Choosing Wisely

Question 1

With what patients should gonorrhoea PCR be requested?

Answer 1

Symptomatic

Asymptomatic - only if high risk (e.g. ATSI, MSM, multiple sexual partners, overseas travel/ partners)

Question 2

What tool can be used to determine whether C spine imaging is required in trauma patients?

Answer 2

Canadian C Spine Rule

Question 3

Name a tool for children and a tool for adults that can be used to determine whether CT brain is needed after head injury

Answer 3

Adults - Canadian CT Head Rule

Children - PECARN (Paediatric emergency care applied research network) or CHALICE

Question 4

Do anti-histamines have a role in treating anaphylaxis?

Answer 4

No
Prompt adrenaline = treatment
Sedating anti-histamines may cause drowsiness/ cause hypotension/ mask symptoms of anaphylaxis

Anti-histamines do have a role in mild-mod allergic conditions e.g. urticaria, hayfever

Question 5

Evidence shows what association between introduction of solid foods and development of nut allergies?

Answer 5

Introducing solid foods containing peanut at an early age (6 months, not before 4 months) is associated with lower risk of developing peanut allergies as a child

Question 6

Should carotid US be performed following syncopal episode?

Answer 6

No, not routinely

Occlusive carotid arterial disease causes focal symptoms e.g. weakness, altered sensation, altered speech - not syncope

Question 7

Name 4 features of headache that may warrant imaging

Answer 7

New onset headache in elderly
Progressively worsening headache
Headache that wakes someone from sleep
Headache worse with Valsalva manouvre

Question 8

If ANA is negative, should ds-DNA Ab still be performed?

Answer 8

No - only if suspicion of SLE remains high

Question 9

What is the latest evidence regarding US guided subacromial injections?

Answer 9

No advantage of US guided versus landmark-guided subacromial injection

Question 10

Do benzodiazepines have a role in lower back pain?

Answer 10

No

Question 11

In what patient group is FOBT appropriate?

Answer 11

In ASYMPTOMATIC patients at or slightly above average risk of colorectal cancer (usually 50yo +)

If GI symptoms or unexplained IDA -> refer for endoscopy

Question 12

A 38 year old woman on the COCP develops a DVT - should thrombophilia screen be performed?

Answer 12

No - only perform in patients <50yo if VTE occurs without exogenous oestrogen, major transient risk factor or if occurs at an unusual site (test is expensive and may inappropriately prolong duration of anti-coagulants)

Question 13

In a patient with 1st episode VTE in the context of a major transient risk factor (e.g. pregnancy, surgery) - how long should anti-coagulation be continued for?

Answer 13

3 months

Question 14

In patients with ITP without risk factors for bleeding/ upcoming surgery, a platelet count of what or above is acceptable?

Answer 14

Platelet count >30 in adult ITP without risk factors - no treatment needed

Question 15

What 2 office based investigations are important for most patients presenting with syncope?

Answer 15

ECG
Lying and standing BP

(NOT carotid US, unless syncope was associated with focal neurological deficit)

Question 16

Do salbutamol or corticosteriods have a role in the treatment of bronchiolitis?

Answer 16

No

Question 17

Why are PPI not routinely prescribed for infants with reflux?

Answer 17

Because it is no better than placebo in infants with reflux - there may be evidence if GORD in older children

PPIs associated with A/E e.g. nausea, diarrhoea, constipation, increased rates of infection, increased rates of food allergy

Question 18

What is the 1st line imaging choice for children/ adolescents with suspected appendicitis?

Answer 18

US abdomen

CT only if US result not clear or otherwise indicated (to reduce unnecessary radiation exposure)

Question 19

Why aren’t oral antibiotics routinely given in uncomplicated acute otitis externa or uncomplicated acute discharge from grommets?

Answer 19

Because topical agents provide adequate coverage of most causative organisms
Oral Abs have A/E
Reduce antibiotic resistance & risk of opportunistic infections

Question 20

What is the 1st line imaging for investigation of hoarseness?

Answer 20

No imaging

Refer to ENT for direct laryngoscopy for IX hoarseness

Question 21

Why is D dimer not useful during pregnancy to evaluate for possible PE?

Answer 21

Because D dimer is levels are raised throughout pregnancy (as is ESR)

Question 22

How often should urine ACR be tested in pregnancy in pre-eclampsia?

Answer 22

Not repeated - no role for testing for proteinuria once pre-eclampsia is diagnosed (used for diagnostic purposes, not prognostic purposes)

Question 23

Bilateral leg cellulitis is uncommon - what is the likely cause of bilateral redness/ swelling in a patient with chronic venous insufficiency?

Answer 23

Lipodermatosclerosis

Question 24

Name 3 features that would indicate bilateral lower leg cellulitis rather than venous changes/ lipodermatosclerosis

Answer 24

Fever
Neutrophilia
Expanding area of redness over hours/ days

Question 25

What is the 1st line treatment for inflamed epidermoid (formerly sebaceous) cysts?

Answer 25

Incision and drainage | antibiotics not routinely used - inflammation is usually due to leakage of cyst contents into surrounding tissue

Question 26

Why shouldn't anti-fungals be prescribed for suspected nail infection until confirmed by a lab result?

Answer 26

Because 50% of thickened/ discoloured nails are due to age, pressure from footwear, trauma or other skin disorder e.g. psoriasis

Question 27

In light of increasing antibiotic resistance, what is the recommendation regarding antibiotic use for acne?

Answer 27

Avoid prolonged duration | Do not use on own - combine with BPO or retinoids

Question 28

What is the most common trigger for acute urticaria in children?

Answer 28

URTI and other viral infections

Question 29

Is there a role for phsiotherapy in frozen shoulder?

Answer 29

Not beyond devising a simple home exercise program - no evidence for ongoing physiotherapy

Question 30

Under what circumstances should a thyroid US be performed?

Answer 30

If there is a palpable thyroid nodule or enlarged thyroid/ goitre

Question 31

Use of what medication increases risk of 'floppy iris syndrome' during intra-ocular surgey e.g. cataract surgery?

Answer 31

Selective alpha 1 blockers e.g. tamsulosin (in Duodart), prazosin Avoid use if awaiting cataract surgery - inform surgeon, they may need to change surgical technique

Question 32

In ankle injury after normal x-ray, if there is persistent symptoms e.g. pain and swelling, what imaging modality is 2nd line?

Answer 32

MRI

Question 33

Under what circumstances should US leg veins be requested for suspected DVT?

Answer 33

If Wells score for DVT is 2 or more, or if D dimer is positive (after Wells score <2)

Question 34

What is the investigation of choice in a pregnant woman with suspected PE?

Answer 34

VQ perfusion scan (D dimer elevated in pregnancy, perfusion scan is much lower dose radiation than CTPA)

Question 35

Routine self-monitoring of BSL is not recommended for T2DM patients on oral medication. Name 4 situations where it may be advised.

Answer 35

``` Symptomatic hypoglycaemia Heavy machinery operators (on a sulfonylurea e.g. gliclazide) To demonstrate affect of diet on BSL Pregnancy Elderly with renal impairment ```

Question 36

Acute bronchitis is a common condition seen in patients presenting with cough. It is mostly viral (>90%) and self-limiting. List 2 features of acute bronchitis.

Answer 36

Cough +/- sputum lasting <3 weeks | No features of pneumonia (fever, tachypnoea, tachycardia, haemoptysis, signs of consolidation)

Question 37

Should a pelvic examination be routinely performed during pap smears?

Answer 37

No

Question 38

What is the recommendation for oral antibiotic use in otitis media in children?

Answer 38

Do not routinely give antibiotics if review in 24-48hrs is possible instead, in non-indigenous children aged 2-12 yo with no fever/ vomiting/ lethargy (may reduce risk of perforation but no affect on pain or severe complications - whereas 1 in 14 children will have A/E to antibiotic e.g. rash, diarrhoea)

Question 39

PSA testing in men who are unlikely to live another how many years is not recommended

Answer 39

PSA not recommended in men who are unlikely to live another 7 years - as the mortality benefits of early detection of prostate cancer is not seen until at least 6-7 years

Question 40

Should vitamin D be routinely screened for in pregnant women?

Answer 40

No - not unless risk factor e.g. overweight, reduced sun exposure

Question 41

Why are medications containing <30mg codeine not recommended for analgesia

Answer 41

Studies show that doses of codeine <30mg up to 6 hourly are no more effective than panadol or NSAID alone Codeine is metabolised to morphine and a person's ability to metabolise codeine is highly variable