21/10/21 - 22/10/21

Question 1

Typical demographic for pyloric stenosis. in whom do we need to consider pyloric stenosis as a DDx?

Answer 1

• need to consider pyloric stenosis as a differential diagnosis for all infants presenting with vomiting → particularly those under 3 months of age
  
  • Should be suspected in infants 3-6 weeks with non-bilious vomiting after meals

Question 2

History of pyloric stenosis (3 points)

Answer 2

• gradual onset of non-bilious vomiting after feeds → becoming more forceful and projectile in nature
• child is typically hungry and irritable and easily re-fed after a vomit
• failure to gain weight or even weight loss

Question 3

Examination of pyloric stenosis (3 points)

Answer 3

• Dehydration
• Visible gastric peristalsis → may be seen after a feed, just before the baby vomits
• Pyloric Mass → felt below the liver edge just lateral to the edge of the right rectus abdomens muscle

Question 4

5 investigations of pyloric stenosis. 4 bloods and 1 imaging

Answer 4

• Bloods → VBG, UEC, FBE, BGL
  
  • VBG → hypokalaemic alkalosis, hypochloraemia
• Abdominal Ultrasound** → confirms diagnosis

Question 5

Presentation of Acute Bacterial Prostatitis (2 main + 2 bonus)

Answer 5

• UTI Symptoms → dysuria, frequency and urgency
• Systemic Features → fever (>38), chills and sweats
• Obstructive Symptoms → urinary retention, dribbling, weak stream
• Prostate Symptoms → pelvic or perineal pressure, prostate tenderness on DRE

Question 6

Investigations for Acute Bacterial Prostatitis (2 main + 1 bonus)

Answer 6

• Urine MCS
• If in hospital - consider blood cultures
• Imaging to determine if prostatic abscess has formed → U/S, CT or MRI

Question 7

Treatment for Acute Bacterial Prostatitis (1 point)

Answer 7

• Trimethoprim 300mg PO for 2 weeks

Question 8

Definition of Chronic Bacterial Prostatitis (1 point)

Answer 8

Defined as recurrent UTI with culture of a recognised uropathogen from urine or prostatic fluid

Question 9

Treatment of Chronic Bacterial Prostatitis (1 point)

Answer 9

1. ciprofloxacin 500mg PO, BD for 4 weeks

Question 10

Clinical Features: History for OSA (4 points + 4 bonus)

Answer 10

1. Habitual snoring during sleep
2. Witnessed apnoeic episodes
3. Falling asleep inappropriately during non-stimulating activities such as watching television, sitting reading, travelling in a car, when talking with someone
4. Feeling tired despite adequate time in bed
   - Poor memory + concentration
   - Morning Headaches
   - Insomnia
   - History of T2DM and difficult to control HTN → should increase suspicion of OSA

Question 11

Clinical Features: Physical Examination for OSA (3 points)

Answer 11

1. BMI >35
2. Thick Neck
3. Narrow Oedematous or Crowded Oropahrynx

Question 12

Subjective Assessment of OSA - 2 quizzes

Answer 12

1. STOP BANG

2. ESS

Question 13

Drivers who are NOT fit to hold an unconditional license secondary to OSA. (4 points)

Answer 13

NOT fit to hold an unconditional license if:

• established OSA
• frequent self-reported episodes of sleepiness or drowsiness while driving
• has had crashes caused by inattention or sleepiness
• if treating doctor believes that driver is at significant risk to driving as a result of a sleep disorder

Question 14

How often to patients with OSA need review? Who with?

Answer 14

Yearly
For private - with GP
For commercial - with sleep specialist

Question 15

If there is a delay in seeing the sleep specialist, can a patient who may qualify for a conditional commercial license drive?

Answer 15

• If delay prior to seeing sleep specialist in assessment for a conditional commercial license (and do not meet criteria for an unconditional license), then the driver is permitted to drive pending assessment if:
  
  • the person has an appointment to see the specialist at the earlier practicable opportunity
  • in the opinion of the GP, the conditions which the driver has are not likely to lead to acute incapacity or loss of concentration. These conditions include ischaemic heart disease, OSA or blackouts other than vasovagal syncope.

Question 16

Order of Stepping Up Therapy in managing asthma in child 1-5yo.

Answer 16

1. SABA as required
2. Preventer + SABA as required
   
   1. Preventer → Low Dose ICS OR Montelukast
3. Stepped Up Preventer + SABA as required
   
   1. Preventer → High Dose ICS or Low Dose ICS + Montelukast
4. Referral to Specialist for additional therapy

Question 17

Indications for preventer treatment in children aged 1-5yo.

Answer 17

In children that have mild symptoms greater than every 3 months → preventer is not indicated.

In children that have mild symptoms every 4-6 weeks → preventer to be considered

In children with moderate or severe flare-ups + mild flare-ups weekly → preventer is indicated.

Question 18

Points to consider when assessing asthma symptom control. (4 points)

Answer 18

• Frequency in Daytime Symptoms: ≤ 2 days per week → >2 days per week (lasting only a few minutes) → >2 days per week (lasting minutes to hours)
• Limitation of Activities: No limitation → Any Limitation
• Nocturnal Symptoms: No symptoms → Any Symptoms
• Need for SABA reliever: ≤2 days per week → >2 days per week

Question 19

POints to consider when choosing between low dose ICS and montelukast as preventer. (2 points ICS, 3 points Montelukast)

Answer 19

• ICS → atopy or raised blood eosinophil count

- Montelukast → refuses pMDI + spacer/mask or comorbid allergic rhinitis or parental refusal of ICS

Question 20

Dosing of Low and High Dose ICS (Name 1)

Answer 20

Beclometasone Dipropionate: 100-200 microg → >200microg (maximum 400microg)
Budesonide: 200-400microg → >400microg (maximum 800microg)
Ciclesonide: 80-160microg → >160microg (maximum 320microg)
Fluticasone: 50microg
Fluticasone Propionate: 100-200microg → >200microg (maximum 500microg)

Question 21

Dosing of montelukast based on _____? (2 points)

Answer 21

Children 1-5yo → 4mg PO Daily

Children >6yo → 5mg PO Daily

Question 22

Clinical Presentation of Bronchiectasis (3 points + 5 bonus)

Answer 22

1. Chronic Productive Cough
2. Recurrent Bronchial Illness
3. Sputum is usually purulent and intermittently bloodstained
   - fatigue, breathlessness, pleuritic chest pain, clubbing of the fingers, coarse crackles on examination

Question 23

Investigations for Bronchiectasis (1 point)

Answer 23

• HRCT is gold standard

Question 24

Imaging for all breast symptoms that are not consistent with hormonal change. (1 point)

Answer 24

U/S +/- Mammography

Question 25

In women <35yo - discuss imaging for breast symptoms (4 points)

Answer 25

1. U/S is first line
   Use Mammography if:
   - U/S does not match clinical findings
   - U/S shows inconclusive, suspicious or malignant findings
   - clinical findings are suspicious or malignant

Question 26

In women >35yo - discuss imaging for breast symptoms (1 point)

Answer 26

U/S + Mammogram

Question 27

In pregnant women - discuss imaging for breast symptoms (2 points)

Answer 27

• U/S is the most useful modality
• Mammography should be used if the clinical or U/S findings are indeterminate, suspicious or malignant or there is inconsistency between test results

Question 28

Risk Factors for Oral Candidiasis (5 local, 2 systemic)

Answer 28

Local

1. Dentures
2. Poor Oral Hygeine
3. Inhaled Corticosteroids
4. Salivary Gland Dysfunction
5. Smoking

Systemic

1. Medication
2. Immunocompromise

Question 29

Treatment of Oral Candidiasis (1 point)

Answer 29

Miconazole 2% 2.5ml QID for 7-14 days, continue treatment for 7 days after symptoms resolve

Question 30

Common presentation of Nasal Foreign Body (1 point)

Answer 30

Most common presenting complaint → unilateral malodourous rhinorrhoea

Question 31

Non-invasive methods of removing foreign body?

Answer 31

• Non-Invasive Technique → “mother’s kiss” which is a positive pressure procedure
  
  • puff of forced exhalation into child’s mouth while covering the non-affected nostril with a finger such that the glottis closes over and the air is forced through the nasal cavity along with the foreign body.