7/11/21

Question 1

Difference in presentation between cystitis and pyelonephritis in paediatrics.

Answer 1

• UTI/Cystitis → dysuria, frequency, urgency and lower abdominal discomfort
• Pyelonephritis → systemic features such as fever, malaise, vomiting and loin tenderness

Question 2

Paediatrics: Duration of ABx for cystitis vs pyelonephritis. When are IV ABx required?

Answer 2

• if seriously unwell or <3 months → admitted for IV ABx
• if cystitis → 3-7 day course of ABx
• if pyelonephritis → 7-10 day course of ABx

Question 3

ABx for non-severe pyelonephritis, be specific. (paedaitrics)

Answer 3

1. trimethoprim + sulfamethoxaole 4+20mg/kg up to 160+800mg orally BD for 10/7. If clinical response is rapid, stop therapy after 7 days

OR
1. trimethoprim 4mg/kg up to 150mg orally, 12 hourly for 10/7. If clinical response is rapid, stop therapy after 7 days

1. Cefalexin 12.5mg/kg up to 500mg PO Q6H for 10/7. If clinical response is rapid, stop therapy after 7 days

Question 4

Clinical Feature of Paediatric Vulvovaginitis (4 points)

Answer 4

• Itching in the vaginal area
• Discharge from the vagina
• Redness of the skin of the labia majora
• Dysuria

Question 5

Causes of Paediatric Vulvovaginitis (4 points)

Answer 5

• Lining of the vagina can be quite thin and therefore easily irritated.
• Moisture and dampness around the vulva → worsened by tight clothing or being overweight
• Irritants → soap residue, bubble baths, antiseptics
• Threadworms can sometimes cause or worsen vulvovaginitis → children with threadworms often scratch at night

Question 6

Management points for Paediatric Vulvovaginitis (4 points)

Answer 6

• Wear loose cotton underwear and avoid tight jeans
• Maintain healthy weight - diet and exercise
• Don’t use a lot of soap in the bath or shower → remove soap residue
• Avoid bubble baths and antibacterial products
• Vinegar Baths → add half cup of white vinegar to shallow bath and soak for 10-15 mins. Daily for a few days
• Soothing Creams → soft paraffin or nappy-rash cream → settles the soreness as well as protect the skin from moisture.

Question 7

History taking of a Straddle Injury (paeds) (7 points)

Answer 7

• Mechanism of Injury
• Timing and Setting of Injury
• First Aid
• Inability to pass urine or faeces
• Other Injuries
• Witnesses
• Consider whether injury is consistent with history → ?NAI

Question 8

Management of a straddle injury. Minor vs Non-Minor.

Answer 8

• Contact local forensic paediatric service if concerned re: NAI
• Review Tetanus Status
• If MINOR Injury → bleeding is more and child can void spontaneously
  
  • Salt water baths
  • Simple analgesia
  • Reduction of strenuous activity for 24/24 - reduce risk of re-injury
  • Topical anaesthetic cream or barrier cream → reduce local pain on micturition
• If NON-MINOR injury → ongoing bleeding, laceration borders not visualised, labia minora tear, unable to void, clinician concern
  
  • similar management as minor injury
  • consider urethral catheter if unable to void (for example in the context of a vulval haematoma)
  • refer to local paediatric team or local gynaecology/surgical service

Question 9

Post-Natal Check (8 points)

Answer 9

• Enquire about vaginal discharge (lochia) and whether ceased
• Ask about healing of the perineum if vaginal delivery
• Review abdomen (uterus should be impalpable) and Caesarean Wound if present
• Check for any urinary or bowel problems (incontinence)
• Check if breast-feeding and whether there are concerns
• Check if intercourse has resumed and whether there are problems or concerns
• Discuss contraception options
• Advise on post-natal exercises
• Adequate diet, rest and personal care, sleep, exercise
• Psychological Health - Edinburgh Post-Natal Depression Scale , social supports
• Consider Pelvic Examination - checking perineum and pelvic floor strengths
• Cervical Screening Test (if due)
• Review antenatal screening tests for follow-up action - rubella booster
• Other → smoking and alcohol

Question 10

Clinical Features of Post Natal Depression (4 points)

Answer 10

• difficulty coping with baby
• guilty thoughts of being a bad mother
• excessive anxiety of well-being of the baby
• irritability toward family

Question 11

Management of Post Natal Depression. Mild to Moderate vs Severe.

Answer 11

Mild-Moderate Depression → psychological therapies

Severe Depression → antidepressants with SSRIs to be considered as first line therapy

Question 12

Clinical Features of NORMAL CRYING

Answer 12

• at 6-8 weeks of age → a baby cries 2-3 hours per 24 hours
• increases in early weeks of life and peaks at around 6-8 weeks and usually improved by 3-4 months of age
• usually worse in late afternoon or evening but can occur at any time
• infant may draw legs up as if in pain → but NO EVIDENCE that this is due to intestinal pathology

Question 13

2 main non-pathological causes of normal crying

Answer 13

• Excessive Tiredness → if infants total sleep duration over 24 hours falls more than an hour short of the average of their age
  
  • Birth - 16 hours
  • at 2-3 months - 15 hours
  • at 6 weeks - tired after being away for more than 1.5 hours
  • at 3 months - tired after being awake for more than 2 hours
• Hunger - more likely if poor weight gain

Question 14

Points of Management of a crying baby (5 points)

Answer 14

1. Engage in partnership with parents → acknowledge concerns, taking time to observe the baby-parent interactions and offer follow-up
2. Explain normal crying and sleep patterns
   
   • Use normal crying curve to explain the natural history of a crying infant
   • Use a sleep/cry diary to explain the infant’s cry/sleep/feeding patterns
   • Encourage parents to recognise signs of tiredness → frowning, clenched hands, jerking arms and legs, crying and grizzling
3. Assist parents to help baby deal with discomfort and distress
   
   • Establish pattern to feeding/settling/sleep
   • Aim to settle the baby for daytime naps and night-time sleep in a predictable way → quiet play, move to the bedroom, wrap the baby, give the baby a brief cuddle, then settle in the cot while still awake
   • Avoid excessive stimulation - noise, light, handling. Excessive quiet should be avoided - gentle music
   • Darken the bedroom for daytime sleeps
   • Baby massage/rocking/patting
4. Provide patient information
5. NO ROLE FOR MEDICATION including anti-reflux medication, anticholinergic medications, colic mixtures, simethicone, limited evidence for probiotics use.

Question 15

Causes of Delirium (9 points)

Answer 15

1. Infections → urosepsis, pneumonia and CNS infections
2. Metabolic Disturbance → hypo/hyperglycaemia, hyponatraemia
3. Medication Toxicity and Drugs and Alcohol Toxicity
4. Organ Failure → kidney or liver failure, respiratory failure with hypoxia/hypercapnia
5. Intracerebral Events → Stroke, Subdural Haematoma, Haemorrhage
6. Cardiac Events → MI, arrhythmias, CCF
7. Seizures and Post-Ictal States
8. Withdrawal States → from EtOH or benzodiazepines
9. Pain and Discomfort → urinary retention or constipation

Question 16

Delirium Screen (11 points)

Answer 16

1. FBE
2. UEC
3. Calcium
4. LFTs
5. CRP
6. Blood Glucose
7. O2 Saturation → with or without blood gas measurement
8. Urine Dipstick → urine MCS
9. ECG
10. CT Brain
11. Chest X-Ray

Question 17

Indications for use of Syringe Driver in Palliative care (6 points)

Answer 17

• Persistent Nausea and Vomiting
• Dysphagia
• Bowel Obstruction
• Coma
• Poor Absorption of Oral Drugs
• Patient Preference

Question 18

The Final Five Drugs used in a syringe driver for palliative care (5 points + bonus for dosing)

Answer 18

1. Morphine - 2.5-5mg via subcut infusion one hourly PRN for pain or dyspnoea
2. Metoclopramide - 10mg subcutaneous injection Q4H PRN for nausea
3. Haloperidol - 0.5mg subcutaneous injection Q4H PRN for agitation or delirium
4. Clonazepam - 2-6 drops sublingually PRN for severe agitation or if sedation required in delirium
5. Hyoscine Butylbromide - 20mg subcutaneous injection Q4H PRN for excessive secretions

Question 19

Non-Pharmacological Management of T2DM (6 points)

Answer 19

Diet - Dietary review

BMI - 5-10% weight loss in those who are overweight/obese with T2DM

Physical Activity → 150mins of physical activity/week plus 2-3 sessions of resistance exercise

Cigarette Consumption → zero cigarettes/day

Alcohol Consumption → ≤2 standard drinks/day

Blood Glucose Monitoring → Advise 4-7mmol/L and 5-10mmol/L post-prandial

Review medication and also patient understanding of treatment and self-management

Question 20

Diabetes Cycle of Care: 6 month, 12 month, 2 yearly (3,5,1)

Answer 20

6 Monthly

1. Weight, Height + BMI
2. Blood Pressure
3. Assess feet for complication

12 Monthly

1. Review and discuss diet, physical activity, smoking status, medications
2. Assess diabetes management by measuring HbA1c
3. Review and discuss complication prevention → eyes, feet, kidneys and CVD
4. Measure Total Cholesterol, Triglycerides, HDL cholesterol
5. Assess for microalbuminuria

2 Yearly

1. Comprehensive eye examination - more frequent for those who are at higher risk

Question 21

Diabetic medication changes in context of renal impairment.
Metformin, Sulfonylurea, GLP-1 receptor agonists. (tides), SGLT2 Inhibitors (flozins), DPP4 inhibitors (gliptins), insulin.

Answer 21

• *Metformin**
• eGFR 30-60 → reduce dose → 500mg PO Daily rather than BD → can increased to 1g daily depending on response
• eGFR <30 → contraindicated
• *Sulphonylurea (SU)**
• eGFR <30 → dose reduction (risk of hypoglycaemia increases as eGFR decreases)
• avoid glibenclamide if eGFR <60
• *GLP-1 Receptor Agonist**
• eGFR <30 → contraindicated
• *SGLT2 Inhibitors (dapagliflozin)**
• eGFR <45 → contraindicated (efficacy decreases)
• FLOzin FOrty-Five
• *Gliptins (DPP4 inhibitors)**
• safe with dose adjustment
• No dose adjustment for linagliptin
• *Insulin**
• normal doses titrated to blood sugar levels (risk of hypoglycaemia increases as eGFR decreases)

Question 22

In the context of CKD - discuss the use of ACEi/ARB. When to cease? What is the other consideration prior to commencing an ACEi or ARB? How do you manage this.

Answer 22

• Essential in patients with CKD → unless drop in eGFR by >25% can continue ACEi/ARB
• Potassium → Caution should be exercised if baseline potassium is 5.5mmol/L → rises in potassium of 0.5mmol/L are expected
  
  • Hyperkalaemia >6.5mmol → predisposes to cardiac arrhythmias
  • Management → low K+ diet, potassium wasting diuretics, avoid salt substitutes, resonium → CEASE ACE inhibitor/ARB/Spironolactone if K+ persistently above >6.0 and non-responsive to above therapies

Question 23

Differential Diagnoses for Behavioural and Development Problems in Children.

Answer 23

1. Autism Spectrum Disorder
2. Attention Deficit Hyperactivity Disorder (ADHD)
3. Early-Life Trauma
4. Post Traumatic Stress Disorder
5. Oppositional Defiant Disorder/Conduct Disorder
6. Anxiety Disorder
7. Global Developmental Delay
8. Intellectual Disability
9. Language Disorder
10. Vision/Hearing Impairment
11. Child Abuse
12. Fetal Alcohol Syndrome

Question 24

History questions in context of behavioural and development problem in paediatrics. (8 points)

Answer 24

• FHx of ADHD, learning difficulties, developmental delay, intellectual disability
• Birth History → alcohol or drug use in pregnancy + APGAR scores
• Developmental Milestones - including attachment and behavioural history
• Concerns on previous vision or hearing testing
• Diet History in particular dietary iron intake
• Sleep History → quantity and quality
• History suggestive of absence seizures
• Previous Head Injuries or Concussions
• Symptoms of Hypothyroidism
• Educational Competency

Question 25

Risk Factors for behavioural and developmental problems in paediatrics (6 points)

Answer 25

• Prenatal Exposure → infection, alcohol, smoking
• Birth Complications → prematurity or birth weight
• Perinatal Infections → herpes simplex virus, Zika Virus
• Medication Conditions → lead poisoning, congenital heart disease
• Genetic Conditions → Down Syndrome, Fragile X Syndrome
• Adverse Childhood or Family Experiences → Poverty including housing or food insecurity, exposure to racism, abuse or neglect
• Parental Unemployment or Mental Health problems
• Parents with limited educations/literacy
• Teenage Parents

Question 26

Investigations in the context of behavioural and developmental problems in paediatrics. (4 points)

Answer 26

• FBE
• Audiology Testing
• Vision Testing
• Fe Studies

Question 27

Investigations in the context of considering treatment in a patient with Chronic Hep C Infection (8 points)

Answer 27

Virology

• HCV PCR
• HCV Genotype
• Hepatitis B Serology → Hep B Surface Antigen (HBsAg), anti-HBc, anti-HBs
• HIV
• Hepatitis A Serology

Other

• FBE
• UEC including eGFR
• LFTs
• INR
• Pregnancy
• Liver Fibrosis Assessment → Fibroscan
• Liver U/S → should be performed in patients with cirrhosis to rule out hepatocellular carcinoma

Question 28

What is involved in the pre-treatment assessment of patient with Chronic Hep C infection? (5 points)

Answer 28

All patients with HCV infection with life expectancy >12months should be considered for treatment

• Virological Evaluation
  
  • confirm diagnosis of chronic HCV infection
  • identify genotype of HCV infection
  • document the HCV treatment history
• Evaluate for presence of cirrhosis
• Evaluate for presence of HIV or Hepatitis B
• Consider whether coexisting liver diseases are present
• Consider concomitant medications for risk of drug-drug interactions including ethinyloestrodiol-containing oral contraceptives, PPI, statins, OTC preparations and recreational substances
• Discuss the need for contraception
• Discuss the importance of treatment adherence

Question 29

Causes of Early Pregnancy Bleeding (5 points)

Answer 29

1. Ectopic Pregnancy
2. Early Pregnancy Loss
3. Implantation of Pregnancy
4. Threatened Abortion
5. Cervical, Vaginal or Uterine Pathology → polyps, inflammation/infection, gestational trophoblastic disease

Question 30

Investigations in the context of Early Pregnancy Bleeding (3 points)

Answer 30

1. Transvaginal Ultrasound → to determine the location and viability of early pregnancy
2. Serial Beta-hCG - 48 hours apart
3. Maternal Blood Group and Antibody Status

Question 31

History Questions in Fever in Returned Traveller (8 points)

Answer 31

Signs and symptoms → time of onset

• Arthralgia + Myalgia
• Coryzal Symptoms
• Cough
• Headaches
• Jaundice
• Lymphadenopathy/Petechia/Bruising
• Abdominal Pain
• Vomiting/Diarrhoea/Constipation
• Sick Contacts

Travel Destinations + Timeline

• Urban vs Rural Travel, Altitude
• Possible infections given location
• Incubation Period of given illnesses based on timeline

Nature of Travel → Relevant activities + exposures

• Contact with Animals/Insects/Bites
• Sexual Contacts → use of condoms
• Food → unwashed vegetables, salads, street foods, unbottled water
• Swimming in freshwater

Drugs → prescription, complementary, illicit

General Medical Information → routine childhood and travel immunisations + prophylaxis (malaria)

Question 32

Examination Findings in Fever in a Returned Traveller

Answer 32

• Evaluation of skin lesions + rashes → rose spots (typhoid), maculopapular (dengue and rickettsia), purpura/petichiae (meningococcal)
• Hepatosplenomegaly + Spelnomegaly
• Lymphadenopathy
• Jaundice
• Retinal or Conjunctival changes
• Genital Lesions
• Neurological Findings

Question 33

DDx of Fever + Rash in a returned traveller (8 points)

Answer 33

1. Dengue Fever
2. Chikungunya
3. Measles
4. Enteric Fever
5. Rickettsial Disease
6. Acute HIV Infection
7. Zika Virus
8. Meningococcal

Question 34

Syphilis Management (9 points)

Answer 34

1. RPR testing on day of treatment as baseline
2. Infectious Syphilis benzathine penicillin 1.8g IM stat, (weekly for 3 weeks if late latent syphilis)
3. Educate regarding Jarisch-Herxheimer Reaction
4. Notify State Health Department
5. No sexual contact for 7 days following administering treatment
6. 3. No Sex with partners from the last 3 months (primary syphilis) and 6 months (secondary syphilis) until the partners have been tested and treated is necessary
7. Contact Tracing
   
   • Primary → 3 months plus duration of symptoms
   • Secondary → 6 months plus duration of symptoms
   • Late-Latent → long-term partners only
   • Treat all sexual contacts of patients with primary or secondary syphilis regardless of serology with benzathine penicillin 1.8g IM, stat.
8. Test of Cure (RPR testing) → at 3 months, at 6 months and at 12 months
9. Consider Testing for HIV and other STIs at the 3 months review

Question 35

Antiviral Therapy for Shingles. When is it recommended?

Answer 35

• Antiviral therapy is recommended for all patients who present within 72 hours of the formation of the rash or for immunocompromised patients at any time regardless of duration of the rash.

Antiviral Therapy
- valaciclovir 1g TDS for 7/7 (children >2yo -> 20mg/kg up to 1g)

Question 36

Analgesia options for treatment of Shingles (3 options)

Answer 36

• *Neuropathic Pain**
• (to intact skin only) → lidocaine 5% patch, up to 3 patches applied at the same time to the painful area (after the shingles has healed), wear up to 12 hours then patch-free interval
• can use gabapentinoids in addition to, or as an alternative to, the lidocaine 5% patches

Noiciceptive Pain
Mild Pain
1. Ice Packs + Protective Dressings
2. Paracetamol 1g PO Q4-6H PRN up to max 4g daily
3. if pain severe → Prednisolone 50mg daily mane for 7/7, then taper over 14 days then cease → can reduce duration of pain in combination of anti-viral drug

Alternatives for severe pain:

1. Amitryptilline 10-25mg PO nocte, increasing every 7 days to usual maximum dose of 75mg nocte
2. OR opioid orally → usual principles of opioid prescribing apply → can start with endone 5mg Q4H (can also use tramadol and tapentadol)

Question 37

Treatment of Post-Herpetic Neuralgia (6 points)

Answer 37

• Commence management with ice-massage and paracetamol
• Lidocaine 5% patch → up to 3 patches at the same time to painful area. Wear up to 12 hours followed by patch free interval.
• gabapentinoid (pregabalin 75mg PO daily)
• tricyclic antidepressant (amitriptyline 10mg PO)
• Can also consider Transcutaneous Electrical Nerve Stimulation (TENS) daily for 2 weeks
• Can consider opioid analgesic (tramadol 100mg PO daily)

Question 38

Treatment for Actinic Keratoses (1 point)

Answer 38

1. Fluorouracil 5% cream topically, once or twice daily for 2-4 weeks on the face or 3-6 weeks on the arms and legs
2. Imiquimod 5% cream topically, at night 3 times weekly for 3-4 weeks. In the morning, wash the treated area with mild soap and water. Review patient at 4 weeks - if lesions persist, repeat treatment once.
3. Ingenol Mebutate 0.015% gel topically on the face or scalp, once daily for 3 consecutive days OR 0.05% gel topically on the trunk or limbs, once daily for 2 consecutive days