17/11/21

Question 1

Oral anitbiotic choices for treatment of acne.

Answer 1

1. Doxycycline 50-100mg orally, once daily for 6 weeks, then review

Question 2

ECG Changes in pericarditis (1 main point + 2 bonus)

Answer 2

• Widespread CONCAVE ST Elevation and PR depression throughout most of the limb-leads (I,II, aVL, aVF) and precordial leads (V2-6)
• Reciprocal ST depression and PR elevation in lead aVR
• Sinus tachycardia due to pain and/or pericardial effusion

Question 3

Clinical Features associated with cardiac tamponade (3 main)

Answer 3

• Beck’s Triad → muffled heart sounds, elevated JVP, hypotension

Question 4

Non-Pharmacological Options for management of insomnia.

Answer 4

1. CBT including sleep hygeine/education
2. Brief behavioural therapy
3. Exercises

Question 5

Specific Sleep Hygeine advice (5 points)

Answer 5

Sleep-Wake Activity Regulation

• Avoid lying in bed for extended periods of time worrying about sleeping → if cannot sleep for 20mins then get up, do something relaxing and return to bed when sleepy
• Avoid oversleeping + napping during the day
• Regularity of schedule → get up at the same time each day

Sleep Setting and Influences

• Regular Exercise but not vigourous within 3 hours of bedtime
• Do not have electronic devices in the bedroom + avoid exposure to bright light from late evening onwards
• Avoid stressful ruminations before or at bedtime → plan for this earlier in the day.
• Avoid caffeine after midday
• Reduce/Avoid Alcohol Intake + Tobacco Intake + Illicit Drugs

Sleep-promoting Adjuvants

• light snack or warm drink before bed
• warm bath or shower before bed

Question 6

Difference between gestational hypertension and pre-eclampsia?

Answer 6

Both are diagnosed after 20/40.

Gestational hypertension does not ahve all the liver, renal, thrombocytopenia, urine acr, neuro and pulmonary changes or preeclampsia.

Question 7

What is chronic (preexisting) hypertension in pregnancy?

Answer 7

• Hypertension diagnosed or present before pregnancy or before 20/40 gestation

Question 8

1st line and 2nd line medications for treatment hypertension in pregnancy? (be specific)

Answer 8

1. First Line → Methyldopa or Labetalol
   
   1. Methydopa 250-750mg TDS
   2. Labetalol 100-400mg TDS
2. Second Line → Nifedipine, Hydralazine or Prasozin
   
   1. Nifedipine Sustained Release 20-40mg daily
   2. Hydralazine 25-50mg TDS
   3. Prazosin 0.5-5mg TDS

Question 9

Which anti-hypertensive can you not use in pregnancy?

Answer 9

• ACE inhibitors are contraindicated in pregnancy → use as been associated with fetal death and neonatal renal failure

Question 10

Diagnosis of chronic bacterial prostatitis

Answer 10

Diagnosis → comparing leucocyte count and the results of the pre- with post-prostatic massage urine samples - 2 glass test

Question 11

Treatment of Chronic Bacterial Prostatitis?

Answer 11

1. ciprofloxacin 500mg PO, BD for 4 weeks

2. OR Norfloxacin 400mg PO for 4 weeks

Question 12

If no evidence of bacterial prostiatitis and still having prostatic symptoms, what is our diagnosis?

Answer 12

If no evidence of bacterial prostatitis → chronic (nonbacterial) prostatitis or chronic pelvic pain syndrome → no need for ABx and treatment is symptomatic

Question 13

Diagnostic Criteria of Kawasaki Disease (5 points)

Answer 13

1. Bilateral non-exudative conjunctivitis
2. Polymorphous rash
3. Cervical lymphadenopathy (at least 1 lymph node >1.5cm in diameter)
4. Mucositis → cracked lips, injected pharynx, strawberry tongue
5. Extremity Changes - erythema of palm/soles, oedema of hands/feet (acute phase), and periungal desquamation (convalescent phase)

Question 14

Causes of Nappy Rash (5)

Answer 14

**Common**
Irritant Dermatitis
Candidiasis
Seborrhoiec Dermatitis
Psoriasis
Milaria
Atopic Dermatitis
**Uncommon**
Staphylococcal Infection
Strep Vulvovaginitis
Perineal Dermatitis
Herpes Simplex
Allergic Contact Dermatitis
**Rare**
Kawasaki Disease
Tinea

Question 15

Treatment of Kawasaki Disease

Answer 15

• Intravenous Immunoglobulin (IVIg) 2g/kg intravenously, as a single slow infusion over 10 to 12 hours
• methyprednisolone sodium succinate 30mg/kg up to 1000mg intravenously, over 1 hour, daily for up to 3 consecutive days
• aspirin 3 to 5mg/kg PO daily

Question 16

Vaccinations due at 12 months.

Answer 16

MNP

• MMR2
• Nimenrix
• Prevenar13

Question 17

Causes of Nipple Pain in Breastfeeding (5)

Answer 17

1. Poor Fit and Hold
2. Breast Pump Trauma and Misuse
3. Nipple Candidiasis
4. Mastitis
5. Tongue-Tie
6. Nipple Vasospasm
7. Nipple Eczema
8. Nipple Bacterial Infection

Question 18

General Management Advice for Sore Nipples

Answer 18

1. Try to use “chest to chest, chin on breast” feeing position
2. Vary feeding positions
3. Start feeding from less painful side first if one nipple is sore
4. Express some milk first to soften and “lubricate” the nipple
5. Gently break the suction with your finger before removing the baby from the breast
6. Ice to sore nipple
7. Keep nipples dry by exposing breasts to air
8. Soothing hydrogel pads inside the bra

Question 19

Other points of advice to mother with cracking nipples

Answer 19

• Do not feed from the affected breast - rest the nipple for 1-2 feeds
• Express the milk from that breast by hand → feed that expressed milk to the baby
• Start feeding gradually with short feeds
• Refer to Lactation Consultant → consider nipple shield but only after seeking face to face expert advice
• Paracetamol or Ibuprofen prior to feeding

Question 20

Causes of Thrombocytopenia

Answer 20

1. Pregnancy → Gestational Thrombocytopenia (10% of pregnancy) is mild and becomes less common as the pregnancy progresses
2. Medications (antibiotics)
3. Chronic Liver Disease
4. Autoimmune Disease → Systemic Lupus Erythematosus
5. Haematological Malignancy
6. Infection → Viral, Bacterial or Intracellular Parasites (Malaria)
7. Alcohol
8. Nutrient Deficiencies → Folate, B12 or Copper
9. Artefactual Thrombocytopenia → in the absence of clinical features including petechiae and ecchymoses

Question 21

Examination Findings in Thrombocytopenia

Answer 21

• *Examination Findings**
• Bleeding of the Oropharynx
• Haematuria
• Petechiae
• Menorrhagia
• Neurological Findings → confusion, gross motor or sensory deficits

Examination Findings to determine cause:

• Splenomegaly + Lymphadenopathy → Lymphoma with ITP
• Sepsis or Thombosis → Disseminated Intravascular Coagulopathy
• Portal Hypertension or other examination findings of Liver Disease

Question 22

Management of ITP: Advice.

Answer 22

• Restrict activities to minimise risk of head injuries
  
  • Avoid contact sports → footy, rugby, soccer, martial arts
  • Limit activities that have a risk of traumatic injury
• Avoid aspirin/NSAIDs/IM injections
• Decrease alcohol intake → >8 std drinks per day can lead to haematological defecits
• Monitor for significant bleeding symptoms
• Monitor for signs of intracranial haemorrhage - severe headache

Question 23

History Findings for Acute Angle Glaucoma

Answer 23

1. Halo around lights
2. Red Eye
3. Nausea and Vomiting
4. Painful Eye
5. Decreased Vision

Question 24

Examination Findings for Acute Angle Glaucoma

Answer 24

• Reduced visual acuity
• Conjunctival redness
• Corneal edema or cloudiness
• A shallow anterior chamber
• a mid-dilated pupil (4-6mm) that reacts poorly to light or is fixed

Question 25

GP Management of Acute Angle Glaucoma (5 points)

Answer 25

1. Emergency Ophthalmology Consult - transfer to hospital via ambulance 2. Place the patient supine 3. Analgesia PRN - morphine 4. Antiemetic PRN - ondansetron/metoclopramide 5. Nil by Mouth - NO eye patches → do not want to maintain the conditions that cause pupillary dilation as this will perpetuate the attack

Question 26

Causes of Burning Feet (5)

Answer 26

1. Vascular - Ischaemic Rest Pain, Chillblains, Raynauds 2. Diabetic Neuropathy 3. Complex Regional Pain Syndrome 4. Tarsal Tunnel Syndrome 5. Psychogenic 6. Morton's Neuroma

Question 27

Clinical Features of Tarsal Tunnel Syndrome

Answer 27

- Anterior burning pain in the forefoot with associated aching in the calf

Question 28

Non Pharmacological Management of Chillblains (4 points)

Answer 28

- Avoiding cold, damp and wind - Wear loose warm clothes → trousers > short + gloves - Thick cotton socks and closed shoes (e.g boots) - Stop Smoking → especially if impaired circulation - Keep home and workplace well-insulated without draughts and heated in winter - Soaking hands in warm water can warm the hands up for several hours - Vigourous indoor exercise keeps the body warm

Question 29

Pharmacological Management of Chillblains

Answer 29

1. Betamethasone Dipropionate 0.05% BD with or without occlusive dressing 2. for prophylaxis in before or during winter months - nifedipine controlled release 20mg daily

Question 30

Non-Pharmacological Management of Osteoporosis? (6 points)

Answer 30

1. Calcium 1300mg/day 2. Vit D - if <50mmol/L for supplementation. Ensure 15mins of sunlight/day 3. Exercise -> Resistance or Balance Exercises 4. Smoking Cessation 5. Reduce Alcohol below 1 std drink/day 6. Falls Prevention Strategies -> removal of home hazards and appropriate well-fitting footwear

Question 31

Dosing of Aledronate and Pros and Cons.

Answer 31

- **Alendronate** (Fosamax): 70mg Oral, Weekly - Advantages - oral dosing, low cost - Disadvantages - can cause or exacerbate GIT irritation, more frequent dosing, absorption reduced by food, antacids, calcium, magnesium and iron.

Question 32

Dosing of Risedronate and Pros and Cons

Answer 32

- **Risedronate** (Actonel): 35mg Oral Weekly or Risedronate: 150mg PO Monthly - Advantages - oral dosing, low cost, enteric coated formula available for weekly dose (lower incidence of GIT side effects) - Disadvantages - can cause or exacerbate GIT irritation, more frequent dosing, absorption reduced by food, antacids, calcium, magnesium and iron.

Question 33

Dosing of Denosumab and Pros and Cons

Answer 33

- **Denosumab** (Prolia): 60mg SC, 6 monthly - Advantages: SC administration avoids GIT side effects, dose adjustment not required in kidney disease, 6 monthly dosing can improve compliance - Disadvantages: 1. adherence to 6 montly dosing regimen is essential to prevent loss of bone mineral density between doses, 2. therapy must be indefinite, or replaced by bisphosphonate 3. if stopped, withdrawal or interruption of treatment (dose delayed by >4 weeks) is associated with increased risk of multiple, spontaneous vertebral fractures** 4. can also cause hypocalcaemia - needs to be replete of Ca2+ -> Ca2+ → 2.10-2.60 5. Before administering Vit D >50 6. Needs renal function tested prior to commencement -> Creatinine Clearance >30

Question 34

Dosing of Zoledronic Acid and Pros and Cons

Answer 34

- **Zoledronic** **Acid** (Aclasta): 5mg IV, yearly for 3 years - Advantages: IV dosing avoids GIT side effects, 3 yearly dosing can improve adherance - Disadvantages: can cause transient flu-like symptoms, can cause hypocalcaemia