24/9/21 Flashcards
How long does it take to achieve maximum protection when taking daily PrEP for men? How long for women?
Men - 7 days
Women - 20 days
What are the 5 Steps in prescribing Prep?
- Behavioural Suitability
- Clinical Suitability
- Other Testing
- Prescribing PrEP
- Ongoing Monitoring
What is involved in Step 2 of prescribing PrEP -> Clinical Suitability? (3 points)
HIV Status + ?recent exposure
Renal Function
Nephrotoxic Medication
If HIV negative but recent exposure, what are the next steps?
Refer to/Consult with PEP prescriber -> consider PrEP following completion of PrEP
What is involved in Step 3? (Other Testing)
STI Testing + Heptatits B + C Testing
- STI testing - as per STI guidelines
- Hepatitis B testing - HBsAg, Anti-HBs, Anti-HBc → vaccinate if not immune. If HBsAg is positive → refer to HBV specialist
- Hepatitis C testing → anti-HCV, followed by HCV RNA if anti-HCV positive. If HCV RNA positive → treat Hepatitis C
What are the 2 options when prescribing PrEP (Step 4)?
Who is suitable for either option?
- Daily Continuous PrEP → 1 pill daily of tenofovir/emtricitabine → start 7 days before HIV risk
- suitable for anyone with ongoing risk of HIV exposure
- On-Demand PrEP (2-1-1 method) → tenofovir/emtricitabine → 2 pills 2/24 before sex, 1 pill 24/24 later, 1 pill 48/24 after first dose
- suitable only in cis-male who have sex with men whose HIV risk if from anal sex not from IVDU
What are the 9 points involved in ongoing monitoring following commencement of PrEP (Step 5)?
HIV Testing Side Effects Hep A Hep B Hep C STI Screening Renal Function (eGFR) Urine Protein Creatinine Ratio Pregnancy Test
What testing takes place at baseline when starting PrEP?
HIV Testing Hep A Hep B Hep C STI Screening Renal Function (eGFR) Urine Protein Creatinine Ratio Pregnancy Test
What testing takes place at 1 month following commencement of PrEP?
HIV Testing
Side Effects
Pregnancy Test
What testing takes place at 3 months following commencement of PrEP?
HIV Testing Side Effects STI Screening Renal Function (eGFR) Urine Protein Creatinine Ratio Pregnancy Test
What testing takes place every 3 months after the commencement of PrEP?
HIV Testing
Side Effects
STI Screening
Pregnancy Test
What additional testing needs to take place following commencement of PrEP?
eGFR + urine protein creatinine ratio -> every 6 months or sooner as per CKD guidelines
Hep C -> 12 monthly but more frequent if ongoing risk -> e.g MSM with anal trauma or IVDU
Hep B -> If required Hep B immunisation -> check immune response 1 month after last vaccination
Short Term and Long Term side effects of PrEP (2 each please)
Short Term - headache + nausea
Long-Term - Renal Toxicity + Lowered Bone Density
In Lewy Body Dementia, what are the three associated features along with the memory loss?
- Any 2 of: fluctuating confusion, visual hallucinations, spontaneous motor Parkinsonism and sleep behaviour disorder
In frontotemporal dementia, what are two of the earliest manifestations of this disease?
- personality change and altered behaviour can be the earliest manifestations of this condition
Lab Findings for Cholestatic Picture of deranged LFTs.
Common Causes of Cholestatic Picture (give me 3)
- Laboratory Findings → ALP >200 + ALP > 3xALT
- Common Causes:
- Biliary Obstruction
- Pregnancy
- Drugs → erythromycin, oestrogen
- Infiltration → Malignancy
Lab Findings for Hepatocelluliar Damage Picture for deranged LFTs.
Common Causes of Hepatocelluliar Damage Picture. (give me 3)
- Laboratory Findings → ALT >200 + ALT > 3xALP
- Common Causes
- Infection → Hepatitis B, C, A, EBV, CMV
- Alcohol → AST often >2xALT
- Fatty Liver
- Drugs → paracetamol
- Metal Overload
- Hypoxia
- Autoimmune
Risk Factors for Pancreatic Cancer (4 points). How many fold is the increase in risk with these risk factors?
- ≥2 affected first degree relatives
- Lynch Syndrome OR BRCA2 Gene Carrier + ≥1 affected first degree relative
- Hereditary pancreatitis with PRSS1 mutation
- Peutz-Jehger Syndrome
5 times the risk of the general population
3 indications for referral to specialist in the context of pancreatic cancer.
- Unexplained weight loss + any of: back pain, abdo pain, nausea/vomiting, diarrhoea or constipation, new onset diabetes → CT Abdo → Pancreatic Mass → specialist referral
- Jaundice + Age ≥ 40yo → specialist referral
- Risk Factors -> specialist referral
When is Genetic Testing recommended in the context of deranged iron studies - ?haemachromatosis?
Recommended in individuals with suspected iron overload (ferritin >200 in females and >300 in males) and a transferrin saturation >45%
Who qualifies for cascade gene testing in hereditary haemachromatosis?
all first degree relatives with HHC who are C282Y homozygous or C282Y/H63D compound heterozygous
Treatment for Moderate to Severe Travellers Diarrhoea. Be Specific.
- azithryomycin 1g PO stat (child 20mg/kg up to 1g)
- Antimotility drugs can be used in combination with ABx in adult patients who do not have fever or bloody stools**
- if fever or bloody stools + diarrhoea does not improve after 1st large dose → continue azithromycin 500mg PO daily for further 2 days
Explain the pathophysiology of posterior vitreous detachment.
Vitreous Gel → fills the central cavity of the eye providing structural support
- with age → this vitreous gel undergoes liquefaction and this leads to separation from the retina. This is a normal event and occurs in approximately 60% of people aged between 40-70 → this is called Posterior Vitreous Detachment (PVD)
In PVD, why do patients see flashes and floaters?
In PVD → as the vitreous pulls away from the retina → neurons are excited → flashes seen by patient
Symptoms are intermittent, can occur over a period of time prior to full detachment. As the vitreous pulls away → vitrous floaters can be seen in the line of sight. These floater represent the collagen fibres within the gel or the previous points of attachment of the gel to the optic disc.
DDx for Flashes and Floaters (5 points)
- Retinal Tear or Detachment
- PVD
- Vitreous Haemorrhage
- Diabetic Vitreous Haemorrhage
- Migraine
What is Trachoma? If we do not treat Trachoma, what can result?
Form of chronic C. trachomatis conjunctivitis → leading cause of preventable blindness in the world
Without treatment can lead to → eyelid scarring, corneal ulceration, corneal scarring and loss of vision
How can you prevent Trachoma? How can you treat Trachoma? What should you not do?
- regular face washing + treatment of household contacts is recommended
- community-wide treatment may be required in areas where prevalence is high
- Epilation (removal of eye lashes) → not recommended as a long-term solution as they will regrow.
- azithromycin 1g orally stat (child 20mg/kg up to 1g`)
What are the two components of clinical diagnosis of GORD?
When symptoms are frequent (>2times/week) + significant enough to impair quality of life → GORD
What are the 2 cardinal symptoms of GORD?
Heartburn and Regurgitation
Indications for Upper GI endoscopy in context of GORD. (11 points - name all 5 alarm features + 2 more)
- alarm symptoms
- anaemia
- dysphagia (difficulty swallowing) or odynophagia (painful swallowing)
- haematemesis and/or malaena
- vomiting
- weight loss
- new symptoms in an older person
- changing symptoms
- severe or frequent symptoms
- inadequate response to treatment
- diagnostic clarification of symptoms
Lifestyle Measures to treat mild GORD (8 points give me 4)
- avoidance of high-fat meals, alcohol, coffee, chocolate, citrus fruit, tomato products, spicy foods and carbonated beverages
- weight loss is effective
- Other Measures:
- eating smaller meals
- drinking fluids mostly between meals rather than with meals
- avoiding lying down after eating
- avoiding eating 2-3 hours before bedtime or vigourous exercise
- elevating head of the bed (if symptoms occur at night)
- stopping smoking
Medication options for Mild GORD
- Antacid + Alginate (Gaviscon) or Magnesium Hydroxide + Aluminium Hydroxide Prep
- PPI Options
- esomeprazole 20mg daily
- pantoprazole 40mg daily
- omeprazole 20mg daily
What causes acromegaly?
excessive secretion of growth hormone from a pituitary adenoma
What are the clinical features of acromegaly? (10 points - give me 5)
- acral overgrowth
- increased sweating
- soft tissue changes
- impaired glucose tolerance
- neuropathy
- arthritis
- hypertension
- cardiomyopathy
- sleep apnoea
- gigantism
How do you diagnose acromegaly?
increased serum growth hormone concentration that does not suppress during an OGTT + elevated plasma insulin life growth factor (IGF-1) concentration
Aetiology of Bacterial Vaginosis
Polymicrobial syndrome → reduction of Lactobacillus species in the vagina and overgrowth of anaerobic (Mobiliuncus species) and other fastidious bacteria
How do you diagnose Bacterial Vaginosis? What is Amsel’s Criteria?
- vaginal smear → key to diagnosis, culture not required
Amsel Criteria → 3 of the following features must be present
- thin, white homogenous discharge
- vaginal fluid pH >4.5
- clue cells
- fishy odour
Treatment of Bacterial Vaginosis (2 options)
- metronidazole 400mg PO BD for 7/7
- metronidazole 0.75% vaginal gel, 1 applicatorful intravaginally nocte for 5/7
Normal CST -> Now HPV non16/18 + LSIL -> next step?
repeat HPV in 12 months
Pharmacotherapy in Urinary Incontinence. One for urge incontinence and one for stress incontinence.
Anticholinergic Medications → reduces involuntary detrusor contractions mediated by acetylcholine. Good for Urge Urinary Incontinence
- most common is **oxybutynin**. Newer drugs include solifenacin and darifenacin
- By using the ocybutynin patch → dry mouth is less common than in oral preparation
SNRI including duloxetine can work in storage urinary incontinence
- works by relaxing the bladder and increasing outlet resistance - Adverse effects - nausea, fatigue, dry mouth and constipation
Clinical features of atypical pneumonia. (5 points + DxT)
Clinical Features
- Fever, Malaise
- Headache
- Minimal respiratory symptoms - non-productive cough
- Signs of consolidation absent
- CXR - diffuse infiltration incompatible with chest signs
Diagnostic Triad → flu + headache + dry cough → atypical pneumonia
4 pathogens that commonly cause atypical pneumonia. Name that pathogen.
- Chlamydia pneumoniae
- Chlamydia psittaci
- Legionella pneumophilia
- Mycoplasma pneumoniae
Examination findings - Pulled Elbow
- not using the affected limb
- elbow in extension and forearm in pronation
- distressed ONLY on elbow movement
- no swelling, deformity or bruising of the elbow or wrist
- market resistance and pain with supination of the forearm
Age Range most common for pulled elbow
1-4 yo
Treatment of Pulled Elbow
- Pronation Manoeuvre
- one hand with pressure on radial head and other on child’s hand
- fully pronate the forearm and flex the elbow → may feel click over the radial head
- Supination Manoeuvre
- one hand with pressure on the radial head and other on the child’s hand
- fully supinate the forearm and flex the elbow → may feel click over the radial head
What is the criteria of diagnosis of functional constipation? (6 points)
Must include ≥ 2 criteria for at least 1 month in infants or 2 months in older children
- ≤ 2 stools per week
- History of retentive posturing or excessive volitional stool retention → withholding or incomplete evacuation
- History of painful or hard bowel movements
- History of large diameter stools
- Presence of faecal mass in the rectum
In toilet trained children:
- At least 1 episode of faecal incontinence
First Line Treatment - Oral Laxatives. What to use for different age groups. When to refer and what to avoid.
- Infants < 1 month - coloxyl drops
- Infants 1-12 months - iso-osmotic laxatives (Movicol or Osmolax) or Lactulose
- Children: Iso-osmotic laxative or lubricant (paraffin oil)
- Children with stool withholding behaviours, pain while defacating or rectal bleeding or fissures may benefit from inpatient disimpaction management
- rectal treatments (suppositories or enemas) should be avoided
Dosing for outpatient disimpaction. What do use and how much?
- dose is PEG (macrogol or movicol) 1-1.5mg/kg/day for 3-6 days → maintenance therapy is 0.75mg/kg/day
- medication to be started over the weekend or school holidays
- If PEG not tolerated → move to liquid paraffin (Parachoc)
When can you cease medication for constipation?
Constipation should be resolved for at least 1 month prior to cessation
- Treatment may be required for several months and if stopped early can lead to recurrence
