.5 mg once a day, 500mg of Metformin twice a day, co-codamol PRN and atorvastatin 20mg at night.
His blood pressure (BP) is consistently raised on his home BP monitor and today in the clinic today is 158/95 mmHg. You would like to start a further medication to try and lower his BP. His K+ is 4.0 mmol/l.
What would be the most appropriate next medication to add according to the NICE guidelines?
A. Bendroflumethiazide
B. Chlortalidone
C. Candesartan
D. Spironolactone
E. Doxazosin
D- If poorly controlled HTN on ACEi, Ca2+ blocker and thiazide and K+ below 4.5, add spironolactone.
A 9-year-old boy who is having an asthma attack is brought to surgery. Which one of the following findings would be categorise the asthma attack as life-threatening, rather than just severe, according to the British Thoracic Society guidelines?
A. Heart rate 140 bpm
B. Peak flow 30% of best
C. Use of accessory neck muscles
D. Sats 93%
E. Respiratory rate 36/min
B- PEF under 33% of best is life threatening.
A 74-year-old man has been brought to the GP by his son who is worried about his memory. Over the last year, there has been a steady decline in his memory and he is now forgetting to pay his bills and is leaving the cooker on. As well as this, he has had changes in his gait, smaller strides, and instability.
Over the last 3 months, he has been struggling with using the toilet. He has unintentionally emptied his bladder frequently. His past medical history consists of an ischaemic stroke 4 years ago and he takes clopidogrel and atorvastatin.
What is the most likely diagnosis?
A. Alzheimer's disease
B. Dementia with Lewy bodies
C. Normal pressure hydrocephalus
D. Parkinson's disease
E. Vascular dementia
B- NPH presents with urinary incontinence, gait abnormality and dementia.
A 69-year-old man with metastatic prostate cancer presents with worsening pain. He currently takes oral modified-release morphine sulphate 60mg bd but it is decided to convert this to subcutaneous administration as he is frequently vomiting. What is the most appropriate dose of morphine to give over a 24 hour period using a continuous subcutaneous infusion?
A. 20mg
B. 30mg
C. 40mg
D. 60mg
E. 120mg
D- oral morphine to SC is divide by 2, takes 60mg BD so 120/2 = 60.
You see a 60-year-old man in your GP practice who is normally fit and well. He came to see you two weeks ago with a viral infection. You recorded his clinic blood pressure as 168/105 mmHg. You arrange ambulatory blood pressure monitoring (ABPM), bloods, urine dip, an ECG, and you are seeing him today with the results.
His subsequent ABPM average is 157/100 mmHg. You arranged some blood tests including plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol. He had normal renal function and his glucose was within normal limits. A urine dip for protein was normal and an ECG was also normal. You check the back of his eyes and the fundi are normal. You calculate his QRisk as 28%.
You discuss treatment options with the patient. What should your management plan include?
A. Offer amlodipine and lifestyle advice and aim for clinic BP <140/90 mmHg
B. Offer amlodipine, lifestyle advice, atorvastatin and aim for clinic BP <140/90 mmHg
C. Offer amlodipine, lifestyle advice, atorvastatin and aim for clinic BP <135/85 mmHg
D. Offer ramipril, lifestyle advice, atorvastatin and aim for clinic BP <140/90 mmHg
E. Offer ramipril, lifestyle advice, atorvastatin and aim for clinic BP <135/85 mmHg
B- if QRisk over 10% and HTN over 55, offer Ca2+ blocker, statin and lifestyle advice and clinic bp aim of 140/90 with ABPM aim of 135/85.
You have been called to see a 17-year-old patient who was admitted last night and later diagnosed with diabetic ketoacidosis. Two 500mL fluid bolus were given and she was started on a fixed-rate intravenous insulin infusion.
This morning her Glasgow coma scale score has dropped by 4 points to 9/15. There is evidence of grunting with apnoeic episodes. She is still suffering from recurrent vomiting. You notice she has become incontinent of urine. Once the patient is stabilised, a chest x-ray and urine dipstick are performed and they are both normal.
What is the patient most likely suffering from?
A. Acute respiratory distress syndrome
B. Cerebral oedema
C. Encephalitis
D. Idiopathic intracranial hypertension
E. Uraemic encephalopathy
A 39-year-old woman presents to the clinic following a referral. She reports difficulty performing her job due to a short temper and forgetfulness. She has also experienced mild, intermittent twitching and jerking movements in her limbs. Her paternal grandfather and father both passed away from young-onset dementia at the ages of 67 and 55, respectively.
Her wife has observed these changes and mentions that she has lost interest in previously enjoyed activities. A neurological examination indicates mild cognitive impairment and impaired fine motor control.
What is the most likely diagnosis?
A. Bipolar disorder
B. Frontotemporal dementia
C. Huntington's disease
D. Lewy bodies dementia
E. Parkinson's disease
C. Huntingtons, as presents with progressive neurological decline. Often starts as cognitive, psychiatric or mood issues before having chorea (involuntary, abnormal movements). Also is autosomal dominant so often has FH + anticipation.
A 65-year-old man presents with severe epigastric pain radiating to his back. He states that the pain is 9/10 severity. He has associated nausea and vomiting. Serum amylase is raised. You suspect a diagnosis of acute pancreatitis.
How would you initially manage his acute pain?
A. IV morphine in 1-2mg boluses until comfortable
B. IM pethidine
C. IV morphine 10mg STAT
D. Regular paracetamol
E. Regular paracetamol and ibuprofen
A- Give IV Morphine in 1-2mg boluses, rather than 10mg all in one go.
A 34-year-old woman attends a routine antenatal clinic at 16 weeks gestation.
She has no significant past medical history but suffers with occasional frontal headaches.
She is noted to have a blood pressure of 148/76mmHg.
Urinalysis reveals;
pH 6.5 Protein+1 Nitrates 0 Leuc 0 Blood 0
What is the most likely diagnosis?
A. Gestational hypertension
B. Pre-eclampsia
C. HELLP
D. Nephrotic syndrome
E. Chronic hypertension
A 12-year-old boy with a history of migraines, asthma, and mild obesity presents to his GP with his mother. His migraines have become more frequent, occurring 2-3 times per week, and they are affecting his school performance. The mother asks for medication to reduce the frequency of his migraines.
What is the most appropriate management?
A. Ibuprofen
B. Prochlorperazine
C. Propranolol
D. Sumatriptan
E. Topiramate
E- Propanolol and topiramate are the only 2 of those that are prophylactic, and B blockers are contraindicated in asthma.
A 72-year-old man presents with his daughter. She reports that he seems to have been struggling intermittently with his attention, and sometimes his speech is muddled. She says he has been very low in mood and does not seem to enjoy anything anymore, saying he doesn't have any energy.
He has also been experiencing visual hallucinations and at night he 'acts out' his dreams. His gait appears slow and shuffling.
Given a likely diagnosis of Dementia with Lewy bodies, which of the following medications should be avoided in this patient?
A. Donepezil
B. Haloperidol
C. Carbidopa/Levodopa
D. Clonazepam
E. Sertraline
B- shouldn't give antipsychotics to those with dementia as can lead to Parkinsonism.
A 76-year-old man with renal cell carcinoma and lung metastases is admitted to the hospital. He is experiencing significant pain and is deemed to be in the final days of his life.
The following blood test results were obtained in the community before his admission:
Na+ 142 mmol/L(135 - 145) K+ 4.3 mmol/L(3.5 - 5.0) Bicarbonate 27 mmol/L(22 - 29) Urea 21.2 mmol/L(2.0 - 7.0) Creatinine 356 µmol/L(55 - 120)
What is the most appropriate medication to control this man's pain?
A. Buprenorphine
B. Low dose ketamine
C. Oxycodone
D. Paracetamol
E. Tramadol
A- Buprenorphine or fentanyl are used to manage pain in palliative patients with severe renal impairment as are not renally excreted.
A 26-year-old woman is found to be hypertensive with a blood pressure of 155/110 mmHg during labour for her first baby at 24 weeks. Urinalysis shows +++ protein. Which of these is the most appropriate way to manage her hypertension?
A. Prescribe lisinopril with target blood pressure < 135/85 mmHg
B. Immediate delivery of the foetus
C. Prescribe nifedipine with target blood pressure < 135/90 mmHg
D. Prescribe labetalol with target blood pressure < 135/85 mmHg
E. Prescribe aspirin and intramuscular steroids
D- labetalol is 1st line for managing pre-eclampsia, as ACEi contraindicated in pregnancy. Wouldn't immediately deliver in pre-eclampsia unless HELLP.
A 67-year-old man is diagnosed with Parkinson's disease after presenting to his GP with a resting tremor and difficulty initiating movement. He is started on a medication to treat this by his neurologist. At his review a few months later, he says that his symptoms have been much better but his wife has been complaining because he has started to spend a significant amount of money betting on football matches. His wife adds that this is very out of character for him.
Which of the following medications is he likely to have been prescribed?
A. Amantadine
B. Bromocriptine
C. Entacapone
D. Levodopa
E. Selegiline
B- Bromocriptine, a dopamine receptor antagonist, is associated with the highest chance of inhibition disorders out of the antiparkinsonian medications