Free UKMLA general practice questions with explanations

C. Borrelia burgdorferi

An expanding annular rash with central clearing (erythema migrans) accompanied by flu-like symptoms after woodland exposure in a UK endemic area such as the New Forest is characteristic of early localised Lyme disease, caused by Borrelia burgdorferi and transmitted by Ixodes ricinus ticks. Lyme disease is diagnosed clinically when erythema migrans is present, without waiting for serology, and oral doxycycline is started.

E. Doxycycline 40 mg modified-release once daily

Moderate to severe papulopustular rosacea is treated with an oral tetracycline, and modified-release doxycycline 40 mg once daily is the licensed option in the UK: at this dose it works through its anti-inflammatory rather than antibacterial effect, which is why it does not drive resistance and is used in courses of 8 to 12 weeks, usually alongside a topical agent such as ivermectin. Oral isotretinoin is a specialist option for disease that fails tetracyclines. Erythromycin is used when a tetracycline is contraindicated, for example in pregnancy, but is less effective and less well tolerated. Systemic steroids and anti-staphylococcal penicillins have no place, and topical steroids make rosacea worse.

C. Papulopustular rosacea

Flushing triggered by alcohol and heat, persistent centrofacial erythema with telangiectasiae, and inflammatory papules and pustules in a middle-aged woman are the features of papulopustular rosacea. The two discriminators against acne vulgaris, the nearest alternative, are the flushing history with telangiectasiae and the absence of comedones, which are the defining lesion of acne and never occur in rosacea; acne also typically starts in adolescence. The malar rash of lupus is fixed, photosensitive and characteristically spares the nasolabial folds, whereas rosacea involves them, and lupus does not produce pustules. Seborrhoeic dermatitis gives greasy yellow scale in the nasolabial folds and eyebrows without papules or pustules.

C. Oral azithromycin

A partially vaccinated infant under 1 year is a priority contact for pertussis post-exposure prophylaxis under UKHSA guidance. Oral azithromycin is the macrolide of choice in infants because of its short 3-day once-daily course and better gastrointestinal tolerability than erythromycin, which also raises the risk of infantile hypertrophic pyloric stenosis two- to threefold in infancy, most of all in the first 14 days of life.

E. Single dose of nonavalent vaccine

Since 2023 the UK uses the nonavalent HPV vaccine (Gardasil 9) given as a single dose in Year 8 to all eligible adolescents, irrespective of sex (gender-neutral programme since 2019). The previous two-dose schedule was simplified after immunogenicity and population-effectiveness data supported equivalent protection from one dose under age 25. Immunocompromised individuals still receive three doses. Takeaway: routine UK HPV vaccination is a single nonavalent dose at age 12-13 for both girls and boys.

D. Bendroflumethiazide

Thiazide diuretics such as bendroflumethiazide reduce renal urate excretion by competing with uric acid for organic anion transporters in the proximal tubule, raising serum urate and precipitating gout. Thiazide and loop diuretics are key drug-related precipitants to review, and an ARB such as losartan is often substituted because it is mildly uricosuric. Takeaway: Thiazide (and thiazide-like) diuretics are the classic antihypertensive precipitants of gout; ACE inhibitors, ARBs, beta-blockers and calcium-channel blockers are not.

E. Prochlorperazine

The acute phase of vestibular neuritis is treated symptomatically with a vestibular sedative, and prochlorperazine (buccal or intramuscular if vomiting prevents oral use) is the usual choice, with an antihistamine such as cinnarizine or cyclizine as an alternative. These drugs damp the vestibular imbalance and the nausea for the few days of severe symptoms. They must then be stopped, because continued vestibular suppression delays the central compensation on which recovery depends, and the patient should be encouraged to mobilise. Corticosteroids and antivirals are not routinely recommended: steroids may speed recovery of caloric responses but do not improve symptoms or long-term outcome, and antivirals have no demonstrated benefit.

E. Issue a fit note covering the expected period of recovery

Any registered doctor can issue a fit note (as can nurses, pharmacists, physiotherapists and occupational therapists since 2022), and the expectation is that the clinician responsible for the patient's care at the time issues it. A hospital doctor discharging a patient who will be off work for more than seven days should therefore provide a fit note covering the anticipated recovery rather than sending the patient to a GP who did not treat them. The first seven days of absence can be self-certified, but that does not prevent a fit note being issued at discharge for the whole expected period. The fit note is advice to the patient and employer about fitness for work; no note is ever required to return to work.

D. Enrolment in the Care of Next Infant programme with health visitor support

Families who have lost a baby to sudden infant death are at higher risk of anxiety and of a further loss, and in the UK they can be enrolled before birth in the Care of Next Infant (CONI) programme, run with the Lullaby Trust through local health visiting and paediatric services. It offers structured support from the health visitor with regular contact, weight monitoring, a symptom diary, a room thermometer and safer-sleep advice, and, where the family wishes, an apnoea monitor for reassurance. Monitors have not been shown to prevent sudden infant death, so the monitor is offered as part of the package rather than as the intervention itself. The advice that actually reduces risk is the same for every baby: back to sleep, in a clear cot in the parents' room for the first six months, a smoke-free home, no sofa or armchair sleeping, and not overheating. A previous sudden infant death that was fully investigated and unexplained is not in itself a safeguarding concern.

E. Acanthosis with parakeratosis

The clinical description of well-demarcated erythematous plaques with silvery scale on extensor surfaces and scalp is classic for psoriasis, which histologically shows acanthosis (thickening of the stratum spinosum with elongated rete ridges) and parakeratosis (retention of nuclei within the stratum corneum). Additional features include Munro microabscesses (neutrophils in the stratum corneum) and dilated dermal papillary capillaries, accounting for the Auspitz sign.