Multiple Choice Questions MCQ

Question 139# Print Question

A 52-year-old has a fasting lipid profile checked as part of an annual occupational health check. Combined with his blood pressure and current smoking status his 10-year risk of cardiovascular disease is calculated to be 23% percent. Following appropriate counseling he chooses to start simvastatin 40mg on.

What should his target cholesterol be?

A. Total cholesterol:HDL ratio < 5

B. Total cholesterol < 5 mmol/l

C. Target cholesterol is inappropriate in this situation

D. Total cholesterol < 4 mmol/l

E. Total cholesterol:HDL ratio < 4

Question 136# A 23-year-old woman is diagnosed with Graves' disease. Which one of the following statements regarding treatment is correct?
A. Block-and-replace regimes are usually of a shorter duration than carbimazole titration therapy
B. Concurrent administration of propranolol and carbimazole should be avoided
C. Patients on block-and-replace regimes have fewer side-effects than those using titration therapy
D. Carbimazole should be started at no higher than 10mg/day for patients commencing a titration regime
E. In the block-and-replace regime levothyroxine should be started at the same time as carbimazole
Correct Answer A: Graves' disease: management: Despite many trials there is no clear guidance on the optimal management of Graves' disease. Treatment options include titration of anti-thyroid drugs (ATDs, for example carbimazole), block-andreplace regimes, radioiodine treatment and surgery. Propranolol is often given initially to block adrenergic effects. ATD titration: Carbimazole is started at 40mg and reduced gradually to maintain euthyroidism Typically continued for 12-18 months Patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime Block-and-replace: Carbimazole is started at 40mg Thyroxine is added when the patient is euthyroid Treatment typically lasts for 6-9 months The major complication of carbimazole therapy is agranulocytosis Radioiodine treatment: Contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition The proportion of patients who become hypothyroid depends on the dose given, but as a rule the majority of patient will require thyroxine supplementation after 5 years

Question 137# A 30-year-old female is started on carbimazole 20mg bd following a diagnosis of Grave's disease. What is the best biochemical marker to assess her response to treatment?
A. Total T4
B. TSH
C. Free T4
D. ESR
E. Free T3
Correct Answer B: The answer the College are looking for is TSH. There is however a significant proportion of patients for whom TSH monitoring alone is insufficient. TSH may remain suppressed for several weeks as continued production of thyroid stimulating immunoglobulins seen in Grave's disease reduces the need for the pituitary to secrete TSH. Thyrotoxicosis: Graves' disease accounts for around 50-60% of cases of thyrotoxicosis. Causes: Graves' disease Toxic nodular goitre Subacute (de Quervain's) thyroiditis Post-partum thyroiditis Acute phase of Hashimoto's thyroiditis (later results in hypothyroidism) Toxic adenoma (Plummer's disease) Amiodarone therapy Investigation: TSH down, T4 and T3 up Thyroid autoantibodies Other investigations are not routinely done but includes isotope scanning

Question 138# A 54-year-old man with type 2 diabetes mellitus is reviewed in clinic. He is currently taking pioglitazone, metformin, aspirin and simvastatin. Which one of the following problems is most likely to be caused by pioglitazone?
A. Photosensitivity
B. Thrombocytopaenia
C. Myalgia
D. Peripheral oedema
E. Hyponatraemia
Correct Answer D: Thiazolidinediones: Thiazolidinediones are a new class of agents used in the treatment of type 2 diabetes mellitus. They are agonists to the PPAR-gamma receptor and reduce peripheral insulin resistance. Rosiglitazone was withdrawn in 2010 following concerns about the cardiovascular side-effect profile. The PPAR-gamma receptor is an intracellular nuclear receptor. Its natural ligands are free fatty acids and it is thought to control adipocyte differentiation and function. Adverse effects: Weight gain Liver impairment: monitor LFTs Fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin Recent studies have indicated an increased risk of fractures Bladder cancer: recent studies have showed an increased risk of bladder cancer in patients taking pioglitazone (hazard ratio 2.64) NICE guidance on thiazolidinediones: Only continue if there is a reduction of > 0.5 percentage points in HbA1c in 6 months

Question 140# Which one of the following increases the risk of developing peripheral oedema in a patient taking pioglitazone?
A. Concomitant use with gliclazide
B. Serum sodium < 140 mmol/l
C. Concomitant use with insulin
D. Concomitant use with metformin
E. Serum potassium < 4.0 mmol/l
Correct Answer C: Thiazolidinediones: Thiazolidinediones are a new class of agents used in the treatment of type 2 diabetes mellitus. They are agonists to the PPAR-gamma receptor and reduce peripheral insulin resistance. Rosiglitazone was withdrawn in 2010 following concerns about the cardiovascular side-effect profile. The PPAR-gamma receptor is an intracellular nuclear receptor. Its natural ligands are free fatty acids and it is thought to control adipocyte differentiation and function. Adverse effects: Weight gain Liver impairment: monitor LFTs Fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin Recent studies have indicated an increased risk of fractures Bladder cancer: recent studies have showed an increased risk of bladder cancer in patients taking pioglitazone (hazard ratio 2.64) NICE guidance on thiazolidinediones: Only continue if there is a reduction of > 0.5 percentage points in HbA1c in 6 months

Question 139# A 52-year-old has a fasting lipid profile checked as part of an annual occupational health check. Combined with his blood pressure and current smoking status his 10-year risk of cardiovascular disease is calculated to be 23% percent. Following appropriate counseling he chooses to start simvastatin 40mg on. What should his target cholesterol be?
A. Total cholesterol:HDL ratio < 5
B. Total cholesterol < 5 mmol/l
C. Target cholesterol is inappropriate in this situation
D. Total cholesterol < 4 mmol/l
E. Total cholesterol:HDL ratio < 4
Correct Answer C: In primary prevention of CVD, a target cholesterol is not appropriate. Hyperlipidaemia: management: In 2008 NICE issued guidelines on lipid modification. Key points are summarised below. Primary prevention: A systematic strategy should be used to identify people aged 40-74 who are likely to be at high risk of cardiovascular disease (CVD), defined as a 10-year risk of 20% or greater. NICE updated their lipid guidelines so that the following risk models are valid: Framingham Joint British Society 2 (JBS2) QRISK ASSIGN (Scotland only) The 1991 Framingham equations may still be used. It is however recommended that adjustments are made in the following situations: First-degree relative with a history of premature coronary heart disease (defined as < 55 years in males and < 65 years in females) - increase risk by 1.5 times if one relative affected or up to 2.0 times if more than one relative affected Males of South Asian ethnicity - increase risk by 1.4 times Along with lifestyle changes drug treatment should be considered for patients with a 10-year CVD risk of 20% or greater: Simvastatin 40mg on is the first line treatment There is no target level for total or LDL cholesterol for primary prevention Liver function tests should be check at baseline, within 3 months and at 12 months but not again unless clinically indicated Secondary prevention: All patients with CVD should be taking a statin in the absence of any contraindication NICE recommend increasing simvastatin to 80mg if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained.

Your-Doctor Multiple Choice Questions (MCQ)

Your-Doctor
Multiple Choice Questions (MCQ)