14/09/2023….

Thursday

1....For people with Trisomy 21, which is the most common congenital heart defect?

Atrial septal defect

Atrioventricular septal defect
Patent ductus arteriosus
Tetralogy of Fallot
Ventricular septal defect

Key learning points

Cardiovascular Health , Children and Young People, Genomic Medicine

 Atrioventricular septal defect is the commonest congenital heart defect

in Down's

Explanation
Fifty percent of people born with Trisomy 21 have congenital heart disease.

Defects, in order of decreasing frequency, are:

1. Atrioventricular septal defect

2. Ventricular septal defect
3. Patent ductus arteriosus
4. Tetralogy of Fallot, and
5. Atrial septal defect.

References:

Centres for disease control and prevention: Facts about Atrioventricular Septal Defect
(AVSD)

MSD Manual: Atrioventricular Septal Defect

2….A 62-year-old male presents with a few small scaly lesions on the forehead, scalp
and face. You diagnose solar keratoses.

Which one of the following is appropriate initial treatment in general practice?

 5-Fluorouracil cream
1% Diclofenac gel
Excision biopsy
Oral azathioprine
Oral retinoids
Photodynamic therapy
Steroid creams
Topical ibuprofen

Key learning points

Dermatology, Improving Quality, Safety and Prescribing

 Solar keratoses should initially be managed with topical treatments such

as diclofenac cream (Solaraze) and 5-fluorouracil cream (Efudex).

Explanation
Solar keratoses should initially be managed with topical treatments such as diclofenac
cream (Solaraze) and 5-fluorouracil cream (Efudex). Both treatments have been shown
to be effective at clearing up these lesions. Solaraze is 3% diclofenac, the 1% being a
rubefacient

Excision is reserved for suspicious lesions, as there is the risk of squamous cell
carcinoma transformation.

Cryotherapy is probably more suited to thicker lesions and photodynamic therapy is

more suited to treatment where they are numerous or at sites of poor healing.

Salicylic acid ointment can help to descale a lesion before applying 5-fluorouracil cream.

Reference:
BMJ Best Practice: Actinic keratosis

Primary Care Dermatology Society: Actinic keratosis

British Association of Dermatologists. Patient Information Leaflet - actinic keratoses.

3….A 20-year-old male presents with a very itchy rash afflicting both groins and
suprapubic region of four weeks duration.

On examination he had multiple annular scaly plaques with spreading peripheral

borders and central clearing:

What is his diagnosis?

Allergic contact dermatitis

Dermatophytosis
Fixed drug eruption
Psoriasis
Sarcoidosis

Key learning points

Dermatology

 Intense itching is not usually a prominent feature in psoriasis

Explanation
Dermatophytosis is common in young active adults. It usually presents with annular
scaly plaques with active peripheral margins and central clearing resulting in increasing
size of the lesions. The lesions are typically itchy and increase in number over a period
of time. The affliction of groins is referred to as 'tinea cruris' and involvement of limbs
and trunk as 'tinea corporis'. Such patients can also be said to be suffering from 'tinea
cruris et corporis'.

Allergic contact dermatitis will present with itchy papulo-vesicular eruption at the site of
contact of the allergen

Fixed drug eruption presents with erythematous or hyperpigmented macules or patches,

sometimes with central bullae. History of drug intake may be forthcoming and history of
recurrent such episodes at the same site may be present.

Many candidates will have incorrectly opted for psoriasis in this case. Psoriasis presents
with papulosquamous lesions with micaceous scaling. Annular lesions may be present
BUT intense itching is not usually a prominent feature and this is a key point in the
history. It's really important with dermatology questions (as in real life) to take careful
note of the history rather than a knee jerk reaction to the appearance, because many
conditions can have similar appearance and the diagnosis may rest on subtleties in the
history, as in this case.

Sarcoidosis may present with scaly plaques, however features of peripheral activity and
central clearing are usually not seen and itching is not a feature.References:

References:

BMJ Best Practice: Dermatophyte infections

The British Medical Journal: The diagnosis and management of dermatophyte infections
(PDF)

Primary Care Dermatology Society: Tinea corporis

4….A 42-year-old former beef farmer is currently being looked after in a care home after
a severe deterioration in his memory and ability to care for himself.

You examine him and note that he has nystagmus, bilateral lateral rectus palsy, ataxia,
a broad based gait and peripheral neuropathy with sensory loss in his feet. You
understand that his father died at an early age, apparently from Alzheimer's disease.

He is known to drink alcohol.

Which one of the following is most likely to be the underlying diagnosis?

Early Alzheimer's disease

Huntington's chorea
Korsakoff's psychosis
New variant CJD
Wernicke's encephalopathy

Key learning points

Neurology

 Wernicke's encephalopathy is caused by thiamine deficiency and may

present with visual symptoms, muscle incoordination, loss of memory
and hallucinations

Explanation
Wernicke's encephalopathy is associated with haemorrhage into the areas of the brain
called the mamillary bodies, and this occurs in patients with thiamine deficiency. It is a
particular problem in patients chronically abusing alcohol, and those patients with
another malnutrition state, such as that related to AIDS, or disseminated malignancy.

It is said that Wernicke's and Korsacoff's are the acute and chronic stages of the same
condition. Wernicke's in its early stages can be reversible especially the eye signs. In
this particular scenario, there is memory loss suggesting Korsacoff's has started and is
almost certainly irreversible. It underlines why it is important to institute early thiamine
replacement in patients admitted to hospital with symptoms of alcohol withdrawal.

5…A 60-year-old woman has chronic kidney disease stage 4.

Which of the following additional vaccines are recommended?

Hepatitis A and B
Hepatitis B, Influenza and Pneumococcal
Hepatitis A and B, Influenza and Pneumococcal
 Hepatitis B, Influenza, Haemophilus influenzae type b (Hib) and
Pneumococcal
Hepatitis B, Influenza, Pneumococcal and MenACWY

Key learning points

Children and Young People, Population Health

 Patients with CKD stages 4 and 5 should receive Hepatitis B, Influenza

and Pneumococcal vaccines in addition to the usual immunisation
schedule

Explanation
Patients with CKD stages 4 and 5 should receive Hepatitis B, Influenza and
Pneumococcal vaccines in addition to the usual immunisation schedule. There is no
recommendation for these patients to receive Meningiococcal ACWY, Hepatitis A or Hib
vaccine.

References:

The Green Book: Immunisation of individuals with underlying medical conditions (PDF)

UK Government: Complete Immunisation Schedule Feb 2022

Oxford Vaccine Knowledge Project: UK Immunisation schedule

6….A 70-year-old woman presented with episodic impairment of consciousness.

Which of the following is the most likely cause?

Alzheimer type dementia

Chronic sub-dural haematoma
Creutzfeldt-Jacob disease
Depressive stupor
Normal pressure hydrocephalus
Key learning points
Neurology, Older Adults

 Subdural haematoma can be associated with gradual onset of

headaches, memory loss, personality change, dementia, confusion and
drowsiness (all of which can be fluctuating).

Explanation
This is quite a grey question. The clinical scenario is very brief with no mention of any
neurological signs so a logical deduction must be made.

Alzheimer's disease would be expected to have a continuous impairment of

consciousness in its advanced stages but could be episodic if there were variation in
drugs therapy or concurrent illnesses.

Similarly normal pressure hydrocephalus, Creutzfeldt-Jacob and depression would

present with dementia (or apparent dementia) but not fluctuant.

Of all those listed, chronic subdural haematoma is the one which can be associated with
fluctuating level of consciousness. This would make it the most likely answer in this
scenario.

BMJ Postgraduate Medical Journal: Chronic subdural haematoma in the elderly

Alzheimers - MSD Manual

7….A 23-year-old female attends clinic for a routine appointment regarding a six month
history of occasional fits.

She has seen the neurologists who have diagnosed idiopathic epilepsy and have
prescribed lamotrigine. She informs you that she is doing well with this medication and
has not had a fit for two months.

She has been told that she must stop driving but you have seen that she drove to attend
the clinic. You discuss this with her and insist that she stops driving to which she
informs you that she had stopped driving but since she is fit free she must continue to
drive because of her employment.
Which of the following is the most appropriate action to take in these circumstances?

Inform patient that you will notify the DVLA

Inform patient that you will notify the police
Inform the epilepsy clinic that she is still driving and allow them to deal with
this issue
You cannot inform any external body due to patient confidentiality
Your only action is to write in the notes that the patient has been
repeatedly warned but chose to ignore advice as she presents no serious risk
in view of her epilepsy control

Key learning points

Improving Quality, Safety and Prescribing

 If a patient with epilepsy continues to drive despite advice to the

contrary then the doctor has a duty of care to society overriding
confidentiality to the patient and may inform the DVLA.

Explanation
The law is quite clear on such issues regarding epilepsy and the ability to drive.

If the diagnosis is confirmed the patient must stop driving and inform the DVLA
regarding the diagnosis.

If the patient continues to drive despite advice to the contrary then the doctor has a duty
of care to society overriding confidentiality to the patient and may inform the DVLA.

8….You are completing an ESA113 medical report that has been requested by the
Department of Work and Pensions with regards a patient of yours who has applied for
employment and support allowance.

Which of the following should you omit from such a medical report?
 Embarrassing information
Harmful information (e.g. diagnosis of a malignancy the patient is unaware
of)
Information about medical conditions where more than 10 years have
elapsed since diagnosis
Letters or reports from other healthcare professionals (the information
provided should only be first-hand from the GP)
Reference to criminal convictions not directly relevant to the patient's
condition or disability, whether spent or not

Key learning points

Leadership and Management

 When releasing medical information about a patient the Rehabilitation of

Offenders Act 1974 should be observed, meaning that information
should not contain reference to criminal convictions whether spent or
not unless that information is directly relevant to the patient’s condition
or disability.

Explanation
Information in medical reports may be made available to patients on request or if they
appeal against a benefit entitlement decision (harmful information is the exception, see
below).

Any relevant medical information should be provided in a report and this may include
diagnoses going back many years if they continue to impact on the patient significantly.

Harmful information is any detail provided in the report that would be considered
harmful to a patient's health should they become aware of it. Such information may be
legally withheld from a patient and not released by the Department of Work and
Pensions. Any harmful information should be clearly recorded in the relevant section of
the report or clearly marked on separate paper so that it is managed appropriately.

Data protection legislation dictates that information which would simply embarrass the
author, or someone else should not be withheld. Care should be taken when providing a
report that issues that cannot be substantiated are not included. For example,
inappropriate personal remarks or suspicions of malingering without firm basis.
Letters or reports from other health care professionals are an important source of
valuable information and should be included.

The Rehabilitation of Offenders Act 1974 should be observed meaning that your report
should not contain reference to criminal convictions whether spent or not unless that
information is directly relevant to the patient's condition or disability.

References and Further Reading:

DWP Medical (factual) Reports: A guide to completion - April 2017

Useful guidance for GPs completing further medical evidence forms (PDF)

9…..Following morning surgery your receptionist informs you that a pharmaceutical

company representative has come to see you with a gift, and that under his arm he has
a small white box, on which the words "Apple EarPods" are inscribed.

The same representative took the practice out for a meal at a local bistro recently and
has written to you to ask if you would like to participate in post-marketing surveillance of
one of their new lipid lowering drugs.

Pharmaceutical representatives have to abide by the ABPI code of practice.

Which one of the following statements are true?

Gifts do not have to be relevant to a GP's work

Gifts should cost no more than £15
Promotion of prescription only medicine to the public is allowed provided it
is in the best interests of the patient
The number of mailings that can be sent to GPs is unrestricted
The pharmaceutical industry can continue to support continuing medical
education for GPs

Key learning points

Improving Quality, Safety and Prescribing
  The pharmaceutical industry can continue to support continuing medical
education for GPs

Explanation
Amendments to the ABPI code 2011 include banning of promotional aids such as mugs,
diaries, pens and post-it notes. Items can be provided to healthcare professionals to
pass on to patients only if they are part of a formal patient support programme. In other
words, no gifts are allowed.

Medical equipment and services should not carry an inducement to prescribe a

particular product. Hospitality is restricted to scientific and educational meetings.
Meetings held outside the UK must have good reasons for being held abroad.

The ABPI code of practice also regulates the training and regulation of pharmaceutical
representatives.

If a GP requests removal from a mailing list, their names must be removed promptly.

Information released to the media in advance of a product becoming licensed must not
be designed to encourage patients to ask for a specific medicine.

If you feel a pharmaceutical company, or one of its representatives, have infringed the
code, you can make a complaint to the Prescription of Medicines Code of Practice
Authority (PMCPA). It can apply sanctions if the company is found to be in breach of the
code and can require the withdrawal of the offending material.

A recent survey of 400 doctors showed that 48% were unaware of the code, while 86%
had no knowledge of how to make a complaint.

Further Reading:
Association of the British Pharmaceutical Industry (ABPI). The Code of Practice for the
Pharmaceutical Industry 2014.

10….You have been forwarded an absent colleague's pathology results and come
across a full blood count taken on a patient who presented with vague lower abdominal
symptoms and change in bowel habit.
When considering the management of men of any age and non-menstruating women
who present with unexplained iron deficiency anaemia, what is the threshold
haemoglobin below which you should consider urgent referral?

100 g/L for men and 110 g/L for women

120 g/L for men and 100 g/L for women
110 g/L for men and 120 g/L for women
110 g/L for men and women
120 g/L for men and women

Key learning points

Gastroenterology

 A man with unexplained iron deficiency anaemia of 120 g/L or lower or

100 g/L or lower in a non-menstruating woman should be referred
urgently for further investigation.

Explanation
In making a diagnosis of iron deficiency anaemia you would also expect to see a low
serum ferritin with a red cell microcytosis and hypochromia.

Colonic cancer, gastric cancer and coeliac disease are the most important
gastrointestinal causes of iron deficiency anaemia. Patients should have a PR
examination, urine testing and coeliac screen.

Unexplained iron deficiency anaemia can be one of the few 'early' clues to an
underlying malignancy presenting to you in primary care. Whilst menorrhagia can be a
cause of iron deficiency in women of child-bearing age, you should be careful to take a
detailed history and any man or non-menstruating woman presenting with anaemia
should be referred for urgent investigation. In order to refer appropriately, it is important
that you have an understanding of the appropriate referral thresholds, although in many
cases there may be additional red flags that would warrant referral.

Whilst occult bleeding from the gastrointestinal tract is a common cause of iron
deficiency anaemia, it is important to remember that blood may be lost by other means,
including urological cancers (although this will invariably be more noticeable).
Reference:

NICE CKS: Iron deficiency anaemia management

Key things for you to remember : 14/09/2023

 Atrioventricular septal defect is the commonest congenital heart defect in Down's
 Patients with CKD stages 4 and 5 should receive Hepatitis B, Influenza and
Pneumococcal vaccines in addition to the usual immunisation schedule
 Solar keratoses should initially be managed with topical treatments such as
diclofenac cream (Solaraze) and 5-fluorouracil cream (Efudex).
 Intense itching is not usually a prominent feature in psoriasis
 A man with unexplained iron deficiency anaemia of 120 g/L or lower or 100 g/L or
lower in a non-menstruating woman should be referred urgently for further
investigation.
 The pharmaceutical industry can continue to support continuing medical
education for GPs
 If a patient with epilepsy continues to drive despite advice to the contrary then
the doctor has a duty of care to society overriding confidentiality to the patient
and may inform the DVLA.
 When releasing medical information about a patient the Rehabilitation of
Offenders Act 1974 should be observed, meaning that information should not
contain reference to criminal convictions whether spent or not unless that
information is directly relevant to the patient’s condition or disability.
 Subdural haematoma can be associated with gradual onset of headaches,
memory loss, personality change, dementia, confusion and drowsiness (all of
which can be fluctuating).
 Wernicke's encephalopathy is caused by thiamine deficiency and may present
with visual symptoms, muscle incoordination, loss of memory and hallucinations