30/10/21 Flashcards
Risk Factors for Erectile Dysfunction (8 points)
- Increased Age
- CV disease + Risk Factors for CV Disease → Obesity, Diabetes, Sedentary Lifestyle, Obesity, Diabetes, HTN, Dyslipidaemia, OSA, Smoking
- Endocrine Disorders → T2DM, Androgen Deficiency, Thyroid Disorders, Hyperprolactinaemia
- Neurological Conditions affecting brain, spinal cord or autonomic nervous system
- Medication → beta-blockers, thiazides, antidepressants, anti-psychotics, anti-androgens
- Prostate Cancer Therapy
- Penile Disorders
- Recreational Drug or Alcohol Use - Cocaine…
First Line and Second Line Therapy for Erectile Dysfunction.
- PDE5 Inhibitors
2. Vacuum Erection Devices or Intracavernosal Injection
What constitutes low and high risk of death or significant morbidity with sexual exertion. (3, 5)
- *Low Risk**
- NO uncontrolled hypertension
- NO recent myocardial infarction (within last 8 weeks)
- Can climb 2 flights of stairs in 10 seconds
- *High Risk** - needs cardiology review prior to engaging in sexual intercourse
- ACS in the last 2 weeks (without revascularisation)
- High-Risk Arrhythmias
- Severe Aortic Stenosis
- Symptomatic Hypertrophic Obstructive Cardiomyopathy
- New York Heart Association - Class IV Symptoms
History for Uveitis (3 points + 1 bonus)
- painful red eye → deep ache that radiates the periorbital or temple area
- worse with movement and accomodation
- begins with general sensitivity around the eye and progressing to photophobia, redness and visual loss
- +/- blurred vision
- develops over several days
6 examination for uveitis (3 key + 3 bonus) plus findings for 3 key examinations
Visual Acuity - can be reduced in posterior uvetitis
Pupils - constricted, may be irregular and is sluggish in response to light. Direct and consensual photophobia
Slit Lamp Examination:
- Conjunctiva → diffusely injected conjunctiva with circumcorneal involvement aka “ciliary flush” → no perlimbal sparing as occurs in conjunctivitis. Tearing but no purulent discharge
- Examine cornea, anterior chamber and posterior chamber as well
Bonus:
Red Reflex - may be normal or altered (secondary cataract)
Tonometry - check for secondary glaucoma
Fundoscopy - look for evidence of choroiditis or retinitis, or complications such as retinal detachment
Management of Uveitis (5 points)
- Urgent Referral to Ophthalmology
- Seek and Treat Underlying Causes + Treat complications such as glaucoma
- Mydriatics → sympathomimetics such as phenylephrine HCl → this will present formatino of synechiae by pupillary dilation
- Parasympatholytic Agents → atropine, cyclopentolate → produce mydriasis and cycloplegia which reduces pain and photophobia
- Topical Corticosteroids following consultation with ophthalmology and consideration of possible infectious aetiology
Definition of Cushings Syndrome
Definition: Syndrome to describe the chemical features of increased free circulating glucocorticoid.
Clinical Features/History of Cushing Syndrome (9 points)
- Change in Appearance → as disorder progresses body to quoted configuration of a lemon on matchsticks
- Central Weight Gain → Truncal Obesity
- Hair Growth and Acne in Females
- Muscle Weakness
- Amenorrhoea/Oligomenorrhoea
- Thin Skin + Spontaneous Bruising
- Polymyalgia/Polydipsia
- Insomnia
- Depression
Examination Findings of Cushings Syndrome (4 points)
- Moon Face
- Buffalo Hump
- Purple Striae
- Large Trunk and Thin Limbs → “lemon with matchsticks” sign
Investigations of Cushings Syndrome (2 points)
- Plasma Cortisol
- Overnight Dexamethasone Suppression Tests
How to determine nicotine dependence? (3 points)
- Minutes after waking for first cigarette → if smoking <30mins from waking
- Number of cigarettes/day → if smoking >10 cigarettes/day
- Cravings or Withdrawal Symptoms in previous quit attempts
Contraindication in regards to age range for NRT?
Age <12 years old. Suitable for adolescence.
Main options for smoking cessation pharmacotherapy. (2 points)
- NRT
2. Varenicline
Classification of Acne (3 stages)
Mild → few comedones and papulopustules, no scarring - lesions are confined to the forehead, nose and chin (T-zone)
Moderate → numerous papulopustules and comedones, with some nodules but no scarring - lesions affect extensive areas of the face and sometimes the trunk
Severe → nodules, cysts and scarring - lesions may be confined to the face but commonly also affect the trunk
Initial Therapy for Mild Acne. Be Specific.
Benzoyl Peroxide 5% (unless history of atopic dermatitis or dry or sensitive skin)
- if mild acne on the chest or back - use a wash
- if history of atopic dermatitis or dry or sensitive skin → start with benzyl peroxide 2.5%
If initial therapy was not enough, and mainly comedonal acne - what is the next step?
Change to Topical Retinoid
1. Adapalene 0.1% cream or gel topically, for 6 weeks then review
If initial therapy was not enough, and comedonal AND inflammatory acne - what is the next step?
If comedonal AND inflammatory → change to topical combination of benzoyl perioxide and retinoid (if more comedonal) or benzoyl peroxide and antiobiotic (if more inflammatory)
Benzoyl Peroxide + Adapalene 2.5% + 0.1% gel topically, once daily for 6 weeks then review
- for acne that is mostly comedonal
Benzoyl Peroxide + Clindamycin 5% + 1% gel topically, once daily for 6 weeks then review
- for acne that is comedonal AND inflammatory
If no improvement in 6/52 then what next? Males vs Females?
Males: Oral Abx
Females: COCP/Spironolactone/Oral ABx
ABx: Doxycycline 50-100mg orally, once daily for 6 weeks, then review
COCP: Ethinylestradiol + Cyproterone 35micrograms + 2mg orally, OD on days 1-21 of 28 days cycle
Spironolactone 25-50mg orally, once daily, increasing gradually to 50-100mg once daily as tolerated, review in 6 months
If no improvement following Oral ABx/COCP/Spironolactone - next step? Discuss some side effects of this.
Refer to specialist for oral isotretinoin.
Adverse Effects → dry lips and dryness elsewhere (eyes and mucosal lining of the nose), early flare of acne, sun sensitivity, less common is impaired night vision
Who should get cyclical combined MHT?
With Endometrial Tissue who:
- PERImenopausal → <12 months since last period as breakthrough bleeding can occur on continuous MHT
- premature ovarian insufficiency
Whos should get continuous combined MHT?
With Endometrial Tissue who:
- POSTmenopausal → >12 months since last period
- have been taking cyclical MHT for >1 year and withdrawal bleeds are becoming lighter
- have premature ovarian insufficiency
- have migraines
Who should get oestrogen only MHT?
Total Hysterectomy - unopposed oestrogen can increase risk of endometrial Ca
Time from HPV infection to Cervical Cancer.
10-15 years
True or False -> most cervical cancers are not caused by HPV infection.
False. Nearly all cervical cancers are caused by HPV infection - 99%
Which strains of HPV are the main causes of cervical cancer and also protected by the vaccine?
HPV 16 and 18 cause more than 70% of cervical cancers in Australia
- HPV vaccine protects against both of these types → does not protect against other types of HPV
Women who have sex with women do not need cervical screening. True or False. Discuss.
No difference in the prevalence of abnormal cervical cytology and cervical intraepithelial neoplasia (CIN) between women who had sex with women and controls.
Sexual activities between women are risks for HPV infection and therefore cervical cancer.
Women who have sex with women may have also had sex with men previously and some continue to do so.
Complications of Hospital Admission from RACF (5 points)
- Hospital Acquired Infections → UTI, Pneumonia, IVC Site
- Falls in unaccustomed areas
- Delirium
- Mental Health including Depression
- Medication Errors
- Pressure Sores
- Thromboembolism (DVT)
- Constipation
- Deconditioning
- Malnutrition
- Insomnia
Lower Limb Cellulitis Mimics (4 points)
- Dependent Rubor
- Lipodermatosclerosis
- Dermatitis
- Venous Eczema
- Lymphoedema
- Panniculitis - Erythema Nodosum
- Venous Thrombosis - superficial thrombophlebitis
Management of Venous Eczema (5 points)
- Betamethasone Dipropionate 0.05% ointment BD for 2 weeks and once daily for 2 weeks
- Dermeze BD 2 hours after betamethasone (continue even when skin not inflamed)
- Soap Free Wash only
- Elevate Legs when lying down
- Measure Ankle Brachial Index to assess arterial supply
- Once measured ABI → grade 1/Graduated compression stockings up to knee
- Regular Walks/Exercise
Probability Diagnoses of Cough (5)
- URTI
- Postnasal drip/rhinitis/sinusitis
- Acute Bronchitis
- Chronic Bronchitis or COPD
- Smoking
Serious Diagnoses of Cough (7)
- CV -> LF Failure
- Lung Cancer
- Infection
- Asthma
- Inhaled Foreign Body
- Pneumothorax
- Cystic Fibrosis
Pitfalls (Often Missed) Diagnoses of Cough (7)
- Atypical Pneumonia
- GORD
- Bronchiectasis
- Sarcoidosis
- Smoking - children/adolescents
- Whooping Cough
- . ILD
TB Investigations? (3 points)
- CXR
- 3 Sputum Samples for acid fast bacilli (AFB) culture + susceptibilities in addition to standard microscopy, culture and sensitivity testing (MCS)
Demographics of Giant Cell Arteritis (2 points)
Age >50, Peak 70-79
Women > Men
Classic Symptoms of Giant Cell Arteritis (6 points)
- Jaw Claudication
- Severe Headache
- Polymyalgia Rheumatica
- Visual Symptoms (commonly diplopia or visual loss)
- Scalp Tenderness
- Malaise
Examination of Giant Cell Arteritis (1 point)
- Temporal Artery Abnormality → artery is tender, enlarged, difficult to compress, nodular or pulseless
Investigations for Giant Cell Arteritis (2 bloods + 1 other)
- ESR + CRP
- Temporal Artery Biopsy
When do you consider treating for Giant Cell Arteritis? What two features should be present.
TENDERNESS and HYPERSENSITIVITY over the superficial Temporal Artery + RAISED CRP AND ESR → COMMENCE ORAL PREDNISOLONE
Management of Giant Cell Arteritis (5 points)
- Referral to Vascular Surgeon for Temporal Artery Biopsy
- Prednisolone
- Aspirin 100mg
- Regular review of inflammatory markers
- Consider risk of osteoporosis with increase dose of corticosteroid for extended period of time
Differential Diagnosis for Acute Vomiting in the paediatric poputlation. (8 points - name 5)
- Gastroenteritis
- Sepsis → septicaemia, pneumonia, UTI
- Head Injury → meningitis, raised intracranial pressure
- Abdominal Conditions → surgical obstruction, appendicitis, torsion of testes
- Endocrine or Metabolic Disorders - DKA, Addison’s Disease
- Medication → ABx, NSAIDs, laxatives
- Poisoning + Envenomation
- Cyclical Vomiting Syndrome
Management of Gastroenteritis in Paediatrics (5 points)
- Keep child drinking fluids → water, oral rehydration solution, breastmilk or formula.
- DO NOT give over the counter medicines that reduce vomiting and diarrhoea
- Hand Hygiene
- Keep child away from kindergarten/childcare for 48/24 following last episode of diarrhoea/vomiting
- ondansetron 4mg PO
Characteristics of Trigeminal Neuralgia. Which divisions of the trigeminal nerve are usually affected? What are some common triggers for trigeminal neuralgia paroxysms?
Recurrent, unilateral shock-like pain in one or more divisions of the trigeminal nerve
- especially V2 or V3 - maxillary or mandibular divisions
- triggered by simple stimuli
- touch, eating, brushing teeth, speaking, shaving or cold winds
Investigations when suspecting trigeminal neuralgia.
- MRI Brain
- typically normal but there is a small incidence of definable pathology → e.g intracranial tumours, vascular anomalies
- Pain simulating trigeminal neuralgia may occur in young adults with MS due to presence of demyelinating plaque at the root entry of the trigeminal nerve into the pons.
Management of Trigeminal Neuralgia (4 points)
- Avoid Triggers (touch, cold wind)
- Drugs -> carbamazepine MR 100mg PO BD
- MRI Brain
- Refer to neurologist for diagnosis if unclear
General Travel Advice (9 points)
- Purchase Travel Insurance
- Avoid unwashed/uncooked food
- Avoid open drinks
- Carry first aid kit
- Avoid risk-taking behaviour → drug trafficking/road safety (wear a helmet while on a motorbike or scooter)/sex (use a condom)/tattoos (fresh needles)
- 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
Malaria Prophylaxis advice - non-pharmacological (6 points)
- Applying effective insect repellant + other insecticide products (mosquito coils or vaporising mats) → regular application of DEET
- Light-coloured long trousers and long-sleeved shirts in the evening
- Sleeping in screened accomodation or using mosquito nets
- Avoiding outside activities between dusk and dawn
- Avoid perfume and aftershave
- Spray thin clothing with insect repellent or pre-impregnante with permethrin
Malaria Prophylaxis - pharmacological options
- Doxycycline 100mg PO daily, starting 1-2 days before entering and continue for 4 weeks after leaving
- Most cost-effective for malaria chemo-prophylaxis
- Atovaquone + Proguanil (Malarone) 250+100mg, start 1-2 days before entering and continue for 7 day after leaving
- Equal effective + favourable side effect profile
- Mefloquine 250mg PO once weekly, starting 2-3 weeks before entering and continue for 4 weeks after leaving
Causes of Pelvic Organ Prolapse (10 points)
- Pregnancy and Childbirth
- Maternal Age <25yo at first delivery
- High Infant Birth Weight
- Prolonged Second Stage of Labour
- Assisted Birth → Forceps/Ventouse
- More Births
- Menopause and Age
- Constipation
- Being Overweight
- Smoking and/or Chronic Cough
- Inherited Risk
Management of Pelvic Organ Prolapse in a GP Setting (5 points)
- Educate/Explain benign and non-progressive nature of prolapse
- Weight Loss/Maintaining Healthy Weight
- Avoid Heavy Lifting
- Pelvic Floor Muscle Training
- Bowel Management Advice - avoid straining/avoid constipation
Investigations of urolithiasis (3 points)
- Urine Dipstick → blood (haematuria in 85% of cases)
- Dipstick may also revel nitrites → Urine MCS can suggest UTI
- Imaging:
- CT KUB + Xray KUB
- Follow-up imaging is needed so performing simultaneous scans allow for decrease in exposure to subsequent ionising radiation and provides clue to composition of the stone.
- U/S in young people who want to avoid radiation + pregnant women
- CT KUB + Xray KUB
- Renal Function Test - severe renal failure may alter management decisions
Prevention of Recurrent Stones (4 points). Investigations if recurrent stones (6 poitns)
- Good Hydration → drink to level where urine is clear as renal calculi precipitate from concentrated urine
- Low Sodium Diet → increased sodium diet causes increased urinary calcium excretion be reducing calcium reabsorption from urine
- Low Oxalate Diet
- Low Protein Diet → stones result from acidic urine which is primarily related to protein in the diet
If recurrent stones → further metabolic work-up: serum calcium and uric acid levels, parathyroid levels, 24-hour urinary calcium, citrate and oxalate
