29/9/21 - 30/9/21

Question 1

Bronchiolitis: Age Group. Progression of Disease. Peak Severity.

Answer 1

• Viral LRTI - usually affecting <12 months of age

- Peak severity → d2-3 of illness with resolution over 7-10 days

Question 2

Clinical Presentation of Bronchiolitis. (6 points)

Answer 2

Bronchiolitis typically begins with acute URTI + onset of one or more of:

• cough
• tachypnoea
• fever
• retractions
• widespread crackles/wheeze

Question 3

When assessing severity of bronchiolitis, what are the 6 categories we can use?

Answer 3

1. Behaviour
2. Apnoeic Episodes
3. O2 saturations
4. Use of Accessory Muscles
5. Feeding
6. Respiratory Rate

Question 4

Do we need to investigate bronchiolitis?

Answer 4

No. - Only investigate if there is deterioration or diagnostic uncertainty

Question 5

How do you manage a child with bronchiolitis? What o2 saturations are we aiming for?

Answer 5

Most cases - supportive treatment → oxygenation, fluid intake and minimal handling

Oxygenation
- O2 therapy should be commenced if O2 <90% persistently. Not for brief spells of desaturation below <90%. Similarly O2 should be ceased if O2 saturations are sitting >90% persistently. If not requiring O2 for >2 hours, can cease O2 monitoring.

Question 6

Care at home for a baby with bronchiolitis? (7 points…some points also apply in general to a bub with a fever)

Answer 6

1. Plenty of Rest
2. More frequent breastfeeds or more frequent formula feeds, Frequency is key
   3 Saline nasal drops or nasal sprays can clear the nasal passages of mucus → allow baby to feed more comfortably
3. Do not allow anyone to smoke at home or around the baby
4. if fever making child miserable → paracetamol and/or ibuprofen
5. Dress Child appropriately → not too hot or cold
6. Wipe child’s forehead with a sponge or facewasher soaked in slightly warm water to cool them down.

Question 7

Dosing of paracetamol and ibuprofen in paediatrics? (context of 1st line in AOM)

Answer 7

• Paracetamol 15mg/kg QID PO PRN

- Ibuprofen 10mg/kg TDS PO PRN

Question 8

If mild symptoms + <48/24 of symptoms + no red flags of AOM -> treatment?

Answer 8

NO ABx for 48/24

Analgesia - paracetamol + ibuprofen

Question 9

If AOM requiring ABx -> which ABx and dose?

Answer 9

• amoxicillin 30mg/kg up to 1g orally, 12 hourly for 5 days

Question 10

6 cases when ABx therapy should be considered in AOM.

Answer 10

1. Infants younger than 6 months
2. Children younger then 2 years with bilateral infection
3. Systemically unwell (e.g lethargic, pale and very irritable); fever alone is not an indication for ABx therapy
4. Children with otorrhoea
5. Aboriginal and Torres Strait Islander children
6. Children at high risk of complications (immunocompromised children)

Question 11

Causes of Acute Decompensated Heart Failure (there are 13..give me 5)

Answer 11

1. Myocardial Iscahemia
2. Pulmonary Embolism
3. Anaemia of Chronic Disease
4. Significant Emotional or Physical stress
5. Systemic Infection
6. Electrolyte Disturbances
7. Hyper or Hypothyroidism
8. Tachy or Bradyarrhythmias
9. Worsening Renal Failure
10. Uncontrolled HTN
11. Dietary Indiscretion or Vigourous Fluid Administration
12. Non-Compliance to medication regimen
13. Cardiodepressant and other drugs
    
    • Anti-inflammatory drugs
    • Antiarrhythmic Drugs
    • Calcium Channel Blockers
    • Beta-Adrenergic Blocking Agents

Question 12

3 Symptoms and 3 Physical Signs of Mild to Moderate Acute Decompensated Cardiac Failure

Answer 12

Symptoms

• progressive dyspnoea
• symptoms of abdominal and peripheral congestion → ankle swelling and epigastric tenderness or a sensation of abdominal fullness
  
  • abdominal tenderness → hepatic congestion
• Other → nocturia and neurologic symptoms

Physical Signs

• Signs of congestion → elevated jugular venous pressure (JVP), positive hepatojugular reflux test, tender and enlraged liver
• Diminished air entry at the lung bases → pleural effusion (R>L)
  
  • can have up to moderate pulmonary oedema
• Leg/Pedal Oedema → bilateral, pretibial and ankles in ambulatory patients. sacral oedema in patients who are bed ridden

Question 13

How do you treat acute cardiogenic pulmonary oedema in the pre-hospital setting? (5 points)

Answer 13

1. Remain upright
2. Urgent ambulance transfer to hospital
3. Frusemide 20-80mg IV or IM repeated 20/60 later
4. if O2<94% → high-flow O2 via oxygen mask
5. If no response to frusemide + O2 → add Glyceryl Trinitrate 400microg sublingually → repeat dose every 5 mins up to max 1200 microg

Question 14

Acute Cardiogenic Pulmonary Oedema: 8 signs and symptoms. (name 4)

Answer 14

rapid onset of severe dyspnoea, often occurs first at night, as well as tachypnoea, tachycardia, with or without poor peripheral perfusion (ashen, cool peripheries, sweaty, reduced capillary return), agitation, restlessness and widespread lung crackles.

Question 15

Diagnosis of Multiple Myeloma (4 points)

Answer 15

• C - Calcium
  
  • Hypercalcaemia, presenting with abdominal pain, constipation, polyuria
• R - Renal Failure
  
  • Uraemic symptoms, fluid overload
• A - Anaemia + Other Cytopenias
  
  • Leukopenia/Neutropenia with increased risk of infections
  • Thrombocytopenia with increased risk of bleeding
• B - Bone Pain + Bone Fractures

Question 16

Investigations for Multiple Myeloma ( 6 points + 2 bonus)

Answer 16

• FBE with differential and blood film
• UEC
• Calcium
• Serum Protein Electrophoresis, immunofixation
• Routine Urinalysis
• 24-hour urine collection for proteinuria, electrophoresis and immunofixation

Additional Tests

• Bone Marrow Aspirate
• Imaging of the Skeleton → Whole Body CT, MRI or PET Scan to detect lytic lesions and fractures

Question 17

4 aspects of imaging that are definitive of MM

Answer 17

• bone loss, osteopenia, focal lytic lesions and fractures are defining of MM

Question 18

6 Live Vaccine Contraindications

Answer 18

1. High-Dose systemic immunosuppressive therapy - chemo, radio or high dose oral corticosteroids
2. Pregnant women. Avoid pregnancy for 28 days after vaccination.
3. Malignant Conditions of the Reticuloendothelial System → lymphoma, leukaemia or Hodgkin’s Disease)
4. AIDS or Symptomatic HIV infection
5. Receiving biologic or targeted synthetic DMARDs
6. Metastatic Malignancy

Question 19

3 Symptoms and 3 Signs of Upper Motor Neuron Pathology

Answer 19

Symptoms:

1. Stiffness
2. Clonus
3. Spasms
   (4. Emotional Lability)

Signs:

1. Spasticity
2. Preserved reflex in wasted limb
3. Hyperreflexia

Question 20

3 Symptoms and 4 Signs of Lower Motor Neuron Pathology

Answer 20

Symptoms:

1. Weakness
2. Wasting
3. Fasciculations

Signs:

1. Muscle Weakness
2. Muscle Atrophy
3. Fasciculations
4. Hyporeflexia or Absent Reflexes

Question 21

Features (demographics, time course, signs, symptoms) suggestive Multiple Sclerosis (7 points)

Answer 21

1. Relapses and Remissions
2. Age 15-50yo
3. Optic Neuritis
4. Lhermitte Sign - an electric shock-like sensation that occurs on flexion of the neck
5. Internuclear ophthalmoplegia
6. Fatigue
7. Heat Sensitivity → Uhtoff Phenomenon

Question 22

Demographics of patients with Myasthenia Gravis?

Answer 22

Early peak in the 20-30yo (female) and late peak in the 60-80yo (males)

Question 23

Cardinal Features of Myasthenia Gravis?

Answer 23

Cardinal Feature is fluctuating skeletal muscle weakness, often with true muscle fatigue

Question 24

Cardinal Feature of Guillain Barre Syndrome?

Answer 24

Cardinal Feature → progressive, mostly symmetrical muscle weakness + absent or depressed deep tendon reflexes

Question 25

How (and who) do you investigate to make diagnosis of Multiple Sclerosis?

Answer 25

• A clinical isolated syndrome (CIS) → single first clinical episode reflecting a focal or multifocal demyelinating event in the CNS
• All patients with CIS → neuroimaging with contrast enhanced MRI to determine if there is explanatory acute inflammatory lesion in the brain or spinal cord
  
  • If no or few lesions seen on MRI → lumbar puncture to test CSF for oligoclonal bands

Question 26

Diagnosis of Motor Neuron Disease (3 points)

Answer 26

• History + Physical Examination
• Supported by electrodiagnostic studies → nerve conduction studies + electromyography (EMG)
• Not excluded by neuroimaging and laboratory studies

Question 27

Causes of Chest Pain (6 categories + 15 causes..give me 7 specific causes)

Answer 27

Cardiovascular	
- Acute Heart Failure
- Stable Angina
- Valvular Heart Disease
- Pericarditis/Myocarditis/Endocarditis
Respiratory/Pulmonary	
- Respiratory Infections → frequently accompanied by chest discomfort and cough
Gastrointestinal	
- GORD 
- Oesophageal Spasm
- Oesophageal Rupture
Musculoskeletal	
- Rib Contusions and Rib Fractures
- Intercostal Muscle Strain
- Costochondritis
Psychiatric	
- Panic Attack
Other	
- Herpes Zoster
- Referred Pain

Question 28

Important points in Chest Pain History (11 points)

Answer 28

• Onset of Pain - abrupt or gradual
• Aggravating and Alleviating Factors
  
  • Worse with breathing or coughing
  • Worse with movement or pressing on that area
• Quality of Pain → sharp, stabbing, pleuritic
• Pain radiation → shoulder, arm, jaw, back
• Site of Pain → substernal, chest wall, back, diffuse, localised
• Timing → constant, episodic, duration of episodes, when pain began
• Associated symptoms - SOB, faintness, fever, nausea/vomiting, dizziness, weight loss, sweating or back pain
• Haemoptysis
• Recent Events → Trauma, Major Surgery or Medical Procedures, Immobilisations
• Other → Smoking or Cocaine Use
• Co-morbidities → HTN, Diabetes, Peripheral Artery Disease, Malignancy, Connective Tissue Disorders, Bicuspid Aortic Valve, Recent Pregnancy

Question 29

Lifestyle modifications to treat Mild GORD (8 points)

Answer 29

1. eating smaller meals
2. drinking fluids mostly between meals rather than with meals
3. avoiding lying down after eating
4. avoiding eating 2-3 hours before bedtime or vigourous exercise
5. elevating head of the bed (if symptoms occur at night)
6. stopping smoking
7. weight loss
8. • avoidance of high-fat meals, alcohol, coffee, chocolate, citrus fruit, tomato products, spicy foods and carbonated beverages

Question 30

How long should PPIs be continued for initial therapy prior to step down?

Answer 30

• Initial treatment should be 4-8 weeks → if symptoms are well managed, step down to maintenance therapy

Question 31

What options are there for step-down of PPI therapy? Also can you cease PPI abruptly?

Answer 31

• Step-down therapy by halving the daily dose of PPI or dosing on alternate days → then step down to PRN therapy.
• Stopping therapy completely can result in prolonged remission in symptoms in up to 30% of patients
  
  • if therapy is ceased abruptly → symptoms can recur

Question 32

5 Medications on discharge following MI for secondary prevention.

Answer 32

1. Aspirin 100-150mg/day - continue indefinitely
2. Clopidogrel - for 12 months
3. Statin, highest tolerated dose - continue indefinitely
   
   • atorvastatin 40-80mg PO daily
4. Beta-Blocker (vasodilatory) in patients with reduced LV systolic function (LV ≤ 40%)
   
   • for stable patients → atenolol 25-100mg PO daily
     
     • if stable with preserved LV function → consider ceasing beta-blocker at 12 months
   • if Heart Failure (reduce peripheral vascular resistance while maintaining or improving cardiac output, stroke volume and left ventricular function)
     
     • nebivolol 1.25mg PO daily → increasing to max 10mg daily
5. ACEi or ARB in patients with heart failure, LV systolic dysfunction, diabetes, anterior MI, HTN
   
   • perindopril arginine 2.5mg PO daily → increasing to 10mg daily

Question 33

How many weeks should a patient should not drive following an MI?

Answer 33

2 weeks