General Flashcards
1
Q
Non Modifiable causes of osteoporosis
A
Female
Ageing
Race eg Asian
Family history of maternal hip #
2
Q
Modifiable risk factors for osteoporosis
A
Smoking
Low Dietary calcium
Lack of vitamin D
Alcohol > 2 std/day
Caffeine intake > 4cups/day
Physical inactivity
3
Q
Medical causes of osteoporosis
A
Eating disorders Malabsorption eg coeliac disease Cushing’s Diabetes mellitus Hyperthyroidism Hyperparathyroidism Sex hormone deficiency Acromegaly Connective tissue disease eg RA Liver Failure Kidney Failure Heart failure
4
Q
Drugs causing osteoporosis
A
Corticosteroids Antiepileptics eg phenytoin, carbamazepine Excessive thyroxine Breast Ca hormone therapy Prostate cancer hormone therapy Heparin Thiazolidinediones eg rosiglitazone
5
Q
What is a T-score
A
Number of standard deviations above or below the mean bone density of a 30 yr old adult >= -1 =. Normal -1 - -2.5. Osteopenia
< -2.5 Osteoporosis
6
Q
What is a z score
A
Number of standard deviations away from the mean BMD of age, gender and ethnicity matched controls. When z < 2.0 consider coexisting contributing factor
eg. Corticosteroid use, Hyperparathyroidism, Alcoholism.
7
Q
Contraindications to HRT
A
Absolute:
Pregnancy
Current thromboembolism
Suspected or Active Oestrogen dependent tumour
Acute Ischemic Heart disease
Cerebrovascular disease
Undiagnosed vaginal bleeding
Active Liver disease
Active SLE
Relative (Seek Specialist Advice):
Previous Oestrogen Dependent Tumour (Breast, Ovary, Endometrial)
Increased risk of DVT/VTE
Previous Ischemic Heart Disease
Focal Migraine
Hypertriglyceridemia
Avoid in: Uncontrolled Hypertension and
Acute Intermittent Porphyria (progesterone)
8
Q
Preconception care
A
Smoking cessation
Alcohol cessation
Weight and diet optimisation
Folate supplementation 0.5 or 5.0 (high risk) start 1/12 before pregnancy to end of first trimester.
Iodine supplementation 150 mcg. 220 mcg when breast feeding.
Physical activity 30 mins daily
Excessive gestational weight gain increases risk of: Gestational diabetes, preeclampsia, c-section, miscarriage, obese child (metabolic syndrome), large for dates. Weight loss is not recommended in pregnancy.
9
Q
Contraindications Combined oral contraceptives
A
Absolute:
Pregnancy to 6 weeks post partum (if Breast feeding)
Previous DVT,
Previous oestrogen dependent tumour,
Previous stroke,
Uncontrolled Hypertension
Acute liver disease,
Migraine
35 yo w inc CVD risk (eg. smoking >15/day),
Immobilisation,
Chronic Liver disease,
SLE positive
Porphyrias
10
Q
Contraindications to IUD
A
Absolute: Pregnancy, active PID, undiagnosed DUB, previous ectopic. Relative: Very large uterus, very small uterus, Anemia, immunodeficiency, impaired clotting, valvular heart disease, previous PID.
11
Q
Hypertension in pregnancy: definitions
A
Hypertension: SBP > 140 or DBP > 90 Severe Hypertension: SBP > 160 or DBP > 110 Increase greater than 30/15 from baseline is concerning SBP > 170 = Urgent Treatment (referral) Timing usually after 20 weeks
12
Q
Types of hypertension in pregnancy.
A
Preeclampsia = htn + end organ damage (usually proteinuria) Gestational Hypertension = new onset htn at > 20 weeks, resolving
13
Q
Effects of smoking preconception
A
Male infertility Female infertility Delayed conception Delayed conception during assisted reproduction
14
Q
Effects of smoking in pregnancy
A
Increased risk of: miscarriage, preterm birth (2x), placental problems (previa, abruption), preeclampsia, ectopic, foetal growth restriction, low birth weight, small for dated, birth defects
15
Q
Effects of smoking on early childhood
A
Increased risk of: SIDS, T2DM, obesity, HTN, Nicotine dependence, ADHD, conduct disorder, psychiatric problems (eg Depression)
16
Q
Alcohol in pregnancy
A
No level of alcohol is considered safe in pregnancy. Risks increase with quantity and frequency. Foetal alcohol spectrum: Facial abnormalities eg flat nasal bridge and epicanthal fold Impaired growth Abnormal structure and function of the nervous system and Foetal alcohol disorder Limb defects Intellectual and learning disabilities MSK defects Behavioural difficulties Poor social skills
17
Q
Motivational Interviewing The 5 As
A
Ask Assess Advise Assist Arrange
18
Q
Motivational interviewing Stages of change:
A
Precontemplative Contemplative Planning Action Maintenance Relapse
19
Q
Motivational interviewing and intervention: Approach to education
A
- How big is the problem 2. Consequences of not doing/changing 3. Benefits of change 4. Barriers to change
20
Q
Opportunistic screening
A
SNAP + Weight. All Depression. > 13 yo Chlamydia risk. 15 - 29 yo. Annual testing if sexually active Skin Cancer: opportunistic advice to All. self check > 12 yo, high risk = 3-12 mth screening, others opportunistic. Preconception care 15-49yo Colorectal Ca 50+, 2 yearly fobt CV risk: from 45+, (35yo ATSIC) every 2 years. Cholesterol 45+ (35yo ATSIC) every 1 - 5 years depending on risk. Bp from 18+ every 6 weeks to 2 years (high - low risk) Pap smear 18 - 69 or 2 years after sexually active. Every 2 years if normal. Mammogram 50 - 69 2 yearly. 40+ if 1st deg relative Dx
21
Q
Stroke Risk ABCD2
A
Age >60 1pt BP > 140/90. 1pt Clinical features: unilateral weakness 2pt Speech impairment w. No weakness. 1pt Duration. > 60 min 2pt, 10 -59min. 1 pt Diabetes. 1pt Other high risk features: AF, 2 or more TIAs in 7 days (crescendo), carotid artery disease. High risk 4-7 immediate CT/MRI +/- Doppler Lower risk 0-3 CT head in 72 hrs
22
Q
Ideal Weight gain in pregnancy
A
First trimester 0.5 - 2kg total 2nd - 3rd trimester BMI 30.0 0.2 kg/wk
23
Q
Chronic Abdominal Pain Red flags
A
Older patient, Nocturnal Pain, Nocturnal diarrhoea, Progressive symptoms, Rectal bleeding, Fever, Anaemia, Weight loss, Abdominal mass, Faecal incontinence or urgency (recent onset),
Consider: pancreatic cancer, ovarian cancer, small and large bowel cancers, Mesenteric Ischemic, Crohn disease, metabolic disorder (eg lactase deficiency) If no red flags: Consider chronic appendicitis, adhesions, irritable bowel syndrome, Peptic ulcer,
24
Q
Spondyloarthropathy types and features
A
Ankylosing spondylitis Reiter’s syndrome Psoriatic arthritis Enteropathic arthritis (Inflammatory Bowel Disease) Features: Chronic Systemic involvement + joint involvement sacroiliac joint involvement Affect areas around the joint including tendon attachments (esp knee, hip, foot)
25
Ankylosing spondylitis Features and treatment
Back +/- gluteal pain and stiffness causing early waking
Pain improves with mobilising
Weight loss, fever, fatigue
Reduced spinal flexion and extension (Schober's test)
Uveitis (40%) due to HLA-B27 antigen
Age
M \> F
Strong familial component
Vertebrae changes (syndesmophytes -\> fusion -\> bamboo spine)
Ix: Elevated CRP and ESR during acute inflammation Seronegative (RA -ve) ANCAs are oft +ve
HLA-B27 genotype
positive Schober's test - clinical flexion (mark out 2 points 5cm below and 10 cm above L5. On touching toes should extend to \>20 cm)
X-ray SI joints - early erosion and sclerosis. Spine - syndesmophytes -\> bamboo spine
Tx: anti-inflammatory drugs eg indomethacin 100mg PR note (first line), cox-2 inhibitors (celecoxib) DMARDs eg sulfasalazine 500mg PO daily TNFa blockers eg. Inflixiamb
26
Reactive arthritis (Reiter's syndrome) Common causes
Urogenital: Chlamydia trachomatis (male, 20 - 40yo) Enteric: Salmonella typhimurium, Shigella flexneri, Yersinia enteroclitica, Campylobacter jejuni Other: Streptococcal infections. Acute reactive arthritis may require prednisolone 25 mg daily Chronic reactive arthritis is managed as for ankylosing spondylitis
27
Viral Arthritis Causative organisms
Influenza Mumps Rubella Varicella Hepatitis B,C Epstein Barr Virus (esp myalgias) Cytomegalovirus Adenovirus (children) Ross River virus Barmah Forest virus Features: acute onset (within 10 days of viral illness), rash, polyarthritis, symmetrical inflammation, esp hands and feet, lymphopenia or lymphocytosis Terminates rapidly.
28
Arthritis Red flags
Fever Weight loss Profuse rash Lymphadenopathy Cardiac murmur Severe pain and disability Malaise and fatigue Vasculitic signs (palpable purpura, livedo reticularis, glomerulonephritis + Fever, wt loss, etc) Multi system involvement
29
Management of Spondyloarthropathies
eg: Psoriatic arthritis, Reactive arthritis, Enteropathis arthritis, Ankylosing spondylitis (adult and juvenile onset), and Unclassified spondyloarthritis.
Management:
Identify the most active elements of the disease and treat
Educate and reassure
Regular assessment and support
Genetic counselling esp ankylosing spondylitis + HLA-B27
Work and Posture advice
Physiotherapy referral
Occupational therapy referral
NSAIDs: Indomethacin 75 - 200mg PO or 100mg PR daily
DMARDs - Sulfasalazine 500mg daily
TNF-a inhibitors eg inflixamab
30
Complications of diverticulitis (6)
Bleeding Perforation Abscess Peritonitis Fistula (bladder, vagina, small bowel) Bowel obstruction
31
Red flags chronic Abdo pain
Progressively worsening symptoms
Recent Bowel changes eg incontinence
Weight loss
Fevers
Anaemia
PR bleeding
Abdominal mass
Nocturnal pain
Advanced age
32
Red flags for acute abdo pain
History: Progressively worsening vomiting Collapse at toilet (intraabdominal bleeding) Lightheaded Ischemic heart disease Distension Malignancy Signs: Fever Pallor Diaphoresis Hypotension Tachycardia or AF Prostration Rebound tenderness or guarding Decreased Urine output
33
ray Findings in Osteoarthritis
Joint space narrowing
Subchondral cysts
Ostophytes
Altered shape of bone ends.
34
Osteoarthritis
Principals of Management
Explanation
Exercise
Rest
Heat Packs, Heated blankets
Diet/Weight reduction
Mobility aids
Physiotherapy
Occupational therapy
Simple analgesics (Paracetamol)
NSAIDs (esp COX-2 if history or risk of GIT complications)
Glucosamine/Chondroiton
Surgery if severe.
35
Criteria for the diagnosis of Rheumatoid Arthritis
Symptom duration \> 6 weeks
Early morning stiffnes \> 1 hr
Arthritis in 3 + regions
Bilateral compression tenderness of the MTPs
Symmetrical involvement
RF +ve
Anti-CCP +ve
Bony erosions on xrays of hands or feet (late change)
36
Rheumatoid Arthritis: Principles of Management.
Patient education and support
Early treatment with DMARDs (methotrexate 5-10mg weekly + folate 5-10mg weekly) Can add sulfasalazine and/or hydrochloroquine if required, also infliximab.
Fish Oil 4g
Paracetamol, NSAIDS, Corticosteroids
Early referral to specialist
Regular functional assessment
Regular review
Regular Exercise
Physiotherapy referral
Occupational therapy referral
Daily joint mobilisation
Weight management
37
Gout Treatment
Acute:
NSAIDs eg indomethacin 50mg TDS 3-5 days then taper.
Colchicine 0.5mg q6h until pain relief (~24 hrs).
Corticosteroids: intra articular or oral (40mg daily for 4 days then wean to 10 days.
Chronic:
Allopurinol 100 - 300mg daily PO (lower doses if renal insufficiency)
Weight Reduction
Avoid purine rich food (eg organ meats)
Reduce alcohol intake
Water - 2 litres/day
Reduce sugary soft drinkss
Avoid diuretics and aspirin
Wear comfortable shoes.
38
Management of large congenital melanocytic naevi more than 20cm in diameter
Lifetime surveillance be undertaken whether or not any surgery has been performed. This could include baseline photography and three-monthly evaluation for the first year of life, followed by six-monthly evaluation for the next three years, and then yearly evaluation
Parents or patients report immediately any concerning changes that occur between follow-up visits
Biopsies be undertaken immediately of any areas which show suspicious features
39
Management of Cafe au Lait Macules
Solitary cALMs are common in up to 3% of healthy infants and 25% of children.
Multiple cALMs are rare in healthy children.
Children with three or more cALMs should be monitored for other features of NF-1
Most Children with six or more cALMs will eventually be diagnosed with neurofibromatosis-1 (NF-1), potentially affecting multiple organ systems.
Café au lait macules may also be seen in multiple other rare syndromes.
Treatment: Isolated cALMs may be treated with pigment laser therapy.
40
6 week baby check
How are family coping.
ANy Concerns
Jaundice, Colour, Birthmarks
Consider trisomy 21
Head Circumfrence, Lentgth, Weight and growth velocity
Engaging with examinars face
Eyes tracking, symetrical light reflections in eyes
Red eye reflex
cleft palate and uvula if able
Heart (ventriculo-septal defect, PDA) and lungs (central cyanosis, chest resesion, CCF, infection)
All limbs moving normally
Ventral suspension - head should be held inline with torso (serebral palsy)
Femoral Pulses (absent in coarctation of aorta)
decended testes, genital normality
Hip Dysplasia (Ortalani = downwards presure , Barlow = liftting, ie relocating)
41
Abdominal Pain and bowel changes in children
DDx
Most likely: Functional Gastrointestinal Disorder (50%) (eg IBS, Abdominal migraine, functional dyspepsia, childhood functional abdominal pain))
Must Exclude:
Coeliac Disease, IBD, Food Allergy, Eosinophilic Oesophagitis, Colorectal Cancer, Gastroenteritis.
42
Causes of Secondary Amenorrhoea
Pregnancy or contraception
PCOS
Hypothalamic-Pituitary axis disorder
Prolactinoma
Malabsorption
Thyroid disorder (Hyperthyroid, Hypothyroid)
Eating Disorder eg Anorexia nervosa
Strenuous exercise
Emotional Stress
Premature ovarian failure
Kidney Disease, Liver Disease
RACGP Exam lists as: Hypothalamic-pituitary axis disorder (stress, exercise, anorexia), Pituitary tumour (prolactinoma), Medication (OCP), Autoimmune (coeliac, pernicious anemia, thyroid), PCOS
43
Causes of Primary Amenorrhoea
Hypothyroidism
Turner's Syndrome (45 XO)
Kallmann's syndrome (normal stature + loss of smell)
True gonadal dysgenesis
Hepaphroditism
Androgen secreting tumour
Congenital Adrenal Hyperplasia
Androgen Insensitivity syndrome
Mullerian developmental abnormalities.
44
45
How do you manage a Pt with BP \>160/100
\> 45 YO Non idigenous
\> 35 YO Indigenous
1. Assess for known CV disease or CVD Risk if no known disease
2. Frequent and sustained lifestyle advice and support (eg smoking cessation)
3. If known CVD or Moderate (10-15%) to High Risk (+ 15%) consider commencing BP Lowering (eg. perindopril 5mg) and Lipid lowering (Atorvastatin 40mg) medication.
4. Monitor individual risk factor response to interventions
5. Regular review of absolute risk
Low risk = 2 yearly
Moderate RIsk = 6 - 12 monthly
High Risk = as clinically needed
46
4 Blood Pressure Lowering Combinations to Avoid:
1. ACEI or ARB + K sparing diuretic (eg spironolactone) - May cause hyperkalemia
2. Beta blocker + Verapamil or Diltiazem (CCB) - May cause heart block
3. ACEI + ARB - May cause hypotension and kidney injury
4. Betablocker + Thiazide diuretic - May potentiate worsening glycaemic control
47
Ideal BP medication combinations for the following:
1. Diabetes
2. Post MI
3. CCF
4. CAD
1. Diabetes: ACEI (eg perindopril) + CCB (eg Amlodipine)
2. Post MI: ACEI or ARB + Beta blocker (Atenolol 50mg BD)
3. CCF: Thiazide Diuretic + ACEI or ARB
4. CAD: Beta blocker + Dihydropyridine CCB (eg Amlodipine)
48
Absolute contraindications to Beta Blockers
Asthma
Moderate to Severe COPD
Decompensated Heart Failure
Cardiogenic Shock
2nd or 3rd degree Heart Block
Symptomatic Bradycardia
Severe Peripheral Vascular Disease
Sick Sinus Syndrome
49
Factors affecting adherance to medication
Education
Treatment Complexity
Doctor - Patient Relationship
Beliefs
Health literacy
Side effects.
Ecconomic factors (eg cost)
50
Dx and Treatment
Female
Lower abdominal pain and tenderness
Cervical motion tenderness
Adnexal tenderness
Temp + 38oC
Pevic Inflammatory Disease
14 Days Metronidazole 400mg TDS PO
14 Days Doxycycline (not preg) 100mg BD TDS
500mg Ceftriaxone IM stat
1 gm Azithromycin PO stat
51
Red Flags for Breast Lumps
Hard and Irregular
Skin dimpling or puckering
Skin oedema (peau d'orange)
Nipple discharge
Nipple distortion
Nipple eczema (Paget disease)
52
Probable Diagnosis of different types of nipple discharge:
1. Bloodstained
2. Green -Grey
3. Yellow serous
4. Yellow pus
5. Milky white
1. Bloodstained: Intraduct papilloma
2. Green - Grey: Fibrocystic disease or duct ectasia
3. Yellow serous: Intraducta carcinoma
4. Yellow pus: Breast abscess
5. Milky white: Galactorrhoea eg. hyperprolactinemia.
53
Differential Diagnosis for post coital bleeding
Cervical Ca
Intra-Uterine Ca
Chlamydia (\< 30 YO)
Cervical ectropion
Cervical polyps
IUD
OCP (can change to higher oestrogen dose)
Ix:
Pap smear (all ages) if not last taken within 3/12
Referral for endometrial sampling (\>35 yo)
54
Management of cycle irregularity
Under 35:
Reassurance, OCP
Over 35: Referred to Gynaecologist for consideration of hysteroscopy and endometrial sampling.
55
3 Most common bacterial causes of Otitis Media
Strep pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
56
Considerations for commencing HRT
1. Previous Breast Ca
2. Presence of Distressing vasomotor symptoms
3. Assess Cardiovascular Disease Risk (Known Cardiovascular Disease, Smoking, Lipids, BP)
4. Oestrogen + Progesterone if Uterus still intact
5. Lowest dose for shortest duration possible.
6. OCP or IUD + Oestrogen if requiring contraception
57
Considerations in Therapeutic Choice of HRT
1. Discuss a woman’s goals and concerns about menopause and her treatment preferences
2. Oestrogen with or without progestogen is the most effective treatment for women with menopausal symptoms
3. Consider potential benefits and harms and assess cardiovascular risk
4. Tailor the dose and duration of therapy according to individual symptoms and existing risks
5. Inform women about the limited efficacy and safety data on complementary and alternative medicines
58
Features of Autism
1. Impairment in Social interaction
2. Impairment in Communication
3. Repetitive Activities (eg. echolalia)
4. Behavioural Problems
5. Fixated Intrests (eg sensory sensitivities)
59
Management Options For Cystic Fibrosis
Referral to Specialist
Physiotherapy for airway management
Hypertonic saline nebulisers
Bronchodilators
Antibiotics for Respiratory infections
Pancreatic enzyme replacement
Dietician referral for dietary manipulation
Lung and Liver transplant.
60
Contraindications to a medical termination
Beyond 9 weeks gestation
Adrenal failure
Severe Asthma
Porphyria
Hypocoagulation Disorders (Including anticoagulant therapy)
Previous allergic reactions to these medications.
61
Leading causes of accidental death in children
Drowning
Crush Injuries from large objects
Motor vehicle accidents
Strangulation and suffocation
Unsafe Sleeping environments
62
Risk Factors for Gestational Diabetes
Previous GDM
Previously elevated BSL
Ethnicity eg. ATSI, Middle eastern, Pacific Islander, South east asian
Age \> 40
First degree relative with DM, Sister with GDM
Obesity esp BMI \>35
Previous baby with macrosomia (\>4.5Kg birth weight)
PCOS
Medications (corticosteroids, antipsychotics)
63
Conditions associated with vitamin D deficiency
Coeliac Disease
Obesity
Use of anticonvulsants
Hyperparathyroidism
64
Complications of Untreated Sleep Apnoea
Ischemic Stroke
Heart Failure
Impaired Cognitive Function
Increased risk of MVA
HTN
Depression
Diabetes
65
Features of Cassical Migraine
Unilateral Headache
Throbbing
Nausea
Vomiting
Photophobia
Elation
Flushing
Cravings
Optical changes - zigzag lines and tunnel vision
66
Causes of multiple spider naevi
Oestrogen therapy
Liver disease (eg alcoholic cirrhosis)
Thyrotoxicosis
Pregnancy
Trauma
67
Features of Labyrinthitis
Severe Vertigo - may be positional
Nausea and Vomiting
Hearing Loss (Sensorineural ie Webbers lateralises to unaffected side)
Tinnitus
Nystagmus away from lesion
68
Features of Vestibular Neuritis
Vertigo
Nausea and Vomiting
No affect on hearing
69
Asthma diagnosis in Adults:
History (4)
Supporting Evidence (8)
2 or more of the following:
Cough
Wheeze
Chest tightness
Breathlessness
Supported by:
Recurrent of seasonal
Identifiable triggers (eg. cold air, URTI, etc)
Response to SABA
Wheeze on auscultation
Family history of atopy
Commenced in childhood
FEV1 or PEF \< predicted
Unexplained Eosinophillia
70
Asthma in Adults Diagnosis:
Spirometry pre and 10 mins post bronchodilator:
Reversible airway limitation:
FEV1 increased \>/= 200mls and 12%
or,
Expiratory airway limitation:
FEV1/FVC \< the lower limit of normal for age.
71
Management of Asthma Adults.
Commencing therapy.
Start SABA if:
Symptoms less than twice per month with no requirement for oral corticosteroids in last 12 months.
Start SABA + ICS (or LRA) if:
Any episode of artificial ventilation, or
Requiring oral corticosteroids in last 12 months, or
Uncontrolled Severe or bothersome symptoms, or
Waking due to asthma at least once in last month, or
If asthma symptoms twice or more per month.
Usually trial low dose ICS
Review everyone in 4-6 weeks - consider repeat spirometry and technique/compliance
Consider Leukotriene receptor antagonist (Monteleukast, SIngulair) if not responding to ICS + SABA and compliance and puffer technique are satisfactory. Not on PBS \>15YO
72
DDx of Asthma in Adults:
Coronary Artery Disease
GORD
Obstructive Sleep Apnoea
Aspirin exacerbated respiratory disease
Congestive Cardiac Failure.
73
DDx for Asthma in Children
Croup
Bronchiolitis
Inhaled Foreign Body
Sleep DIsordered Breathing
Structural Airway Disease (eg Tracheomalacia, vascular ring)
Reccurent Respiratory tract infections
Suppurative Lung Disease (eg CF)
Other upper airway disorders eg. Post nasal drip, OSA
Tumours
Congenital Heart Disease
Pulmonary oedema
74
Probability Diagnoses of wheeze in young children:
Bronchiolitis: **\< 2 YO**, Sudden onset, Coryzal symptoms, Fine global crackles.
Viral Pneumonitis: **\> 2 YO**, Sudden onset, Coryal symptoms, fine global crackles.
Viral Induced wheeze: Gradual onset late infancy/early chilhood, Intermittent episodes, Interval symptoms (exercise, cold air), No improvement with SABA.
Asthma: Gradual onset late infancy/early chilhood, Intermittent episodes, Interval symptoms (exercise, cold air), Improvement with SABA.
Protracted Bacterial Bronchitis, Chronic or intermittent symptoms, progressively worsening, wet cough \> 4 weeks, responding to antibiotics.
Tracheomalacia/Broncomalacia: Chronic or intermittent symptoms since birth, well, thriving.
Inhaled Foreign Body: Sudden onset of symptoms, no coryzal symptoms
75
Red Flags for Cough in a child
Increased sputum production
Difficulty breathing
Systemic symptems (eg. failure to thrive, fatigue, etc)
Feeding difficulties
Recurrent Pneumonia
Inspiratory Stridor
Abnormal Respiratory exam findings
Clubbing
CXR abnormalities
76
Examination of children with asthma
Height & weight,
Skin inspection (eczema etc.)
Upper airways inspection (eg. inflammed turbinates, polyps)
Chest deformities (eg pectus excavatum)
Chest auscultation (wheeze, crackles, etc)
Heart auscultation for murmurs
Fingers for clubbing
77
Diagnosing Asthma in Children
Symptoms
Spirometry
Symptoms as for adults, must have \> 1 of:
Wheeze, Cough, Chest tightness, Breathing Difficulty
Spirometry \>/= 5 yO can be attempted.
\>/= 12% improvement, 10 mins post bronchodilator.
When not able to perform spirometry:
\< 6 MO refer to specialist
\> 6MO Trial of Bronchodilator.
If clear improvement then Asthma
If no improvement at 4-6 weeks refer.
78
79
Drugs causing Hyponatremia
Hypovolemic: Diuretics: eg. Hydrochlorothiazide
Euvolemic: Amphetamines
Hypervolemic: TCAs, SSRIs, NSAIDS, Chlorpromazine, Chemo
80
Vaccination Schedule
0 - 6 Months
Birth: Hep B
2 mths:
Tetanus, Diptheria, Pertusis, Hep B, H. influenzae B, Polio (hepB-DTPa-Hib-IPV)
13v Pneumococcal (13v PCV)
Rotavirus
4 mths:
hepB-DTPa-Hib-IPV, 13vPCV, Rotavirus
6mths:
hepB-DTPa-Hib-IPV, 13vPCV, Rotavirus
Flu vac should be given to Indigenous children annually, from 6months of age.
81
Vaccinations
12 months to 4 years old
12mths:
Measles, Mumps, Rubella (MMR)
Haemophillus influenzae b (HiB)
Menigococcal C (MenC)
18mths:
Measles, Mumps, Rubella, Varicella (MMRV)
4 years:
MMR if MMRV not given at 18mths
DTPa-IPV
Note: indigenous should recieve:
Influenza annually from @ 6mths
Pneumococcal @ 12 - 18 mths
Hep A @ 12-24 mths (2 doses, 4 weeks apart) in high risk areas.
82
Vaccinations
12 years old
Human Papiloma Virus (HPV)
Varicella
Tetanus, Diptheria, Pertusis
83
Catch up Vaccination
10 - 19 years old
DTPA initial, then 2 doses DT (tetanus and DIptheria) (4 wk intervals)
Polio (IPV) 3 doses, 4 week intervals
Hep B (1ml): 2 doses, 4 month interval, (11 - 15 yrs only),
or
Hep B (0.5ml): 3 doses, 0, 1 and 3months, (10 - 19YO)
MMR: 2 doses, 4 week interval
Varicella: 2 doses, 4 week interval
Menigococcal C, 1 dose
Note: Pneumococcal 23vPPV available for Indigenous 15 yrs or older if medically at risk.
Influeza available to anyone over 6mths who is medically at risk (Diabetes, Renal Failure, Lung Disease, Heart Disease...)
84
Indigenous Health Check
Child:
All Children
1. Vaccinations up to date - organise catch up if required. Icluding Influenza \>6mth
2. Growth Monitoring - height, weight, \< 5YO
3. Ear examination annually \< 15YO
4. Visual acuity at 4 YO
5. Oral health - every visit - 0 - 5YO, and annually 6 - 18YO
6. Nutritional History - if high risk area
7. Skin Check - Scabies and impetigo - if high risk area
85
Refugee Health
Aspects of Screening
1. Communication: Cultural and Linguistic Barriers. Telephone interpreter service available. Do not use friends or family.
2. Communicable Diseases (eg TB, malaria, HIV, STIs, Ebola)
3. Dietary Aspects eg Malnutrition (check Vit D, Iron, BMI)
4. Mental Health eg. PTSD, Depression. Perform K10, refer to trauma counselling if indicated.
5. Immunisation Status: Immunisation Cards? Testing for Abs, and organising catchup schedule.
6. Thourough Clinical Examination: CV, Respiratory and Skin
7. Organise Oral and Eye and hearing checkups as required.
8. Arrange Investigations as indicated.
9. Organise follow-up for results, etc.
86
Refugee Health:
First Visit...
History and Eamination
History:
Country of Origin
Other countries and camps stayed at
Immediate health problems
Any health undertakings on Visa
Medications and Drug allergies
Previous Medical History, including injuries, infections and transfusions
Previous Surgical History
Level of schooling and work history/exposures
Developmental progress (children)
Dietary adequacy
Examination:
Height, Weight, BMI
Blood Pressure
Urinalysis
87
Refugee Health
Investigations - first visit.
FBE, ESR
UEC, LFT
Urinalysis
Thick and Thin blood films + Malaria antigen
Tuberculin Skin Test +/- CXR if symptoms
Hep B Ag, Ab, Hep C Ab
Syphyllus serology
Urine PCR Chlamydia and Gonorrhoea \> 13YO
HIV
Faecal H.pylori antigen
Parasites/Worms Shistasomiasis & Strongyloides serology
Faecal OCP
Vit D, B12, RC Folate, Iron Studies
Lead levels \<13YO
88
Refugee Health
Second Visit....
Arrange Womens Health checks - Pap smear, mamogram
Management Plan for Chronic health problems
Cardiovascular an Diabetes risk assessment
Assess for Mental Health issues
Assess for Developmental issues (children)
Assess for Social issues, inc social isolation
Check Oral health
Check Vision and Hearing.
Organise
Arrange appropriate referrals, eg Social worker, Hearing assessment
89
Testing in Hep B Ag positive Pt.
LFTs
Coagulation Profile
HBV Viral Load
HBeAg/Anti-HDe serology
HAV, HCV, HDV serology
HIV serology
Alpha Fetoprotein
Abdominal USS
90
Reasons to Involve a professional Interpreter when dealing with NESB Pt.
(The 5 Cs)
Consent - Informed consent requires understanding.
Complex Instructions
Competence to make health decisions, including refusal of treatment.
Crisis - If urgent or timely decisions need to be made by the doctor regarding the patients health or well being or that of others.
Chronic Illness management - For effective management patients need a thorough understanding of illness and reasons for treatment
Telephone Interpreter Service is fast, free and professional
91
Catch up Vaccinations for a 4 year old refugee who had DTPa and Polio at 2, 4 and 6 months.
MMR - 2 doses 4 weeks apart
DTPa + IPV: 1 dose (as part of usual 4 year old vacination)
HiB: 1 dose (Hiberix)
Meningococcal: 1 dose
Testing for Hep B and Varicella antibodies
If negative can have these organised
Hep B (0.5ml) 3 doses: 0, 1, 4-6 months
Varicella x 1 (Booster at 12 YO)
92
Live vaccines
and considerations
MMR
Varicella
Yellow Fever
Must be administered on same day or \> 1 month apart
Mantoux test (TST) cannot be performed within 1 month of live vccine
93
Symptoms of Post Traumatic Stress Disorder
Re-experiencing phenomena eg flashback, nightmares
Avoidance and Emotional numbing
Hyperarousal eg exaggerated startele response, irritability
Complex PTSD:
Dissociation, Personality Change, Poor Relationships, Aggression, Self harm, Loss of meaning in life.
94
Health Benefits of Identifying ATSI Patients
Assess Disease Risk
Appropriate Screening and Treatment
Appropriate Immunisations
Enhance Access to Medications (eg. CTG, ciprofloxacin)
Ensure Access to Medicare Benefits (eg. Aboriginal Health Check)
Facilitate Access to Outreach/Support Workers
To Access Practice Incentive Payments
To be able to Audit the Care and Needs of ATSI patients
95
Practice Measures to Improve Indigenous Participation/Presentation
Cultural Safety Training for Staff
Placing Aboriginal Art, Literature and Information in the Waiting Room
Participating in Celebrations of Indigenous Culture (eg NAIDOC week)
Engaging with Indigenous Elders in the Community as project officers
Awareness of Barriers to Care - eg Bulk Billing indigenous patients
Encouraging staff to develop a therapeutic relationship with community members
96
Responding to Disclosures of Abuse (Physical, Emotional, Sexual)
Respond with compasion, support and belief
Be Non-judgemental
Address Safety Concerns
Acknowledge the Complexity of the situation
Put patients Identified Needs First
Take Time to Listen, Provide Information and offer referral
Validate Experiences, Challenge Assumptions, Provide Encouragement
Assist to make own decisions.
97
Domestic Abuse
Managing followups
Be Patient and supportive
Provide Follow-up and continued support
Respect the patients wishes and decisions. Do not pressure into decisions
Be nonjudgemental if patients do not act on referrals immediately.
98
Strategies for Improving Medication Compliance
Simplify Medication Regime.
Utilise "Close The Gap" if elligible
Dosing Aids eg Webster Packs
Patient Education of role and importance of each medication
Home (Domicillaery) Medication Review
Engage with the "Good Medicines Better Health" Program (Indigenous)
Utilise and Indiginous health worker for medication review.
99
What are the immunisation difference for indigenous people
Fluvac now reccomended for all Aboriginal people \> 6 MO
Pneumococcal vacination at + 50 YO for low risk
Pneumococcal vaccination + 15 YO for high risk.
All others as per schedule
100
What are the Requirements for a GPMP
GP in attendance with patient
Patient Consent
Copy offered to Patient
Needs: Identify Healthcare Needs of Patient
Goals: Develop a management plan acceptable to the patient
Actions: Identify what actions are to be taken by the patient
Treatment Services: Identify treatments and services to be initiated
Making referrals to these services
Clear documentation of the patients Needs, Goals, Actions, Treatment Services and Review Date.
101
What are the requirements for a TCA
Involves GP and 2 other providers in the patients care
Patient Consent to share information with other providers
Discussing treatments and services which would be of benefit
Consent from chosen providers to participate
2 way collaboration/communication with other providers.
Documentations of Goals, Providers, Treatment Services, Patient Actions and Review Date
Provision of Plan to Providers.
102
Differences between Adjustment Disorder and Depression
Adjustment -
Within 3 mo from the stressor
Follows the stressor,
Lasts less than 6 mo,
Symptoms are mild (forget about suicide )
Depression (major)
Does not follow a stressor,
Lasts at least 2 weeks,
Symptoms are much more serious and persistent (including suicide)
103
Mood Disorders without psycotic features
Disruptive Mood Dysregulation Disorder: Childhood, Onset before 10 YO
Major Depressive Disorder - SADAFACES, Suicide ideation often a feature
Persistent Depressive Disorder (Dysthymia) - lasting \> 2 years, brief episodes, less severity than MDD.
Premenstrual Dysphoric Disorder: Women, Associated with period.
Substance/Medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition - eg Hypothyroidism
Note: Adjustment Disorder is considered a Trauma and Stress related Disorder.
104
Criteria for an Adjustment Disorder
Emotional or behavioral symptoms develop in response to an identifiable stressor or stressors within 3 months of the onset of the stressor(s)
plus either or both of
(1) marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influence symptom severity and presentation are taken into account and/or
(2) significant impairment in social, occupational, or other areas of functioningThe stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder
Also:
* The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder
* The symptoms do not represent normal bereavement
* After the termination of the stressor (or its consequences), the symptoms persist for no longer than an additional 6 months
105
Define Culturally Safe and Unsafe Practice
Culturally Safe = Effective clinical practice for a person from another culture
Culturally Unsafe = any action which diminshes, demeans or disempowers the cultural identity and well being of another.
106
Criteria for Close the Gap
1. GP + one staff member must recieve cultural awareness training within 12 months of registering.
2. GP must perform regular AHC and GPMP
3. GP must be registered
4. Patient must register each year
5. Patient must be at risk of, or have a chronic disease
6. Accessible by any Aboriginal or TI patient.
7. Patient must be registered and scripts must be marked with CTG to access PBS.
107
Developmental Red flags
2 mths
8 mths
10 mths
12 mths
18 mths
3 yrs
2 mths: Not smiling, Not startling to sound, No visual Tracking, Excess head lag, Asymmetrical Moro reflex
8 mths: Not weight bearing on legs, Not reaching out to grab things, Not fixing on small objects, Not vocalising, Persistent primitive reflexes
10 mths: Unable to sit unsupported
12 mths: Not responding to Name, Showing a hand preference.
18 mths: Not walking, No pincer grip, Persistently casting away objects.
3 yrs: Inaccurate use of spoon, Not speaking in sentences, Not understanding simple commands, Not interacting with other children.
108
Expected Milestones at 6 weeks
Moro reflex
Head control when pulled up
Coos
Startles at loud noise
Smiles in response
109
Expected Milestones at 6 months
Gross Motor: Sitting, When Prone can support with hands
Fine Motor: Ulnar Grasp
Speech and Language: Babbles, Responds to Name
Social Skills: Stranger Anxiety
110
Expected Milestones at 12 months
Gross Motor: Walking with support
Fine Motor: Pincer grip, throws objects.
Speech and Communication: Two words with meaning, Follows one step commands
Social Skills: Drinks with cup, waves bye
111
Expected Milestones at 18mths
Gross Motor: Walking independently, Climbs stairs, sits on chair.
Fine Motor: 3 cube tower, takes off shoes, picks up 100s & 1000s
Speech and Communication: 10 words, points to body parts, follows simple commands
Social Skills: Uses spoon, Domestic mimicry, toileting awareness
112
Expected milestones at 3 years old
Gross Motor: Tricycle, Stands on one foot, Jumps
Fine Motor: Threads beads, Dresses and undresses, Copies a circle and cross, stacks 8 cubes
Speech and Communication: Counts to 10, Short sentences, Understands prepositions
Social Skills: Dry by day, Plays with children, Knows age and gender.
113
Risks for CKD
Impaired Glucose regulation (eg. Diabetes)
Hypertension
Age \> 60
Family History - 1st deg relative
Ethnicity - Aboriginal, Afro American, etc.
BMI 25-29 inc 40% \> 30 inc 80%
Smoking
Poor Diet
Physical Inactivity
Cardiovascular Disease
114
CKD Stages
Stage eGFR
1 \>90
2 60 - 89
3a 45 - 59
3b 30 - 44
4 15 - 29
5 \<15 or dialysis
115
Define micro and macroalbuminuria
UACR mg/mmol
Male Female
Normal \<2.5 \<3.5
Microalbuminuria 2.5 - 25 3.5 - 35
Macroalbuminuria \> 25 \> 35
116
Reccomended targets for reducing CVD and CKD in diabetes
HBA1C 6.5 - 7.0
BP \<130/88
In Patients with High risk for CVD eg. CKD stage 3A or above, Diabetes + microalbuminuria, Diabetes + age \> 60 YO, etc. Keeping to BP target reduces progression of CKD by 80%.
Review every 8 - 12 weeks until targets met.
117
When to refer to Specialist in CKD
If any one of:
eGFR \< 30 (Stage 4 - 5)
Persistent albuminuria UACR \> 30 mg/mmol (3 or more successive specimens)
Rapidly declining (\> 5ml/min) eGFR from \< 60 over 3 or more successive readings in a 6 month period
CKD + hypertension with difficulty getting to target despite 3 antihypertensives
Haematuria + Macroalbuminuria (UACR males \>25, Females \> 35)
Note: Murtagh also adds: Diabetes + eGFR \< 60, or 24hr Protein \> 1gm
118
Gout Management in CKD
Avoid NSAIDS if CrCl \< 30 (Celecoxib) and \< 25 (All others)
Paracetamol 1gm QID is acceptable
Colchicine can be used but at half normal dose
Prednisolone is a better alternative
Allopurinol for ongoing maintenance.
If using Opioids in CKD preferences are:
Fentanyl
Oxycontin
Buprenorphine
Always start t lower doses.
119
List the symptoms that may be encountered by a patient with terminal End Stage Kidney Disease:
Itchy Skin (manage with Topical moisturisers, Evening Primrose oil and low dose Gabapentin)
Restless Legs (Manage with Low dose Gabapentin)
Nausea (Manage with Metoclopramide, Haloperidol 50% normal dose)
Dyspnoea (Manage with education, fans, supp O2, Opiates, Benzos)
End Stage Symptoms:
Pain (Opiates + Benzos)
Terminal Aggitation (Benzos)
Terminal Secretions (Reassurance, glycopyrolate)
120
What are the 2 reccomended tests to test for Chronic Kidney Disease.
What is the diagnosis criteria
First-void spot Urine Albumine Creatinine Ratio
eGFR
CKD = eGFR \< 60 and/or UACR \> 2.5 (Men), \> 3.5 (Women)
on at least 2 occaisions \> 3 months apart
121
Management Recommendations in CKD
Salt intake \< 6gms (Na \< 2.3gms)
Maintain adequate protein 1gm/kg/day
Decrease Fats
Weight management BMI 18-25
Regular Exercise
Commence ACEI or ARB - BP \< 130/80 -\> and repeat EGFR in 7 days
Frusemide 40mg daily
Refer if eGFR \< 30, Persistent UACR \> 30, 6 month decline in eGFR (3 readings), Haematuria + macroalbuminuria
Uncontrolled hypertension (3 agents)
122
Define Resistant Hypertension
blood pressure that remains above 140/90 mmHg in spite of
concurrent use of three antihypertensive drugs from different
classes (including a diuretic) for at least 1 month.
123
Investigations for Resistant Hypertension
FBC
UEC (eGFR)
LFT
Fasting Lipids
Plasma aldosterone : renin ratio
Urine MCS (red cells)
Spot UACR
Ambulatory 24Hr BP monitoring
Renal tract Ultrasound
Cardiac echo
ECG
124
Bood Pressure Targets for:
Diabetes
Microabuminuria
Macroalbuminuria
Chronic Kidney Disease
Everyone else
Diabetes 130/80
Microabuminuria 130/80
Macroalbuminuria 130/80
Chronic Kidney Disease 140/90
Everyone else 140/90
125
Features of Bipolar
Elevated, Expansive or Irritable Mood
Diminished need for sleep
Accelerated Speech
Racing thoughts and flights of ideas
Increased Activity (eg sexual activity
Grandiose Ideas
Reckless or Risk Taking Behaviour
126
Enuresis History
Timing: Day or Night only
Previously Dry during Day or Night
Diabetic Hx or Symptoms (polyuria, polydipsia)
UTI symptoms (dysuria)
Symptoms of Sleep Apnoea
Social or Psychological Stressors
Family History of Bed wetting
Constipation or Encoparesis
127
Education and Direction to Resources (eg Black Dog Institute)
Sleep Hygene
Regular Exercise routine
Structured Problem solving
Mental Health Care Plan
Discuss commencing SSRI
Consider Referral for Counselling/CBT
Avoidance of Alcohol and other drugs
Review in 1 week for progress
128
Management Options for Nocturnal Enuresis (5)
Initial management:
Education about Enuresis
Motivational Therapy
Behavioural Modifications/Conditioning Therapy
Bladder Training Exercises
Use of an Alarm Device
If Initial Management fails then consider..
Fluid restriction before bed
Desmopressin
Alarm Device
Planned Waking time to void.
129
Treatment of H.pylori
Reasons
1st line therapy
Follow-up
There are many reasons for treating H.pylori including: Peptic Ulcer Disease, Dyspepsia, NSAID use, Atrophic gastritis, Fam Hx of gastric cancer and patients request.
Tx:
Esomeprazole 20mg BD 7 days
Amoxycillin 1gm BD 7 days
Clarithromycin 500mg BD 7 days
Follow-up
Follow-up is advisable
Urease breath test 4 weeks after cessation of Abs and 2 weeks after cessation of PPI (H2RB is ok)
Ongoing PPI is not required unless regular use of NSAIDS.
130
Indications for BMD scanning
Available to all Patients over 70 years old, or
Can be performed at + 50 YO if:
Minimal trauma fracture
Xray spine confirming compression fracture
Corticosteroid treatment \>7.5mg daily \> 3months
Early menopause
Hypogonadism
≥ 3 months glucocorticoids (at Prednisone ≥ 7.5mg)
Coeliac disease/malabsorption disorders
Rheumatoid arthritis
Primary hyperparathyroidism
Hyperthyroidism
Chronic kidney or liver disease
Androgen deprivation therapy
131
132
Side Effects of OCP
Headaches
Bloating
Nausea
Acne
Weight gain
Breakthrough Bleeding
Breast Tenderness
Decreased Libido
133
134
Indications for Ultrasound in Breast Examination
Evaluation of a palpable lesion not seen on mammography
Improved differentiation of a lesion detected on mamography
Detection of an underlying mass or altered architecture associated with mamographic calcifications.
For implant evaluation
As a guidance or localisation technique for biopsy.
135
Causes of Hyperprolactinemia
Prolactin \> 500 mLU/L
Prolactin \< 5000: Exercise, Hypophysitis (pituitary inflammation, rare), Macroprolactin (common), Nipple stimulation, pituitary disease, sarcoidosis, stress, trauma, Medications (Metoclopramide, TCAs, oestrogens, verapamil, opiates, methyldopa), Hypothyroidism, Cirrhosis, Chronic renal failre, pituitary adenoma (non-functioning)
Prolactin \> 5000: Prolactinoma, GH secreting tumur
136
Hereditary Thrombophillias
Factor V Leiden Mutation
Prothrombin Gene Mutation
Protein C Deficiency
Protein S deficiency
Antithrombin Deficiency
Dysfibrinogrnemia
137
Managing inherited thrombophillias
1. Educate regarding signs and symptoms of VTE
2. Obtain family history of VTE - Positive family hx increase risk of DVT in individual.
3. Avoid Oral contraceptives
4. reduce other risk factors for DVT (especially if positive family Hx)
5. FVL homozygous should have DVT prophylaxis for any surgery
6. Limited or unclear evidence on how to manage thrombophillias in pregnancy. Refer to Obstetrician for assessment (significant factors include family history, type of mutation, obesity, etc.)
7. Advice on reducing clot risk during long travel including compression stockings, alcohol avoidance, hydration, mobilise every 2 hours, loose clothing, dont smoke.
138
Travel History - the returned traveller.
Have you travelled in the last 12 months
Travel dates and itinerary for each destination
Date of return
Pre-travel vaccines
Antimalarial medications prescribed and taken as directed
Sexual contacts and contraception
IVDU
any insect or animal bites or scratches
Personal protective measures against insects
Exposure to fresh water
Contact with animals
Consumption of unpurified water and raw foods
Any illness in fellow travellers
139
Symptoms of Schistasomiasis
Fever
Abdominal Pain
Dry cough
Headache
Diarrhoea
Myalgias
Neck Pain
Urticarial Rash
140
Investigations for fever in the returned traveller
FBC, UEC, LFT, THICK AND THIN FILMS (X3), Blood Cultures (x2), Urine MCS, Chest Xray.
+ any specific tests for specific exposures.
141
Patients Not Suitable for CVD Risk Assessment.
Established CVD
Diabetes and aged \> 60
Diabetes with microalbuminuria (\> 20 micrograms/min or urinary albumin:creatinine ratio \> 2.5 mg/mmol for males or \> 3.5 mg/mmol for females)
Moderate or severe chronic kidney disease (persistent proteinurea or
eGFR \< 45 mL/min/1.73m2)
A previous diagnosis of familial hypercholesterolaemia
Systolic BP ≥ 180 mmHg or diastolic BP ≥ 110 mmHg
Serum total cholesterol \> 7.5 mmol/L\*
Aboriginal and Torres Strait Islander adults aged over 74
