27/11/21 Flashcards
Dermatomes of Upper Limb - C5-T1. Basic Description of regions.
C5 - Upper Arm
C6 - Lateral Forearm + Thumb and Index Finger half
C7 - Palm and middle finger and half indec
C8 - 4th and 5th fingers, medial forearm
T1 - anterior arm and medial forearm
Cervical Spine Level if Biceps and Brachioradialis Reflexes are affected?
C5-C6
Cervical Spine level if triceps reflex is affected?
C7
Movements affected if C5 is affected?
Shoulder Abduction
External Rotation
Elbow Flexion
Forearm Supination
Movements affected if C6 is affected?
Shoulder Abduction
External Rotation
Elbow Flexion
Forearm Supination and Pronation
Movements affected if C7 is affected?
Elbow Extension
Forearm Pronation
Wrist Extension
Wrist Flexion
Movements affected if C8 is affected?
Wrist Extension
Finger Extension + Flexion + Adduction + Abduction
Distal Thumb Flexion
Movements affected if T1 is affected?
Finger Abduction + Adduction
Distal Thumb Flexion
Thumb Abduction
Clinical Manifestations of Cervical Radiculopathy (4 points)
- Neck, Shoulder or Arm Pain
- Upper extremity muscle weakness
- Sensory symptoms
- Diminished Deep Tendon Reflexes
Mechanisms of Cervical Radiculopathy (2)
- Cervical Spondylosis
2. Disc Herniation
Do you use chronological age or adjusted age when calculating timing of vaccination doses of pre-term infants?
if medically stable - use chronological age
Recommended schedule for Hep B vaccinations in premature infants? How is this different to the normal vaccination schedule?
- Recommended Schedule
- Hepatitis B vaccine at birth
- 3 Doses of Hepatitis B Vaccination at 2,4 and 6 months
- BOOSTER HEPATITIS B VACCINATION at 12 months
Pneumococcal Schedule for Preterm Infants? How is this different to the normal vaccination schedule?
- All preterm infants <28 weeks gestation → 4 doses of 13vPCV and 2 doses of 23vPPV
- 13vPCV → 2,4,6 and 12 months of age
- 23vPPV → 1st Dose: 4 years of age, 2nd Dose 5 years after 1st later.
Dose at 6 months is extra
Age range for febrile seizures? Proportion of children that get Febrile Seizures? Associated with_____?
- 6 months - 5 years
- Benign - occur in 3% of healthy children
- Associated with simple viral infections
Recurrence of Febrile Seizures? What does it depend on?
- Recurrence Rate
- Depends on the age of the child at first seizure → the younger the child at initial seizure, the greater the risk of further febrile seizures
Risk Factors to develop epilepsy from having febrile seizures (4 points)
- FHx of Epilepsy
- Neurodevelopmental Problem
- Prolonged or Focal Febrile Seizures
- Febrile Status Epilepticus
Characteristics of Simple Febrile Seizures (4 points)
- FHx of Epilepsy
- Neurodevelopmental Problem
- Prolonged or Focal Febrile Seizures
- Febrile Status Epilepticus
Characteristics of a complex Febrile Seizures (4 points)
Fever and ANY of the following:
- focal features at onset or during the seizure
- duration >10minutes
- incomplete recovery within 1 hour
- recurrence WITHIN the same illness
WTF is an afebrile febrile seizure?
Seizures in an acute infectious illness (particularly gastroenteritis) without documented fever
Features consistent with simple febrile seizures
Investigations for a febrile seizure?
- If focus of infection identified → no investigations are indicated
- NO ROLE for EEG in simple of complex febrile seizures
What NOT to do in a febrile seizure?
- During a seizure → do NOT put child in the bath, do NOT restrain them, DO NOT put anything in their mouth
How long should you wait before calling an ambulance in the context of a febrile seizure?
Call ambulance if seizure lasts for more than 5 minutes
When to refer to a paediatrician in the context of a febrile seizure?
- Complex Febrile Seizure
- Seizures unable to be controlled
- Child clinically unwell
- Child does not return to normal mental state in 1 hour
- Concern regarding nature of febrile illness
- Frequent seizures
Characteristic symptoms associated with alcohol withdrawal? (4 points)
- Anxiety
- Tremor
- Sweating
- Nausea and Vomiting
- Agitation
- Headache
- Perceptual Disturbances
- Occasionally - seizures
Medications to manage alcohol withdrawal (2 points)
- Prescribing short-course of diazepam to reduce withdrawal severity -> Diazepam 20mg PO every 2 hours until symptoms subside → cumulative total of 60mg is usually adequate. Do not use more than 100mg without seeking specialist advice.
- Thiamine to reduce risk of Wernicke’s Encephalopathy -> Thiamine 300mg IM or IV daily for 3-5 days then thiamine 300mg orally daily for several weeks.
Eligibility Criteria for Outpatient Alcohol Withdrawal Management? 5 points
- No previous severe withdrawal including no seizures or delirium tremens
- No concurrent acute medical illness
- No evidence of psychosis, suicidal thoughts or severe depression
- No evidence of other drug use except cannabis
- Supportive, stable and drug free, alcohol free home environment
Options for alcohol cessation? Be Specific with dosing
- Disulfiram 100mg PO, once daily for 1-2 weeks, increased as required and as tolerated to 300mg daily
- Acamprosate 666mg PO TDS (>66kg) OR 666mg PO mane, 333mg midi and nocte (<66kg)
- Naltrexone 50mg PO daily
Basic Principles of each alcohol cessation medication?
Disulfiram - makes patient physically unwell if drink alcohol
Naltrexone - reduces pleasure related to alcohol + reduce cravings
Acamprosate -> reduce withdrawal symptoms which trigger people to drink
Characteristics of an infected diabetic foot ulcer? (5 points)
At least 2 of the following:
- Local Swelling or Induration
- Erythema extending more than 0.5cm in any direction from the wound
- Local Tenderness or Pain
- Local Warmth
- Purulent Discharge
Classification of Mild Infected Diabetic Foot Ulcer?
erythema <2cm from wound margin
involves just skin and subcut tissue
Classification of Moderate Infected Diabetic Foot Ulcer?
erythema >2cm from wound margin OR involving deeper structures -> muscle, joint, bone
Classification of Severe Infected Diabetic Foot
SIRS response
Management of an acute mild diabetic foot ulcer?
- Dicloxacillin 500mg PO Q6H
- OR Flucloxacillin 500mg PO Q6H
Rank the dressings from least absorbent to most. Alginate, Foams, Hydroactive, Hydrocolloid, Hydrogels, Semi-Permable Films.
- Semi-Permable
- Hydrogels
- Hydrocolloid
- Foam
- Alginate
- Hydroactive
Wound dressing for chronic ulcers?
Hydrocolloid Dressings
Cause of Hyperparathyroidism (1 point)
- Most commonly caused by single parathyroid adenoma
Management options for hyperparathyroidism?
Definitive surgery → cures 95% of cases and low morbidity
Watch and Wait in patients who are >50yo and have:
- Corrected Ca <2.90
- Normal Renal Function
- No Nephrolithiasis or Nephrocalcinosis
- BMD T-Score >-2.5
- No Symptoms
Clinical Manifestation of Hypercalcaemia
BONES, STONES, GROANS AND PSYCHIC MOANS
- Bone Pain
- Polyuria
- Nephrolithasis
- Constipation
- Fatigue
2 Main Causes of Hypercalcaemia
- Parathyroid Disease
2. Malignancy
Who should be tested for chlamydia?
- Offered to <30years and sexually active
- Partner change in last 12 months
- STI in last 12 months
- Sexual Partner with STI
- Increased risk of complications of Chlamydia Infection → TOP or IUD insertion
- Signs or Symptoms of Chlamydia
For women, what are the options for chlamydia testing?
- Female - endocervical swab (best test if examined)
- If not examined - self-collected vaginal swab.
- If endocervical swab or self-collected vaginal swab cannot be taken
Management of Chlamydia
- Doxycycline 100mg PO BD for 7 days
- If uncomplicated genital or pharyngeal infection → 7/7 course
- If ano-rectal infection → 7/7 if asymptomatic, 21/7 if symptomatic
- Contact tracing up to 6 months
- No Sexual Contact for 7 days after treatment is administered
- No sex with partners from the last 6 months until they have been tested and treated
- Notify State Health Department
- can complete Partner Directed Partner Therapy
- check in 1 week time - review compliance, review contact tracing
- TEST OF CURE IS NOT ROUTINELY RECOMMENDED → only if pregnant or if ano-rectal chlamydia - retest for cure in 4 weeks time
- Test for re-infection in 3 months time - to detect re-infection
5 As of Smoking Cessation Approach
Ask Assess Advise Assist Arrange Follow-Up
Main questions when assessing nicotine dependance?
- How long from first waking up to first cigarette?
- How many cigarettes/day?
- Cravings/Withdrawal symptoms in previous quit attempts
Pharmacotherapy for nicotine dependance?
- NRT
- Varenicline
- Bupropion Sustained Release (if top 2 are unsuitable)
Which Pharmacotherpay for smoking cessation is safe in pregnancy?
NRT
Contraindications for use of Bupropion Sustained Release? 3 points
Monoamine Oxidase Inhibitor concurrent
Pregnancy
Seizure history
Atypical Presentation of Chest Pain
- burning pain
- pain that increases with respiration
- “sharp” pain
- upper abdominal pain
- remember “silent infarctions” especially in those with diabetes or older patients
Management Points for Chest Pain
- ECG
- Arrange Ambulance transfer for Hopsital
- Aspirin 300mg PO stat
- If haemodynamically stable and NO INFERIOR MI -> GTN spray 400-800mg sublingually, repeat every 5 mints if pain persists up to total of 3 doses
- If pain persists -> add opioid - Morphine 2.5-5mg IV → repeated at 5-10minute intervals
- O2 only if patient is hypoxaemic -> O2<94%
Diagnosis of PCOS (basic steps)
- Irregular Menstrual Cycles AND Hyperandrogenism
- if no hyperandrogenism -> for biochemical testing
3, if no irregular cycles OR hyperandrogenism -> for U/S - 10 follicles on both ovaries
After menarche, how long does it take for a regularity of menstrual cycles to occur?
2 years
For regulating menstrual cycles in the context of PCOS, what are the options?
- COCP
- levonorgesterol IUD
- Metformin
Base investigations in HTN (7 points)
- Urine Dipstick for blood
- Proteinuria/Albuminuria - first void specimen
- ECG
- FBE
- UEC
- Fasting Glucose
- Fasting Lipids - Total Cholesterol, LDL, HDL, TGs
What investigations are recommended in the context of CVD + HTN?
Echocardiography + Carotid Ultrasound
What investigations are recommended in the context of CKD and HTN?
Renal Artery Doppler U/S
When would you suspect renovascular disease as the cause of secondary hypertension?
- Unexplained creatinine elevation and/or acute and persistent elevation in serum creatinine of at least 50% after administration of ACEi, ARB or Renin Inhibitor
- Systolic or Diastolic Abdominal Bruit
What is the diagnostic triad of a pheochromocytoma?
Headache
Palpitations
Sweating
Diagnostic Investigation Options of Pheochromocytoma.
Metanephrine and Normetanephrine Excretion AND/OR plasma catecholamine, metanephrine and normetanephrine concentration OR 24-hr urinary catecholamine
What pathogen is responsible for Q Fever? Main mode of transmission?
- From Coxiella burnetti
- Most commonly reported zoonotic disease
- Main transmission route of C. burnetti is through inhalation of aerosols or dust contaminated by secretions from infected animals including birth products, faeces and urine.
- Contact with livestock and other animals
Clinical Features of Q-Fever (1 specific to Q fever, others are general)
- Not all patients show clinical symptoms
- Fever - Rigors - Chills
- Headache
- Extreme Fatigue
- Drenching sweats
- Weight Loss
- Arthralgia - Myalgia
- Abnormal LFTs**
Investigations in the context of Q-Fever
AVOID Blood Culture → high risk of laboratory acquired infections
Nucelic Acid Testing → collect within 1 week of disease onset. Fastest turnaround time to achieve diagnosis. Also a negative nucleic acid testing does not exclude the possibility of Q Fever
Serology
LFTs → elevated AST and ALT but other LFTs are normal
Management of Q Fever (ABx choice)
Doxycycline 100mg BD for 14/7
Brucellosis Clinical Features (3)
- Acute Non-Specific Symptoms
- Inflammation of the Live or Spleen OR Gastrointestinal Signs may occur
- Testicles and Epididymis may become inflamed
- Symptoms last for 2-4 weeks and followed by spontaneous recovery
- Some infected people develop an intermittent fever → “undulant fever”
Leptospirosis Clinical Features (3)
- Fever, Chills, Headache
- SEVERE MYALGIA - particular of the calves, thighs and lumbar region
- Conjunctival Suffusion
Clinical Presentation of External Auditory Exostosis (3 points)
- EAE is usually asymptomatic and is only diagnosed at the advanced stage
- can present with prolonged blocked feeling in the ears following water activities because of water trapping in the EAC or chronic cerumen/wax impaction
- can also present with recurrent otitis externa, otalgia, conductive hearing impairment due to stenosis of the EAC
What is external auditory exostosis also known as?
Surfer’s Ear
What is the management of External Auditory Exostosis?
- Surgical removal is the definitive management
Causes of Barotrauma?
- Flying (most common)
- Diving, Decompression, Hyperbaric Oxygen Chambers + Blast Injuries
Clinical Features of Barotrauma? (4 points)
- Ear Pressure or Pain
- Hearing Loss
- Tinnitus
- Bleeding into the Tympanic Membrane
- Rarely → rupture of the round or oval window → vertigo and sensorineural hearing loss
Management of Barotrauma? (2 points)
Most barotrauma injuries heal spontaneously
Analgesia PRN
Nil requirement for ABx
Nil evidence for decongestants, antihistamines, glucocorticoids
Prevention options for Barotrauma? (2 points)
- Oral Decongestants, Antihistamines, Nasal Decongestants prior to flying or diving can reduce obstruction around the Eustachian Tube and facilitate pressure equalisation
- Swallowing or Valsalva manoevre → equalise pressures and prevent tissue damage
- Chewing gum or sucking on hard candies
- Special Earplugs for flying but not for diving
Clinical Features on History of Temporomandibular Dysfunction (4 points)
- Main presenting complaint is pain in the TMJ or mandible → refer to scalp or neck, exacerbated by yawning, mastications, talking for extended periods of time.
- Difficulty opening the mouth or brief locking of the mandible on opening or closing.
- Clicking, popping or crepitus within the TMJ itself
- Pain worse with mandibular movements - particularly when eating
- Otological Symptoms: aural fullness, otalgia, tinnitus, vertigo and subjective hearing impairment → more common in myofascial than intra-articular disorder
- Headache and TMD are comorbid diseases → presence of one may increase the prevalence of the other
Non-Pharmacological Management of Temporomandibular Dysfunction (4 points)
- Patient Education + Reassurance +/- CBT (given psychiatric component of TMD)
- Jaw Rest
- Soft Diet
- Warm Compresses over region of pain
- Passive Stretching Exercises
- Behaviour Modification → improving sleep hygeine, stress reduction, elimination of parafunctional habits such as teeth clenching and grinding
Red Flags to trigger referral to specialist in the context of Tempromandibular Dysfunction (4 points)
- Persistent and Worsening Pain
- Trismus
- Cranial Nerve Abnormalities
- Neurologic Dysfunction
- Concurrent Infection
- Systemic Illness
- Weight Loss
- Asymmetrical Neck or Facial Swelling
- Unilateral Hearing Loss
- Vestibular Dysfunction
- New Onset or Unilateral Tinnitus
Common Causes of Short Stature in Adolescents? (2 points)
1, Familal Short Stature
2. Constitutional Delay of Growth and Puberty
Explain what is Familial Short Stature and what management?
- Short compared to their peers but are an appropriate heigh in the family as evidenced by mid-parental height.
- Monitoring growth is all that is required
Definition of Constitutional Delay of Growth and Puberty? Boys? Girls?
- Girls: Lack of Breast Development (Tanner Stage 2) in girls ages >13
- Boys: Testicular Volume <4.0ml by the age of 14
Management of Constitutional Delay of Growth and Puberty? Boys? Girls?
- Without intervention, most adolescents with CDGP will undergo spontaneous puberty
- If the adolescent is experiencing emotion distress → can consider low dose testosterone can be used to induce puberty in boys >14yo.
- No clear evidence for use of oestrogen in females with CDGP
Criteria for Referral to Specialist Service (4 points
- Height less than the first centile or significantly out of keeping with mid-parental height expectation
- Growth Velocity <25th centile
- Height crossing two centile lines on growth chart
- Delayed puberty
Investigations of Short Stature in Adolescents?
- FBE
- UEC
- LFTs
- CMP
- ESR
- Coeliac Serology
- TFTs
- IGF-1
- Karyotype Testing in all girls whose height is less than the 1st centile or significantly out of keeping with their mid-parental height, or with pubertal delay, even if the classical Turner Syndrome stigmata are not present
Risk Factors for C. difficile infection (4 points)
- exposure to broad spectrum ABx such as cephalosporins, quinolones and lincosamides
- hospitalisation
- cancer chemotherapy
- use of proton pump inhibitors
Diagnosis of C. difficile infection (2 points)
Clinical Features suggestive of C. difficile infection → diarrhoea, ileus, toxic megacolon
AND EITHER
- microbiological evidence of toxin-producing C. difficile in stools
- colonscopic findings or histopathology results that demonstrate pseudomembranous colitis
Management of C. difficile infection (4 points include pharm and nonpharm)
- if asymptomatic → do not require treatment
- Rehydration Therapy
- Stop implicated ABx
- Avoid PPI after diagnosis
For first episode of Mild - Moderate C. difficile disease
- Metronidazole 400mg (child 10mg/kg up to 400mg) orally or enterally, 8-hourly for 10 days
Clinical Features of Mumps? (3 points)
- Few days of fever, headache, myalgia, fatigue and anorexia
- Followed by development of salivary gland swelling within 48 hours - Parotitis
- unilateral or bilateral
- Initial unilateral involvement is followed by contalateral involvement a few days later in 90% of cases
- Usually self-limited and individuals recover completely within a few weeks
Complications of Mumps (2 points)
- Orchitis
- Neurologic Manifestations → meningitis, encephalitis and deafness
Treatment for Scarlet Fever of Strep Throat. Be specific
- Phenoxymethylpenicillin 500mg (15mg/kg up to 500mg) 12 hourly for 10/7
- If compliance to 10 day regimen of phenoxymethylpenicillin is unlikely
- Use: benzathine benzylpenicillin IM, single dose
- long-acting and adequate concentrations of benzylpenicillin for up to 4 weeks
- Use: benzathine benzylpenicillin IM, single dose
Indications for ABx in Streptococcal Pharyngitis (4 points)
-
patient aged 2-25 from populations with high incidence of acute rheumatic fever → e.g ATSI, Maori and Pacific Islander people
- patients with existing rheumatic heart disease
- patients with scarlet fever
- very severe symptoms of pharyngitis (need for hospitalisation, severe throat pain, dysphagia)
Suppurative Complciations of Streptococcal Pharyngitis (3)
- Tonisillopharyngeal cellulitis or abscess
- Otitis Media (OM)
- Rhinosinusitis
- Necrotising Fasciitis
- Streptococcal Bacteraemia
- Meningitis or Brain Abscess
- Jugular Vein Septic Thrombophlebitis
Non-Suppurative Complications of Streptococcal Pharyngitis (3)
- Acute Rheumatic Fever
- Reactive Arthritis
- Scarlet Fever
- Streptococcal Toxic Shock Syndrome
- Acute Glomerulonephritis
- Paediatric Autoimmune Neuropsychiatric Disorder associated with Group A Streptococci (PANDAS)
