Bahrain GP Exam Materials 2020
(8000 MCQs with explanations)
Is an huge study materials more than 8000 new MCQs (with explanation for each question) for those preparing for NHRA Exam – Bahrain (National Health Regulatory Authority) for general practitioner include all of the following :
– Cardiology system
– respiratory System
– GIT System
– Neurology system
– Nephrology system
– endocrine system
– Rheumatology system
– Pediatric Section
– Obs. and Gynecology section
– General Surgery Section
– Family Medicine Section
– Preventive Medicine
-The last new 30 exams (3000 new MCQs).
– Do Not miss ! weekly updated questions,
– All questions are corrected by specialist doctor
– No need to study other sources !
– Enough to pass easily
– The materials are suitable for BAHRAIN exam only !! beware !
– 100 % success rate
Questions samples :
Question sample 1
A 62-year-old man is reviewed. His blood pressure is poorly controlled at 152/90 mmHg despite treatment with ramipril 10mg od, bendroflumethiazide 2.5mg od and amlodipine 10mg od. In addition to the antihypertensives he also takes aspirin and simvastatin. His most recent blood tests show the
Na+ 139 mmol/l
K+ 4.2 mmol/l
Urea 5.5 mmol/l
Creatinine 98 μmol/l
What is the most appropriate change to his medication?
A. Add frusemide
B. Increase ramipril to 20mg od
C. Add spironolactone **
D. Add candesartan
E. Add atenolol
Hypertension – step 4
??Ü__r_K+ 4.5 then higher-dose thiazide-like diuretic
This patient has reached step 4 in the NICE hypertension guidelines. As their potassium is less than 4.5 mmol/l spironolactone 25mg od should be started.
Diagnosis and management
NICE published updated guidelines for the management of hypertension in 2011.
Some of the key changes include:
??classifying hypertension into stages
??recommending the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)
??calcium channel blockers are now considered superior to thiazides
??bendroflumethiazide is no longer the thiazide of choice
Blood pressure classification
This becomes relevant later in some of the management decisions that NICE advocate.
Stage 1 hypertension Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
Stage 2 hypertension Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
Severe hypertension Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg
If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis.
Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment.
Ambulatory blood pressure monitoring (ABPM)
??at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)
??use the average value of at least 14 measurements
If ABPM is not tolerated or declined HBPM should be offered.
Home blood pressure monitoring (HBPM)
??for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
??BP should be recorded twice daily, ideally in the morning and evening
??BP should be recorded for at least 4 days, ideally for 7 days
??discard the measurements taken on the first day and use the average value of all the remaining measurements
ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
??treat if = 150/95 mmHg (i.e. stage 2 hypertension)
??offer drug treatment regardless of age
For patients < 40 years consider specialist referral to exclude secondary
Step 1 treatment
??patients 55-years-old or of Afro-Caribbean origin: calcium channel blocker
Step 2 treatment
??ACE inhibitor + calcium channel blocker (A + C)
Step 3 treatment
??add a thiazide diuretic (D, i.e. A + C + D)
??NICE now advocate using either chlorthalidone (12.5-25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide
NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice
Step 4 treatment
??consider further diuretic treatment
??if potassium 4.5 mmol/l add higher-dose thiazide-like diuretic treatment
??if further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or betablocker
If BP still not controlled seek specialist advice.
Blood pressure targets
Clinic BP ABPM / HBPM
Age 80 years 150/90 mmHg 145/85 mmHg
Direct renin inhibitors
??e.g. Aliskiren (branded as Rasilez)
??by inhibiting renin blocks the conversion of angiotensinogen to angiotensin I
??no trials have looked at mortality data yet. Trials have only investigated fall in blood pressure. Initial trials suggest aliskiren reduces blood pressure to a similar extent as angiotensin converting enzyme
(ACE) inhibitors or angiotensin-II receptor antagonists
??adverse effects were uncommon in trials although diarrhoea was occasionally seen
??only current role would seem to be in patients who are intolerant of more established antihypertensive drugs
Question sample 2
A 45-year-old woman is referred to your office for a Pap smear that is suspicious for malignancy. The cervix appears grossly normal on speculum exam. The next most appropriate procedure is:
a) Radical hysterectomy
b) Simple hysterectomy
c) Cervical cone biopsy
d) Cryotherapy of the cervix
e) Colposcopic directed biopsy
The correct answer is e)
The Pap smear is a screening test. Although the cervix appears normal to the naked eye, once acetic acid is applied and the magnification of the colposcope added, vascular abnormalities will often be seen. The most concerning colposcopic finding is the presence of abnormal vessels. These suggest carcinoma in situ or invasive carcinoma. If the colposcopic exam is negative, a cone biopsy is performed to find the source of the suspicious cells.
A. This is the therapy for early stage cervical carcinoma. The diagnosis of cancer has not yet been made. A biopsy is necessary.
B. Simple hysterectomy is not the proper cure for invasive cervical carcinoma. Also, the diagnosis of cancer has not yet been made. A biopsy is necessary.
C. It is still likely that a cone biopsy will be necessary if a colposcopic exam is unsatisfactory. The first step, however, in the workup, is a colposcopy with directed biopsy. If invasive cancer is then found, appropriate therapy can be started.
D. Cryotherapy is only indicated for low-grade dysplastic lesions of the cervix, after adequate colposcopic exam to rule out malignancy.
Question sample 3
A 3-year-old child presents with stridor and drooling. He is diagnosed with epiglottitis.
What is the most appropriate immediate management?
The correct answer is a)
Epiglottitis is a rapidly progressive bacterial infection of the epiglottis and surrounding tissues that may lead to sudden respiratory obstruction and death. Symptoms include severe
sore throat, dysphagia, high fever, drooling, and inspiratory stridor. Diagnosis requires direct visualization of the supraglottic structures, which is not to be performed until full respiratory support is available.
In children, the airway must be secured immediately, preferably by nasotracheal intubation.
An endotracheal tube is usually required until the patient has been stabilized for 24 to 48 h (usual total intubation time is < 60 h).
A beta-lactamase resistant antibiotic, such as ceftriaxone should be used empirically, pending culture and sensitivity test results. Epiglottitis is caused by H. influenzae type B can be effectively prevented with the H. influenzae type B (Hib) conjugate vaccine.
Question sample 4
A child is brought to the emergency department. He has a temperature of 39.4°C and respiratory distress. He is leaning forward and has a very anxious look. His voice is muffled,
and he is unable to swallow. X-ray shows a swollen epiglottis. Proper treatment at this time
would include all of the following, except:
a) Oxygen therapy
b) Have the child lie down on his back so that he can rest properly
c) Reassure the child and allow the parent to hold him
d) Notify an anesthesiologist and/or otolaryngologist
e) Prepare for possible sudden pulmonary arrest
The correct answer is b)
Children with epiglottitis should be allowed to sit and lean forward to help their aiways open (choice B is the correct answer). All of these signs and symptoms are typical. As these children may obstruct totally at any time, rapid preparations must be made to maintain an airway.
The first emergency department priority for a patient with epiglottitis is securing and providing respiratory support before a definitive airway is obtained. Initially, humidified oxygen (choice A) can be given by a nasal cannula or a nonrebreather mask, as required.
Reassurance and allowing the mother to hold the child (choice C) will decrease distress while you arrange proper treatment.
This child should be evaluated in a controlled setting (i.e., in an operating room in the presence of an anesthesiologist and/or otolaryngologist) (choice D) so that rapid airway control may be achieved, if necessary.
Sudden pulmonary arrest (choice E) is a likely occurrence in children with epiglottitis and should be anticipated.
Question sample 5
A 62-year-old female is referred due to a long-standing ulcer above the right medial malleolus. Ankle-brachial pressure index readings are as follows:
To date it has been managed by the District Nurse with standard dressings. What is the most appropriate management to maximize the likelihood of the ulcer healing?
A. Compression bandaging **
B. Intermittent pneumatic compression
C. Hydrocolloid dressings
D. Refer to vascular surgeon
E. Topical flucloxacillin
Management of venous ulceration – compression bandaging
The ankle-brachial pressure index readings indicate a reasonable arterial supply and suggest the ulcers are venous in nature.
Venous ulceration is typically seen above the medial malleolus
??ankle-brachial pressure index (ABPI) is important in non-healing ulcers to assess for poor arterial flow which could impair healing
??a 'normal' ABPI may be regarded as between 0.9 – 1.2. Values below 0.9 indicate arterial disease.
Interestingly, values above 1.3 may also indicate arterial disease, in the form of false-negative results secondary to arterial calcification (e.g. In diabetics)
??compression bandaging, usually four layer (only treatment shown to be of real benefit)
??oral pentoxifylline, a peripheral vasodilator, improves healing rate
??small evidence base supporting use of flavinoids
??little evidence to suggest benefit from hydrocolloid dressings, topical growth factors, ultrasound therapy and intermittent pneumatic compression
Question sample 6
About 30 people came back home from a party where there was a lot of food such as pastries, cheese sandwiches with mayonnaise and sweets. Within 4-6 hours later, most of them develop vomiting and have loose diarrhea. What is the most likely organism to cause this?
d) E. coli
The correct answer is a)
The is a classic case of food poisoning. Many different bugs can cause food poisoning including all of the above choices.
When vomiting is the major presenting symptom, suspect Staphylococcus aureus. Improperly stored foods with high salt or sugar content favor growth of staphylococci. Intense vomiting and watery diarrhea start 1-4 hours after ingestion and last as long as 24-48 hours.
→ Salmonella (choice B) is found in beef, poultry, eggs, and dairy products. Abrupt onset of moderate to large amount of diarrhea with low-grade fever is seen and in some cases, bloody diarrhea.
→ Campylobacter jejuni (choice C) is found in domestic animals, cattle, chickens. It is spread through fecal-oral transmission in humans and will cause foul smelling watery diarrhea followed by bloody diarrhea.
→ Enterohemorrhagic coli (eg, E coli O157:H7) (choice D) is found in improperly cooked hamburger meat and recently spinach and is the most commonly isolate pathogen in bloody diarrhea. Diarrhea starts 3-4 days after ingestion and usually progresses from watery to bloody diarrhea. It lasts for 3-8 days.
→ Giardia lamblia (choice E) is found in contaminated ground water. Campers are a common group who get this infection. It is spread through fecal-oral transmission and will cause mild bloody diarrhea with nausea and abdominal cramps, which start 2-3 days after ingestion, lasting for 1 week.