2017-GENERAL-MEDICINE-GP-PSYCHIATRY-EXAM-2 Flashcards
A patient comes into your GP rooms complaining of dizziness HR 36, BP 110/67, history of mild congestive heart failure, hypothyroidism and hyperlipidaemia. He is on thyroxine, aspirin, frusemide, verapamil and metoprolol. Rhythm strip shows complete heart block. What do you do?
A - Increase the thyroxine dose
B - Stop the Metoprolol
C - Stop the verapamil
D - Decrease the frusemide
E - Insert a temporary pacing wire
= C - Stop the Verapamil
Patient with new onset renal failure and list of drug options of which needed to be dose reduced:
- Lithium
The predominant form of chronic kidney disease associated with lithium therapy is a chronic tubulointerstitial nephropathy.
Patient with DKA and chose the most likely of the 5 ABG’s. You were given some blood results but NOT given ketones.. So you needed to know from the history that he had DKA.
DKA is characterised by:
1. Hyperglycaemia: blood glucose > 11.0mmol/L or known diabetes mellitus
2. Ketonaemia: ketones > 3.0mmol/L or significant ketonuria (more than 2+ on standard urine sticks)
3. Acidosis: bicarbonate (HCO3-) < 15.0mmol/L and/or venous pH < 7.3
Hx of patient with typical clinical findings + Picture of ECG.
Pericarditis: ST elevation / PR depression.
Characteristic ECG changes
1. Widespread concave ST elevation and PR depression throughout most of the limb leads (I, II, III, aVL, aVF) and precordial leads (V2-6)
2. Reciprocal ST depression and PR elevation in lead aVR (± V1)
3. Sinus tachycardia is also common in acute pericarditis due to pain and/or pericardial effusion
Soldier returning from the Middle East 6 weeks previous had diarrhoea and now has progressively worsening neurological symptoms.
= Guillain Barre
- GBS can be described as a collection of clinical syndromes that manifests as an acute inflammatory polyradiculoneuropathy with resultant weakness and diminished reflexes.
With poliomyelitis under control in developed countries, GBS is now the most important cause of acute flaccid paralysis.
- Although the classic description of GBS is that of a demyelinating neuropathy with ascending weakness, many clinical variants have been well documented in the medical literature, and variants involving the cranial nerves or pure motor involvement and axonal injury are not uncommon.
- Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is the most widely recognized form of GBS in Western countries, but the variants known as acute motor axonal neuropathy (AMAN), acute motor-sensory axonal neuropathy (AMSAN), and Miller-Fisher syndrome also are well recognized.
80 year old patient suffering stress incontinence but no urge/frequency and is otherwise well. Found to have bacteriuria. What treatment?
- Trimethoprim
- No treatment
- Alkalisation
- Cotrimoxazole
= No treatment
A lady whose migraines have worsened and come on more frequently. She takes paracetamol and NSAIDs daily. Whats your next step in treatment?
- Cease all medications
- Add propranolol
- Add Sumitriptan
- Cease all medications
- Most likely medication over-use
Patient with left sided face and arm weakness that resolves in 5 mins and he is put on aspirin and sent for further investigation. What will be found?
- 90% stenosis of left carotid
- 60% stenosis of right carotid
- Left sided MCA
- Left sided ACA
- Right sided PCA
- 60% stenosis Right carotid
CAS usually does not cause neurological symptoms in the posterior circulation, as emboli from the ICA preferentially enter the anterior circulation as a result of the anatomy and the haemodynamics of the circle of Willis. CAS therefore is not typically considered a differential for symptoms such as vertigo or cerebellar dysfunction. Additionally, stenosis of the external carotid artery, which is an artery that supplies the face and neck, is usually benign and not considered to be a risk factor for stroke.
CXR with bilateral hilar lymphadenopathy and a picture of skin manifestations of the condition on patients shins.
= Sarcoidosis
Patient can look left with both eyes but can’t look past the midline in the left eye when looking right and the right eye develops nystagmus. Where’s the lesion?
- Medial longitudinal fasciculus
- Left CN3 nucleus
- Left CN6 nucleus
= Medial longitudinal fasciculus
Left CN3 nucleus = Oculomotor nerve palsy
1. Down & out
2. Diplopia
3. Ptosis
4. Dilated pupil = Mydriasis
Left CN6 nucleus = Abducens Palsy
1. When CN VI is not working, the affected eye will drift toward the nose because the lateral rectus muscle cannot contract.
2. Horizontal diplopia
Patient with SOB with perfusion V/Q mismatch whats the next step?
- CTPA
- Thrombolysis
- LMWH
Cause of Longstanding bulking offensive diarrhoea?
Explain how Chronic Pancreatitis could result in this?
?pancreatic insufficiency
Chronic Pancreatitis
Pancreatic enzymes are essential for proper digestion of fats, proteins, and carbohydrates. Patients with chronic pancreatitis will develop recurrent bouts of acute pancreatitis and chronic abdominal pain. Chronic pancreatitis will eventually lead to scarring and fibrosis of the pancreas, which will decrease the number of pancreatic enzymes, and malabsorption. This will lead to steatorrhea and weight loss.
Pancreatic Insufficiency (EPI) is a condition which occurs when the pancreas does not make enough of a specific enzyme the body uses to digest food in the small intestine.
Patient with total gastrectomy for gastric cancer now has anaemia with MCV 105 - Cause?
B12 deficiency
Patient gone on a motoring holiday and develops unilateral leg swell. DVT from tibial to popliteal vein. Started treatment on enoxaparin in hospital. Best long-term treatment?
= Provoked proximal DVT & Treat with LMWH then OAC for 6 weeks, if provoked = 3 months
Remember DVT risk factors using the mnemonic “THROMBOSIS”: Travel, Hypercoagulable/HRT, Recreational drugs, Old (> 60), Malignancy, Blood disorders, Obesity/Obstetrics, Surgery/Smoking, Immobilization, Sickness (CHF/MI, IBD, nephrotic syndrome, vasculitis)!
Initial parenteral anticoagulation (with LMWH, fondaparinux, or UFH) should be initiated at the same time as warfarin and before dabigatran and edoxaban. Initial parenteral anticoagulation is not required for patients receiving rivaroxaban or apixaban.
sudden, painless loss of vision that lasts for seconds to minutes and is followed by spontaneous recovery (mostly unilateral)
- What is being described here?
- Causes/Pathophysiology?
- Treatment?
- 3 Complications?
What does the CXR show?
CXR with pneumoperitoneum (free air under diaphragm - duodenal rupture or something following MVA
Patient with possible infective endocarditis? What is the most diagnostic test to do next?
- IV blood cultures
- ECHO
- CXR
- CRP
At least three separate sets of blood cultures are recommended prior to initiating antibiotics. Transthoracic echocardiography (TTE) is the initial imaging modality of choice as it is less invasive. The need for transoesophageal echocardiography (TOE) is assessed based on patient risk factors and TTE findings.
Diabetic, hypertensive patient on Metformin 1g BD, Gliclizide and his HbA1c is 10.1% - what do you use to treat him now?
- Increase metformin dose
- Add spirinolactone
- Add another agent
Determine the individual’s HbA1c target – commonly ≤53 mmol/mol (7.0%) but should be appropriately individualised.
List 7 Types of Diabetes medications & their MOA?
Outline the AUSTRALIAN TYPE 2 DIABETES
GLYCAEMIC MANAGEMENT ALGORITHM.
Management of patient with osteomyelitis with positive blood cultures that are methicillin sensitive s.aureus:
1. Flucloxacilin
2. Piparicillin + taxobactam
= Flucloxacillin
Hyponatraemia management question
Severe hyponatraemia
- For severe hyponatraemia (serum sodium concentration lower than 120 mmol/L or with cerebral symptoms), treatment is intravenous sodium chloride 3% (513 mmol/L). The initial target serum sodium concentration should not be higher than 120 mmol/L.
- Rapidly correcting hyponatraemia may produce permanent central nervous system injury, due to osmotic demyelination.
- The goal of therapy in these patients is to raise the serum sodium concentration by 4 to 6 mmol/L, to prevent neurological damage secondary to brain herniation, swelling and cerebral ischaemia. Use:
- Sodium chloride 3% 100 mL IV over 10 minutes. Repeat as needed up to a maximum of 3 infusions.
Guy slept on his side, woke up and couldn’t extend his wrist, loss of sensation over base of thumb.
= Radial Nerve Injury
Radial nerve = wrist extension (wrist drop)
Median nerve = wrist flexion
- Motor function of the median nerve are mainly flexor aspect of forearm, hand, and thumb.
- Sensory innervation to the dorsal aspect of the distal first two digits of the hand is supplied by median nerve.
Patient with severe pneumonia with penicillin allergy - Which antibiotic?
= IV Moxiflox
For patients with immediate severe or delayed severe hypersensitivity to penicillins, use:
- moxifloxacin 400 mg intravenously, daily
Patient with loin pain, fever, night sweats, weight loss and varicocele. What is the diagnosis?
- Cystitis (bladder infection)
- Proctatitis (inflammation of rectum)
- Renal cell carcinoma
= Renal Cell Carcinoma
- Renal cell carcinoma is the most common type of kidney cancer in adults. It accounts for approximately 85% of neoplasms arising from the kidney.
- Signs and symptoms: Renal cell carcinoma may remain clinically occult for most of its course. Only 10% of patients present with the classic triad of flank pain, hematuria, and flank mass.
- Other signs and symptoms include the following:
1. Weight loss
2. Fever
3. Hypertension
4. Hypercalcemia
5. Night sweats
6. Malaise
7. A varicocele, usually left sided, due to obstruction of the testicular vein
Question about regurgitation of food and halitosis, lump and in the neck?
= Esophageal Diverticula
- The most common type of esophageal diverticulum is a posterior outpouching of the hypopharynx, commonly referred to as a Zenker diverticulum. Esophageal diverticula are caused by either an underlying motility disorder that exerts high intraluminal pressure on a weak esophageal wall or forces pulling on the outside of the esophagus. The clinical presentation varies with pouch size and localization, with the most common symptoms being dysphagia, regurgitation, retrosternal pain, and pulmonary symptoms secondary to aspiration. The diagnosis is confirmed by barium swallow. Surgical treatment is rarely required and only recommended in symptomatic patients (primarily those with Zenker diverticulum).
What is Achalasia?
Esophageal motility disorder characterized by inadequate relaxation of the lower esophageal sphincter (LES) and nonperistaltic contractions in the distal two-thirds of the esophagus due to the degeneration of inhibitory neurons
Patient returning from india with diarhoea, weight loss, insomnia, AF what tests do you do?
- TFT
- FBC
- UEC
- Stool culture
Bunch of dementia questions from the formative that they made into MCQ like histories about frontal lobe dementia and lewy body dementia.
- Compare Frontal Lobe dementia with Lewy Body dementia, Vascular dementia and Alzheimers?
A competent 64 has a stroke with significant hemiparesis and subsequently has aspiration pneumonia and does not want further treatment but his son is adamant he received antibiotics. What do you do?
- Organise a MDT to discuss the patient
- Force him with Abx = NO
- Get the son to become his father’s guardian = Can’t at this stage
Patient who thinks he has arthritis as he is finding it hard to stand up from squatting position. Whats the best investigation?
= Proximal myopathy
Testing for specific disorders may be needed:
- If findings suggest myasthenia gravis, an ice pack test and serologic testing (eg, acetylcholine receptor antibody levels, sometimes anti–muscle-specific tyrosine kinase antibodies)
- If findings suggest vasculitis, autoantibody testing
- If family history suggests a hereditary disorder, genetic testing
- If findings suggest polyneuropathy, other tests
- If myopathy is unexplained by drugs, metabolic, or endocrine disorders, possibly muscle biopsy
Some hard ones about the patient having Parkison’s diagnosis 5 years ago and now experiencing dancing like movements and visual hallucinations and neurologist changed his medication recently and now what do you do?
- Review medications
Dancing like movements = Chorea
Definitely a couple about alcohol withdrawal - either identifying it was alcohol withdrawal symptoms or recognising Wernicke’s what the important treatment was?
Diazepam for withdrawal but most importantly - IV Thiamine - prevent WE
Alcohol withdrawal syndrome (uncomplicated)
- Onset: usually 6–24 hours after cessation of or reduction in alcohol consumption
- Autonomic symptoms (e.g., palpitations, sweating, tachycardia, elevated blood pressure, hyperthermia)
- Anxiety, insomnia, vivid dreams, Tremor, hyperreflexia, Headaches, Anorexia, nausea, vomiting
- Alcohol withdrawal seizures: Usually brief, generalized tonic-clonic seizures, Often a single episode
Lady who usually drinks 1 glass wine/night and is on a bunch of meds including lorazepam. She becomes aggressive day 2 post op and she isn’t charted Loraz. What is the cause of this?
= Benzo withdrawal
- Prolonged benzodiazepine use causes dependence and, potentially, substance use disorder. Treatment involves cognitive-behavioral therapy and psychosocial interventions to facilitate withdrawal and continued abstinence (i.e., psychoeducation, motivational interviewing, cognitive-behavioral therapy).
- Acute withdrawal and seizures can be precipitated by using flumazenil to treat benzodiazepine overdose in patients with benzodiazepine dependence.
Patient with motor neurone disorder who has lost ability to move arms + legs but wife cares for him and even still feeds him (+ wine) and he wakes up in the morning with a headache. What’s the cause?
- Hangover
- Anxiety about death
- Hypoventilation
- Dehydration
- Dehydration?
Palliative care drug that helps with fatigue?
- Methylphenidate = Ritalin/concerta
- Modafinil = Modafinil is a stimulant used to improve wakefulness in patients with sleep apnea, narcolepsy, or shift work disorder.
- Pred?
A patient with allodynia in a dermatomal distribution - what is the best pain management for her?
Allodynia is a type of neuropathic pain (nerve pain). People with allodynia are extremely sensitive to touch. Things that don’t usually cause pain can be very painful. These may include cold temperatures, brushing hair or wearing a cotton t-shirt.
- Tx options: Gabapentin, Pregabalin, Amitriptyline, Duloxetine OR LA patch/nerve blocks
What do you use to detect the ceiling of opiate when titrating up?
- Pain free
- Resp depression
- Opioid tox: consider serotonin syndrome
Patient who has mets to his spine what’s the most important thing you must tell the nurse to look out for?
First sign of spinal decompression?
- Back pain, urinary retention, limb weakness, saddle anaesthesia
Metastatic spinal cord compression - usually back pain 1st symptom
Patient remembers getting an ECT but can’t remember when/where. Whats happened/what type of memory loss?
= Retrograde amnesia - The most persistent adverse effect is retrograde amnesia. Shortly after ECT, most patients have gaps in their memory for events that occurred close in time to the course of ECT, but the amnesia may extend back several months or years. Retrograde amnesia usually improves during the first few months after ECT.
What is the best treatment for a patient diagnosed with OCD?
= Clomipramine (SSRIs)
Patient is convinced he has HIV and has been to see 4 others doctors with 4 negative tests that give him brief relief but then continues to be convinced he has HIV. What is the diagnosis?
= Illness anxiety disorder
- Key features of Illness Anxiety 1. Disorder: Preoccupation with having or acquiring a serious illness (in this case, HIV).
- Repeated medical evaluations or tests (multiple HIV tests with consistent negative results).
- Minimal or no somatic symptoms.
- High anxiety about health, often with repeated self-examinations or health checks.
- Temporary relief from negative results, followed by continued or renewed fear.
- Disbelief in medical reassurance.
- In such cases, psychological evaluation and treatment, often involving cognitive-behavioral therapy (CBT), can be helpful in addressing the underlying anxiety and health-related fears.
A stem with information about thought insertion (patient kept saying something about how all she can think about is Malcolm Turnbull something something). What is Thought insertion? What is Thought broadcasting? What are these a symptom of?
= Thought insertion - A delusion that one’s thought is not one’s own but inserted into their mind by an external source or entity.
vs. Thought broadcasting - Delusion that one’s thought is projected and perceived by others.
Olanzapine
- Class of Drug?
- MOA?
- Side effects? (8)
Class of Drug: Olanzapine is an atypical antipsychotic (second-generation antipsychotic).
Clozapine
- Class of Drug?
- MOA?
- Side effects? (10)
Class of Drug:
Clozapine is an atypical antipsychotic (second-generation antipsychotic) and is often reserved for treatment-resistant schizophrenia due to its unique efficacy profile.
Risperidone
- Class of Drug?
- MOA?
- Side effects? (10)
Class of Drug: Risperidone is an atypical antipsychotic (second-generation antipsychotic), used to treat conditions such as schizophrenia, bipolar disorder, and irritability associated with autism.
Mirtazapine
- Class of Drug?
- MOA?
- Side effects? (9)
Mirtazapine:
Class of Drug: Mirtazapine is an atypical antidepressant that belongs to the class of tetracyclic antidepressants. It is primarily used to treat major depressive disorder (MDD) and sometimes anxiety disorders.
Quetiapine
- Class of Drug?
- MOA?
- Side effects? (10)
Class of Drug: Quetiapine is an atypical antipsychotic (second-generation antipsychotic) used to treat schizophrenia, bipolar disorder, and as an adjunct for major depressive disorder.
Clonazepam
- Class of Drug?
- MOA?
- Side effects? (11)
Class of Drug: Clonazepam is a benzodiazepine. It is primarily used to treat seizure disorders, panic disorders, and sometimes anxiety.
Valproate
- Class of Drug?
- MOA?
- Side effects? (12)
Class of Drug: Valproate, also known as valproic acid or divalproex sodium, is an anticonvulsant and mood stabilizer. It is used primarily to treat epilepsy, bipolar disorder, and to prevent migraine headaches.
Lamotrigine
- Class of Drug?
- MOA?
- Side effects? (13)
Lamotrigine is an anticonvulsant and mood stabilizer. It is used primarily to treat epilepsy and bipolar disorder.
Lithium Carbonate
- Class of Drug?
- MOA?
- Side effects? (10)
Class of Drug: Lithium carbonate is classified as a mood stabilizer. It is primarily used to treat bipolar disorder, especially to manage manic and depressive episodes and to prevent relapse.
Whats the diagnosis & management?
= Hyphema = Hyphema is the medical term for blood collecting in the front (anterior) chamber of your eye. The blood pools in the space right in front of your iris, the ring of muscle tissue that gives your eye its color.
Grading
- 0 (microhyphema) = No blood layering, but blood is visible, though it might require special tools to see.
- 1 = Layered blood that fills less than one-third of your anterior chamber.
- 2. 1/3 to 1/2 of anterior chamber.
- 3 = At least 1/2 but doesn’t fill it completely.
- 4 (total hyphema) = Layered, dark red or black blood completely fills your anterior chamber. They’re sometimes called eight-ball or blackball hyphemas. This puts you at much higher risk for angle-closure glaucoma.
A girl in her 20s presents with spotting 2-3 months after starting the triphasic pill. What’s your management?
- A: Increase the dose
- B: Stop and start new meds
- C: Re-assess in few months
- D: Add progesterone
= C: Reassess in few months
Aboriginal kid with CSOM, what is the appropriate management?
- Would you give Abx? Which ones? Which would you NOT give & why?
For an Aboriginal child with chronic suppurative otitis media (CSOM), management should focus on eradicating infection, preventing complications, and preserving hearing. ATSI children are at higher risk for severe ear disease and hearing loss, so early and appropriate intervention is critical.
What is the diagnosis?
- A: SVT
- B: AF
- C: Atrial flutter
- D: Ventricular tachycardia
ECG features of atrial flutter
1. Narrow complex tachycardia
2. Regular atrial activity at ~300 bpm
3. Loss of the isoelectric baseline
4. “Saw-tooth” pattern of inverted flutter waves in leads II, III, aVF
5. Upright flutter waves in V1 that may resemble P waves
6. Ventricular rate depends on AV conduction ratio (see below)
What is the Pathophysiology of atrial flutter?
Classification?
Typical atrial flutter (common) - Sometimes known as type I flutter, this involves the IVC & tricuspid isthmus in the reentry circuit. Further classified based on the direction of the reentry circuit (anticlockwise or clockwise):
- Anticlockwise Reentry: Commonest form of atrial flutter (90% of cases). Retrograde atrial conduction produces: Inverted flutter waves in leads II,III, aVF. Positive flutter waves in V1 — may resemble upright P waves
- Clockwise Reentry: This uncommon variant produces the opposite pattern: Positive flutter waves in leads II, III, aVF. Broad, inverted flutter waves in V1.
Atypical atrial flutter (uncommon)
- Sometimes referred to as type II flutter, does not fulfill criteria for typical atrial flutter.
- Often associated with higher atrial rates and rhythm instability.
- Less amenable to treatment with ablation.
FBE shows: ↓ Hb, ↑ MCV (macrocytic), ↑ MCH (hyperchromic), Hypersegmented neutrophils & ↓ Reticulocytes
What is the diagnosis? What neurological finding you would test?
= Pernicious Anaemia - Posterior columns for B12 deficiency.
- A type of vitamin B12 deficiency caused by autoantibodies against intrinsic factor and/or gastric parietal cells (type II hypersensitivity reaction)
- Antiparietal cell antibodies: target gastric parietal cells.
- Causes ↓ acid production and atrophic gastritis
- ↓ Intrinsic factor production → ↓ vitamin B12 absorption in terminal ileum
- Anti-IF antibodies: bind intrinsic factor and block the vitamin B12 binding site
- Associated with other autoimmune diseases (e.g., hypothyroidism, vitiligo)
- Increases the risk of gastric cancer
Severe thrombocytopaenia on FBE. What is your the management?
- A: FFP
- B: Prednisolone
- C: Azathioprine
- D: Refer to surgical clinic
- E: Abdominal ultrasound
= B: Prednisolone
Isolated thrombocytopaenia = suspected Immune thrombocytopenic purpura
Severe thrombocytopenia, typically defined as a platelet count less than 20,000–30,000/μL, increases the risk of spontaneous bleeding and requires urgent evaluation.
57 year old lady with menopausal symptoms. What do you use to treat her symptoms? (Found this question/answer a bit vague because they didn’t clarify whether she had a uterus or not)
- A: Progesterone
- B: Oestrogen
- C: Oestrogen + progestogen
- D: Clonidine
The first-line hormone replacement therapy (HRT) for symptomatic menopause depends on whether the woman has had a hysterectomy or not, as well as her risk factors.
First-Line Recommendations:
- Intact uterus: Combined estrogen-progestogen HRT (oral or transdermal).
- Post-hysterectomy: Estrogen-only HRT (oral or transdermal).
55-year-old man with fatigue, anhedonia, irritability, anxious. Finances and family stable, lives with wife and children are married. What’s wrong?
- A: Major depression with agitation
- B: Generalised anxiety disorder
- C: Midlife adjustment disorder (empty nest)
Given the symptoms of fatigue, anhedonia, irritability, and anxiety in a 55-year-old man with stable finances and family life, the diagnosis might be Major Depressive Disorder (MDD).
Patient diagnosed with 4.1cm AAA - how do you watch for surveillance?
- A: Tell your practice manager
- B: Marked it as a reminder for 1 years time
- C: Give the patient a form for radiology
4 Indications for AAA repair? Suggested AAA Surveilance intervals? Role of imaging? When to refer?
Indications for AAA repair
1. Male with AAA >5.5 cm
2. Female with AAA >5.0 cm
3. Rapid growth >1.0 cm/year
4. Symptomatic AAA (abdominal/back pain/tenderness, distal embolisation)
Suggested AAA surveillance intervals
- 3.0–3.9cm = 24 months
- 4–4.5cm = 12 months
- 4.6–5cm = 6 months
- >5cm = 3 months
What is the diagnosis?
Best management?
- A: Oral prednisolone
- B: Famicyclovir
- C: Do nothing
= A. Oral Prednisolone for suspected Bells Palsy.
- Acute idiopathic peripheral facial palsy = Bell palsy = most common cause of peripheral facial nerve palsy
Treatment - Idiopathic peripheral facial nerve palsy is self-limited, but early treatment is recommended to improve recovery time and prevent incomplete recovery.
1. Oral glucocorticoids: Consider for all patients (regardless of severity). Start early (i.e., within 48–72 hours of symptom onset). Available agents: prednisone OR prednisolone.
2. Antivirals - Consider adding an antiviral to steroid therapy (do not use as monotherapy). Available agents: acyclovir OR valacyclovir.
Initiate therapy (i.e., oral glucocorticoids with or without antivirals) within 48–72 hours of symptom onset.
54 year old guy comes in with something needings antibiotics & perhaps liver failure - then develops rash in 3-4 days - this exact picture. What is the diagnosis?
- A: Scabies
- B: Drug allergy rash
- C: Opiate pruritis… can’t remember the other choices
= Scabies
- Scabies is a transmissible skin disease caused by the ectoparasitic mite Sarcoptes scabiei var. hominis. This variant infests humans only; scabies cannot be caught or transferred to other animals.
- Scabies is a highly contagious infestation of the human epidermis. Scabies was described by Aristotle who likened the disease to ‘lice of the flesh’. Scabies presents as a rash with intense itching; it may have a characteristic appearance and distribution.
Man with anaemia and gout who experienced pruritus after hot showers. What is the diagnosis?
Polycythemia vera (primary polycythemia) is the most likely diagnosis given the combination of symptoms, including anemia, gout, and pruritus after hot showers.
A picture of macrocytic anaemia, anisocytosis, poikylocytosis with raised GGT. What is the diagnosis?
The description of macrocytic anemia, anisocytosis, poikilocytosis, and raised gamma-glutamyl transferase (GGT) suggests a diagnosis of chronic liver disease, potentially complicated by alcohol-related liver disease. Chronic Liver Disease: The combination of macrocytic anaemia with elevated GGT strongly points towards liver dysfunction. This could be due to alcohol-related liver disease or another form of chronic liver disease that affects red blood cell production and morphology.
Lady with pigment changes over face and neck with macrocytic anaemia. What is the diagnosis?
= Pernicious Anaemia
A lady on a sulfa medication presents with a normocytic anaemia. What is the diagnosis?
A lady on sulfa medication who presents with normocytic anemia may be experiencing sulfamethoxazole-induced hemolytic anemia, especially if she is known to have a glucose-6-phosphate dehydrogenase (G6PD) deficiency.
CASE 1 GEN MED
A male presents with two week history of increasing shortness of breath on exertion. No wheeze. Associated ankle oedema. PMHX: Stent, HTN, smoker, haemorrhoids. Doesnt drink alcohol.
What are you differential diagnosis? (9)
CASE 1 GEN MED
- A male presents with two-week history of increasing shortness of breath on exertion. No wheeze. Associated ankle oedema. PMHX: Stent, HTN, smoker, hemorrhoids. Doesn’t drink alcohol.
- On examination he has bibasal creps, pitting ankle oedema bilaterally. Hyperinflated chest, with associated wheeze and course creps. JVP elevated to 5cm. Some epigastric tenderness on palpation. Other examination findings unremarkable. DRE: rectum empty, no blood on glove.
Explain what these clinical signs mean? What is your differential diagnosis now?
What investigations do you want to order and why?
Differential Diagnosis
1. Congestive Heart Failure (CHF): SOB, ankle oedema, elevated JVP, bibasal crackles. History of stent placement, hypertension, smoking can contribute to heart failure.
2. COPD: Hyperinflated chest, wheeze. Smoking history.
3. Ascites or Hepatic Congestion: Epigastric tenderness, which could be due to liver congestion from heart failure.
4. Interstitial Lung Disease: Bibasal crackles and progressive SOB. Needs further evaluation if other diagnoses are ruled out.
5. PE: Shortness of breath and potential for oedema. Less likely without more acute onset or risk factors.
Comment on your findings, state what your think is going on. What is your overall impression.
He is diagnosed with anaemia. What further investigations do you want now? His Hb 78. MVC 77.
- Iron studies (microcytic anaemia = iron def most likely)
- Colonoscopy
- Endoscopy
So they give you Iron studies… his iron is super low (they give you reference ranges). His colonoscopy result is normal. Endoscopy shows gastric peptic ulcer, negative for H. Pylori. What would you transfuse him?
No .. Hb not less than 70. You would offer him supplemental iron.
Give him iron (* see how you are just repeating yourself as the questions are vague.. Then if you get the question wrong.. You get a slap in the face when you move onto the next answer.).
CASE 2: Gen med
Chronic kidney disease stuff
Know CKD
CASE - GERIATRICS
An 81-year-old female, lives alone, had a fall at a shopping center, rarely goes out anymore due to falls. Was wearing slippers. She feels dizzy when she stands. PMHX: HTN on ACE and thiazide. Has T2DM, on wait list for cataract surgery. Has painful right knee and thinks she needs a TKR. She walks with a limp favouring the right side. TUGT 13seconds, stage 3 retropulsion. Rhomberg negative.
- What are her risk factors for falls? (9)
- What do you make of her TUGT score?
- What about her retropulsion score?
What are her risk factors for falls?
1. Female
2. Age
3. Previous fall
4. Reduced vision
5. Orthostatic hypotension
6. Slippers
7. Pain R knee
8. Poor balance / reduced gait speed
Fear of falls?
TUGT - Interpretation:
- <10 seconds = normal
- <20 seconds = good mobility, can go out alone, mobile without gait aid
- ≤ 30 seconds = problems, cannot go outside alone, requires gait aid
- A score of ≥14 seconds has been shown to indicate high risk of falls.
CASE - GERIATRICS
An 81-year-old female, lives alone, had a fall at a shopping center, rarely goes out anymore due to falls. Was wearing slippers. She feels dizzy when she stands. PMHX: HTN on ACE and thiazide. Has T2DM, on wait list for cataract surgery. Has painful right knee and thinks she needs a TKR. She walks with a limp favouring the right side. TUGT 13seconds, stage 3 retropulsion. Rhomberg negative.
- What is your medical management for this patient?
- What is your other management for this patient?
Falls Prevention!
CASE - GERIATRICS
An 81-year-old female, lives alone, had a fall at a shopping center, rarely goes out anymore due to falls. Was wearing slippers. She feels dizzy when she stands. PMHX: HTN on ACE and thiazide. Has T2DM, on wait list for cataract surgery. Has painful right knee and thinks she needs a TKR. She walks with a limp favouring the right side. TUGT 13secs, stage 3 retropulsion. Rhomberg negative. Before you can start your management plan the patient presents again to ED with with hip/groin pain. An x-ray of the pelvis confirms an inter-trochanteric proximal neck of femur fracture. Which investigations would you order and what you would tell the ortho reg on the phone? What surgery do you consent this patient for?
Communication with Ortho Reg - will want to know diagnosis and how it was confirmed. PMH, Past surg hx, MEDs & Suitability for surgery
NOF
- Classification?
- Radiographic features?
- Tx & Prognosis?
Treatment - Internal fixation can be performed with multiple pins (cannulated screws), intramedullary hip screw (IHMS), crossed screw-nails or compression with a dynamic screw and plate 9. Replacing the femoral head is achieved with either hemiarthroplasty or total hip arthroplasty.
Prognosis - The risk of osteonecrosis depends on the type of fracture. The Delbet classification, originally described by Delbet in adults but more frequently used with reference to paediatric fractures, correlates with the risk of osteonecrosis:
- Type 1 (transphyseal): ~90% risk of osteonecrosis
- Type 2 (transcervical): ~50% risk of osteonecrosis
- Type 3 (basicervical): ~25% risk of osteonecrosis
- Type 4 (intertrochanteric): ~10% risk of osteonecrosis
CASE - PALLIATIVE CARE
- CT showing worsening primary rectal carcinoma and mets to the liver - you had to interpret the CT
- A lot what ‘one investigation or one management’ would you chose to do and the next part would unfold and show you multiple investigations/mx which was annoying
- Medications for management of his pain - didn’t need doses
- One thing that could be causing his pain - hypercalcaemia stuff
- Medications used in the terminal phase?
The most common cancers that metastasized to the liver are colon and rectal cancer, followed by pancreatic.
CASE - PSYCHIATRY 1 - Patient presenting with overdose - do a risk assessment.
- Risk factors for suicide (SAD PERSONS)?
- 6 Protective factors?
- Imminent warning signs of suicide (IS PATH WARM)?
- Risk factors for harm to others: 4 Static? 3 Dynamic?
- What do you need to clarify regarding suicidal ideation? (10)
CASE - PSYCHIATRY 1 - Patient presenting with overdose. Turns out that she has personality disorder and was upset her boyfriend broke up with her so she just had some pills in the cupboard and called her mum.
- Write down all the characteristics that would support a diagnosis of personality disorder (this was a lot of marks - 6? Or something)
- 5 Common features?
- 3 Clusters?
Characteristics of Personality Disorders
1. Deviates markedly from the expectations of the individual’s culture
2. Is inflexible and pervasive across a broad range of personal and social situations
3. Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning
4. Is stable and of long duration, with onset able to be traced back at least to adolescence or early adulthood
5. Is not the result of another mental disorder, drug or physical condition
CASE - PSYCHIATRY - Patient presenting with overdose. Turns out that she has personality disorder and was upset her boyfriend broke up with her so she just had some pills in the cupboard and called her mum. She wants to be discharged.
Outline your management.
CASE - PSYCHIATRY 2
Patient presenting with symptoms of panic attack.
- List the differentials.
Definition: An acute panic attack is an abrupt episode of intense fear associated with physical and cognitive symptoms.
Aetiology
1. Panic disorder
2. Anxiety due to another medical condition (see image)
3. Substance/medication-induced anxiety disorder
4. Other anxiety disorders (e.g., specific phobias)
5. Other psychiatric disorders (e.g., psychotic disorders)
Differential diagnoses of
- Chest pain - MI, PE
- Dyspnea - Asthma
- Syncope and presyncope
- Stroke
- Abdominal pain
- Cardiac arrhythmias
CASE - PSYCHIATRY 2
Patient presenting with symptoms of panic attack.
- Write down all the other physical symptoms the patient would be experiencing during a panic attack.
- How do you manage this patient?
CASE - PSYCHIATRY 2
Patient presenting with symptoms of panic attack. Patient confides to you later that she’s been taking alprazolam and wants to stop - how do you manage this? (9 points)
If a patient confides in you that they’ve been taking alprazolam (a benzodiazepine) and wants to stop, it is important to approach the management with caution due to the risk of dependence and withdrawal symptoms, which can be severe.
Summary
1. Gradually taper alprazolam, potentially switching to a longer-acting benzodiazepine.
2. Provide psychological support, consider SSRI/SNRI or other non-benzodiazepine therapies.
3. Monitor for withdrawal symptoms, and adjust the taper if necessary.
4. Treat any underlying anxiety or panic disorder effectively with non-benzodiazepine options.
