15/09/2023….

Friday

1….A 63-year-old gentleman is seen with a painful, swollen right first metatarsal joint.
He has a past history of gout and he tells you that he uses diclofenac whenever he gets
a flare-up and this clears things up within a few days.

About ten months ago he was started on allopurinol due to recurrent attacks and
currently takes 300 mg daily. You examine him and diagnose a recurrence of gout. This
is the first attack he has had since being started on the allopurinol.

What do you advise him with regard to his medicines during this acute attack of gout?

Add in aspirin to his regular medicines and treat the acute attack with a
NSAID
Increase the allopurinol dose and treat the acute attack with a NSAID
Stop the allopurinol and start an alternative prophylactic agent such as
sulphinpyrazone
Stop the allopurinol whilst treating the acute attack and restart it when
things have fully settled
Treat the acute flare of gout and continue the allopurinol at the same dose
whilst doing so

Key learning points

Musculoskeletal Health

 During an acute attack of gout, any prophylactic treatment with

allopurinol should be maintained at the same level until review of levels
and dosing, four to six weeks later.

Explanation
If an acute attack of gout occurs in a patient already taking allopurinol, the allopurinol
should be continued at the same dose and the acute flare treated appropriately.

Low dose aspirin has insignificant effects on uric acid levels, and aspirin in analgesic
doses (600 to 2400 mg/day) inhibits uric acid excretion and its avoidance is advised.

Uricosuric agents such as sulphinpyrazone or benzbromarone can be used as second

line drugs in patients who are resistant to, or intolerant of, allopurinol.
In this situation during an acute attack, you would not stop the allopurinol and switch to
an alternative, or increase the dose of allopurinol. The acute flare would be treated and
prophylactic treatment evaluated thereafter (typically this would mean reviewing the
allopurinol dosage based on a serum urate level done four to six weeks after the acute
flare-up; the aim of treatment is to maintain the plasma urate level below 300 µmol/L).

The British Society for Rheumatology has an excellent article on the management
of gout which covers all of the above points succinctly.

2….This is the fundoscopic appearance of a 69-year-old gentleman.

What is the underlying diagnosis?

Age related macular degeneration

Chronic open angle glaucoma
Diabetes mellitus
Hypertension
Infective endocarditis

Key learning points

Eyes and Vision, Metabolic Problems and Endocrinology
  Proliferative retinopathy as seen in patients with diabetes is identifiable
by the presence of new vessel formation

Explanation
The above picture shows the fundoscopic appearance of proliferative diabetic
retinopathy. Diabetic patients are offered regular retinal screening to monitor for eye
disease. Despite this screening, patients can present with acute eye signs and
symptoms between screening intervals and so knowledge of the features of diabetic eye
disease is important.

Background retinopathy is characterised by microaneurysms and microhaemorrhages

('dots and blots') and hard exudates.

Pre-proliferative retinopathy involves small retinal infarcts (cotton wool spots) and
extensive microhaemorrhages.

Proliferative retinopathy as displayed in this question is identifiable by the presence of

new vessel formation. This neovascularisation is shown at the top of the image and also
around the optic disc at the bottom right of the image. Identification of proliferative
retinopathy requires urgent specialist input as neovascularisation can lead to vitreous
haemorrhage, retinal detachment, and glaucoma (rubeosis iridis).

Maculopathy describes disease at the macula; microaneurysms, haemorrhages,

exudates, and oedema all occur. Visual acuity is often reduced.

3…Which one of the following statements about pertussis vaccination is correct?

Has a high chance of causing post-vaccination encephalopathy

Is contraindicated in a baby who had a confirmed allergic reaction to
streptokinase
Is contraindicated in a baby whose birth was assisted with forceps
Is contraindicated in a baby with egg allergy
Is recommended because pertussis has high mortality and morbidity

Key learning points

Children and Young People, Infectious Disease and Travel Health ,
Population Health, Respiratory Health

 Egg allergy is not a contraindication to pertussis immunisation

Explanation
The death rate from pertussis has declined significantly due to immunisation and
therefore this is recommended.

Absolute contraindication is anaphylaxis.

Egg allergy and forceps delivery are not relevant. A seizure is not a contraindication.
Streptokinase is a fibrinolytic drug which poses no known problems with pertussis
vaccine. The vaccine should not, however, be given to those who have had a confirmed
anaphylactic reaction to neomycin, streptomycin or polymyxin B (which may be present
in trace amounts).

The risk of post vaccination encephalopathy is low, especially with the acellular vaccine
where it is not described.

Further Reading:

Public Health England. Immunisation against infectious disease (The Green Book).

BMJ Best Practice: Primary prevention of Pertussis

4….A 55-year-old woman returns for review. She has been suffering with lower
abdominal pains and bloating for the last four to five months.

She tells you that she does have a longstanding tendency to constipation which goes
back to her teenage years and she uses lactulose as needed to ensure her bowels are
opened regularly. She reports that at present she opens her bowels most days and the
stools are soft and easily passed. She denies any rectal bleeding or mucus passage.
She denies any urinary symptoms. She had her last period aged 51 and denies any
subsequent vaginal bleeding or discharge.

Clinical examination is unremarkable. Her abdomen feels soft and no masses are
palpable.
Which of the following tumour markers is appropriate to request as part of her
investigation in primary care?

α fetoprotein
Carcinoembryonic antigen (CEA)
CA19-9
CA125
Chromogranin A

Key learning points

Gastroenterology , Gynaecology and Breast, Population Health

 CA125 is a tumour marker associated with ovarian cancer and should

be requested in women over the age of 50 with any persistent or
frequent symptoms that may be suggestive of ovarian cancer.

Explanation
Tumour markers can be a useful tool in certain clinical contexts. In the main, they are
not a 'routine' primary care investigation.

CA125 is a tumour marker associated with ovarian cancer and is a valuable test in the
diagnosis of ovarian cancer with regard to initial primary care investigations. Ovarian
cancer often presents with vague symptoms that can be easily attributable to more
benign pathology (for example, bloating, reduced appetite, early satiety, lethargy) and
therefore a high index of suspicion is needed and use of the CA125 tumour marker can
be helpful.

NICE recommend that women over the age of 50 who have one or more symptoms
associated with ovarian cancer that occur more than 12 times a month or for more than
a month are offered CA125 testing.

These symptoms include:

 Bloating
 Appetite loss
 Early satiety
 Abdominal pain
  Pelvic pain
 Urinary frequency/urgency
 Lethargy
 Weight loss, and
 Change in bowel habit.

The other options are typically specialist tests that would rarely if at all be requested in
primary care and are markers of other cancers:

 α fetoprotein - hepatocellular carcinoma

 CEA - colonic carcinoma
 CA19-9 - pancreatic cancer
 Chromogranin A - neuroendocrine tumours.

References:

NICE: CG 122 Recognition of ovarian cancer in primary care

RCOG: Ovarian Masses in Premenopausal Women, Management of Suspected

(Green-top Guideline No. 62)

BJGP: CA125 test result, test-to-diagnosis interval, and stage in ovarian cancer at
diagnosis: a retrospective cohort study using electronic health records

5….A 23-year-old medical student presents in January with a 'flu like illness.

For the past few weeks, she has had an intermittent fever. There are no other physical
signs. Nine months previously she completed an elective period in India.

Of which one of the following would you be most suspicious?

Cryptosporidium infection
Influenza
Meningiococcal meningitis
Trypanosomiasis
 Vivax malaria

Key learning points

Infectious Disease and Travel Health , Urgent and Unscheduled Care

 Beware malaria in feverish patients returning from foreign travel

Explanation
This is a good example of the importance of a good history - especially of travel abroad
(which may not be offered by the patient).

Influenza would be the commonest cause of a winter illness.

Meningiococcal meningitis doesn't fit with the chronology and trypanosomiasis is an

African (and S. American) disease.

Cryptosporidium infection would usually present with a watery diarrhoea within days of
infection.

Falciparum malaria normally presents within three months of infection, but Vivax can
take up to a year and in the circumstances, is the most likely. The main symptoms
include:

 cyclical fever and chills

 headache
 weakness
 vomiting, and
 diarrhoea.

Although not present in this case, patients may also present with splenomegaly.

Given this history and the travel to India, it would be important for the general
practitioner to be alert to the possibility of malaria and manage accordingly.

6….Theme: Causes of preterm delivery

A Bicornuate uterus
B Cervical weakness
C Chorio-amnionitis
 D Cocaine abuse
E Degenerating fibroid
F Gestational diabetes
G Multiple pregnancy
H Placental abruption
I Polyhydramnios
J Ruptured appendix
K Urinary tract infection

For each of the clinical scenarios detailed below, select the most appropriate option from the
given list.
A 24-year-old in her first pregnancy presents to labour ward at 28 weeks with uterine
contractions and pain, with a temperature and flu-like symptoms. She reports a three
day history of leakage of clear fluid vaginally that has now become offensive.
Please select an option

A 31-year-old in her first ongoing pregnancy at 30 weeks with suspected fetal

tracheoesophageal fistula, presents with a history of uterine contractions having noticed
her abdomen bloat over the previous 48 hours. On examination, the uterus is large for
Please select an option
dates and tense. Fetal parts are difficult to palpate.

A 32-year-old is in her first ongoing pregnancy, having had two previous mid-trimester
miscarriages. She presents to the antetenatal clinic at 25 weeks with backache and the
Please select an option
cervix is found to be 6 cms dilated.

A 29-year-old Afro-Caribbean woman in her first pregnancy presents to labour ward at

26 weeks with a history of increasingly severe abdominal pain. There is no vaginal
bleeding. On examination, the symphysis-fundal height is 34 cms and the uterus is
focally extremely tender to palpation. She has been vomiting throughout the day.
Please select an option

A 26-year-old banker presents at 32 weeks to labour ward with sudden onset of painful
uterine contractions. She is highly agitated, with dilated pupils and a tremor at rest. The
Please select an option
uterus is soft, and clinically small for dates.

Placental abruption

Incorrect- The correct answer is Chorio-amnionitis

Explanation
Chorio-amnionitis most commonly presents following preterm prelabour rupture of
membranes. The first signs are often maternal shivering and temperature.

Polyhydramnios

Correct

Explanation

Any fetal upper gastrointestinal obstruction (neck tumour, tracheal atresia, duodenal
atresia) may present with acute polyhydramnios, causing preterm labour.

Cervical weakness

Correct

Explanation

Cervical weakness (incompetence) classically presents as cervical dilatation in the

absence of uterine contractions. Risk factors are previous history, mid-trimester
terminations of pregnancy and surgery to the cervix.

Ruptured appendix

Incorrect- The correct answer is Degenerating fibroid

Explanation

Fibroids are most common in Afro-Caribbean women. They can degenerate in

pregnancy, causing pain, uterine tenderness, occasionally precipitating preterm labour.
Treatment is supportive: rehydration, analgesia and if appropriate, antibiotics.

Cocaine abuse

Correct

Explanation
Cocaine abuse is associated with fetal growth restriction. Its acute effects include
tremor, restlessness, dilated pupils and tachycardia. It stimulates smooth muscle
contraction. Drug abuse is not confined to the socially deprived.

Key learning points

Maternity and Reproductive Health

 Cocaine abuse is associated with fetal growth restriction

7….A 5-year-old child presents to the surgery after attending a school trip to a farm
some 10 days earlier.

He has watery diarrhoea, abdominal cramps and a low grade fever. According to his
mother he is still able to eat and drink and is passing urine normally. On examination he
looks washed out, his abdomen is soft and mildly tender.

Which one of the following is the most likely diagnosis?

Cryptosporidium
Escherichia coli O157
Q fever
S. aureus
S. suis

Key learning points

Children and Young People, Gastroenterology , Infectious Disease and Travel
Health

 Cryptosporidium results in a chronic watery diarrhoeal illness, which

begins on average around 10 days after exposure

Explanation
Differentials for a gastrointestinal illness posit a visit to a farm would be
between Cryptosporidium, Escherichia coli O157 and S. aureus.

S. aureus food poisoning, usually from dairy products, results in vomiting only a short
time after ingestion.

Escherichia coli O157 usually presents with non-bloody diarrhoea, three to four days
after exposure . Fifty percent have nausea and vomiting. The diarrhoea may become
bloody after two to three days and only 6% develop haemolytic uraemic syndrome.

In contrast, Cryptosporidium results in a chronic watery diarrhoeal illness, which begins

on average around 10 days after exposure.

Further Reading:
BMJ Best Practice: Cryptosporidiosis

Clinical Knowledge Summaries: Child gastroenteritis

GP Notebook. Haemolytic Uraemic Syndrome: Clinical Manifestations.

Health and Safety Executive. Zoonoses.

8….A 30-year-old lady, known to have hay fever, presented to your surgery with a three
day history of itchy, watery, red, eyes bilaterally. Her vision was unaffected and there
was no ocular discharge noted.

You gave her some topical ocular mast cell stabilisers but she presents to you two days
later, saying that her condition has not improved.

Which one of the following would be the best next step in managing this lady's
condition?

Continue with the same treatment

Refer to an ophthalmologist
Start patient on ocular lubricants
Start patient on topical ocular chloramphenicol
Start patient on topical ocular ofloxacin
Key learning points
Eyes and Vision

 Mast cell stabilisers take a few days to work and do not have immediate
effect.

Explanation
A patient with a history of hay fever presenting with itchy red watery eyes should make
the clinician think of vernal conjunctivitis which is associated with hay fever or atopy.

Giving topical mast cell stabilisers in this case is a good option, but the patient should
be informed that the drops may not take immediate effect. The best advice here would
be to tell patient that mast cell stabilisers may take a few days to work.

Ocular topical antibiotics would not be appropriate for vernal conjunctivitis.

Ophthalmology referral should only be considered should the condition worsen despite
treatment

9….A 42-year-old female presents with widespread pain that has been affecting her for
'many months'. She tells you that her muscles 'ache' and describes pain in all her limbs
with particular problems with aching in her shoulders, back and hips. She also tells you
that she gets frequent headaches, intermittent pins and needles in her hands and feet,
intermittent urinary frequency and suffers with poor sleep. She feels the pain in her
muscles is worse with activity. She has no bowel or menstrual symptoms.

On examination her pulse is 72 bpm and regular; blood pressure 118/76 mmHg; her
weight is stable; she has tenderness on palpation of the muscles in the neck and
shoulder area bilaterally and similar findings affecting her gluteal muscles and hips. The
joints themselves appear clinically normal. She walks with a normal gait.

Recent blood tests show: Normal full blood count, normal ESR, and normal creatine
kinase.

What is the most likely underlying diagnosis?

Fibromyalgia
 Hypothyroidism
Polymyalgia rheumatica
Polymyositis
Rheumatoid arthritis

Key learning points

Musculoskeletal Health

 Fibromyalgia is characterised by chronic diffuse muscular pain

associated with fatigue, paraesthesia, urinary frequency and
headaches.

Explanation
Fibromyalgia is a condition of unknown aetiology that is characterised by chronic diffuse
pain predominantly affecting the muscles.

It has a significant female preponderance with 90% of those affected being women. It
typically affects the age range 40-50 years. It is closely linked to anxiety and
depression. Associated symptoms include: fatigue, paraesthesia, urinary frequency, and
headaches.

Diagnostic criteria for fibromyalgia require the presence of 'chronic widespread pain'
(CWP) in addition to tender points on digital palpation of specific sites around the body.
Widespread pain is defined as pain in the left and right hand sides of the body, and pain
both above and below the waist. In addition to this, pain in the axial skeleton must be
present. Pain on digital palpation must be present in at least 11 out of 18 specific 'tender
point sites'. See the link given for more information on the diagnostic criteria (specifically
the location of the tender point sites).

It is important to rule other causes of pain and fatigue and so examination and
investigation should seek specifically to rule out conditions such as rheumatoid arthritis,
systemic lupus erythematosus (SLE), hypothyroidism, osteomalacia, polymyositis and
polymyalgia rheumatica.

The normal blood tests go against an 'inflammatory' diagnosis (normal full blood count
[FBC], erythrocyte sedimentation rate [ESR] and creatine kinase [CK]).
In terms of ruling out rheumatoid arthritis further, the joints are normal.

Hypothyroidism can cause myalgia but the above presentation is more in keeping
with fibromyalgia; the stable weight and absence of bowel or menstrual symptoms leads
away from the diagnosis of hypothyroidism.

10…..Theme: Neurology associated with alcohol abuse

A Alcoholic neuropathy
B Cerebellar ataxia
C Delirium tremens
D Dementia
E Hepatic encephalopathy
F Intoxication
G Subdural haematoma
H Wernicke's encephalopathy

Select the most appropriate diagnosis for the following patients who present with
problems:
A 63-year-old male presents as his family are concerned about his increasing
confusion. He has drunk heavily for many years. On examination he is
confused and sleepy, his speech is dysarthric, he appears jaundiced and has
Please select an option
ascites.

A 42-year-old male vagrant is arrested one morning for being drunk and
disorderly. He has a long history of alcohol abuse and has been arrested
previously. Later the following day he becomes confused and aggressive. On
examination, he is markedly agitated, confused, sweating profusely and is too
Please select an option
distressed and flailing his arms to permit examination.

A 17-year-old male presents, as his parents are concerned about him coming
home after going drinking with his friends. He has been vomting copiously and
has been drowsy. On examination, he smells of alcohol, he is drowsy but
responds to painful stimuli and has otherwise normal neurological examination
Please select an option
except for marked incoordination.

Wernicke's encephalopathy

Incorrect- The correct answer is Hepatic encephalopathy

Explanation

The 63-year-old male with longstanding alcohol abuse has developed confusion and
drowsiness associated with features of decompensated chronic liver disease, hence the
most likely explanation is hepatic encephalopathy. A flapping tremor would be expected.
This is due to nitrogenous toxic metabolites (ammonia) bypassing metabolism in the
liver due to shunting and accumulating in the systemic circulation producing an
encephalopathy. Treatment depends on clearing the bowel and treating any infection.

Alcoholic neuropathy

Incorrect- The correct answer is Delirium tremens

Explanation

This patient has developed agitation and confusion with flailing arms, suggesting
potential visual hallucinations. These symptoms suggest DTs. This is due to acute
alcohol withdrawal in a dependent person and requires appropriate benzodiazepine
therapy. Symptoms may begin a few hours after the cessation of alcohol, but may not
peak until 48-72 hours.

Intoxication

Correct

Explanation

In this patient's case, he is drunk. He has drank excessively, has an alcoholic gastritis
and is intoxicated. Let him sleep it off.

Key learning points

Mental Health, Neurology, Smoking, Alcohol and Substance Misuse

 Symptoms of delirium tremens may begin a few hours after the

cessation of alcohol, but may not peak until 48-72 hours.

Explanation
There are numerous neurological sequelae related to alcohol.
Key things for you to remember :15/09/2023
 Egg allergy is not a contraindication to pertussis immunisation
 Cryptosporidium results in a chronic watery diarrhoeal illness, which begins on
average around 10 days after exposure
 Mast cell stabilisers take a few days to work and do not have immediate effect.
 Proliferative retinopathy as seen in patients with diabetes is identifiable by the
presence of new vessel formation
 CA125 is a tumour marker associated with ovarian cancer and should be
requested in women over the age of 50 with any persistent or frequent symptoms
that may be suggestive of ovarian cancer.
 Beware malaria in feverish patients returning from foreign travel
 Cocaine abuse is associated with fetal growth restriction
 Symptoms of delirium tremens may begin a few hours after the cessation of
alcohol, but may not peak until 48-72 hours.
 Fibromyalgia is characterised by chronic diffuse muscular pain associated with
fatigue, paraesthesia, urinary frequency and headaches.
 During an acute attack of gout, any prophylactic treatment with allopurinol should
be maintained at the same level until review of levels and dosing, four to six
weeks later.