General GP (SJS) Flashcards

Question

What is the management of rosacea?

Answer 1

**General management** * Apply cool packs if severe * Minimise factors that cause flushing or irritation (see aetiology) * Sun protection plus sun avoidance measures are essential * Use an emollient soap-free cleanser, combined with a low-irritant sunscreen to reduce irritation * Some people may use a green-tinted foundation to mask erythrotelangiectatic features **Topical therapy – for mild erythema and inflammatory lesions** * 2% sulphur in aqueous cream tds OR * Metronidazole gel bd OR * Azelic acid gel OR * Clindamycin 1% solution bd OR * Erythomycin 2% gel bd Long-term maintenance with topical metronidazole is often used to control rosacea and prolong remissions. **Systemic antibiotics – for more severe cases or when topical therapy unsuccessful** * Doxycycline 50 to 100mg daily * Erythromycin 250 to 500 mg twice daily * Minocycline 50 to 100mg daily

Answer 2

The prominent clinical feature of scabies is itching. It is often severe and usually worse at night. The pruritus is the result of a delayed type-IV hypersensitivity reaction to the mite, mite feces, and mite eggs.

Answer 3

Permethrin 5% cream (adult and child 6 months or older) Apply topically to dry skin from the neck down, paying particular attention to hands and genitalia. Apply under the nails using a nailbrush. Leave on for a minimum of 8 hours (usually overnight) and reapply to hands if washed. Application time may be increased to 24 hours if there is a history of treatment failure. Repeat treatment in 7 days

Answer 4

Resolution in 85% of patients within 4-6 weeks. Generally good and patients may spontaneously recover even without medication. Related to severity of lesion and more favourable if some recovery or progress seen within 3 weeks of onset.

Answer 5

Space occupying lesion --\> facial twitch or spasm CVA --\> other signs of stroke, not limited to CN VII Ramsay Hunt Syndrome --\> look for vesicles on ear Otitis Media --\> otoscopy

Answer 6

**Basics** Eye care for patients who have impaired eye closure Use of short term (10 days) oral corticosteroids (60 mg/ day) within 72 hours after the onset of symptoms. Antiviral agents if viral etiology is suspected but only in conjunction with corticosteroids.- contentious **Place and person** GP managed Referral to neurologist in cases of new or worsening symptoms or incomplete recovery after 3 months. **Investigate and confirm diagnosis** Assess and exclude other possible identifiable causes **Non-invasive management** Psychological counselling and physiotherapy **Definitive management** Specialists may do surgical nerve decompression if fails to recover. Electrical nerve stimulation to promote motor recovery. Both have limited evidence **Long term** Follow up 1-2 weeks after onset to monitor effect of medications and eye care.

Answer 7

Cataracts Age related macular degeneration Chronic open angle glaucoma Diabetic retinopathy

Answer 8

Branch or central retinal vein occlusion Branch or central retinal artery occlusion CVA/TIA Giant Cell Arteritis Retinal detachment Optic neuritis Migraine

Answer 9

Benign and self limiting Apply heat and massage twice a day Avoid antibiotic ointments Incision and curettage is second line treatment Prevention by managing any associated blepharitis

Answer 10

No easy cure Lid hygiene --\> warm compresses for 5-10mins bd If severe try oral tetracycline for 2-3 months

Answer 11

**Key features** Gritty red eye Purulent discharge Clear cornea **History** Purulent discharge which causes the eyelashes to stick together in the morning Starts on one eye and spreads to the other (usually) Hx of contact with a person that has similar symptoms **Examination** Bilateral mucupurulent dischange with uniform engorgement of all of the conjunctivial blood vessels Non-specific papillary response **(larger fleshy swellings on the inside of the eyelid)** Fluorescein staining is negative

Answer 12

Limit the spread by avoiding close contact with others Use of separate towels and good ocular hygiene Many cases resolve spontaneously within 5 days; however, symptoms can last up to 14 days if untreated. A 'delayed prescription' approach is appropriate. **Mild cases** Saline irrigation of the eyelids and conjunctiva Antiseptic drop such as propamidine isethionate 0.1% **More severe cases** Chloramphenicol 0.5% eye drops 1-2 hourly for 2 days Decrease to 4 times daily for another 7 days Chloramphenicol 1% eye ointment at night **Specific organisms** Pseudomonas use topical gentamicin and tobramycinN. gonorrhea use appropriate systemic antibiotics

Answer 13

Low salt diet + diuretic Vestibular rehab Prochlorperazine maleate (stemetil): 5-10 mg orally every 6-8 hours when required Do not use stemetil long term --\> will stop the brain accommodating to a labyrinthine upset

Answer 14

**Severe vertigo that lasts for days** Acute inflammation of the vestibular nerve Cause unknown Young or middle aged adults Incapacitating sustained (non-positional) vertigo Sudden onset Very unwell and lie still in bed Nausea and vomiting No tinnitus or deafness

Answer 15

Reassurance and explanation Stemetil should be given only in the first few days After 2-5 days steady resolution usually occurs over a period of 6 to 12 weeks

Answer 16

BPPV Meniere's disease Vestibular neuronitis

Answer 17

Treponema pallidum

Answer 18

Rare in Australia High-risk sexual activity and previous STIs increase the risk

Answer 19

**Early syphilis** primary (chancre), secondary (rash or condylomata lata) or latent syphilis (asymptomatic) of less than two years duration exist based on serology results **Late latent syphilis** Latent syphilis has existed for two or more years or of indeterminate duration, in the absence of neurosyphilis and other symptoms and signs of disease **Tertiary syphilis** where cardiovascular involvement and neurosyphilis is present.

Answer 20

Secondary syphilis is caused by haematogenous spread of infection. This leads to a widespread vasculitis. * Non-itchy, reddish/brown skin rash + mucous membrane lesions. * Systemic symptoms inc fever, pharyngitis, headache and arthralgia * **condylomata lata** (clusters of soft, moist lumps in skin folds of the anogenital area)

Answer 21

**Condylomata lata**, is a cutaneous condition characterized by wart like lesions on the genitals. They are generally symptoms of the **secondary phase of syphilis**, caused by the spirochete, **Treponema pallidum**.

Answer 22

One third of people who have latent syphilis will go on to develop tertiary syphilis - approximately 3 to 15 years after the initial infection. There are three different forms: ``` gummatous syphilis (15%) - soft tumours on bone/liver/skin neurosyphilis (6.5%) - dementia/paresis/seizures/apathy cardiovascular syphilis (10%) - aortic aneurysms ```

Answer 23

**Public health** * Syphilis infection (Group C disease) must be notified in writing within five days of diagnosis. * Advice to cease sexual activity until treated **Contact tracing** * For primary syphilis, Trace sexual contacts for the last 3 months. Such contacts should be treated as for the case, even if their serology is negative. * For secondary syphilis, this period should be extended to 6 months * For early latent syphilis, to twelve months. * For late latent syphilis, any sexual partners and also children of infected women should be evaluated. **Early syphilis (less than 2 years' duration)** benzathine penicillin 1.8 g IM, as a single dose **Late latent syphilis (asymptomatic syphilis of longer than 2 years' duration, or of unknown duration.)** benzathine penicillin 1.8 g IM, once weekly for 3 weeks **Tertiary syphilis (syphilis of longer than 2 years' duration, or of unknown duration, with cardiovascular, central nervous system or skin and bone involvement.)** Expert advice is essential. benzylpenicillin 1.8 g IV, 4-hourly for 15 days.

Answer 24

**HSV1 – First infection** * high fever * sore throat * pharyngeal oedema * Generalised muscle pain * Rigors * Cervical lymphadenopathy * Sometimes splenomegaly **Recurrences** * 6-48 hours of pain/burning/tingling * Vesicles then form, crust and heal within 10 days * Systemic manifestations rare

Answer 25

**All patients** * Symptomatic simple analgesia * Consider 2% topical lidocaine * Pt education * Avoid sexual contact when lesions present * 100% use of condoms * Lifelong infection, could have contracted long ago * Lack of serious sequelae for most people **Minor episode (oral)** Aciclovir 5% cream topically, 5 times per day (every 4 hours while awake) for 4 days at the first sign of recurrence **Severe episode** Aciclovir 400 mg orally, 5 times daily for 7 days **Long term suppressive treatment** Aciclovir 400 mg orally, 12-hourly for up to 6 months **Disseminated visceral involvement: pneumonitis, hepatitis, or CNS involvement (meningitis or encephalitis)** Admit to hospital IV acyclovir

Answer 26

Smoking Sexual activity (lifetime number of partners) HIV and immunosuppression OCP use for \>5years

Answer 27

Whilst chlamydia is usually asymptomatic, it is much more common than gonorrhea so in a patient with urethral discharge chlamydia is still more common than gonorrheoa! It could also be HSV

Answer 28

**Infections of the cervix, anus and throat usually cause no symptoms.** **Men** * Urethral discharge 2 – 10 days after unprotected sex * Dysuria * Men who have sex with men * Hx of STD * Multiple sexual partners * Inconsistent condom use **Women** Most women who are infected with gonorrhoea have _no symptoms or vague symptoms that mimic common UTI._ Women with gonnorrhoea are just as at risk of developing serious complications from the infections regardless of the presence or severity of symptoms. The initial symptoms or signs that women MAY experience, include: * Dysuria * Vaginal discharge * Vaginal bleeding * Dyspareunia

Answer 29

**The 5 P’s** 1. Partners * How many? * Male/female/both? * Regular or random? 2. Practices * Frottage/oral/vaginal/anal? * Drugs used? 3. Previous STIs 4. Prevention of STIs 5. Prevention of Pregnancy

Answer 30

**Public health** * Gonococcal infection (Group C disease) must be notified in writing within five days of diagnosis. * Advice to cease sexual activity until treated * Contact tracing Sexual partners of individuals with gonorrhoea should be examined and investigated then treated empirically. **Definitive management** Ceftriaxone: 250mg IM as a single dose It is recommended that all patients with a suspected or confirmed diagnosis of gonorrhoea be treated for Chlamydia if it has not been excluded. As a practical matter, Chlamydia is treated routinely in patients with gonorrhoea. Azithromycin: 1 g orally as a single dose **Long term** Repeat diagnostic method if want to see if infection has cleared.

Answer 31

PID Infertility Epididymitis Reactive arthritis

Answer 32

**Normally asymptomatic but may have Cervical/Urethral discharge** Age 25 years Multiple sex partner/new sex partner History or prior STD Abnormal vaginal bleeding Dysuria

Answer 33

**First pass urine – NAAT (nucleic acid amplification test)** Culture of urethral discharge Also test for gonorrhea, syphilis, HIV and Hep B

Answer 34

**Public health** * Chlamydia infection (Group C disease) must be notified in writing within five days of diagnosis. * Advice to cease sexual activity until treated **Contact tracing** Sexual partners of individuals with chlamydia should be examined and investigated then treated empirically. **Definitive management** Azythromycin 1g as a single dose OR Doxycycline 100mg BD for 7 days **Long term** patients should be re-tested 3-4 months after the initiation of antibiotics

Answer 35

**50% asymptomatic** White-to-grey discharge adherent to the vaginal mucosa Dysuria Vaginal pruritis Previous episodes Dyspareunia Vulvodynia

Answer 36

Amsel criteria

Answer 37

Treatment of sexual partners is not required For symptomatic patients, use: metronidazole 400 mg orally, 12-hourly for 5 days OR metronidazole 0.75% vaginal gel, 1 applicator full intravaginally, at bedtime for 5 nights

Answer 38

Mastalgia Nausea Fluid retention Abdominal bloating Headaches Chloasma

Answer 39

Risk of decreased bone density with prolonged use \>5 years Weight gain up to 2 kg per year Delay in return to fertility up to 9 month

Answer 40

1/3 amenorrhoea 1/3 intermittent bleeding 1/3 heavy bleeding --\> consider removal

Answer 41

Intermenstrual bleeding first 6 months then at least 90% reduction in blood loss and many have amenorrhoea.

Answer 42

Amenorrhoea occurs usually by 3rd injection Small % have heavy bleeding

Answer 43

Improved acne Reduced endometriosis and fibroids risk Reduced menorrhagia, dysmenorrhea, PMT Reduced ovarian and endometrial cancer risk

Answer 44

35 years if smoker At menopause if non smoker

Answer 45

**You have up to 72 hours after unprotected sex to take the ECP.** **You have up to five days after ovulation to have an IUD fitted.** The ECP is most effective at preventing pregnancy (95% effective) if taken within 24 hours of unprotected sex. Within 25 to 48 hours, the effectiveness falls to 85%, and within 49 to 72 hours it is only 58% effective.

Answer 46

Foreign body Earwax Otitis externa Otitis media Cholesteatoma Perforated membrane Trauma Eustachian tube dysfunction Otosclerosis

Answer 47

**Cochlear --\> CN VIII --\> Auditory cortex** Presbycusis Noice induced Menierres Acoustic neuroma Stroke

Answer 48

Do Rinne test Medical emergency and needs high dose steroids early (Prednisolone 1mg/kg up to 60mg daily) Refer to specialist Overall recovery rates are 50-65% If it recovers, usually within 2-4 weeks In some patients, the hearing loss is permanent

Answer 49

**LUDWIGS ANGINA - MEDICAL EMERGENCY** **Mortality = 8%** A serious, potentially life-threatening cellulitis of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheotomy.

Answer 50

**Basics** * Secure the airway! * Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway. * Prevent the development of septic shock and multi-organ failure — give antibiotics early. **Place and person** * Notify ENT, anaesthetics and ICU. * Admit to ICU **Investigate and confirm diagnosis** * Do not delay treatment whilst waiting for investigations. **Definitive management** * Antibiotics * Metronidazole 500mg IV every 12 hours AND * Benzylpenicillin 1.2g IV every 6 hours * Steroids: * Dexamethasone IV * Intensive care * 1:1 nursing * Continuous RR, ETCO2, invasive BP and ECG monitoring * Fluid resuscitation * Indwelling catheter \*For patients with non-immediate hypersensitivity to penicillin: Cephazolin 1g IV every 8 hours. For patients with immediate hypersensitivity to penicillin: clindamycin 450 mg IV every 8 hours

Answer 51

Defined as rapid onset diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. It is a form of cellulitis that involves the skin and subdermis of the external auditory canal with acute inflammation and variable oedema. Acute diffuse otitis externa (swimmer's ear) often occurs following skin maceration of the external ear canal from water exposure. Pseudomonas aeruginosa and/or Staphylococcus aureus are commonly isolated from cultures.

Answer 52

**_RAPID ONSET_** ## Footnote Clinical features * Itching at first * Pain (mild to intense) * Fullness in ear canal * Scant discharge * Hearing loss Signs * Oedema (mild to extensive) * Tenderness on moving auricle or jaw * Erythema * Otorrhoea (offensive if coliform) * Pale cream ‘wet blotting paper’ debri – C. albicans * Black spores of Aspergillus nigra

Answer 53

**Basics** Simple analgesia **Place and person** N/A **Ix** Culture swab **Management** * The external ear canal must be kept as dry as possible for \>2 weeks after treatment * Remove discharge or other debris from the ear canal by dry aural toilet, not by syringing with water. * For bacterial infection: * Dexamethasone 0.05% + framycetin 0.5% + gramicidin 0.005% ear drops * 3 drops in affected ear tds, for 3-7 days * For fungal infection * Triamcinolone acetonide 0.1% + neomycin sulfate 0.25% + gramicidin 0.025% + nystatin * 3 drops 3tds for 3-7 days * The tragus should be pumped for 30seconds after instillation by pressing on it repeatedly, within the limitation of any pain. * Systemic antibiotic therapy provides no additional benefit to topical therapy, unless there is fever, spread of inflammation to the pinna, or folliculitis.

Answer 54

AOM can be either viral or bacterial (or mixed) in origin, but regardless of cause, it is usually self-limiting (60% of children treated with placebo became pain-free in 24 hours, and spontaneous resolution of AOM occurs in approximately 80% of children).

Answer 55

Viral URTI that will self-resolve

Answer 56

Acute otitis media Perforation of the tympanic membrane with otorrhoea

Answer 57

Generally, conservative management with simple analgesia Adults with otitis media --\> conservative management Indications for Amoxycillin * \< 6 months old * Sick child with fever * Vomiting * Red-yellow bulging TM * Discharge * Loss of TM landmarks * Persistent fever and pain after 3 days of conservative approach * Bilateral AOM

Answer 58

rhinovirus, coronavirus, adenovirus

Answer 59

**Catarrhal stage (7-14 days)** * Anorexia * Rhinnorrhoea * Conjunctivitis/lacrimation * Dry cough **Paroxysmal stage (about 4 weeks)** https://www.youtube.com/watch?v=AIVt3e5EVtc * Paroxysms of severe coughing with inspiratory ‘whoop’ * Vomiting (after coughing) * Coughing mainly at night * Lymphocytosis **Convalescent stage** Chronic cough which may last for weeks

Answer 60

**Basics** ABC **Place and person** If younger than 6 months – hospitalization School exclusion until at least 5 days of antibiotic use **Investigate and confirm diagnosis** Nasopharygeal aspirate FBE, IgA serology CXR – to exclude pneumonia **Non-invasive management** Good ventilation Avoid emotional excitement or distress Avoid overfeeding during paroxysmal stage **Definitive management** Antibiotics minimize transmission but do not effect course of disease Azithromycin 500 mg 5 days OR Trimethorpim and sulfamethoxazole 7 days OR Clarithromycin 7 days **Prophylaxis** Same treatment as above for household and other close contacts if commenced within 3 weeks of onset of cough in the patient **Prevention** Acellular pertussis is part of the immunization schedule Initial protection 2, 4 and 6months Booster (dTpa) 4 years 10-15 years Parents or household contacts of newborns

Answer 61

Fever, flank pain, nausea

Answer 62

* Frequent sexual intercourse * Urinary tract infections (UTI) * Diabetes Mellitus * Stress incontinence * Foreign body in urinary tract (calculus, catheter) * Anatomical/functional urinary abnormality * Immunosuppressive states (HIV, transplantation, chemotherapy, corticosteroid use) * Pregnancy * Hospital acquired infection * History of urinary tract infection in childhood

Answer 63

**Bedside tests** Urine dipstick --\> Pyuria (pus in the urine) is always present in pyelonephritis, bacteriuria, haematuria **Bloods and urine** Urine culture – _WBC casts is diagnostic_ Blood cultures FBE – leuckocytosis ESR/CRP **Imaging** -Not needed to confirm diagnosis but may identify cause Renal ultrasound/CT may aid in diagnosis of hydronephrosis from a stone or obstruction

Answer 64

Staghorn calculi are composed of struvite (magnesium ammonium phosphate) and are usually seen in the setting of infection with urease producing bacteria (e.g. Proteus, Klebsiella, Pseudomonas and Enterobacter). Urease hydrolyses urea to ammonium and increase in the urinary pH.

Answer 65

**Bedside Tests** Urine dipstick test - may be +ve for leukocytes, nitrates, blood **Bloods and urine** Urine Microscopy - may be +ve for WBC, RBC and Bacteria Serum calcium, phosphate, uric acid, bicarbonate UEC **Imaging** Plain abdominal xray - approx 80% of stones contain calcium which can be seen on xray CTKUB 99% of stones are visible using this method For Monash exams the INITIAL AND GOLD STANDARD Ix for urolithiasis is CTKUB not AXR U/S Can show some stones and uteric dilatation Useful in pregnant women, young women or unstable patients in whom exposure to radiation is undesirable

Answer 66

**Stone analysis** To determine the chemical composition of the stone The stone is either extracted from surgery or passed by the patient **Parathyroid levels** As a possible cause of calcium-containing stones Hyperparathyroidism --\> hypercalcaemia à calcium stones **Urine microscopy** Amino acid / cysteine levels As a possible cause of cysteine stones **24 hour urine monitoring** should be ordered once the patient is stone free measure volume, pH, creatinine, sodium, calcium, oxalate, uric acid, citrate Helps in determining underlying metabolic cause or aetiology for nephrolithiasis

Answer 67

\<6mm ## Footnote D/C home on “push fluids” (drinking a lot orally to try to pass the stone) Medical expulsive therapy (MET) may also help to pass the stone Tamsulosin (alpha blocker --\> smooth muscle relaxation) Nifedipine (calcium channel blocker --\> smooth muscle relaxation)

Answer 68

\>6mm Extracorporeal shock wave lithotripsy (ESWL) Ureteroscopy Percutaneous nephrolithotomy (PCNL)

Answer 69

**Basics** Education, conservative treatment **Place and person** GP managed, if symptoms persist or worsen refer to orthopaedic/ hand surgeon **Investigate and confirm diagnosis** Nerve conduction study **Non-invasive management** ``` Weight loss (if overweight) Wrist splinting esp at night Ultrasound physiotherapy tx Oral glucocorticoids (short term use only!) Corticosteroid injections into the carpal tunnel region ``` **Definitive management** Surgical decompression * Open * Endoscopic Wide variation in success rates and complications for both

Answer 70

**NO CAST** Non-union Open fracture Compromise neurovascular Articular fracture Salter harris III IV V Trauma

Answer 71

influenza, yellow fever and Q fever vaccines

Answer 72

TDAP - pertussis component tetanus and diphtheria and bordatella pertussis

Answer 73

**Fever, pharyngitis, lymphadenopathy** (94%, usually posterior cervical chain) **and fatigue** Sometimes splenomegaly

Answer 74

Prognosis is typically good for this self-limiting infection. The vast majority of patients recover uneventfully and develop immunity to control the latent infection. Usually, most symptoms will r**esolve in one to two weeks, although fatigue and malaise may persist for months.** Death can occur rarely from airway obstruction, splenic rupture, neurological complications, haemorrhage (thrombocytopaenia) or secondary infection.

Answer 75

Measles There is no specific treatment of measles except for supportive care, but the disease can be prevented by a live virus vaccine. **Immediately notify DoH, isolate for \>4 days after rash onset.** Complications of measles occur more often in immunocompromised and poorly nourished individuals and include pneumonia, laryngotracheitis, otitis media, and encephalitis.

Answer 76

Similarly to malaria, the most important clue is travel to measles-endemic area or exposure to individual with measles in an unvaccinated person. Other key features include: Fever Cough Coryza Conjunctivitis **Koplik’s spots Maculopapular rash**

Answer 77

Measles has Koplick spots Investigations: Measles IgM and IgG serology

Answer 78

Mumps is an acute, self-limited, viral syndrome. It is spread by respiratory droplets, and, before the advent of the mumps vaccine, it affected school-aged children commonly. Classically, mumps causes swelling of the parotid glands; the involvement of other salivary glands, meninges, gonads, and pancreas is also common. **Management** * 5 days of isolation at home * Supportive care * Mumps (Group B disease) must be notified in writing within five days of diagnosis. * School exclusion: exclude for nine days or until swelling goes down, whichever is sooner. **Complications** The more serious complications of mumps, such as meningitis, encephalitis, and orchitis, may occur in the absence of parotitis, which can delay accurate diagnosis of the clinical syndrome.

Answer 79

**Basic** Education and reassurance **Place and person** GP managed **Investigate and confirm diagnosis** * FBE * UEC (rule out renal osteodystrophy) * LFTs (rule out chronic liver dz) * CMP (Hypocalcaemia? Primary hyperparathyroidism (high Ca, low phosphate)) * Parathyroid hormone levels * Vit D levels * TSH (hyperthyroidism?) * Serum and urine electrophoretogram and immunoelectrophoretogram (multiple myeloma) * Anti-TTG and IgA (coeliac) * DEXA scan **Non invasive** * Quit smoking, reduce alcohol * Calcium and vitamin D * Weight bearing exercise * Physio and OT to prevent falls **Definitive** Indications for pharmacotherapy: * Minimal trauma fracture * \>70 yrs and T score -3.0 or lower * T score less than -1.5 and prolonged steroids Options: * Bisphosphonates: * Aledronate, oral, weekly, up to 10 years * Zoledronic acid, IV, yearly for 3 years * SERM – Raloxifene * Monoclonal antibody – Denosumab * Teriparatide (PTH analogue) * Strontium ranelate What do you need to know about bisphosphonates: * Significantly reduces the risk of # and complications of OP * Do not eat or drink before taking the drug * Take once a week, standing up with a full glass of water. * Take the tablet whole, do not crush or chew. * Remain standing up for 30mins after taking. * Do not eat, drink or lie down for 30 mins after taking * Risks * Oesophageal irritation * Upper GI ulcers * Musculoskeletal aches and pains * Osteonecrosis of the jaw (rare) * Atypical femoral stress fractures (rare) * Delays bone healing if there is a #

Answer 80

**1) Is the HTN primary or secondary?** ABCDE * Apnea, Aldosteronism * Bruits / Bad Kidneys * Catecholamines, Cushings, Coartation, Calcaemia * Drugs * Corticosteroids * OCP * Decongestants (pseudoephedrine) * ETOH * NSAIDs * Oestrogen * Psych drugs – MAOi, Lithium, Clonidine * Endocrine (hyperthyroidism) **2) How bad is has it been? - assess for end organ damage** * Heart * LVH (ECG, TTE/TOE) * Kidneys * Albumin:creatnine * Protein:creatnine * eGFR * Eyes * Fundoscopy * Vascular * Auscultate for bruits * U/S or angiogram **3) How bad might it be in the future? - assess overall CV risk**

Answer 81

**HOMESICK** ## Footnote Headache / Hypertension Obesity Medications (some antivirals/ABx) Embolism / Thrombus / Clotting disorders Stroke IHD Cancer (Breast, Endometrial) Kids (ie. parity) / Breastfeeding

Answer 82

* Could it be **cancer**? * Pain not relived by bed rest * Weight loss * Age * Hx or FHx of prostate, breast of lung ca * Could it be **cauda equina**? * Bladder/bowel symptoms * Saddle parasthesia * Bilateral parasthesia in limbs * Could it be **spinal stenosis**? * Pain in legs when walking but relieved by sitting * Age \>65 * No pain when seated * Could it be **AnkSpond** * Morning stiffness * Improves with exercise * Onset \<40years * Slow onset * Could it be a **fracture**? * Point tenderness * **Trauma** * Age \>50 * Osteoporosis or use of corticosteroids Signs and symptoms of **neurocompressive** lower back pain * Pins & needles and/numbness * Muscle weakness * Positive straight leg raise and/or slump test * Sharp, lancinating leg pain * Leg pain \> LBP * High irritability and flares of pain and activity limitation

Answer 83

* Weight loss + exercise * Analgesia * Physio referral * Monitor

Answer 84

**Persistent Crapping Is Irritating and Highling Distressing say Lamenting Patients** * Parasitic infection --\> giardia, cryptosporidium * Coeliac * IBS * IBD (UC/Crohns) * Hyperthyroid * DM * Lactose intolerance/FODMAPS * Pancreatic insufficiency (CF/chronic pancreatitis)

Answer 85

**“SACKED”** Stroke Aortic Aneurism CAD Kidney disease Eye disease (retinopathy) Dilated left ventricle

Answer 86

No “cause” But strong associations with: * ETOH * BMI * Salt intake * Age * Genetics

Answer 87

**Secondary Causes of Hypertension = _READ_** R- Renal (GN, PCKD, renal artery stenosis) E - Endocrine (Cushings, Addisons, Phaeochromocytoma, Hypercalcaemia, Hyperthyroidism) A - Arteries & Apnea (Renal artery stenosis, aortic coarctation) D - Drugs **Drugs which may cause hypertension = CODE NO + psych drugs** C- Corticosteroids O - OCP D - Decongestants (Pseudoephidrine) E - ETOH N - NSAIDs O - Oestrogen P - Psych drugs = MAOi, Li, Clonidine

Answer 88

**COUGH** Cough (increase in bradykinin) Oedema (increase in bradykinin) Unborn baby effects (tetratogen) GFR decrease (up to 30%) Hyperkalemia and hypotension

Answer 89

Reflex tachycardia Flushing Headache Oedema Hypotension

Answer 90

* Ambulatory BP monitoring * Home blood pressure monitoring * Return to clinic for measurement by practice nurse * Measurement at local pharmacy

Answer 91

* **Potassium Sparing Diuretics** * Spironolactone and amiloride * **Alpha Blockers** * Prazosin or Terazosin * **Centrally acting antiadrenergic drugs** * Methyldopa, moxonidine, clonidine

Answer 92

Non-anaemic tissue iron deficiency is a significant cause of symptoms in all ages. The laboratory states her ferritin is normal, using ‘community reference ranges'. This does not mean Ashley is not iron deficient — she definitely is. Elite athletes and dancers often become iron deficient through damage to red cells in their feet. **Symptomatic tissue iron deficiency can result. Ashley's ballet training is probably causing loss of iron as haemoglobinuria, similar to "march haemoglobinuria" in military recruits.** Children and young adolescents absorb iron well from the gut. If Ashley consumes iron-rich food, oral iron supplementation should suffice. Do not use intramuscular iron. The iron can move back along the needle track into the pigment layers. Ugly dark smudges, which are permanent, will likely result.

Answer 93

Firstly, all oral iron supplements require 2-3 months for full effect. BUT, any product with iron salts added can be legally labelled an ‘iron supplement'. Most iron supplements available over-the-counter in Australia have tiny amounts of iron, eg, 5mg in Iron Melts tablets. At least 100mg of inorganic iron is needed per day to achieve the mass effect to push it across gut mucosal barriers. **Thus, the vast majority of OTC iron supplements are almost useless.**

Answer 94

Calcium channel blockers

Answer 95

**What is pyogenic granuloma?** Pyogenic granuloma is a relatively common skin growth that presents as a shiny red mass. The surface has a raspberry-like or raw minced meat appearance. Although they are benign (non-cancerous), pyogenic granulomas can cause problems of discomfort and profuse bleeding. **What causes pyogenic granuloma?** The cause of pyogenic granuloma is unknown. The following factors have been identified as having a possible role to play in their development: * Trauma: some cases develop at the site of a recent minor injury, such as a pinprick. * Infection: Staphylococcus aureus is frequently present in the lesion * Hormonal influences: they occur in up to 5% of pregnancies and are rarely associated with oral contraceptives. * Drug-induced; multiple lesions sometimes develop in patients on systemic retinoids (acitretin or isotretinoin) or protease inhibitors * Viral infection is possible but not proven * Underlying microscopic blood vessel malformations **Management** They are usually removed surgically. Histology is essential to confirm the diagnosis, and to rule out a form of skin cancer such as amelanotic (non-pigmented) melanoma. A lobular collection of blood vessels within inflamed tissue is typical of pyogenic granuloma.

Answer 96

Dermatofibroma Benign so removal for cosmesis is only treatment

Answer 97

Dermatitis herpetiformis usually presents in young adults in the third or fourth decade of life and is twice as common in males as in females. Most patients have a gluten enteropathy, as in coeliac disease. Dermatitis herpetiformis is an ‘immunobullous’ condition, which means it is a blistering condition caused by an abnormal immunological reaction. Like other forms of coeliac disease, it involves IgA antibodies and intolerance to the gliaden fraction of gluten found in wheat, rye and barley.

Answer 98

Actinic keratoses alternatively known as solar keratoses, are pre-malignant skin lesions. They are seen on sun-exposed sites and are most common in those with fair skin. They appear as multiple flat or thickened, scaly or warty, skin coloured or reddened lesions. A keratosis may develop into a cutaneous horn. Management = cryotherapy, 5-Fluorouracil cream or excision

Answer 99

This man has otosclerosis. He has a progressive conductive deafness due to fixation of the stapes in the oval window. It is inherited as a Mendelian dominant and is cured by an operation called stapedectomy.

Answer 100

Pericardial rub Acute rheumatic fever is a post-infective condition caused by pathogenic antibodies. Susceptible patients produce antibodies that cross-react with cardiac tissue 2-4 weeks after pharyngeal infection with Lancefield group A beta-haemolytic streptococcus. The effect is a systemic inflammatory condition including pancarditis (pericarditis, myocarditis and endocarditis), arthritis and intra-dermal inflammation. The pancarditis causes a sustained tachycardia that is particularly prominent at night with loss of normal nocturnal bradycardia and sinus arrhythmia. Conduction abnormalities, including prolonged PR interval, are reported and are included in the diagnostic criteria. Pericarditis may be found clinically with a pericardial rub. In addition patients may have features typical of congestive cardiac failure, including cardiomegaly. Several murmurs are recognised: * Aortic regurgitation causing an early diastolic murmur best heard at the left sternal border in expiration with the patient leaning forward * Mitral regurgitation causing a pansystolic murmur best heard at the apex in expiration radiating into the axilla * The Carey Coombs murmur, which is a mid-diastolic murmur best heard at the apex. This is not due to mitral stenosis but endocarditis of the mitral valves causes thickening and turbulent blood flow that produces the murmur.

Answer 101

This woman is showing symptoms of candidiasis. She has a high BMI and polyuria indicating that she may suffer with diabetes which puts a person at a greater risk of developing infection with Candida albicans.

Answer 102

**Gardnerella infection** This woman is suffering with a condition known as bacterial vaginosis. The exact cause is unknown but typically a bacterial imbalance causes the symptoms. The epithelial cells covered by bacteria are known as 'clue cells' and are diagnostic when seen on microscopy. Metronidazole is the treatment of choice.

Answer 103

Keratoacanthomas are benign lesions that are often mistaken for BCC/SCC. They occur as a result of hyperplasia of hair follicles and are most common in sun exposed areas. They tend to regress spontaneously over a period of six to 12 months without the need for any treatment.However,some experts consider them to be a variant of SCC,so they are often excised as thy cannot be reliably distinguished clinically. Keratoacanthomas should be treated for several reasons. * To obtain pathology: keratoacanthoma can be difficult to distinguish from invasive squamous cell carcinoma. * To be rid of an unsightly, tender or worrisome lesion * To minimise the scar, which can be more unsightly if the lesion resolves on its own. Treatment requires destruction of the lesion. Options include: * Cryotherapy * Curettage and cautery or another form of electrosurgery * Excision * Radiotherapy

Answer 104

What is the colonoscopists adenoma detection rate? This varies wildly and you want it to be as high as possible. Be happy with more than 35%

Answer 105

**PITYRIASIS VERSICOLOR** Common yeast infection of the skin caused by Malassezia Overgrowth of normal skin flora Usually young adults, men more than women and/or those who perspire heavily Not infectious Mildly itchy Clear in winter, recur in summer **Treatment** Topical antifungal cream/shampoo (e.g. Pevaryl®) + minimise sweat

Answer 106

**SEBORRHEIC DERMATITIS** * Chronic or relapsing form of eczema that affects scalp/face * Children – cradle cap * Adults – dandruff * Associated with proliferation of commensal Malassezia yeast * Clinical features * Ill-defined localised scaly patches or diffuse scale in the scalp * Salmon-pink, thin, scaly and ill- defined plaques on the face (including nasolabial folds) * Minimal itch * **Treatment** Keratolytics (e.g. salicylic acid), topical anti-fungals (e.g. Pevaryl®)

Answer 107

**ERYTHEMA MULTIFORME** * Hypersensitivity reaction triggered by infection * 80% HSV but also M. pneumoniae * Clinical features * Eruption within 24 hour period * Target lesions with central darkening * Start on hands and feet – spread along limbs towards trunk * Mucous membrane involvement 2-4 days later (if present) **Mx** Rash settles within weeks without Cx Oral aciclovir (HSV) Symptomatic – antihistamines, mouth wash for mucosal lesions, etc.

Answer 108

**Bowen's Disease --\> Intra-epidermal SCC (‘in situ’)** _Clinical features_ Irregular, flat, red and scaly patch/plaque Commonly sun-exposed areas _Mx_ Cryotherapy Shave or curettage 5-fluorouracil (Efudix®) Topical imiquimod (Aldara®) PDT (photodynamic therapy)

Answer 109

**Keratocanthoma** Arises from hair follicle skin cells for unknown reasons **Clinical features** Rapidly growing eruption for a few months Then shrinks and resolves itself **Mx** Self-resolves Can shave if bothering/cosmetic

Answer 110

* Pain? * Discharge? * Floaters/flashes? * Redness? * Trauma? * Abnormalities of eyelids/orbit? * Contact lenses? * Glare/dazzle night driving * Double vision?

Answer 111

* A family history of the eye condition * Diabetes * An injury to the eye * Exposed their eyes to sunlight without protection over a long period * Smoked for a period of time

Answer 112

* General * mental state * central adiposity or LOW * Vitals * check for postural drop of autonomic neuropathy * Legs * Inspection * Hair loss * Skin atrophy * Ulcers * Superficial skin infections * Necrobiosis lidoidica diabeticorum * Chacot's foot or knee * Bunions/lateral deviation of MTP joints * Proximal muscle wasting * Palpation * Temperature * Pulses * Femoral bruit * Glove and stocking sensation with microfilament * Loss of tone/power * Arms * Superficial skin infection * Tendon xanthomata * Acanthosis nigricans in the armpits, back of neck * Eyes * H test -\> look for CN III opthalmoplegia * Fundoscopy (non-proliferative or proliferative diabetic retinopathy) * Neck * Carotid artery bruits * Acanthosis nigricans * Abdomen * Hepatomegaly from fatty infiltration * Injection sites * Full cardiac exam * Urine dipstick * Random BGL

Answer 113

Peripheral (dihydropyradine) calcium channel blocker

Answer 114

Vit B12 deficiency

Answer 115

The angiotensin-converting enzyme (ACE) test is primarily ordered to help diagnose and monitor sarcoidosis. It is often ordered as part of an investigation into the cause of a group of troubling chronic symptoms that are possibly due to sarcoidosis.

Answer 116

Sertaline/SSRIs

Answer 117

Frieberg's osteochondrosis ## Footnote **Epidemiology** It is commoner in women aged 10-18 (male to female ratio of 1:3). **Aetiology** Physical stress causes repeated microfractures where the middle of the metatarsal meets the growth plate. These restrict circulation to the end of the metatarsal, causing the necrosis. It is an uncommon condition, occurring most often in young women, athletes, and those with abnormally long metatarsals. **Clinical presentation** Clinically they present with pain (sometimes a painful limp), swelling and tenderness. **Management** Initial treatment is generally 4-6 weeks of limited activity, often with crutches or orthotics. In rare cases, surgery is necessary to reduce the bone mass of the metatarsal.

Answer 118

Köhler bone disease is an osteochondrosis of the navicular bone in the foot. Mid-foot pain and a limp are the most common presenting symptoms. There is point tenderness over the navicular bone on examination. Patients often present between two and eight years of age, and boys are three to five times more likely to be affected. The etiology is unknown, and there is usually no history of previous trauma. The diagnosis is mainly clinical; however, plain radiographs usually demonstrate navicular sclerosis, flattening, and fragmentation. It is a self-limited condition and symptoms will eventually resolve.

Answer 119

A self-limiting skeletal disorder of childhood. It is also known as Scheuermann's kyphosis (since it results in kyphosis). Scheuermann's disease describes a condition where the vertebrae grow unevenly with respect to the sagittal plane; that is, the posterior angle is often greater than the anterior. This uneven growth results in the signature "wedging" shape of the vertebrae, causing kyphosis.

Answer 120

**Sesamoiditis** Sesamoiditis is a common ailment of the plantar forefoot, causing pain in the ball of the foot specifically under the big toe joint. The sesamoid bones are very small bones which are located under the big toe joint within the tendons that run to the big toe. They are similar to the knee cap, acting to increase the leverage of the tendons that control the big toe. Due to their location and function they are subjected to massive pressure and forces every time the big toe is used to push the foot forward. Treatment is conservative

Answer 121

Metatarsalgia is a broad term often used by health practitioners to describe pain and inflammation experienced in the forefoot. **Symptoms** This may often include inflammation of the capsule surrounding one or more of the joints in the ball of the foot (capsulitis) or inflammation of the lubricating fluid within the joint or tendons surrounding the joints (synovitis/bursitis). Symptoms may range from a full or inflamed feeling , a bruised tenderness or a burning or throbbing feeling around the bony part of the ball of the foot. **Management is conservative**

Answer 122

**Iritis (anterior uveitis)** ## Footnote Topical steroid drops reduce the inflammation --\> requires urgent referral! Topical **cyclopentolate** drops dilate the pupil and break down posterior synechiae --\> Dilating the pupil also relieves the pain associated with ciliary spasm **How else can it present?** Iris can adhere to the anterior surface of the lens (posterior synechiae) giving an irregular shaped pupil

Answer 123

**Corneal ulcer** Treated with intensive topical antibiotics, ciprofloxacin Stop use of contacts until ulcer has been healed for at least 2/52 REFER!

Answer 124

olopatadine eye drops This is a topical antihistamine

Answer 125

Pilocarpine --\> parasympathomimetic --\> meiosis Latanoprost --\> prostaglandin analogue Timoptol --\> topical eye drop beta blocker

Answer 126

* Assess current smoking * amount per day * how many years * Assess motivation and nicotine dependence * How soon after waking do you smoke? * Do you want to quit? If so, when? Now? In 6 months? * Have you tried to quit before? Why did it fail? * Do you get cravings/withdrawal symptoms if you don't smoke? * Benefits of quitting * 11mins of life for every cigarrete * Feel better * Less coughing/wheezing/infections * Strong immune system * Reduced risk of cancer, heart disease, strokes, lung cancer * SAVE MONEY * Risks of continuing * Lung function decline * COPD * Lung cancer * Heart disease, strokes etc * Set a date * Refer to QUIT line * What will be the barriers/challenges for you? How can we address them? * Patches, verenacline (champix), bupropion (zyban) * Follow up a week after quit date

Answer 127

**5Ds** **Dementia** * Frontrotemporal dementia * Lewy-Body Dementia * Alzheimer’s disease * Parksinon’s related * Alcohol related * Vascular dementia **Depression** **Delirium** **Diseases (Parkinson’s / Huntington’s)** **Disguises (reversible causes of reduced congition).** * brain tumor * sub dural haemorrhage * normal pressure hydrocephalus

Answer 128

* FBE * UEC / CMP * LFT * BGL * TFTs * B12 and folate levels * Syphillis serology * CXR * CTB / MRI brain * Geriatric Depression Scale

Answer 129

Malaria Dengue Typhoid Hepatitis A Pneumonia Gastro HIV STI

Answer 130

**AIRWISE BAT** A – Activities? (adventure, sports, surgery) I – Immunisations and malaria prophylaxis? R – Rural/jungle visit? W – Water (drinking and swimming) I – IVDU S – Sex E – What did you **eat**, street food or hotel? B – bites and stings A – Accomodation (luxury/backpacker) T – Tattoos/piercings Check for respiratory, GIT, urinary, neuro symptoms

Answer 131

Bedside BGL, urine dipstick Bloods and urine FBE, UEC, LFTs, Coags Blood film Thick and thin films Blood cultures Serology for: * Hep A, B, C * Dengue * HIV ELISA Urine MCS Stool MCS Imaging CXR (Dengue haemorrhagic fever)

Answer 132

* How many cigs per day? * How many years? * How long after you wake up do you smoke? * How do you feel about becoming a non-smoker? * Previous quitting attempts? * Is your partner a smoker / non smoker / trying to quit? * Do you get any symptoms if you go longer than usual between cigs? * Do you smoke out of habit (stress, triggers) or dependence (withdrawal symptoms) or both?

Answer 133

Varenicline (Champix) Nicotinic receptor partial agonist Nausea is the most common side effect There is concern about neuropsychiatric adverse effects and people taking varenicline should be monitored for unusual mood changes, depression, behaviour disturbance and suicidal thoughts.

Answer 134

**MONEY can’t buy MEDALS or the independence of DRIVING** Money – Finances, can they pay bills, manage their money? M – Mobility and falls assessment E – Eating, can they buy food, cook it and eat it? D – Danger – leave oven on, forget to turn on the cold water? A – Aggressive when they get confused or hallucinate? L – Lost (walking, supermarket, disoriented within home) S – Sexual disinhibition? Driving – Driving okay? Check whether they remember the road rules, get lost or confused