BJM OnLine Examination

02/09/2023

1.A young adolescent girl presented with a rash in both axillary regions following a day
after application of a new deodorant.

What is the most likely diagnosis?

Erythrasma
Herpes zoster
Impetigo
Intertrigo
Irritant contact dermatitis

Key learning points

Dermatology

 Irritant contact dermatitis presents with vesicular eruption at sites of

contact with the irritant such as deodorants, often on the exposed areas
such as extremities or any other affected area such as the axillary
regions in this case. A burning sensation is experienced as opposed to
the itching in allergic contact dermatitis.

Explanation
Irritant contact dermatitis presents with vesicular eruption at sites of contact with the
irritant such as deodorants, often on the exposed areas such as extremities or any other
affected area such as the axillary regions in this case. A burning sensation is
experienced as opposed to the itching in allergic contact dermatitis.

Erythrasma appears as reddish-brown slightly scaly patches with sharp borders. The
patches occur in moist areas such as the groin, armpit, and skin folds. It is an infective
condition caused by Corynebacterium spp.

Herpes zoster presents as grouped vesicular eruptions on an erythematous base in a

dermatomal distribution.

Impetigo commonly presents in children with painful bullous lesions with honey coloured
crusts.
Intertrigo is an inflammatory disorder of the skin affecting the folds commonly in the
obese and diabetics and may get secondarily infected.

References:

BMJ Best Practice: Contact dermatitis

DermNZ: Irritant contact dermatitis

2.A 65-year-old male patient has recently registered with your practice, having moved
from another area. He had a radical prostatectomy three years ago for early prostate
cancer. He remains clinically well and has been undergoing follow-up in primary care.

You have no previous PSA (prostate specific antigen) readings for comparison but have
checked his PSA at his first visit with you.

Which of the following would be a reason for an urgent re-referral to the local urology
department, bearing in mind that the normal age related range is <4.5 ng/ml?
A PSA reading of >0.2 ng/ml
A PSA reading of >1.0 ng/ml
A PSA reading of >4.5 ng/ml
A PSA reading of >10 ng/ml
PSA readings are irrelevant in these circumstances and the indication for
referral would be based on symptoms alone

Key learning points

People with Long-Term Conditions including Cancer

 After a radical prostatectomy, the PSA should technically become

undetectable, so any measurable level is of potential significance
regarding local or systemic recurrence.

Explanation
After a radical prostatectomy, the PSA should technically become undetectable, so any
measurable level is of potential significance regarding local or systemic recurrence. The
general consensus is that two readings of more than 0.2 ng/ml are likely to be
suspicious of recurrent disease.

Further Reading:

1. Stephenson AJ, Kattan MW, Eastham JA, et al. Defining biochemical

recurrence of prostate cancer after radical prostatectomy: a proposal for
a standardized definition. J Clin Oncol. 2006;24:3973-8.

3.You see a 46-year-old lady who complaines of chronic back pain and widespread
itching. She was diagnosed with diabetes two months ago but this is not responding to
medication. Her skin has a yellow tinge and she is beginning to lose weight. Her fasting
blood sugar is 9.4. Her brother and nephew both died of pancreatic cancer.

Which is the best management option?

 Arrange an MRI of the pancreas

 Arrange a short synacthen test
 Refer routinely to an endocrinologist
 Ultrasound scan of the abdomen

 Urgent Suspected Cancer referral to a gastroenterologist (within the two

week wait pathway)

Key learning points

Gastroenterology

 Refer patients using the urgent suspected cancer pathway (within two
weeks) for pancreatic cancer, if they are aged 40 and over and have
jaundice.

Explanation
With a strong family history of pancreatic cancer, you should already have a low
threshold for investigating any worrying symptoms. This patient has also been
diagnosed with diabetes and has jaundice. This warrants an urgent suspected cancer
referral.
A CT scan should be carried out if patients aged 60 and over present with weight loss
and any of the following:

 Diarrhoea
 Back pain
 Abdominal pain
 Nausea
 Vomiting
 Constipation, or
 New-onset diabetes.

Although Addisons disease coexists more often with type 1 diabetes, patients will
usually be hypoglycaemic and the combination of back pain and likely jaundice makes
pancreatic cancer a strong possbility. An MRI should not be arranged in primary care
and this decision can be left with the specialist. An ultrasound is not the investigation of
choice in this instance. A routine referral would be inappropriate here because of the
red flags highlighted in the history. With such a strong family history, it would be prudent
to investigate this patient further.

Further reading:

NICE NG12: Upper GI cancers

Macmillan Cancer Support: Top tips for GPs

BMJ Best Practice: Pancreatic cancer

4.A 17-year-old secretary comes to see you following an appointment with the
respiratory nurse at the surgery eight weeks ago. She is complaining of an increased
dry cough and an intermittently wheezy chest at night. She does not describe any fevers
and has not had any difficulties in breathing.

She is currently taking Fostair (Beclomethasone diproprionate 100 mcg/Formetorol

fumarate 6 mcg) combination inhaler, 1 puff twice daily, and takes salbutamol as and
when required for shortness of breath.

Prior to the Fostair she had been using Clenil (Beclomethasone 100 mcg), although she
feels that the new inhaler has helped slightly since her last appointment with the nurse.

Thinking about the latest SIGN/BTS guidance, what would be the next step in managing
her asthma?
  Increase the Fostair to two puffs twice daily
 Prescribe amoxicillin 500 mg three times a day for five days
 Refer to a respiratory consultant
 Start Montelukast 10 mg in the evening
Use the salbutamol as and when needed (up to six times a day maximum)

Key learning points

Respiratory Health

 In patients with chronic (non-acute) asthma, already taking a LABA, if

there has been some benefit, the dose of the inhaled corticosteroid
should be increased.

Explanation
There are a number of important pieces of information that you should have picked up
on in this scenario.

Firstly, this question is dealing with the management of chronic asthma and not an
acute attack. This patient is an adult and so the children's guidelines do not apply here.

The patient is already taking a combination inhaler. The features in this case are not
consistent with an infective exacerbation, so antibiotics are not recommended.

This patient has sub-optimal control of her asthma and there is no role for increasing the
usage of salbutamol, as she needs better overall control of her symptoms rather than
acute relief of shortness of breath. Salbutamol is never recommended more then four
times a day for patients unless they become acutely unwell in which case they should
seek a medical opinion.

Since she has already started a combination inhaler of a long-acting beta 2 agonist and
inhaled corticosteroid, the dose of the inhaled corticosteroid should be increased. This
is in keeping with the next step in the treatment of asthma in adults of the British
Thoracic Society guidelines.

You might find it useful to print out the 1 page A4 summary treatment algorithm listed
below and work through a few scenarios. There is a similar algorithm for use in children

Editor's note: We often receive questions from subscribers asking us about differences
in management between SIGN and NICE and "what is likely to crop up in the exam?".
Whilst we do not know what questions will crop up, the RCGP have stated that
candidates should be familiar with SIGN and NICE guidance and should be able to
compare and contrast their advice. Any examination questions should make this
distinction clear.

Further reading:

Asthma Guideline Quick Reference Guide

One page A4 summary treatment algorithm of asthma in adults

5.The age at which a woman reaches the menopause is related to:

Age at menarche
Ethnic group
Family tendency
Parity
Regularity of cycle

Key learning points

Maternity and Reproductive Health

 Age at menopause is influenced by family history and it's worth asking

about this when considering early menopause

Explanation
Studies have not shown a link between age at menarche and age of menopause.

Premature menopause may be associated with smoking, living at high altitude, or poor
nutritional status. There may be a family tendency and possible genetic link.

We could not find any reference to different ethnic groups in terms of menopausal age,
although there are different causes of premature menopause that affect different ethnic
groups.

Further Reading:
Endocrine Online. Premature Ovarian Failure.
6.You visit an 83-year-old man at home and he has difficulty understanding the
treatment that he takes for his asthma. You think that this is largely because he has
impaired hearing.

In general terms, which of the following strategies is most likely to help?

 Avoiding non-verbal communication
 Increasing the pitch of your voice
 Minimising background noise
 Shout
 Speaking extremely slowly

Key learning points

Consulting in General Practice, Ear, Nose and Throat, Speech and Hearing

 Minimising background noise helps patients with impaired hearing

Explanation
Minimising background noise is likely to help as is:

 speaking clearly at a normal or near normal rate

 making best use of non-verbal communication
 decreasing the pitch of your voice.

Never shout at a deaf or hard-of-hearing patient - it's unprofessional and is unpleasant

for a deaf person and can appear rude, even if unintentional.

When speaking to deaf people who have a degree of hearing, use their name to get
their attention and ask if they can hear you. Make sure you face them when talking as
many deaf people use lip-reading to supplement their hearing aid(s) and what hearing
they have.

It is worth remembering that the deaf and hard of hearing tend to respond positively to
people who make the effort to speak clearly and politely.

Further Reading:
Royal National Institute for the Deaf: Communication Tips.
7.
With which of the following is obstructive sleep apnoea characteristically associated?

Hypersomnolence
Impotence
Insomnia
Macrognathia
Polydipsia

Key learning points

Respiratory Health

 Sleep apnoea is commonly associated with obesity, but myxoedema,

acromegaly and retro/micrognathia are also recognised causes.

Explanation
The dominant symptom is hypersomnolence (sleepiness).

Other more common symptoms include:

 Apparent personality changes

 Witnessed apnoeas, and
 True nocturnal polyuria.

Reduced libido is less common.

Sleep apnoea may be associated with:

 Acromegaly
 Myxoedema
 Obesity, and
 Micrognathia/retrognathia.

References:

BMJ Best Practice: Obstructive sleep apnoea

BMJ Practice: Obstructive sleep apnoea/hypopnoea syndrome and obesity

hypoventilation syndrome in over 16s: summary of NICE guidance
BMJ Clinical review: Obstructive sleep apnoea

8.Which one of the following is a risk factor for breast cancer?

Late menarche
Late menopause
Multiparity
Progesterone only pill use
Younger first time mothers

Key learning points

Maternity and Reproductive Health , Population Health

 Late menopause increases the risk of breast cancer.

Explanation
An increased risk of breast cancer is associated with:

 Early menarche
 Nulliparity
 Combined oral contraceptive pill use, and
 Older first time mothers.

Late menopause increases the risk of breast cancer by almost 3% for each-year-older
at menopause.

Reference:
BMJ Clinical Review: Breast cancer-epidemiology, risk factors, and genetics

BMJ Best Practice: Primary invasive breast cancer

Cancer Research UK: Breast cancer risk factors.

9.A 15-year-old patient comes to see you complaining of burning and irritation of his
tongue and rapid changes within the colour of his tongue. On examination, there are
multiple irregular but smooth red plaques on the dorsum of his tongue. He is very
worried about these changes and wants advice from you.

What is the most likely diagnosis here?

Acute necrotising ulcerative gingivitis
Angular chelitis
Aphthous stomatitis
Geographic tongue
Oral hairy leukoplakia

Key learning points

Ear, Nose and Throat, Speech and Hearing

Geographic tongue is a rapid onset but benign condition of the tongue that
requires no therapy other than reassurance.

Explanation
Geographic tongue presents with mild burning and irritation of the tongue. There are
single or multiple well demarcated irregular but smooth red plaques on the dorsum of
the tongue. Stress and spicy food may exacerbate the condition. Management is with
reassurance alone.

 Angular chelitis presents with irritation of the corners of the lips and
dryness.
 Aphthous stomatitis describes solitary or multiple painful ulcers on the
mucosal membranes.
 Oral hairy leukoplakia is an asymptomatic white thickening and
accentuation of the folds of the lateral margins of the tongue.
 Acute necrotising ulcerative gingivitis presents with punched-out ulcers,
necrosis and bleeding of areas between teeth.

You can read more about geographic tongue here:

www.nlm.nih.gov

10.St John's wort (Hypericum perforatum) is an over the counter plant extract which is
often used by patients to self treat when they develop symptoms of depression.
In which one of the following conditions has benefit been shown?
Attention deficit hyperactivity disorder (ADHD)
Dysthymia
Gram positive infections
Major depression
Multiple sclerosis

Key learning points

Mental Health

 St John's Wort may be effective in treating mild to moderate depression.

Explanation
There is enough clinical evidence to justify the use of St John's wort in dysthymia and
mild to moderate depression, but the active ingredient and mechanism of action
remains unclear from the latest psychiatry evidence.

Hyperforin is responsible for St John's wort's enzyme induction effect, but is not yet
shown to be directly active in lifting mood.

A Cochrane review concluded from meta analysis of 29 clinical trials that St John's wort
was superior to placebo for treating mild to moderate depression but not severe
depression. Most of the studies were from German-speaking countries, and some were
small. One study showed no benefit in ADHD over eight weeks. One study has been
shown to improve symptoms in Parkinson's disease, and there is evidence for efficacy
in Gram negative infection.

Dysthymia, a less severe and more chronic depression, has shown some benefit. We
could find no reference for its use in multiple sclerosis (MS).

It is also worth remembering that the latest NICE guidance on depression suggests that
practitioners should not prescribe or advise St John's wort for depression. This is
because of the differing potencies of different formulations, and because it can result in
potentially serious interactions with other medicines, such as anticonvulsants and the
oral contraceptive pill.

It is therefore important to ask patients if they are taking any herbal or "natural
remedies", and try to dispel the myth that "natural" and "safe" are synonymous.
Reference:

1. GP Notebook. St John's wort.

2. Medscape. Depression: Treatment & Medication.

NICE. Depression in adults (CG90)

Key things for you to remember

 Minimising background noise helps patients with impaired hearing.
 Irritant contact dermatitis presents with vesicular eruption at sites of contact with
the irritant such as deodorants, often on the exposed areas such as extremities
or any other affected area such as the axillary regions in this case. A burning
sensation is experienced as opposed to the itching in allergic contact dermatitis.
 Geographic tongue is a rapid onset but benign condition of the tongue that
requires no therapy other than reassurance.
 Refer patients using the urgent suspected cancer pathway (within two weeks) for
pancreatic cancer, if they are aged 40 and over and have jaundice.
 Age at menopause is influenced by family history and it's worth asking about this
when considering early menopause
 Late menopause increases the risk of breast cancer.
 St John's Wort may be effective in treating mild to moderate depression.
 After a radical prostatectomy, the PSA should technically become undetectable,
so any measurable level is of potential significance regarding local or systemic
recurrence.
 Sleep apnoea is commonly associated with obesity, but myxoedema, acromegaly
and retro/micrognathia are also recognised causes.
 In patients with chronic (non-acute) asthma, already taking a LABA, if there has
been some benefit, the dose of the inhaled corticosteroid should be increased.