22/11/21 - 23/11/21

Question 1

Conditions associated with vitiligo?

Answer 1

Thyroid Dysfunction
Diabetes
Pernicious Anaemia

Question 2

Management points for vitiligo?

Answer 2

1. Cosmetic Camouflage
2. Betamethasone Dipropionate 0.05% or Mometasone Furoate 0.1%
3. Pimecrolimus 1% cream
4. Calcipotriol + Betamethasone Dipropionate 50/500microg/g ointment or gel
5. Phototherapy

Question 3

Cause of stress urinary incontinence and clinical features.

Answer 3

Weakness in the urinary sphincter and/or pelvic floor
Loss or urine with activities that raise intra-abdominal pressure such as coughing, sneezing, high impact exercise and heavy lifting.

Question 4

Urge Urinary Incontinence - causes and clinical features

Answer 4

Detrusor overactivity → bladder muscle that contracts involuntarily, usually at lower bladder volumes and with little warning.

Loss of urine preceded by a sudden and severe desire to pass urine with loss of urine en route to toilet. Triggers: running water, cold weather, inserting the key in the door upon returning home

Question 5

Mixed Urinary Incontinence - definition (duh). approach to management?

Answer 5

A combination of stress and urge incontinence. Define which symptom is predominant and most bothersome and treat this symptom first.

Question 6

Overflow Urinary Incontinence - cause/mechanism.

Answer 6

Occurs when patient is chronic urinary retention due to leakage from an overdistended bladder → bladder outlet obstruction and/or poor bladder muscle function

Question 7

Urinary Fistula - cause/mechanism.

Answer 7

Fistulous connections can occur between bladder, vagina, ureter or urethra. Obstetric trauma is a cause of this.

Question 8

Functional Incontinence - cause/mechanism

Answer 8

Involuntary loss of urine caused by either physical limitations such as poor mobility or cognitive disability resulting in an inability to toilet normally

Question 9

Risk Factors for Female Urinary Incontinence (6)

Answer 9

1. Age
2. Obesity
3. Increasing Parity
4. Vaginal Delivery
5. Family History
6. Smoking
7. Other: Caffeine Intake, Diabetes, Stroke, Depression, Faecal Incontinence, Menopause/Vaginal Atrophy, Hormone Replacement Therapy, Genitourinary Surgery, Radiation
8. High Impact Activities → jumping and running → stress incontinence

Question 10

Investigations for Female Urinary Incontinence (3)

Answer 10

1. Urinalysis - Urine MCS
2. Bladder Ultrasound with Post-Void Residual OR Renal Tract Ultrasound
3. Bladder Diary

Question 11

Non-Pharmacological Female Urinary Incontinence (6 points)

Answer 11

• Water → 6-8 cups of fluid a day, reduce fluids after the evening meals
• Caffiene and Alcohol → eliminate caffeiene, fizzy drinks + alcohol can worsen symptoms
• Fibre → avoid constipation
• Physical Activity → 30mins of exercise most day of the week. Avoid fitness activities that cause bladder leakage
• Pelvic Floor Exercises
• Avoid lifting - can weaken pelvic floor
• Toilet Habits → empty bladder with urge, do not strain to empty bladder
  Bladder Training → referral to continence nurse or pelvic floor physiotherapist
• Continence pads or accessories - increase QoL

Question 12

Explain how bladder training works.

Answer 12

• Bladder Training
  
  • FIRST LINE THERAPY** → reduce void frequenct, increase bladder capacity, eliminate detrusor overactivity → scheduled voiding rather than voiding in response to urgency
  Method:
  • Bladder diary reviewed → longest comfortable interval between voiding is chosen
  • Empty bladder on waking and then each time during the day when the interval is reached and again at bed-time
  • If patient feels the urge to void in between → encouraged to used urge suppression techniques (distractions, relaxation etc)
  • After 1-2 weeks → decrease interval by 15mins → reduce interval between the voids
  • A minimum of 6 weeks is required to see benefit.

Question 13

Pharmacological options for management of female urinary incontinence

Answer 13

1. oxybutynin
2. duloxetine
3. little evidence for estrogen - can consider in patients with vaginal atrophy.

Question 14

2 first degree family members >55yo with CRC -> what level of risk? screening + management?

Answer 14

Moderately increased risk.

iFOBT every 2 years from 40-49 years of age
Colonoscopy every 5 years from 50-74 years of age
Aspirin for at least 2.5 years commencing at 50 until 70 years of age

Question 15

1 first degree relative >55yo with CRC -> what level of risk? screening + management.

Answer 15

Average Risk

Every 2 years from 50-74yo
Aspirin for at least 2.5 years commencing at 50 until 70 years of age

Question 16

1 first degree relative <55y0 with CRC -> what level of risk? screening + management.

Answer 16

Moderately increased risk.

iFOBT every 2 years from 40-49 years of age
Colonoscopy every 5 years from 50-74 years of age
Aspirin for at least 2.5 years commencing at 50 until 70 years of age

Question 17

1 first degree relative + 1 second degree relative >55yo -> what level of risk? screening + management.

Answer 17

Average Risk

Every 2 years from 50-74yo
Aspirin for at least 2.5 years commencing at 50 until 70 years of age

Question 18

Clinical Features that warrant further investigation of GIT symptoms (9)

Answer 18

1. FHx of bowel cancer or coeliac disease
2. older than 50 yo for onset of symptoms
3. significant weight loss
4. dysphagia (difficulty swallowing)
5. severe large-volume diarrhoea
6. steatorrhoea
7. persistent vomiting
8. severe abdominal pain
9. fever
10. symptoms that interfere with sleep
11. anaemia
12. evidence of gastrointestinal bleeding (rectal bleeding, haematemesis, positive FOBT)
13. abnormality on abdo examination
14. evidence of inflammation on blood tests or stool samples

Question 19

Criteria for the diagnosis of IBS? (4 points)

Answer 19

3 days of the month for the last 3 months.

2 of the following:

1. pain improves after defecation
2. change in bowel frequency
3. change in stool appearance

Question 20

Investigations for IBS (4 points)

Answer 20

• FBE
• Coeliac Serology
• CRP (only if faecal calprotectin cannot be performed)
• For patients with diarrhoea predominant IBS - faecal calprotectin

Question 21

Non-Pharmacological Management of IBS. (4 points)

Answer 21

In regards to eating patters → regular meal times and portion control

Fibre: adequate fibre intake → can be useful esp in constipation predominant IBS but there are some types of fibre that can worsen IBS symptoms

Low FODMAP Diet: FODMAPs are fermentable carbohydrates that are poorly absorbed. This results in bloating, diarrhoea and discomfort

Psychological Therapies: even if patients do not meet the diagnostic criteria for anxiety or depression → behavioural and psychological therapies can be effective.

Question 22

Pharmacological Management of IBS (3)

Answer 22

1. Loperamide (Diarrhoea)
2. Hyoscine Butylbromide (Buscopan) 20mg PO, up to 4 times daily PRN
3. Mebeverine 135mg orally, up to 3 times daily PRN
4. amitriptyline 5-10mg PO nocte → increase slowly as tolerated up to 30-50mg nocte

Question 23

Risk Factors of Suicide (5)

Answer 23

1. Psychiatric Disorder → especially major depression, bipolar disorder, schizophrenia, schizoaffective disorder, substance use disorder, personality disorder
2. Current Psychosis
3. Family History of Suicide
4. Access to Means of Suicide with high potential lethality → guns, firearms, ropes, hosepipes
5. Definite plan of suicide attempt
6. History of dangerous behaviour on impulse
7. Low likelihood of suicide attempt being detected
8. Ambivalence toward survival of suicide attempt
9. Social isolation or absence of social supports
10. Chronic Medical Illness → especially if painful
11. Recent Major Loss → includes loss of face in some cultures
12. Feeling of Hopelessness

Question 24

When evaluating patients risk of suicide, what questions need to be asked of the patient? (6)

Answer 24

• Suicidal Thinking → frequency and persistence of suicidal thoughts
• Plan → how detailed and realistic?
• Lethality → method and how lethal?
• Means → access to means of suicide
• Past History → previous attempts of suicide?
• Suicide of family member of peer
• *Consider**
• Risk and Protective Factors
• Mental State
• Substance Use
• Strengths and Supports
• Prepatory Actions → weapon, putting affairs in order, making a plan, suicide note, giving away prized possessions

Question 25

Investigations in context of lithium prescribing. (4 points)

Answer 25

• Serum Lithium Concentration - 3-6 months
• Serum Creatinine and Urea Concentrations - 3-6 months
• Serum Sodium Concentration - assess hydration, assess hypernatraemia in patients with altered conscious state, review every 6-12 hours
• TFTs - 6-12 months
• Serum Calcium - 12 months
  
  • Screen for hyperparathyroidism
    ECG

Question 26

Clinical Features of Hypomanic/Manic Episode + how many need to be positive in diagnosis of manic/hypomanic episode (5 points)

Answer 26

B: 3 (or more) of following symptoms (4 if the mood is only irritable)

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep → feels rested after less sleep
3. More talkative than usual or pressure to keep talking
4. Flight of Ideas or Subjective experience that thoughts are racing
5. Distractibility → attention is drawn to unimportant stimuli
6. Increased in goal-directed behaviour or psychomotor agitation
7. Excessive involvement in activities that have a high potential for painful consequences → spending, sexual, speeding

Question 27

Difference between manic and hypomanic episode

Answer 27

1. marked impairment or hospitalisation

2. psychotic features

Question 28

Difference between bipolar 1 and bipolar 2?

Answer 28

Manic Episodes in Bipolar 1, Hypomanic episode Bipolar 2

Depressive episodes -> yes in bipolar 2, not required for bipolar 1

Question 29

Malaria Prevention (4)

Answer 29

Dusk and Dawn - avoid activities from dusk to dawn
DEET -> apply insect repellant
DAKS -> wear light long trousers
Doxycycline -> malaria chemoprophylaxis -> doxycycline, malarone, mefloquine

• sleeping in screened accomodation
• avoid perfume and aftershave
• spray thin clothing with insect repellant and pre-impregnate with permethrin

Question 30

General Travel Advice (6 points)

Answer 30

• Purchase Travel Insurance
• Food Safety → Avoid unwashed/uncooked food, Cook it, peel it, boil it or forget it.
• Water Safety → bottle water, no ice please, brush teeth with bottled water.
• Diarrhoea Management → azithromycin stat
• Carry first aid kit
• Sun protection - for severe sunburn
• Avoid risk-taking behaviour → drug trafficking/road safety (wear a helmet while on a motorbike or scooter)/sex (use a condom)/tattoos (fresh needles)
• Safe Sex practices
• Insect bite precautions → insect repellant/chemoprophylaxis for malaria
• Avoid swimming in contaminated fresh water
• Beware of animal exposure for rabies
• Beware of risk of dengue fever, lymphatic filariasis and chikungynya
• DVT Prophylaxis → compression stockings, calf exercises, walking around plane

Question 31

Clinical Features of Urethritis (3)

Answer 31

• Urethral Discharge → Gonorrhoea - usually copious and purulent. More common in MSM and indigenous population. Non-Gonococcal urethritis - usually less discharge
• Dysuria → in young men → dysuria indicates an STI until proven otherwise
• Urinary Frequency → suggestive of bladder infection

Question 32

Management of Urethritis (pharm 2 and non-pharm 3)

Answer 32

Non-Gonococcal Urethritis → Doxycycline 100mg PO BD for 7/7

Gonorrhoea → Ceftriaxone 500mg in 2ml of 1% lignocaine IM stat + Azithromycin 1g PO stat

• *Other**
• if considering non-gonococcal urethritis → can add doxycycline to ceftriaxone instead of azithromycin
• Advise no sexual contact for 7/7 after treatment is administered
• No sex with partners from last 6 months until parters have been tested and treated as necessary
• Contact Tracing - if gonorrhoea → 2 months
• Notify Health Department