The Correct Answer is DStem gives clues to osteoporosis – progressive kyphosis over 3 years, history of hysterectomy 50 years previously (?sparing of ovaries). The X-ray interpretation is also consistent with osteoporosis.
The Correct Answer is B/E Dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow were significantly related to aspiration and were predictors of the subset of patients with silent aspiration. The prediction of patients at risk for aspiration was significantly improved by the presence of concurrent findings of abnormal volitional cough and cough with swallow on clinical examination.
Patients likely to aspirate can be identified best by the presence of an abnormal voluntary cough, an abnormal gag reflex, or both. The prediction of patients at risk for aspiration was not improved by additional clinical information (i.e., presence of dysphonia or bilateral neurological signs).
B) is possibly marginally better answer than E) because presence of dysphonia does not improve accuracy of prediction of risk of aspiration.
The Correct answer is B
![Accommodating risk: Responses to BRCA1/2 genetic testing of women who have had cancer [An article from: Social Science & Medicine]](https://lh3.googleusercontent.com/blogger_img_proxy/AEn0k_t1LujstLJyPa-n6B8XaHUornl80mGKHqc87czUoymyKObd_9IIvu1vBcKgJxUlldKmYVsy8-ZsqLeuSiTI0RK7d6J3dqnUh4iS2GMKc85jRAbE0XmpT96ZJ7lsLc519Ex23nAuXdTTawmHWf358wpa9Gb245YA9hixXTlXLMZXDkiYNYeRct5_0tjmkCwueDDmmv2GDEXtznLse52eltIm_ToVZnB8In-1yUO-CQ=s0-d)
BRCA 1 & BRCA 2 cause early breast cancer (dominant inheritance). ATM gene causes breast cancer
– DNA repair disorder (recessive inheritance). P53 mutations are found in ~60% of all human cancer types including breast. Note Li-Frumeni syndrome – vulnerable to a wide range of cancers, 50% likelihood of Ca by age 30 & 90% by age 65. The precise function of p53 is unknown – may act as DNA policeman to prevent transcription & replication of unstable DNA.
Bcl-2 is involved in the control of apoptosis (programmed cell death) & prevents the p53 mediated destruction of cells with damaged DNA. It also may prevent the death of cells severely damaged by chemotherapy, & mediates drug resistance & contributes to neoplasia by this mechanism rather than promoting aberrant cell growth. It was first identified because of an association with follicular lymphoma.
The Correct Answer is B
Maternal pattern of transmission
Mitochondrial inheritance
2 distinctive features
matrilineal inheritance
both sexes affected but transmission only by females as mitochondria are only maternally derived
the presence of both normal & mutation carrying mitochondrial DNA in a cell – explains wide phenotypic variation between affected individuals in a family
The Correct Answer is D
The glycolytic enzyme glucokinase plays an important role in the regulation of insulin secretion and recent studies have shown that mutations in the human glucokinase gene are a common cause of an autosomal dominant form of non-insulin-dependent (type 2) diabetes mellitus (NIDDM) that has an onset often during childhood.
The Correct Answer is B
Linkage analysis methods all rest on the biological phenomenon of recombination of homologous
chromosomes. During meiosis homologous chromosomes pair up and exchange material. The probability of a recombination event occurring between loci far apart on a single chromosome is larger than for loci closer together. Hence, alleles at loci near each other are generally inherited (or co-segregate) together, making it possible to follow transmission from generation to generation at unknown loci by using alleles at neighbouring loci (i.e. the neighbouring locus alleles act as surrogates for the presence of alleles at other loci).
The Correct Answer is A
History is most consistent with HNPCC
HNPCC is linked to mutations caused by microsatellite instability in several mismatch repair genes, notably
hMSH2 &
hMLH1. As a result, there is defect repair of DNA mismatches with abnormal cell growth & tumour development. The majority of these mutations are inactivating insertions or deletions.
The correct Answer is A
Factor V Leiden is the most common hereditary blood coagualtion disorder in the United States. It is present in 5% of the Caucasian population and 1.2% of the African American population.
Factor V Leiden increases the risk of venous thrombosis 3-8 fold for heterozygous (one damaged gene inherited) and substantially more, 30-140 fold, for homozygous (two damaged genes inherited) individuals.
The prothrombin 20210 mutation is the second most common inherited clotting abnormality. It is more common than protein S and C deficiency and Antithrombin deficiency combined; 2% of the general population is heterozygous. It is only a mild risk factor for clots, but together with other risk factors (such as oral contraceptives, surgery, trauma, high blood pressure, obesity, smoking, etc) or combined with other clotting disorders (like Factor V Leiden), the risk of clotting increases dramatically.
Factor V Leiden can be associated with the following complications:
- Venous Thrombosis blood clots in veins, such as:
- Deep vein thrombosis (DVT), veins in arms and legs
- Superficial thrombophlebitis
- Sinus vein thrombosis, veins around the brain
- Mesenteric vein thrombosis, intestinal veins
- Budd-Chiari syndrome, liver veins
- Pulmonary Embolism (PE), blood clots in the lungs
- Arterial clots (stroke, heart attack) in selected patients (some smokers)
- Possibly with stillbirth or recurrent unexplained miscarriage
- Preeclampsia and/or eclampsia (toxemia while pregnant)
Source
The Correct Answer is B
With a nonsense mutation, the new nucleotide changes a codon that specified an amino acid to one of the STOP codons (TAA, TAG, or TGA). Therefore, translation of the messenger RNA transcribed from this mutant gene will stop prematurely. The earlier in the gene that this occurs, the more truncated the protein product and the more likely that it will be unable to function.
With a missense mutation, the new nucleotide alters the codon so as to produce an altered amino acid in the protein product.
The Correct Answer is B
CF is an autosomal recessive disease resulting from mutations in a gene located on chromosome 7. The prevalence of CF varies with the ethnic origin of a population. CF is detected in approximately 1 in 3000 live births in the Caucasian population of North America and northern Europe, 1 in 17,000 live births of African-Americans, and 1 in 90,000 live births of the Asian population of Hawaii. The most common mutation in the CF gene (~70 percent of CF chromosomes) is a 3-base-pair deletion that results in an absence of phenylalanine at amino acid position 508 (F508) of the CF gene protein product, known as the CF transmembrane regulator (CFTR). The large number (>400) of relatively uncommon (<2 style="font-family:Arial, sans-serif;">
More than 95 percent of male patients with CF are azoospermic, reflecting obliteration of the vas deferens that probably reflects defective liquid secretion.
The Correct Answer is A
Heterozygous his (H63D)
The gene identified by Feder and colleagues (1996) ("HLA-H" but now defined as HFE) lies approximately 5Mb telomeric to HLA-A and shows similarity to MHC class 1 genes. A single mutation is associated with HHC in 65 to 100 percent of cases.
The mutation is a G to A transition at nucleotide 845 and results in the substitution of cysteine with tyrosine at position 282 (C282Y) and disruption of a disulphide bridge required to stabilise the protein. A second mutation, a C to G change causing a histidine to aspartic acid substitution at position 63 (H63D) was also identified.
Recent data from numerous countries have confirmed that the C282Y mutation is primarily responsible for the large majority of HLA-linked HHC cases. The figures range from approximately 95 percent in Australia to 90 percent in Great Britain, 80 percent in the United States to 60 percent in Italy. The higher values are found in populations of Northern European extraction, the lower percentage in patients of Southern European (Mediterranean) extraction. (Jazwinska et al, 1996; Carella et al, 1996). Thus it must be emphasised that a varying proportion (10 to 40 percent) do not carry either mutation, and clinicians should not be misled into believing that patients who are not homozygous for the C282Y mutation do not have HHC. A small proportion (approximately 7 percent) of HHC cases are compound heterozygotes (i.e., carrying one copy of each of the C282Y and H63D mutations). Non-HFE-associated familial haemochromatosis has been described recently from Italy (Carella et al, 1997) and it is now established that the juvenile form of haemochromatosis, while clinically closely resembling the adult form, but occurring in the second and third decades of life, is not due to this mutation; nor are African iron overload or neonatal haemochromatosis.
There is emerging clinical evidence to suggest that the second mutation (H63D) has a significant independent role in causing iron overload although this is usually of mild to moderate degree. Thus, compound (C282Y/H63D) heterozygotes may develop iron overload of a degree previously recognised as consistent with homozygous HLA-associated HHC, although as a group they do not have as severe iron overload as C282Y homozygotes (Crawford et al, 1998). The H63D mutation appears to have both low penetrance and comparatively low expressivity.
The molecular basis of the iron overload due to these two mutations is rapidly being elucidated. In cultured cells, the wild-type HFE protein associates with the transferrin receptor and lowers the affinity of this receptor for transferrin. The C282Y mutation prevents the complexing of HFE with 2 microglobulin and the protein therefore accumulates in the endoplasmic reticulum and does not emerge to the cell surface and does not associate with the transferrin receptor (TfR). The H63D mutation in contrast lacks the ability of the wild-type HFE protein to decrease the affinity of TfR for transferrin (Feder et al, 1998). Thus, the two mutations have independent effects on iron metabolism relating to the affinity of TfR for transferrin on the cell surface.
The Correct Answer is B
Acute glaucoma usually occurs in people who are known to have the chronic disease but it may present for the first time before the diagnosis has been made. There is diurnal variation of IOP that is highest in the early morning
Risk factors include:
- Older age
- Family history of acute glaucoma
- Shallow anterior chamber (check other eye)
- Drugs with anticholinergic actions like tricyclic antidepressants and antispasmodics or anticholinergic eye drops. There are many reports of glaucoma triggered by nebulized anticholinergic and beta-agonist medications. Intranasal cocaine for nasal procedures (and no doubt for recreation) has caused acute attacks, as has paroxetine.
- Hypermetropia
- Diabetes
- Dim lighting, emotional upset (dilatation of pupils exacerbates drainage block).
The Correct answer is E
H
2 antihistamines, such as cimetidine, famotidine, and ranitidine, may have a role when used in combination with H
1 antihistamines in selected instances of urticaria. H
1 and H
2 antihistamines are thought to have a synergistic effect and often result in a more rapid and complete resolution of urticaria than H
1 antihistamines alone, especially if given simultaneously intravenously.
Commonly used first-generation agents include diphenhydramine, hydroxyzine, doxepin, chlorpheniramine, and cyproheptadine. The second-generation agents that are currently available in the United States are cetirizine, desloratadine, loratadine, and fexofenadine. All 4 are active in chronic urticaria.
The Correct Answer is D
General practitioners (though not at present ambulance paramedics) may wish to start thrombolytic treatment outside hospital providing that they have facilities for managing arrhythmia and for resuscitation, including defibrillators (which may be provided by an attending ambulance); they can accurately diagnose acute myocardial infarction by using clinical and electrocardiographic criteria; and they believe that pre-hospital treatment in each case will result in an appreciable time saving, particularly if this is the only way of achieving a 90 minute "call to needle" time
The call
to needle time should ideally be no longer than 60 minutes,
but 90 minutes is a reasonable target for those patients with
a readily diagnosed acute myocardial infarction.
Reference:
Guidelines for the early management of patients with myocardial infarction C F M Weston, W J Penny, D G Julian
The Correct Answer is D
Non A - non B hepatitis has an incubation period of 6 - 8 weeks and is transmitted by blood transfusion, coagulation products and by contaminated water. It is associated with a carrier state unlike hepatitis A in which carrier states do not occur. Acute cholangitis is a medical emergency with a high mortality rate. 5 - 10% of people fail to eliminate the virus in hepatitis B, it has poorer prognosis especially if associated with the presence of virus D.
The Correct Answer is D
Terfenadine is an OTC antihistamine and there have been reports of serious cardiac arrhythmia's if given with erythromycin or systemic anti fungal agents. Ciprofloxacin causes a potentiation of theophyline levels, this drug has a narrow therapeutic window and therefore toxic effects can occur. Cimetidine potentiates the effect of oral anticoagulants including warfarin.
The Correct Answer is B
Although the mean IQ. is 80, it is often average or above. Specific learning difficulties are more common, but speech, language, hearing and visual difficulties are rarely a problem. If a diplegia is present, the early development of spasticity is associated with a better outcome.
The Correct Answer is E
A study in the USA in 1980 that owning pets was associated with increased survival following myocardial infarction. An Australian study showed significant differences in blood pressure and lipid levels between pet owners and those without animals. A further study from Cambridge showed a 50% decrease in minor health problems within one month of cat or dog ownership. This reduction was maintained at 10 month follow up.
The Correct Answer is D
Sub-arachnoid haemorrhage is typically due to rupture of an intracranial saccular aneurysm. 10% die without warning, 45 - 50% of all patients will die within 3 months. Only 30% of patients will survive without disability and of those going to surgery about 45% will achieve their previous quality of life. Surgery has an operational mortality of approximately 2% in major centres. Peak age range is 55 - 60 years of age and there is a familial tendency.
The correct Answer is C
In women chlamydia is usually asymptomatic and causes a cervicitis rather than a vaginitis. a negative MSSU with dysuria in a sexually active woman should lead to a search for the organism. If present in pregnancy there is a 50% transmission rate to the neonate with the risk of conjunctivitis, and pneumonitis. Treatment should begin before delivery . In men the common presentation is with non specific urethritis or epididymitis, it is not associated with prostatitis.
The Correct Answer is B
Herpes simplex infection usually heals within 6 - 10 days with typical acyclovir. Recurrence rate is less than 5% if treatment if commenced promptly. Visual acuity is not affected with peripheral lesions but is more likely if the central cornea is affected. Referral is indicated because of the potential threat to vision.
The Correct Answer is D
Neck pain is very common, women are more prone than men in a ratio of 2:1. It is usually a benign transitory condition with 85% of patients symptom free within 1 - 4 weeks. About 18 - 20% relapse within 2 years. Soft collars are of no proven benefit and they are not prescribable on an FP10. NSAIDs have a role in reducing the severity of symptoms and in selected patients manipulation is of definite benefit.
The correct Answer is A
Under the Children's Act the wishes of the Child are paramount and the doctor must treat the child if he feels that the child is mature enough to make a decision about himself.
The Correct Answer is C
Unfavourable factors in depressive illness include, and obsessional personality, previous significant depressive illness, loss of any parent but especially mother prior to the age of 12 years, bereavement in later life, no sympathetic close relationship, poor social circumstances, being house bound or tied to the house by an ill relative. Conversely, favourable factors include, a secure childhood, support from a friend or relative and an active social life with outside activities.
The Correct Answer is AFebrile convulsions are associated with temperatures in the 6 month to 6 year age group and 90% of the fevers are caused by viral infections. The prevalence in one recent study was 2.4%. The fits typically last less than 10 minutes and autonomic behaviour and transient neurological sequelae are not usual. Diazepam can safely repeated within 20 minutes of the first dose if the fit does not respond or recurs. There is a 50% chance first degree relative has had a febrile convulsion, with idiopathic epilepsy there is only a 10% chance of family history.
The correct Answer is D
Progestogen only pills cause little or no change in clotting mechanisms and do not affect lipid levels. They need not be stopped prior to surgery. They are not secreted in breast milk. If started on the first day of the cycle they provide immediate protection. If started after a combined oral contraceptive has been given they should be commenced immediately after the last combined pill has been taken and not at the end of the 7 pill free days.
The Correct answer is B
The classic studies of Murray Parkes showed that bereavement has a definite and high mortality for the remaining partner. Over 55 years of age the death rate for men is 40% in the first year following death of a spouse. Overall the death rate is 20%. Even by the third year the death rate is still greater that for the normal population.
The Correct Answer is D
Irritable bowel syndrome has been treated by increasing dietary fibre, however some patients find that excess bran makes the symptoms worse. In one study, 70% of patients improved on a bland diet free of wheat and milk. Increased fermentation in the gut is directly implicated as a trigger for the condition. Metronidazole substantially alters the aerobic/anaerobic balance within the bowel and can increase the fermentation rate. Nystatin has been shown to decrease fermentation and improves symptoms. Stress is a well known trigger factor and hypnosis and relaxation techniques decrease the symptoms and the relapse rate if IBS.
The Correct Answer is B
Cramps especially occurring during the night are common. However there are a large number of causes which should be excluded. Drug therapy especially diuretics and sympathomimetics, even if the latter are inhaled, are frequent causes. Peripheral vascular disease and venous obstruction do not cause cramps, but cramps may coexist. About 80% of those with cirrhosis have nocturnal cramps. Lumbar spine dysfunction especially nerve involvement at the L5/S1 level is a potent cause of nocturnal cramps.
The Correct Answer is A
40% of throat swabs yield no growth, 30% are streptococcal, 20 % viral and 10% other organisms including haemophilus. The decrease in incidence of rheumatic fever and glomerulonephritis predates the introduction of antibiotics and is ascribed to the raised standards of cleanliness and housing conditions. Tonsillar exudate in an under 15 year old is more typical of streptococcal, in an over 15 year old of glandular fever. However the appearances and the presence of lymphadenopathy are not characteristics of any specific type of infection.
The Correct Answer is B
There are about one million new case of back pain per year and the average general practitioners sees about 50 acute backs per year. Many people do not consult, however 10 - 15 million working days are lost per year because of back pain. 80% recover in 3- 4 weeks however in 50% of patients there is a recurrence within the next 5 years. About one third of patients are referred for specialist opinion but only 1:200 of the original sufferers
and 1:60 of those referred undergo surgery. Several studies have shown that rest, in the early stages, reduces the overall time away for work.
The Correct Answer is C
The average practitioner will have 2 - 3 new patients with gout per year, 20% of patients will have a family history. It is 6 times commoner in males than females. Chronic tophaecous gout is now rare, but that and renal gout with calculi are indications for allopurinol treatment. 25 - 40% of those with gout will have or will develop hypertension. Triglyceride levels are higher in gout sufferers.
The Correct Answer is B
At present less than 50 % of mothers breast feed their babies successfully . Whether this government target can be met is a matter of considerable doubt. Mastitis is typically caused by staphylococcus. Breast feeding dose take considerably longer than bottle feeding and this point should be emphasised to reassure mothers. Obesity is rare in breast fed infants but more common in bottle fed infants Introduction of cows milk should not take place until one year of age. The solute load is too great for children until this age. Full cream milk and not semi-skimmed should be used.
The Correct Answer is EThe use of rating scales and/or questionnaires has been integral to the diagnosis of attention-deficit/hyperactivity disorder (ADHD). Thyroid testing, EEGs, and blood lead levels are not indicated in the routine workup for ADHD. Continuous performance testing is designed to obtain samples of the child's behavior, but the sensitivity and specificity are too low to be useful at this time.
Ref: American Academy of Pediatrics: Clinical practice guideline: Diagnosis and evaluation of the child with attention deficit/hyperactivity disorder. Pediatrics 2000; 105(5): 1158-1170.
The Correct Answer is DFindings associated with self-induced vomiting include parotid gland enlargement, submandibular lymphadenopathy, abnormal dentition, perimolysis (loss of dentin on the lingual and occlusal surfaces of the teeth), and abrasions on the dorsum of the hand (caused by scraping against the incisors during attempts to induce vomiting). These signs would most strongly support the diagnosis of bulimia nervosa.
Ref: Becker AE, Grinspoon SK, Klibanski A, et al: Eating disorders. N Engl J Med 1999; 340(14): 1092-1098.
The correct Answer is ALike all drugs, SSRIs have significant side effects, including inhibition of the cytochrome P-450 system. However, citalopram (Celexa) is least likely to inhibit this system, making it a preferred SSRI for patients taking multiple medications for other illnesses.
Ref: Sampson SM: Treating depression with selective serotonin reuptake inhibitors: A practical approach. Mayo Clin Proc 2001;76(7):739-744. 2) Ables AZ, Baughman OL III: Antidepressants: Update on new agents and indications. Am Fam Physician 2003; 67(3):547-554.
The Correct Answer is BLoss of appetite is often seen in patients who take fluoxetine, and can be especially troublesome in the elderly. Fluoxetine, a selective serotonin reuptake inhibitor, has no effect on the norepinephrine system; therefore, it does not produce the side effects common to the tricyclic antidepressants. These include anticholinergic side effects (dry mouth, constipation), orthostatic hypotension, cardiac conduction disturbances, and drowsiness. Skin rash is uncommon.
Ref: Tasman A, Kay J, LiebennanJA (eds): Psychiatry. WB Saunders Co, 1997, pp 1616-1619. 2) Physicians' Desk Reference, ed 54. Medical Economics Co, 2000, pp 962-967.
The Correct Answer is DStimulant medications do not precipitate seizures and can be given safely to patients with a history of seizures. Substantial weight loss may occur in up to 15% of patients, but eventual adult height and weight are not affected. The number of side effects is similar for methylphenidate and dextroamphetamine. No significant changes in pulse or blood pressure occur either at rest or with exercise. Studies have shown that children treated with stimulants do not have an increased risk of developing addiction to illegal drugs in adolescence, and they may actually have a decreased incidence of developing addiction to illegal drugs when compared with attention-deficit/hyperactivity disorder patients who are not treated with stimulants.
Ref: Elia J, Ambrosini PJ, Rapoport JL: Treatment of attention-deficit-hyperactivity disorder. N Engl J Med 1999; 340(10): 780-788.
The Correct Answer is CLithium is used as a mood stabilizer in bipolar disease and can be used as monotherapy, especially when the depression is mild. A well-recognized side effect of lithium is hypothyroidism. It is recommended that TSH be monitored in patients treated with lithium. Hyperparathyroidism, but not hypoparathyroidism, has been reported, but it is not as common as hypothyroidism. Nephrogenic diabetes insipidus has been reported only rarely. Hypoaldosteronism is not a side effect of lithium therapy.
Ref: Griswold KS, Pessar LF: Management of bipolar disorder. Am Fam Physician 2000; 62(6):1343-1353.
The Correct Answer is EThis patient's findings include all four categories of criteria for the diagnosis of post-traumatic stress disorder (PTSD). First, a traumatic event occurred in which the patient witnessed or experienced actual or threatened death or serious injury and responded with intense fear, horror, or helplessness. Second, on exposure to memory cues, the patient has reexperiencing symptoms such as intrusive recollections, nightmares, flashbacks, or psychologic distress. Third, the patient avoids trauma-related stimuli and feels emotionally numb. Finally, the patient has increased arousal, manifested by hypervigilance, irritability, or difficulty sleeping. The symptoms must also persist for at least 1 month and significantly disturb the patient's social or occupational functioning, or both.
Acute stress disorder also occurs after exposure to a traumatic event, but symptoms appear within 4 weeks of the trauma and last from 2 days to 4 weeks. Patients with this disorder also have more dissociative symptoms, describing themselves as feeling "in a daze" or having temporary amnesia about the event. PTSD increases the risk of later developing comorbid psychiatric problems. The most common diseases that occur with PTSD are major depression, dysthymia, generalized anxiety disorder, substance abuse, somatization, panic disorder, bipolar disorder, and dissociative disorders.
Ref: Lange JT, Lange CL, Cabaltica RB: Primary care treatment of post-traumatic stress disorder. Am Fam Physician 2000; 62(5): 1035-1040.
The Correct Answer is BThe timing of the symptoms (starting about 2 days after paroxetine was stopped) and the symptoms (headache, lightheadedness) are consistent with SSRI discontinuation syndrome. This syndrome is more likely with abrupt withdrawal, after prolonged treatment, and at higher doses.
Ref: Rosenbaum JF, Fava M, Hoog SL, et al: Selective serotonin reuptake inhibitor discontinuation syndrome: A randomized clinical trial. Bioi Psychiatry 1998; 44(2):77-87.
The Correct Answer is DThe predominant symptom associated with dysthymic disorder is depression. Other names commonly used for this disorder are depressive neurosis, characterological depression, and minor depression. The depression associated with dysthymic disorder lacks the severity of major depression and is sustained over a 2-year period. Delusions, loosening of associations, and incoherence are not associated with dysthymic disorder.
Ref: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 text revision. American Psychiatric Association, 2000, pp 376-381.
The Correct Answer is ADrug-seeking behavior in patients who abuse prescription drugs includes insistence on brand-name drugs, claiming a high tolerance to pain medications, overreporting symptoms, and insistence on a prescription for a controlled drug at the first visit.
Ref: Longo LP, Parran T Jr, Johnson B, et al: Addiction: Part II. Identification and management of the drug-seeking patient. Am Fam Physician 2000; 61(8):2401-2408.
The Correct Answer is BSome depressed patients develop mania or hypomania when exposed to antidepressants. This variant is sometimes called bipolar III disorder. Medication is the key to stabilizing bipolar disorder. The initial treatment of mania usually includes lithium or valproic acid. If the patient is psychotic, a neuroleptic medication may also be given. Long-acting benzodiazepines may be used initially to treat agitation, but short-acting agents are not recommended. Tricyclic antidepressants should be avoided, as they may induce rapid cycling of symptoms in these patients.
Ref: Griswold KS, Pessar LF: Management of bipolar disorder. Am Fam Physician 2000; 62(6): 1343-1353, 1357-1358.
The Correct Answer is AFor the purpose of treating seasonal affective disorder, the 10,000-lux fixture has been shown to be more effective and less time consuming that the 2500-lux fixture. This is the standard for initiating therapy. More portable head-mounted light visors have less proof of efficacy.
Sunscreen has been reported to be beneficial in patients with light-sensitive skin conditions. The benefit of light therapy appears to be mediated through the eyes. Significant retinal disease is considered a contraindication to therapy. Ophthalmologic evaluation is recommended if therapy is considered necessary.
Light therapy may be given in divided sessions. In order to encourage compliance, the therapy may be given at different times of the day. Patients with delayed sleep phase syndrome have benefited from morning therapy, while patients with advanced sleep phase syndrome have benefited from evening therapy.
Although clinical response may be seen after a few sessions, several weeks of therapy may be needed to see a full response. Therapy should not be abandoned after just 1 week because of lack of response.
Ref: Gabbard GO, Atkinson SD (eds): Synopsis of Treatments of Psychiatric Disorders, ed 2. American Psychiatric Press Inc, 1996, pp 543-546.
The Correct Answer is ABetween 10% and 25% of children with attention-deficit/hyperactivity disorder (ADHD) have specific learning disabilities or cognitive deficits (e.g., dyslexia) .The ratio of boys to girls with ADHD is 4: 1 in epidemiologic surveys and 9: 1 in clinical samples. Sixty-five percent of children with ADHD have at least one other psychiatric or behavioral disorder. There is no evidence that megavitamins or other alternative therapies provide any benefit in ADHD. Antisocial personality disorder develops during adolescence or adulthood in as many as 50%-80% of cases followed over time.
Ref: Behnnan RE, Kliegman RM, Jenson HB (eds): Nelson Textbook of Pediatrics, ed 16. WB Saunders Co, 2000, pp 100-103. (ABFP, 2001, 62).
The Correct Answer is EAttention-deficit/hyperactivity disorder (ADHD) can be a difficult diagnosis. Included in the differential are bipolar disorder, Tourette's syndrome, and ineffective parental discipline. Some authors believe that ineffective discipline is more common than ADHD. The clue to this situation is lack of effective parental control, either witnessed by the physician or gathered historically. Tourette's syndrome has vocal and motor tics or utterances as part of its presentation. Bipolar disease is characterized by alternating periods of highs and lows, when the child cycles between intense activity with a euphoric mood, and motor inactivity with associated depression.
Ref: Johnson TM: Evaluating the hyperactive child in your office: Is it ADHD? Am Fam Physician 1997;56(1): 155-160. (ABFP, 2000, 62).
The Correct Answer is DOf the conditions listed, borderline personality disorder is the most likely diagnosis in this patient. One diagnostic hallmark of this disorder is a history of self-destructive behavior, often manifesting itself as accident proneness. The behavior frequently dates to adolescence. These patients may demand prompt solutions to problems and may pressure the physician to prescribe mediation. Complicated or incomplete recovery from organic or functional illness may occur. Patients with borderline personality disorder may consciously or unconsciously invent vague, undiagnosable illnesses, such as chronic viral infection or chronic pain.
Ref: 1)Sansone RA, Sansone LA: Borderline personality disorder: Office diagnosis and management. Am Fam Physician 1991; 44 (1): 194-198.
2) American Psychiatric Association, 1994, pp 650-654.
The Correct answer is CFirearms and ready access to firearms are closely associated with suicide and an increased risk of attempted suicide. The elderly have the highest rates of suicide, although the greatest total number of suicides occurs in the under 40 age group. Men are three to five times more likely to commit suicide than are women. Alcoholism and depression are the most common mental illnesses associated with suicide. There is evidence that media coverage of the suicides of others can precipitate more teen and young adult suicides.
Ref: Wallace RB (ed): Maxcy-Rosenau-Last Public Health & Preventative Medicine, ed 14. Appleton & Lange, 1998, pp 1250-1252.
The Correct Answer is DPsychometric tests cover four essential areas: language skills, visuo-spatial skills, sequential-analytical skills, and motor planning and execution skills. Evaluation for conduct disorder, learning disabilities and sensory impairment should be carried out in children with difficulty concentrating.
Ref: Behrman RE, Kliegman RM, Arvin AM (eds): Nelson Textbook of Pediatrics, ed 15. WB Saunders Co, 1996, pp 91-92.
The Correct Answer is CObsessive-compulsive disorders often begins in childhood or early adulthood and rarely remits without specific therapy. Obsessive-compulsives are acutely aware that their rituals or repetitive thoughts are irrational, unlike schizophrenics who usually do not regard their unusual thoughts or acts as “crazy”. All tricyclic antidepressants are not equivalent in controlling obsessive-compulsive disorder (OCD) symptoms, and clomipramine has been shown to be superior in efficacy to several others such as amitriptyline, imipramine, and nortriptyline. Clomipramine is also more effective than monoamine oxidase inhibitors. The adverse effects of clomipramine include anticholinergic side effects such as blurred vision and dry mouth
Ref: Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry/VI, ed 6. Williams & Wilkins, 1995, pp 1218-1227.
The Correct Answer is BParoxetine (Paxil) has emerged as the drug of choice for treatment of social phobias. Also known as social anxiety disorder, social phobias characteristically cause fear of situations that may lead to embarrassing scrutiny. Patients learn to avoid situations where they feel others may notice them, such as church gatherings, classroom settings, and other group events. Lithium (Eskalith) and haloperidol (Haldol) are used for more severe psychiatric disturbances, while alprazolam (Xanax) would be best reserved for secondary use because of the possibility of dependency. Trazodone (Desyrel) is approved for treatment of depression, but its strong sedative properties make it inappropriate in this scenario.
Ref: 1) Brown CS: Depression and anxiety disorders. Obstet Gynecol Clin North Am 2001;28(2):241-268. 2) Braunwald E, Fauci AS, Kasper DL, et al (eds): Harrison’s Principles of Internal Medicine, ed 15. McGraw-Hill, 2001, pp 2543-2544. (ABFM, 2002).
is associated with psoriatic nail changes. About 20% develop conjunctivitis and 7% iritis. Only 7% of patients with psoriasis will develop evidence of arthropathy.
therapy of 30 minutes per day is as effective as conventional overnight treatment.
to local lymph glands. Chronic sun exposure leads to loss of skin elasticity, an increase in telangiectasia and prominent sebaceous glands. Sunburn typically takes 4 - 8 hours to develop after exposure .
The Correct answer is E
bullae. Intra oral bullae are a prominent feature of pemphigus vulgaris, they are either yellow or haemorrhagic and burst to leave an area of ulceration. Lichen planus classically affects the mouth giving erosive lesions or producing "cotton wool" patches.
