Exam Flashcards
55 yo female. Painless swelling L elbow. Carpenter. No history of injury.
Most likely diagnosis
- olecranon bursitis
55 yo female. Painless swelling L elbow. Carpenter. No history of injury.
Most likely causes
Repetitive pressure 2 Overuse injury 2 Tophaceous gout 2 RA 2 Crystal arthropathy Infection of bursa 1
Management of olecranon bursitis
Avoid exacerbating activity 1 Ibuprofen 400mg orally tds 1 corticosteroid injection 1 Aspiration of fluid 1 Educate/explain re benign condition 1
26yo male office worker
Requests genetic test
Father age 50 has short term memory loss, abnormal twitching and new onset low mood
Paternal grandmother - depression and died of dementia age 48
Asymptomatic
No PMHx, no etOH, no smoking
Wife 6 weeks pregnant
Exam NAD
Probability of developing the same disease as father given the likely diagnosis
Huntington disease is autosomal dominant - chorea, depression, dementia
50%
With respect for genetic testing for Huntington disease which specific aspects would you discuss first?
- Huntington Disease is incurable
- Genetic testing does not predict age of onset
- If positive almost 100% certainty he will get the disease if he lives a normal life span
- 50% change he will pass it on to his child if he is positive
- A positive result will have implications for life/income protection insurance
- A result may alleviate uncertainty
- if positive may be able to join research trial
- May adversely impact career progression
Regarding feral predictive genetic testing what can be offered?
- amniocentesis
- chorionic villus sampling
29 female. Asthma. Presents with dyspnoea and palpitations. Each episode lasts 10 minutes and resolves gradually.
Non smoker
Become that’s one 100mcg 2 puffs BD
Salbutamol
name 3 investigations to assess the cause of the symptoms.
- ECG
- 24 hour ECG = ECG event monitor
- TSH
- FBC
- Serum blood glucose
20 year old with dyspnoea and palpitations lasting 10 mins. Ix NAD. What is likely diagnosis?
Panic attacks OR anxiety OR Panic disorder
29 yo female with panic disorder. 3 managment steps
- education re. Breathing control strategies e.g. slow controlled breathing (deep breathing)
- Refer for psychological therapies (CBT)
- Commence SSRI or SNRI
- Avoid stimulants - must give example e.g. caffeine or pseudo ephedrine
- Refer for self help, online /emental health program
- relaxation techniques, psychological education
Nursing home 78yo female
Pain and swelling L calf for 24 hours
10 days ago upper GI haemorrhage secondary to peptic ulcer
PMHx: HTN, dyslipidaemia, stroke -> poor mobility
Meds, pantoprazole 40, ramipril 5, atorvastatin 80
OBS HR 72, sats 98, RR 14, BP 144/78 temp 36.9
What specific exam finding to assess the cause of this presentation (4)
- Localised calf tenderness
- Swelling of entire leg
- Calf swelling >3cm larger than asymptomatic side
- Pitting oedema confined to symptomatic leg
- Presence of /prominent collateral superficial veins or venous congestion
- erythema OR warmth of leg
- raised JVP
- Pain on dorsiflexion of left foot
What ix do you do to confirm dvt
Venous duplex Doppler ultrasound of the left leg
Nursing home 78yo female
Pain and swelling L calf for 24 hours
10 days ago upper GI haemorrhage secondary to peptic ulcer
PMHx: HTN, dyslipidaemia, stroke -> poor mobility
Meds, pantoprazole 40, ramipril 5, atorvastatin 80
OBS HR 72, sats 98, RR 14, BP 144/78 temp 36.9
Has DVT. What is next management step?
Urgent referral to ED
Urgent referral to haematologist/vascular specialist
Seek urgent haem/vasc advice
55 F
Unemployed
Low mood for weeks, anhedonia, poor sleep, poor concentration
Lumbar disc hernia Timon tramadol 100mg tds and nortriptyline
MSE withdrawn, poor eye contact, unkempt. No psychosis/ abnormal thought processes
What do you prescribe to help with her presentation
Mirtazapine 15mg Nocte orally 3
ago elating 25mg po nocte 2
Person with depression presents with suicidal ideation and plan. Further history to assess suicide risk (5)
- preparation for death e.g. leaving a note/will 1
- Protective factors that would stop her acting on her plan
- Current symptoms of psychosis
- Previous suicide attempts 1
- Previous self harm
- FHX suicide
- Drug and alcohol use
- Feelings of hopelessness
- Social isolation/lack of support
- Access to means - car/gun/other weapons
- Social/peer suicides/recent bereavement
All score 1 max 5
You assess a patient as high risk of suicide, try voluntary hospital admission but refuses. Next 2 steps
- try to persuade her to stay in the surgery
- Arrange emergency police attendance/dial for polic via 000 to facilitate involuntary psychiatric admission 1
- detain under mental health act 1
73yo retired engineer
Back pain interfering with sleep. Increased thirst, constipation
PMHx - adenocarcinoma of prostate diagnosed 8 months ago - radical prostatectomy + brachytherapy. On goes goserelin and oxycodone -not helpful
Last PSA 3mo ago was < 3.8
Exam - focal vertebral spinal tenderness T11/12/L3. Full ROM and peripheral joints. Neuro NAD.
Give 3 DDx
Hypercalcaemia (2)
Metastasis to vertebral bodies/spine (2) bony Mets score only 1
Multiple myeloma (1)
Osteoporotic fracture (1)
Prostate cancer with Mets to spine - management (3)
Refer to radiation oncology for consideration of radiotherapy to spine (1)
Paracetamol 1g QID PO (1)
Ibuprofen 400mg PO tds (1)
Bisphosphonate therapy - need example Alendronate 70mg orally once weekly (1)
glucocorticoid therapy (1)
appropriate opioid therapy (1)
How to take alendronate
Reddy-Max + D -cal
1 tablet weekly of Alendronate 70mg + cholecalciferol 140mcg
the other 6 days of the week - 500mg - 2 tablets daily
Patient is worried might lose ability and capacity to make decisions related to health. What options are available (2)
- Prepare advance care plan
- Appoint enduring guardian
- Appoint a medical enduring power of attorney
Working in large regional town
68 yo. 2 days increasing sob
Exam 140/80 p 96 RR 30 temp 37. Chest fair air entry and diffuse rhonchi with bilateral basal creps
PMHx - MI 2 years ago recovered well following thrombolysis
Meds aspirin, atovastatin 40mg
Quit smoking 8 mo ago with 40 pack year hx. Wife recently had influenza
What diagnoses would you consider (4)
AND select 5 investigations to establish cause (5)
Congestive heart failure
COPD
Influenza virus
Pneumonia
CXR ECG Echocardiogram FBE CRP ESR
Now experiencing central chest tightness while in you surgery. Pale and clammy HR 122 RR 32, BP 92/66. Bibasal crackles and bilateral ankle and pedal oedema. What are your next immediate specific management steps. (5)
Answers Max 5 1. Arrange urgent transfer to emergency department via ambulance (if not listed don’t score anything for whole question) 1 2. Sit patient up 1 3. Obtain ECG 1 4. Attach defibrillator 1 5. IV access 1 6. Aspirin 300mg stat dose orally 1 7. S/L GTN spray or tablet 1 8. Frusemide 20-80mg IM or IV bonus/oral stat dose 1 9. IV morphine 2.5mg slow IV bonus 1 10. Oxygen if saturation <94% on air 1 Wrong If incorrect dose will be incorrect
Flat attached to daughters 18 months ago when wife died
Daughter brings him to see yo and says she is worried - socially withdrawn over past 6 months. Stay sin flat, refusing to go out Often I gnoses what she says to him. Complains that everyone is mumbling and is becoming increasingly irritable. Has tv turned up loud.
HTN and OA
Olemesartan 20/hCT 12.5
Paracetamol
9.1 You request an audio gram. Apart from hearing issues what are the other possible causes for this presentations (4)
Answers max 5
1. Depression 2 2. Anxiety 1 3. Dementia 1 4. Alcohol/substance abuse 1 (need to be specific) 5. Space occupying lesion 1 6. Cerebrovascular causes 1 7. Normal pressure hydrocephalus 1 8. Chronic subdural haematoma - must say chronic to explain the 6 month history 1 9. Elder abuse 1
How to describe audiometry with high frequency dip
- Presbycusis/bilateral high frequency sensorineural deafness score 3 group 1 group score 3
- Bilateral high frequency deafness score 2, group 1, group score 3
- Bilateral sensorineural deafness score 2
- High frequency/sensorineural deafness not specifying bilateral score 1
- Age relate deafness score 1
Ax confirms behaviour is hearing loss. For the pattern of hearing loss bilateral high frequency sensorineural deafness in the audio gram what features of history apart from age would you look for in determining a cause of the deafness (5)
Family history of deafness Use of otoxic drugs (gentamicin) Exposure to loud noises Occupational noise exposure Hx of head trauma Acute or gradual onset
How to assess for risky behaviours in young people
Home Education/employment Eating and exercise Activities Drugs Sexuality Suicide Safety
Important - substance abuse, pregnancy prevention, injury prevention and road safety
Immunisation in older age
Annual influenza vaccination - funded 65 and over and with medical risk conditions
Pneumococcal vaccination Prevenar 13 - 70 years and over
Herpes Zoster Zostavax 70-79 years
People who have conditions that increase their reissue of pneumococcal disease require a dose of 13 valent PCV followed by 2 doses of 23vPPV
Immunisations and diseases 2 months and 4 months
Diphtheria, tetanus and pertussis, hepatitis B, polio, haemophilus influenzae type b = Infanrix hexa
Rotavirus = rotarix
Pneumococcal = Prevenar 13
Immunisations and diseases at 6 months
Infanrix hexa = diptheria, tetanus, pertussis, hepatitis B, haemophilus influenza b, polio
For children with at risk conditions Prevenar 13
12 months vaccines and diseases
meningococcal ACWY = Nimenrix
Measles, mumps, rubella = Priorix
Pneumococcal = Prevenar 13
18 months vaca
Haemophilus influenza b = ActHIB
MMRV = Priorix-Tetra
Diphtheria, tetanus, pertussis = Infanrix
4 years vaccination
Diphtheria, tetanus, pertussis, polio = Infanrix IPV
At risk children = penumovax 23
12 - 13 years school program vaccination
Human papilloma virus = Gardasil 9
Diphtheria, tetanus, pertussis = Boostrix
14-16 year old school program
Meningococcal ACWY = Nimenrix
Who is zoster recommenced for
> /=60
MOst useful for >70 and funded for this population
50 can have it but not routinely recommended
=/>50 who have had previous herpes zoster can have zoster vaccine at the recommended age.
The risk of repeat episode of zoster is about 5% in immunocompetent
An episode of herpes zoster boosts cellular and hum oral immunity in most people likely for 1-3 years.
Suggested people should wait at least 1 year after an episode of herpes zoster before they receive zoster vaccine
=/>65 how often to screen for falls
Average risk = Every 12 months
Moderately high risk = presenting with a fall or who report recurrent falls or with multiple risk factors = every 6months
Question to ask for falls screening
- Have you had 2 or more falls in the past 12 months?
- Are you presenting following a fall
- Are you having difficulty with walking or balance
Multifactorial risk assessment for falls
History, exam, cognitive and functional assessment
- details of falls/fear of falling
- Polypharmacy
- impaired gait/balance/mobility
- foot pain/deformities/unsafe footwear
- home hazards
- bifocal or multifocal glasses
- incontinence
- recent d/c from hospital
- chronic illness such as stroke, MS, Parkinson disease, cognitive impairment, dementia
- Ditamin D deficiency/poor sun exposure
Physical exam assessing falls
- visual acuity and visual fields
- muscle weakness
- neuro impairment
- cardiac dysrhythmias
- postural hypotension
- 6m walk/balance, sit to stand
cognitive and functional impairment assessment for falls
GPCOG
ADL and home assessment e.g. by OT
If unsteady, gait and mobility assessment by PT
Falls risk reduction
Prescribe or refer for a home based exercise program or participation in a community based exercise program targeting balance which may include strength and endurance
If unsteady refer to physio for falls prevention
Exercises should specifically challenge balance and be done for a least 2 hours per week and continue forever
R/v medication
Home assessment - reduce fall hazards
Avoid multifocal lenses
PT or nurse for urge incontinence
Investigate causes of dizziness
What preventative activities for 65+ yo
Immunisation SNAP Falls visual impairment if symptomatic Annual questioning re hearing impairment Hearing impairment - a whispered voice out of the field of vision (0.5m) or finger rub at 5cm has a high sensitivity as does a single question about hearing difficulty Dementia
How to screen for dementia in those at increased risk
“How is your memory? And collateral history
Other symptoms = decline in thinking, planning and organising and reduced emotional control or change in social behaviour
GPCOG
Prevention strategies for dementia
150 minutes/week of moderate intensity walking or equivalent Social engagement Cognitive training and rehabilitation Mediterranean diet Smoking cessation Management of vascular risk factors
= SNAP + social engagement + management of vascular risk factors
How often and what for MSM STI testing
Gonorrhoea, chlamydia, syphilis, HIV every 12 months. Higher risk - 3-6 monthly - unprotected anal sex - >10 partners in past 6 months - Participate in group sex - Use recreational drugs during sex
Urine throa and rectal swab for chlamydia pcr
Throat and rectal swab for gonorrhoea pcr
Serology for hiv, sypilis, hep a and b
More often if they have multiple sexual contacts.
Who to screen for hep c
HIV positive
HIstory of IVDU
How often and what to screen ATSI STI
12 monthly chlamydia, gonorrhoea, syphilis, HIV and if not vaccinated or immune hep A and B. Hep C if injects drugs
How often to assess
- smoking
- weight
Smoking - opportunistically
Weight - measure bmi and waist circumference every two years - try for 5-10 % LOW
Recommend
- reduce energy intake
- reduce sedentary behaviour
- increase physical activity
- measures to support behaviour change
5As
Ask - what concerns do you have about your weight? Have you tried to lost weight before?
Assess - BMI and waist circumference =/>94 males =/>80 females increased risk
Advice - weight loss can have health benefit is - BP, prevention of DM. risks of being overweight
Assist/agree - discuss goals - 5% LOW and specific measurable changes to diet and physical activity. If not >1kg/wk loss over 3 months refer
Arrange: after achieving initial LOW advise they may regain weight without a maintenance program that includes support, monitoring and relapse prevention.
Behaviour change techniques for LOW
- goal setting
- self monitoring of behaviour and progress
- stimulus control - recognising and avoiding triggers that prompt unplanned eating
- cognitive restructuring = modifying unhelpful thoughts or thinking patterns
- Problem so loving
- Relapse prevention and managment
How to advice patients to follow Australian dietary guidelines
- eat high quantities of:
- veg
- fruit
- whole grain cereals
- poultry
- fish
- eggs
- low fat milk, yoghurt and cheese
- less discretionary food choices including sugary soft drinks
If high risk
- provide lifestyle advice to limit intake of foods containing saturated fat, added salt, added sugars and etOH and increase serves of fruit and veg
- refer to dietitian, group diet program or phone coaching
How often to repeat lipids
Low risk CVD risk <10% 5 yearly
Moderate risk CVD risk 10-15% 2 yearly. Consider pharmacotherapy if not reaching target after 6 months or if fhx premature CVD or ATSI
High risk. Every 12 months
Fasting BGL results and definitions
And oGTT
And HBA1C
<5.5mmol/L diabetes unlikely
5.5-6.9 perform oGTT
>/=7 (>11.1 non fasting) - diabetes likely, repeat fasting BGL on a different day to confirm
Impaired fasting = 6.1 -6.9
GTT
2 hour glucose 7.8-11 = impaired glucose tolerance
>/= 11 = diabetes
Hba1c =/>6.5%
What to do if suspected TIA
Age >60 (1) BP elevated (1) Clinical features unilateral weakness (2), speech impairment without weakness (1) Duration > 60 (2), 10-59 (1) Diabetes (1)
Additional information
- presence of AF
- Signs that might indicate carotid disease (anterior circulation signs), in those who are candidates for carotid surgery
- =/>2 TIAs within previous 7 days (crescendo TIA)
High risk = ABCD2 score 4-7 and/or AF, potential carotid disease or crescendo TIA: urges brain and carotid imaging (within 24 hours).
If carotid territory symptoms consider duplex ultrasound if candidate for revascularisation
Low risk - CTB +/- carotid USS with 48-72 hours
Colorectal cancer average or slightly increased risk and what to do
Asymptomatic with
- no personal history of bowel cancer, colorectal adenoma, IBD or family history of colorectal cancer
- one first-degree or second degree relative with CRC diagnosed aged =/>55years
=> 2 yearly FOBT from age 50
Colorectal cancer moderately increased risk
Asymptomatic with
- one first degree relative with CRC diagnosed aged <55 OR
- 2 first degree or one first degree and 2 second degree relative on the same side with CRC diagnosed at any aged (without potentially high risk features)
-> Colonoscopy every 5 years from age 50 or at an age 10 years younger than the age of first diagnosis of the CRC in the family
Consider FOBT in intervening years
High risk colorectal cancer
Asymptomatic with any of
- thee or more first degree or second degree relative on the same side with CRC (suspected Lynch syndrome, also known as hereditary non-polyposis CRC or other Lynch syndrome related cancers -> refer for genetic screening and bowel cancer specialist. Aspirin
- 2 or more first degree relative on the same side diagnosed with CRC with high risk features
- multiple CRC in the one person
- CRC aged <50
- a family member who has /had Lynch syndrome related cancer
- at least one first degree or second degree relative with CRC, with a large number of adenoma throughout the large bowel (suspected familial adenomatous polyposis)
- somebody in the family in whom the presence of high risk mutation in the adenomatous polyposis Coli or one of the mismatch repair genes has been identified. -> colonoscopy in intervening years.
Prevention of breast cancer (5)
- physical activity
- adequate folate
- Mediterranean diet
- Normal BMI
- decreased etOH consumption
Average or slightly higher risk of breast cancer - who
- one first degree relative with BC =/>50
- one second degree with BC any age
- 2 second degree relatives on the same side with BC =/>50
- 2 first degree or second degree relative with BC aged =/>50 on different sides
Risk up to 75years is 1:8-1:11
What to do re average risk of BC
Clarify risk at ancder Australia website
2 yearly mammogram age 50-74
Breast awareness
Who is at moderately increased risk of BC
- 1 first degree relative diagnosed <50 without high risk features
- 2 first degree relatives on same side with BC
- 2 second degree relatives on Same side, at least 1 diagnosed <50
Risk = 1:8-1:4
Moderately increased risk breast cancer what to do
- clarify risk
- 2 yearly mammogram age 50-74 (may be from 40 if first degree relative diagnosed <50)
- consider referral to family cancer clinic for further assessment
Potentially high risk or carrying a mutation
- potentially high risk of ovarian cancer
- 2 first or secon degree relatives on same side with breast or ovarian cancer + 1 or more of the following features on the same side of the family
- additional relatives with ovarian cancer
- breast cancer diagnosed before age 40
- bilateral breast cancer
- breast and ovsarian cancer in the same woman
- Ashkenazi Jewish ancestory
- breast cancer in a male relative
- one first degree or second degree relative diagnosed with breast cancer <45 plus another first degree relative on the same side with sarcoma age <45
- member of family with high risk breast cancer gene mutation
Risk 1:2 - 1:4
Potentially high risk of breast cancer - what to do
- Refer to family cancer clinic for risk assessment, possible genetic testing and management plan - may include chemoprevention with selective oestrogen receptor modulators e.g. tamoxifen or raloxifene or aromatise inhibitors
- May have mastectomy or salpingooophorectomy
- May do regular clinical breast exam, mammography, MRI or US
