26/09/2023….

Tuesday

1….A 70-year-old man is admitted to hospital after a fall. He denies any loss of
consciousness but admits to increasing dizziness when attempting to get around his
flat.

He has a past medical history of cardiac failure, type 2 diabetes mellitus and
hypertension. His medications, which were recently altered by the hospital clinic, include
bendroflumethiazide, aspirin, ramipril, gliclazide, furosemide, simvastatin and
doxazosin, the latter being recently introduced.

Which single observation would help establish his diagnosis?

24 hour ambulatory ECG

Arterial blood gases
Axillary temperature recording
Lying and standing blood pressures
Recumbent blood pressure measurement

Key learning points

Cardiovascular Health , Urgent and Unscheduled Care

 Drug induced postural hypotension is particularly associated with alpha

blocker therapy

Explanation
This patient has drug induced postural hypotension, a problem associated with
antihypertensive therapy and particularly alpha-blockers.

Note that the clue lies in the recent introduction of doxazosin.

References:

BMJ Best Practice: Orthostatic hypotension

Clinical Knowledge Summaries: Alpha blockers

2….Which of the following patients requires use of a cardiovascular risk assessment tool (such
as QRISK) to determine whether they are high risk of cardiovascular disease (CVD)?

A 58-year-old woman with a history of a myocardial infarction 12 months ago

A 55-year-old woman with an eGFR of 50 ml/min/1.73m2 without albuminuria
A 45-year-old man with type 1 diabetes with a HbA1c of 48 mmol/mol and no nephropathy or
microalbuminuria
A 60-year-old man with a body mass index of 38 kg/m2
An 89-year-old man who has no significant medical history nor other risk factors for
cardiovascular disease

Key learning points

Cardiovascular Health , Population Health

 Certain patient groups should be considered at high risk of CVD without

the need for CVD risk assessment tools

Explanation
Certain patients should be automatically considered at high risk of cardiovascular
disease (CVD) and use of a CVD risk assessment tool such as QRISK2 is not needed
in these cases.

Such high risk CVD patients are:

 Those with pre-existing CVD

 Those aged 85 and above
 Those with an eGFR <60 ml/min/1.73m2 and/or albuminuria
 Those with familial hypercholesterolaemia or other inherited lipid
disorders
 Those with type 1 diabetes who are: over 40 years old, or have a history
of diabetes for at least 10 years, or have established nephropathy, or
have other CVD risk factors.

In this case, the only patient that requires use of a CVD risk assessment tool is the
patient with the BMI of 38. The others would automatically be considered as high risk.

It is worth noting that those with a BMI higher than 40 kg/m 2 will have their risk
underestimated by standard CVD risk assessment tools.
References:

Clinical Knowledge Summaries: CVD risk assessment and management

NICE: Cardiovascular disease: risk assessment and reduction, including lipid

modification CG181

QRisk: QRisk scoring

3….Theme: Heavy menstrual loss

A Combined hormonal contraceptive pill
B Danazol
C Depo-Provera
D Weight loss advice
E Intrauterine device (copper coil)
F Intrauterine system (hormone releasing system eg Mirena)
G Mefenamic acid
H Oral norethisterone days 5-26 of cycle
I Progesterone only contraceptive pill
J Smoking cessation advice
K Tranexamic acid

Please select the most appropriate management for the gynaecological cases below.

Each of the possible options may be used once, more than once or not at all.
A 25-year-old female presents with heavy, regular menstrual loss. She has never been
pregnant and is planning to start trying for a family after her wedding in 15 months' time
and currently using condoms for contraception. She tried a combined contraceptive pill
in the past but forgot to take it at times and thought it made her gain weight so
discontinued it. She takes PMH Asthma DH salbutamol inhaler as required. She has no
Please select an option
known drug allergies. Her BMI is 35.

A 42-year-old female who presents with heavy regular menstrual loss. She has two
children and her partner has had a vasectomy, prior to which she had used the
combined oral contraceptive pill and intrauterine system, which had been expulsed 3-4
weeks after insertion. She is currently taking tranexamic acid 500 mg three times daily
during her menses. Despite this, she is changing tampons and pads every hour for the
first 3 days and has had multiple episodes of flooding at work. PMH Nil DH Nil. She has
no known drug allergies. She would prefer to take a tablet if possible. Her BMI is 36.
Please select an option

A 30-year-old female presents for advice. She recently stopped the depo-provera
injection for contraception as she and her partner are thinking of trying for a family
within the next 12 months and she was informed it could take a number of months after
stopping the injection for her periods to return to normal. She is keen however to have
contraception as she has a number of family functions over the next couple of months
and does not wish to get pregnant prior to these. She is also concerned as prior to
starting the depo injection, she suffered with heavy, painful periods. She used to take
mefenamic acid for these, which she tolerated well. PMH Nil DH Nil. She has no known
Please select an option
drug allergies. Her BMI is 28.

Weight loss advice

Incorrect- The correct answer is Intrauterine system (hormone releasing

system eg Mirena)

Explanation
The IUS is first line in patients presenting with menorrhagia where the anticipated
minimum use would be 12 months. She has missed pills in the past and requires
contraception so, needs long acting contraception which would also help her
menorrhagia. Depo-provera would give long acting contraception as well as possible
reduction in bleeding however, return to fertility on stopping can be delayed.

.
Intrauterine system (hormone releasing system eg Mirena)

Incorrect- The correct answer is Oral norethisterone days 5-26 of cycle

Explanation
This is recommended by NICE as a third line management option. This patient has tried
the IUS, tranexamic acid and COCP and would prefer an oral agent rather than long-
acting progestogen hence norethisterone is the most appropriate answer. Her BMI rates
her UKMEC catogory 3 for COCP (risks outweigh advantages)

.
Progesterone only contraceptive pill

Incorrect- The correct answer is Combined hormonal contraceptive pill

Explanation
This will cover her contraception for the few months required. IUS not
appropriate as planning to conceive within the next 12 months. Mefenamic
helps with dysmenorrhea and menorrhagia but does not give contraceptive
cover, which is required here.
Key learning points
Gynaecology and Breast, Maternity and Reproductive Health , Sexual Health

 The IUS is first line in patients presenting with menorrhagia where the
anticipated minimum use would be 12 months

Explanation
The levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena®) is the preferred
first choice for the treatment of menorrhagia, provided that long-term contraception with
an intrauterine method is acceptable (anticipated minimum use of 12 months).

Further reading:

NICE Guidelines: Menorrhagia

4….You are called to the death of a 78-year-old male on the care of the elderly unit.

He has a long history of breathlessness associated with heart failure and the nurses
state that he suddenly collapsed and died. He was not resuscitated.

Which of the following is the most appropriate sole cause of death that you may place
on a death certificate?

Cardiac arrest
Heart failure
Ischaemic heart disease
Old age
Respiratory arrest

Key learning points

Improving Quality, Safety and Prescribing

 When writing a death certificate, you should state the pathological

cause, such as ischaemic heart disease and avoid using modes of
dying such as liver, heart or respiratory failure.
Explanation
Cardiac arrest, syncope, apnoea, respiratory arrest, heart, liver or kidney failure are all
modes, rather than underlying causes of death, and thus unacceptable for a death
certificate.

Generally, a cause of death is the pathological condition responsible for death, for
example, ischaemic heart disease or myocardial infarction.

"Old age, 'senility' or 'frailty of old age' should only be given as the sole cause of deathin
very limited circumstances. These are that:

 You have personally cared for the deceased over a long period (years,
or manymonths)
 You have observed a gradual decline in your patient's general health
and functioning
 You are not aware of any identifiable disease or injury that contributed
to the death
 You are certain that there is no reason that the death should be
reported to the coroner

You may mention old age or frailty as a contributory cause, especially if it explains the
severe effect of a condition that is not usually fatal. You should bear in mind that
coroners, crematorium referees, registrars and organisations that regulate standards in
health and social care, may ask you to support your statement with information from the
patient's medical records and any investigations that might have a bearing on the cause
of death. You should also be aware that the patient's family may not regard old age as
an adequate explanation for their relative's death and may request further investigation.

While there is no statutory age limit or restriction on referring to 'old age', a death
certified as due to old age or senility alone will usually be referred to the coroner, unless
the deceased was 80 or older, all the conditions listed above are fulfilled and there is no
other reason that the death should be referred. Similar terms, such as 'frailty of old age',
will be treated in the same way."

Death Cerificates at a glance

5….An 8-year-old boy wakes up screaming at night. This usually happens shortly after he has
gone to sleep.

His parents say that he sits up and seems awake but does not respond to them. Episodes last a
few minutes and then the child nods off again. His parents have taken his pulse during the
episode and say it is very fast. When woken after a recent attack, he appeared confused about
what had happened.

This occurred about four months ago and happened most nights for about two weeks and then
went away on its own.

Which one of the following is the diagnosis?

Cardiac arrhythmias
Nightmares
Night terrors
Obstructive sleep apnoea
Seizures

Key learning points

Children and Young People

 Patients experiencing night terrors may wake up confused and unable

to recall what happened to them during the episode

Explanation
This scenario is the classical description of night terrors.

Episodes seem to be more common in families, suggesting a genetic predisposition and

there is often an association with increased sympathetic outflow. Patients may wake up
confused, unable to recall what happened to them.

Parents will rarely give this much information without prompting.

Night Terrors - PatientPlus

Night Terrors - Medscape

6…..A 52-year-old woman who complains of exertional breathlessness presents to the
clinic as she is desperate to stop smoking. She has had a number of unsuccessful
attempts to stop smoking over the years and has tried nicotine patches.

Which of the following would be an appropriate choice to assist in her attempts at

smoking cessation?

Acupuncture
Hypnotism
Nicotine gum
Nortriptyline
Varenicline

Key learning points

Respiratory Health , Smoking, Alcohol and Substance Misuse

 Varenicline is recommended as a possible treatment to help smokers

who have said they want to stop smoking

Explanation
Varenicline (Champix) is an oral anti-smoking agent with dual action, reducing the
craving for cigarettes and also making the smoking of cigarettes less pleasurable.

Varenicline appears to be more effective in clinical trials than either bupropion or

placebo and is prescribed for 12 weeks in the first instance with further 12 week course
if craving still persists.

Reference:
NICE: Varenicline for smoking cessation (TA123)

British National Formulary: Varenicline

7….In May 2012, the GMC published a study looking at prescribing errors in general
practice, called the PRACtICe study.

What drug was most commonly associated with prescribing errors?

 Carbamazepine
Gabapentin
Paracetamol
Prednisolone
Simvastatin

Key learning points

Improving Quality, Safety and Prescribing

 According to the PRACtICe study, simvastatin was the drug most

commonly associated with prescribing errors.

Explanation
The PRACtICe study commissioned by the GMC has highlighted a number of important
conclusions with regard to prescribing errors in general practice.

The drugs listed as options above were associated with prescribing errors with
frequency listed as follows:

 Carbamazepine - 1.2%
 Gabapentin - 1.2%
 Paracetamol - 1.2%
 Prednisolone - 2.4%
 Simvastatin - 10.5%.

Reference:
General Medical Council (GMC)Investigating the prevalence and causes of prescribing
errors in general practice: The PRACtICe Study.

8….A 50-year-old man has multiple medical problems - both physical and psychiatric.
He has been complaining of weak muscles and pain since an accident at work and has
made an insurance claim.

He makes a complaint about the practice and asks to see a copy of his medical records.
He eventually receives a copy of his records. He comes to you a week later. The
diagnosis 'conversion disorder' is written in a letter from the insurance company doctor -
he asks you what this is.
What would you do?

Explain that a conversion disorder means he had symptoms affecting his

muscles, but the doctor from the insurance company felt that psychological
factors were associated with the symptoms and his symptoms couldn't be
explained by a physical illness
Explain that the doctor from the insurance company felt he was pretending
to have a weak leg
Explain that the doctor from the insurance company thought he had
hypochondriasis
Explain to him that he shouldn't worry about things like this - he should just
try to continue with his rehabilitation
Tell him you have done your duty by releasing the records and that you are
not obliged to give him any further information

Key learning points

Improving Quality, Safety and Prescribing

 Patients are entitled to explanations of any medical terminology that

they do not understand

Explanation
The patient is entitled to an explanation of the details that he does not understand.

A conversion disorder occurs when patients have symptoms that can't be explained by
a physical illness and when psychological factors are associated with the symptoms.

Hypochondriasis occurs when patients are preoccupied with fears that they have a
serious disease. This happens because they misinterpret physical symptoms.

Deliberately pretending to have a weak leg is malingering.

He needs an explanation and is unlikely to engage in rehabilitation if he feels that he

does not know what is going on.
9….Theme: Visual field defects
A Bitemporal hemianopia
B Central scotoma
C Cortical blindness
D Left homonymous hemianopia
E Left inferior homonymous quadrantanopia
F Left superior homonymous quadrantanopia
G Left uniocular visual loss
H Right homonymous hemianopia
I Right inferior homonymous quadrantanopia
J Right superior homonymous quadrantanopia
K Right uniocular visual loss

Please choose the most appropriate description for the following visual field defects.

The visual fields are represented so that the shaded areas are the areas that the patient
cannot see. Please note that the VF defects are depicted as if you are looking at the
patient.

Please select an option

Image 1
Please select an option
Image 2

Please select an option

Image 3

1
Bitemporal hemianopia

Correct
Explanation

There has been a lesion at the site of the optic chiasm as the temporal vision of the
patient has been lost. This is often due to a pituitary tumour.

2
Central scotoma

Correct

Explanation

Here, the patient would be unable to see anything centrally in their vision. A common
cause of this is multiple sclerosis.

3
Cortical blindness

Incorrect- The correct answer is Right inferior homonymous

quadrantanopia

Explanation

The patient is unable to see anything inferiorly on their right side. The likely site for a
lesion is in the optic radiation to the parietal lobe.

Please note that the VF defects are depicted as if you are looking at the patient,
therefore the right VF is on your left. So, in this case the quadrantic defects are both
inferior and on the right.

Key learning points

Eyes and Vision, Neurology

 A lesion at the optic chiasm, such as a pituitary tumour, may result in a

bitemporal hemianopia on visual field testing

Explanation
In the eyes, fibres convey information from the temporal and nasal aspects. These
fibres cross over at the optic chiasm so that the fibres conveying the nasal aspects of
the vision remain on the same side and the fibres that convey information about the
temporal view cross over.

Information is then conveyed along the optic tracts to the lateral geniculate body.

The pictures show you what the patient's vision is like if you were sat in front of them,
not the vision you would see if you were them. ie: the right eye is on the left of the
diagram and the left eye is on the right of the diagram.

10….A 37-year-old woman has a potassium reading of 3.1 mmol/L. There is no obvious cause,
so you call her in to assess her in detail.

When you take a history you realise that she has urges to eat a large amount of food and that she
tends to binge eat. She then takes laxatives. She denies ever making herself vomit. These
episodes occur about three times a week. Her body mass index is 19.5 kg/m2.

Which one of the following is the most likely diagnosis?

Anorexia nervosa
Bulimia nervosa
Delusional disorder
Normal variant behaviour
Refeeding syndrome

Key learning points

Mental Health

 Not all people with bulimia nervosa make themselves vomit.

Explanation
The diagnosis that best fits with this case history is bulimia nervosa. She has recurrent
binges and then tries to compensate for these by taking laxatives.

Bulimia is common in older patients (from their 20s onwards), whereas anorexia is more
common in teenagers. Having been assessed 'in detail' there is no direct mention of
delusional behaviour and she is only marginally underweight, taking a BMI of 20
kg/m2 as the lower limit of normal.
Urges to eat large amounts of food, binge eating, frequent use of laxatives and the low
potassium tend to suggest that this is not a normal variant behaviour.

Refeeding syndrome is very rare in general practice and is usually associated with
parenteral nutrition in the hospital setting (although it can occur with enteral nutrition
after a long period of starvation).

Key things for you to remember : 26/09/2023

 Drug induced postural hypotension is particularly associated with alpha blocker
therapy
 Certain patient groups should be considered at high risk of CVD without the need
for CVD risk assessment tools
 Patients experiencing night terrors may wake up confused and unable to recall
what happened to them during the episode
 A lesion at the optic chiasm, such as a pituitary tumour, may result in a
bitemporal hemianopia on visual field testing
 The IUS is first line in patients presenting with menorrhagia where the anticipated
minimum use would be 12 months
 When writing a death certificate, you should state the pathological cause, such
as ischaemic heart disease and avoid using modes of dying such as liver, heart
or respiratory failure.
 Patients are entitled to explanations of any medical terminology that they do not
understand
 According to the PRACtICe study, simvastatin was the drug most commonly
associated with prescribing errors.
 Not all people with bulimia nervosa make themselves vomit.
 Varenicline is recommended as a possible treatment to help smokers who have
said they want to stop smoking