General Practice/Public Health Flashcards
On a routine health exam, a 40-year-old woman is found to have hypercholesterolemia. She mentions that her older sister has hypertension. Which one of the following suggests a familial cause for her hypercholesterolemia?
A. Tendon xanthomas.
B. Xanthelasma of the eye.
C. The family history of hypertension.
D. Age of the patient.
E. The presence of corneal arcus.
A. Tendon xanthomas
Familial hypercholesterolemia (FH) is an autosomal-dominant inherited condition characterized by a genetic defect in one of several genes affecting receptor-mediated uptake of low-density lipoprotein (LDL). Affected individuals present with characteristic metabolic and clinical features including high cholesterol levels and increased risk of premature cardiovascular disease.
Clinical features of FH are: -Premature cardiovascular disease (CVD) -Aortic stenosis -Tendon xanthomas (11%) -Corneal arcus (27%) -Xanthelasmas (12%)
There are many other potential causes of premature CVD and aortic stenosis. Likewise, corneal arcus and xanthelasma are non-specific signs, but tendon xanthomas, which may gradually develop in Achilles’ tendons and extensor tendons of the dorsum of the hand, are pathognomonic for FH. However, they are rarely identifiable before adulthood.
Corneal arcus in a young adult is suggestive of FH, but not pathognomonic.
- See picture of achilles tendon xanthoma, xanthelasma, corneal arcus below -
- RACGP - AJGP- Familial hypercholesterolaemia: A guide for general practice
A 52-year-old man presents to your clinic, seeking advice on screening for colon cancer. Although he has no gastrointestinal symptoms, he is concerned because his younger brother has been recently diagnosed with colon cancer at the age of 50 years. There is no other family history of colorectal cancer. Which one of the following is the most appropriate advice regarding current and future management?
A. He should have a fecal occult blood test (FOBT) now.
B. No screening procedure is required now.
C. Colonoscopy should be performed now, and if normal, no further testing is required.
D. Colonoscopy should be performed now and yearly thereafter.
E. Colonoscopy should be performed now and 5-yearly thereafter.
E. Colonoscopy should be performed now and 5-yearly thereafter.
Colorectal cancer (CRC) screening methods and intervals depend on the individual’s risk category. Based on the risk of developing CRC, the population is classified in four categories:
- See table below
This patient is asymptomatic, but has a brother (first-degree relative) diagnosed with CRC at the age of 50 years (< 55 years).
Therefore, he should be placed in category 2. People in category 2 should be offered iFOBT every two years fron the age of 40 to 50 years and colonoscopy everu five years from 50 to 74 years of age. Since he is 52 years now, colonoscopy now and then every five years afterwards is the most appropriate option.
Sarah, whose husband has a plasma cholesterol of 6.4 mmol/L (normal < 5.5mmol/l), wants to know which cooking oil she should use when she cooks. Which one of the following would you advise?
A. There is not much difference between cooking oils.
B. Any margarine is suitable.
C. An oil rich in saturated fat rather than those rich in unsaturated fats.
D. She should use either canola or sunflower oil.
E. None of the above.
D. She should use either canola or sunflower oil.
Epidemiological studies have shown reduced mortality from cardiovascular causes if diets containing increased levels of mono- and polyunsaturated fatty acids are used. Canola oil and olive oil have a high concentration of monounsaturated fatty acids, while sunflower oil is rich in polyunsaturated fatty acids. Both canola and sunflower oil are appropriate dietary oils for Sarah’s husband.
For lowering the plasma cholesterol levels, the National Heart Foundation of Australia recommends that saturated fat (option C) in the diet be replaced with a combination of mono- and polyUNsaturated fats.
Cholesterol content of foods does increases LDL cholesterol. LDL cholesterol is directly related to the amount of saturated and trans fat contents of dietary intake.
A 42-year-old olive-skinned man comes to your GP practice because he is concerned about contacting melanoma after he watched a TV program about it. He has no family history of melanoma or other skin cancers. On examination, there is no abnormal finding. You reassure him but he says that he will come back to you if he finds anything unusual. Which one of the following will you recommend instead for follow-up?
A. Follow-up every six months.
B. Follow-up every two years.
C. Follow-up every five years.
D. Start him on regular medication.
E. Follow-up every 12 months.
C. Follow-up every five years.
Australia has the highest incidence of skin cancer in the world. Current clinical guidelines DO NOT recommend systemic skin cancer screening, but in clinical practice many general practitioners do provide skin checks for their patients.
A ‘skin-check’ can be defined as a comprehensive assessment of any asymptomatic patient for any evidence of skin cancer. Current Australian guidelines advise against general population screening for skin cancer, based on lack of evidence that justifies organized screening as an effective method to reduce mortality. Patient self examination with opportunistic screening is the current standard.
One’s risk of contracting skin cancer is classified as ‘high-risk’, ‘intermediate risk’, or ‘low risk’ according to the following table: - See table below -
Recommendations for skin check are as follows: * High-risk: 3-monthly self examination and 12 monthly skin check with doctor * Medium-risk: 3- to 6-monthly self examination and 2- to 5-yearly skin check with doctor * Low-risk: 12-monthly self examination and check with doctor for assessment of risk and advice regarding skin care
With olive-colored skin, this man has a skin type of IV to V. Considering the additional fact that he has no family history of skin cancer, he is low-risk for developing skin cancer. The recommendations for this patient are annual self examination and one-shot check with doctor. However, he has not been fully reassured despite your efforts. For this reason and for putting his mind at ease 5-yearly check – up can be offered.
TOPIC REVIEW
The Fitzpatrick Skin Type is a skin classification system that classifies skin types based on a scoring system
A 37-year-old computer software engineer man comes to you because he is concerned about developing malignant melanoma. His concerned arose when his father was diagnoses with melanoma eight months ago. He does not drink alcohol nor does he smoke. On examination, only multiple benign nevi are noted. Which one of the following would be the most appropriate management of this patient?
A. Excision of his benign nevi.
B. Refer him to a dermatologist.
C. Review him in 12 months.
D. Reassure him.
E. Review him in 2-5 years.
C. Review him in 12 months.
Australia has the highest incidence of skin cancer in the world. Current clinical guidelines do not recommend systemic skin cancer screening, but, in clinical practice many general practitioners do provide skin checks for their patients.
A ‘skin-check’ can be defined as a comprehensive assessment of any asymptomatic patient for any evidence of skin cancer. Current Australian guidelines advise against general population screening for skin cancer, based on lack of evidence to justy organized screening as an effective method to reduce mortality. Patient self-examination with opportunistic screening is the current standard.
One’s risk of contracting skin cancer is classified as ‘high-risk’, ‘intermediate risk’, or ‘low risk’ according to the following table: - See table below -
Recommendations for skin check are as follows: * High-risk: 3-monthly self examination and 12 monthly skin check with doctor * Medium-risk: 3- to 6-monthly self examination and 2- to 5-yearly skin check with doctor * Low-risk: 12-monthly self examination and check with doctor for assessment of risk and advice regarding skin care
With the father being diagnosed with melanoma, this man is categorised as ‘high-risk’ for skin cancers. It is recommended that high-risk people have 3-6 monthly self examination and check up with doctor every 12 months.
(Option A) Removing simple nevi to prevent melanoma is not recommended, because melanoma often arise de novo from other sites other than the nevi.
(Option B) Referring the patient to a dermatologist is not necessary at this stage because the patient is asymptomatic now.
(Option D) Reassuring the patient is not appropriate because he is high risk for melanoma.
(Option E) Check up with doctor every 2-5 years would be the option if this man was categorised as medium risk.
You are giving a lecture in a primary school regarding skin cancer awareness. Which one of the following is the most appropriate advice you should emphasize on?
A. Using sunscreens in the morning.
B. Avoiding or lessening sun-exposure between 10am and 4pm.
C. Annual skin checks and screening.
D. Excision of moles.
E. Avoiding sun-exposure.
B. Avoiding or lessening sun-exposure between 10am and 4pm.
Australia has the highest rate of skin cancers in the world. Protective measures help reduce development of skin cancers. Of all known risk factors for skin cancer, sun-exposure is the most important MODIFIABLE one (not the most important one in general).
All people (especially children aged ≤ 10 years) should be advised to use protective measures when UV levels are 3 and above. UV level throughout the day depends on the season, but generally UV levels are highest between 10am and 4pm, the time during which protection against sun-exposure should be advised.
These measures include:
**Broad-brimmed, bucket or legionnaire-style hats
**Protective clothing
**Sunglasses
**Sunscreens with at least a sun protection factor (SPF) of (needs reapplication every 2 hours)
(Option A) Using sunscreens only in the morning is not because sunscreens are required to be reapplied every 2 hours. UV level in the early hours of the morning is not expected to be that high compared to later hours such as noon and afternoon.
(Option C) Annual skin checks is advisable for those who are high risk for skin cancers, and is not recommended for general population.
(Option D) Excision of moles has not shown to be associated with decreased risk of skin cancers. Furthermore, melanomas have shown to often arise de novo (from areas of the skin with no pre-existing moles).
(Option E) Complete avoidance from sun-exposure results in vitamin D insufficiency and its complications, and is not recommended.
In a randomized controlled trial (RCT) conducted to study the effect of aspirin on prevention of coronary artery events among diabetic smokers, the results in the two arms of the study are as follows: - See table below -
Which one of the following is the relative risk of not using ASA?
A. 1%.
B. 2%.
C. 100%.
D. 200%.
E. 50%.
D. 200%.
D. 200%.
-
Relative Risk (RR):
- Measures the risk of an event occurring in an exposed group versus a non-exposed group.
-
Incidence Calculation:
- Exposed Group (Aspirin): 1 event out of 100 = 1%.
- Non-Exposed Group (Placebo): 2 events out of 100 = 2%.
-
Relative Risk Calculation:
- RR = Incidence in Exposed Group / Incidence in Non-Exposed Group
- RR = 1% / 2% = 0.5
-
Interpreting RR:
- RR of 0.5: Indicates that taking aspirin halves the risk of a coronary event.
- Risk Reduction: 50% less risk for those on aspirin.
- Increased Risk for Non-Exposed: Those not taking aspirin are twice as likely to have a coronary event compared to those taking it.
-
200% Increase:
- Explanation: If not taking aspirin, the risk is doubled (or 200% increased).
The concept of a 200% increase comes from understanding the relative risk (RR) and translating it into a percentage increase.
-
Relative Risk (RR):
- The RR calculated is 0.5. This means that the risk of developing a coronary event for those taking aspirin is half (50%) of the risk for those not taking aspirin.
-
Interpreting the RR:
- If RR = 0.5, it indicates that the risk is reduced by 50% for those taking aspirin compared to those not taking aspirin.
-
Inverse of the RR:
- To find out the increase in risk for those not taking aspirin, we take the inverse of 0.5:
[
\text{Inverse RR} = \frac{1}{0.5} = 2
] - This means that those not taking aspirin have twice the risk (or 2 times the risk) of having a coronary event compared to those taking aspirin.
- To find out the increase in risk for those not taking aspirin, we take the inverse of 0.5:
-
Translating to Percentage:
- Saying that the risk is twice as high can be expressed as a 100% increase. However, since it’s twice (2 times), it’s actually a 200% increase.
- Mathematically:
[
\text{Percentage Increase} = (2 - 1) \times 100\% = 100\% \times 2 = 200\%
]
- 200% increase means that the risk of a coronary event for those not taking aspirin is three times (300%) the risk for those taking aspirin, but specifically, it’s a 200% increase relative to the baseline risk (100%).
Not taking aspirin leads to a 200% increased risk of a coronary event compared to taking aspirin.
In statistics and epidemiology, relative risk or risk ratio (RR is the ratio of the probability of an event occurring in an exposed group to the probability of the event occurring in a non-exposed, comparison group.
Of 100 diabetic smokers who are on aspirin, 1 person has developed a coronary event. So the incidence of coronary event in this group is 1% [1/(1+99)x100], while the incidence of coronary events in the group taking placebo instead of aspirin is 2% [2/(2+98)x100].
In this scenario the exposure is taking aspirin. Exposed group has a 1% chance of developing a coronary event versus 2% in those who do not take aspirin.
The RR is then calculated by dividing the odds of the condition in the exposed group (1%) by that of the non-exposed group:
RR= P(exposed) / P(non-exposed) : RR=1% / 2%=0.5
Here, the RR indicates that the odds of developing a coronary event in those diabetic smokers who are on aspirin is half compared to those on placebo. In other words, those who are on aspirin has a 50% risk reduction. Inversely, those who are not taking aspirin are twice as likely to develop a coronary event compared to those who are taking it. So the RR. This means that not taking aspirin is associated with a 200% increase in incidence of coronary events.
A 67-year-old woman presents for receiving her annual influenza vaccination. She also mentions that her daughter is going to have a baby in 2 months and asks if she should receive other vaccines that may help. Which one of the following vaccines will you advise?
A. Pneumococcal vaccine.
B. Varicella vaccine.
C. Hepatitis B vaccine.
D. DPT vaccine.
E. Hemophilus influenza vaccine.
D. DPT vaccine.
According to vaccination national program every child should be vaccinated against pertussis (whooping cough infection at ages 6 weeks, 4 months and 6 months.
The mother, the father and other adults in close contact with young babies can be the source of whooping cough infection in children who are still too young to be vaccinated. For this reason, they should seek advice from their GPs about the benefits of getting an adult pertussis-containing vaccine.
Vaccination against whooping cough (pertussis) is strongly recommended for adults in contact with children too young to be vaccinated. These people should be vaccinated before or as early as possible after the birth of the baby if they have not had a pertussis vaccine in the past 10 years.
Pneumococcal was indicated for this woman for her own sake, and not the baby’s, if she was older than 65.
You are going to give a lecture about obesity and body mass index (BMI). Which one of the following is the most appropriate advice?
A. BMI alone is the best way to estimate obesity.
B. BMI gives false estimates in elderly people because of a fatty abdomen.
C. Waist circumference is the best way to estimate obesity.
D. BMI in conjunction with waist circumference is the best way to estimate obesity.
E. BMI alone is the best predictor of cardiovascular risk.
D. BMI in conjunction with waist circumference is the best way to estimate obesity.
An adult’s BMI can be compared to thresholds to define whether a person is underweight, of healthy weight, overweight or obese based on the WHO classifications.
BMI is calculated by dividing weight in kilograms by the square of height in meters.
WHO classification is shown in the following table: -See table below-
Individuals with the same BMI may have different ratios of body fat to lean mass. People with high muscle mass (e.g. athletes) may have a lower proportion of body fat than less muscular people, so a higher BMI threshold must be considered.
Women have more body fat than men with equal BMIs. People lose lean tissue with age, so an older person will have more body fat than a younger one at the same BMI.
This fact necessitates waist circumference as an additional factor. Waist circumference is a good indicator of total body fat and is also a useful predictor of visceral fat. Compared to BMI, waist circumference is a better predictor of cardiovascular risk and type 2 diabetes (in women, but not in men).
The best method for estimation of obesity in adults is a combination of BMI and waist circumference. The latter takes into account fat distribution, and in combination with BMI, gives a more accurate benchmark for obesity. Alhtough this combination is useful for determining the cardiovacular risk due to obesity, the most accurate measure for prediction of cardiovascular risk and ischmeic heart disease is ‘waist to hip ratio’ (not an option here).
(Option A) BMI alone is never the best predictor of cardiovascular risk in adults.
(Option B) BMI gives false negative results in older people due to decreased total lean mass, not only the abdomen. Even in an elderly with a flat abdomen, BMI may not be accurate due to the fact the most of their weight is comprised of fat rather than lean mass.
(Option C) Waist circumference alone is not accurate and should not be interpreted as an indicator of cardiovascular risk.
(Option E) BMI is not a predictor of cardiovascular risk an as mentioned earlier, may not be an accurate tool for estimation of obesity in certain groups such as muscular athletes, the elderly, etc
A 49-year-old male, commercial truck driver by profession, presents with left-sided chest pain radiating to his left arm and jaw. Electrocardiography shows ST segment elevation myocardial infarction (STEMI). Thrombolysis is done with tenecteplase, which resulted in resolution of symptoms. Which one of the following would be the best advice regarding driving?
A. He can drive a private car after four weeks.
B. He can drive his commercial truck after four weeks.
C. There is no driving restriction.
D. He can never drive his truck.
E. He should drive carefully and avoid driving on main highways.
B. He can drive his commercial truck after four weeks.
Following an acute myocardial infarction, the patient cannot drive private vehicles for two weeks and commercial vehicles for four weeks.
TOPIC REVIEW
There are several conditions or procedures which lead to reduced ability to drive. Under these circumstances, the treating physician should give appropriate advice regarding driving. It is the patients’ duty (not the treating physician) to inform the Road Safety Department about their condition. Failing to do so will lead to prosecution. The most commonly encountered medical problems/procedures that may be faced and the consequent driving limitations, including non-driving periods, are listed in the following table.
A 65-year-old man presented to the emergency department with complaint of chest pain that turned out to be of cardiac origin. Electrocardiographic changes were consistent with inferior ST elevation myocardial infarction (STEMI). He underwent coronary artery bypass graft the next day. He is a commercial driver and on discharge wants to know if he can continue driving. Which one of the following would be the most appropriate advice?
A. He can drive private and commercial vehicles as long as he feels fine.
B. He should write a letter to road safety department.
C. No commercial driving for four weeks.
D. No commercial driving for three months
E. He can never drive commercial vehicles, but he can drive private vehicles after three months
D. No commercial driving for three months
After coronary artery bypass grafting, one should not drive private vehicles for at least four weeks and commercial vehicles for three months.
(Longer wait compared to acute MI without CABG)
TOPIC REVIEW
There are several conditions or procedures which lead to reduced ability to drive. Under these circumstances, the treating physician should give appropriate advice regarding driving. It is the patients’ duty (not the treating physician) to inform the Road Safety Department about their condition. Failing to do so will lead to prosecution. The most commonly encountered medical problems/procedures that may be faced and the consequent driving limitations, including non-driving periods, are listed in the following table:
ST’s Summary: CABG, vascular repairs (aneurysm, valvular repair), syncope, stroke > can’t drive private car for 1 month, commercial cars for 3 months!
A 65-year-old was found to have an abdominal aortic aneurysm. The aneurysm was repaired by a vascular surgeon, and the patient was transferred to the Intensive Care Unit (ICU) where he stayed for 24 hours. The recovery period was uneventful. The patient is now ready to be discharged, and wants to know whether he can drive his private car. Which one of the following is the most appropriate advice regarding driving?
A. He is unfit to drive for six months post-repair.
B. He is unfit to drive for six months as he has been in intensive care unit.
C. He can drive after he spends a week at home without any symptoms.
D. After his general practitioner considers him fit to drive.
E. He is unfit to drive for four weeks.
E. He is unfit to drive for four weeks.
After repair of an aortic aneurysm or cardiac valvular repair, one is unfit to drive their private motor vehicles for at least four weeks. This extends to three months for commercial vehicles. They can then have their unconditional driving license again.
ICU admission for 24 hours is a normal routine after some surgeries and does not pose any restriction on driving by itself.
Referral to general practitioner is not the correct answer as the patient should be informed of the restrictions upon discharge. The patient may plan to visit his general practitioner in a week and without knowing about his driving limitations.
ST’s Summary: CABG, vascular repairs (aneurysm, valvular repair), syncope, stroke > can’t drive private car for 1 month, commercial cars for 3 months!
You are counselling a patient who is concerned about the cholesterol content of foods. Which one of the following foods contains the most cholesterol content?
A. Yoghurt.
B. Avocado.
C. Coconut oil.
D. Peanut butter.
E. Canola.
A. Yoghurt.
Cholesterol is only found in animal products such as meat, poultry, fish, dairy products and egg. Although vegetable products have different levels of fat, they do not contain cholesterol. Of the given options, only yoghurt (a dairy product) contains cholesterol.
A 45-year-old man presents to the emergency department with a self-limiting episode of seizure. He is known to have epilepsy which has been well-controlled with carbamazepine for the last 12 months. Full investigations including blood tests and CT scan of the head reveals no apparent cause for the seizure. The patient is keen to know about the driving restriction. Which one of the following is the appropriate advice regarding driving?
A. He cannot drive for 4 weeks.
B. He cannot drive for 3 months.
C. He cannot drive for 6 months.
D. He cannot drive for 12 months.
E. He cannot drive for 3 years.
B. He cannot drive for 3 months.
If one develops an episode of seizure after at least 12 months of being well-controlled by antiepileptic drugs, they cannot drive for 4 weeks if a provocative factor (sleep deprivation, alcohol, electrolyte abnormality, CNS lesion, etc) can be identified, and for 3 months if no cause is found.
The patient then may be eligible to hold a conditional driving license provided that the patient does not experience another attack during the mentioned periods.
A 65-year-old commercial driver sustained stroke and presented with left hemiparesis and left homonyms hemianopia. He is now making a good recovery. Which of the following is most appropriate step regarding driving?
A. Permanent restriction of driving.
B. Driving assessment supervised by an occupational therapist.
C. He should not drive for two weeks.
D. Refer him to a neurologist to decide about fitness to drive.
E. He can continue driving.
B. Driving assessment supervised by an occupational therapist.
Cerebrovascular events (e.g. stroke, TIA) make the patient unfit to drive non-commercial vehicles for at least four weeks. Once there is no residual deficit and the risk of recurrence is minimized by appropriate measures such as prophylactic anticoagulation, the patient should be assessed by an occupational therapist (or any other relevant consultants such as ophthalmologist, neurologist, etc. depending on the residual defects) for evaluation of fitness to drive.
There are a wide range of practical assessments available, including off-road, on-road and driving simulator assessments, each with strengths and limitations. Assessments may be conducted by occupational therapists trained in driver assessment
or by others approved by the particular driver licensing authority. Processes for initiating and conducting driver assessments vary between the states and territories and choice of assessment depends on resource availability, logistics, cost and individual requirements. The assessments may also be initiated by the examining health professional, other referrers (e.g. police, self, family) or by the driver licensing authority.
In this case, improvement should be assessed by an occupational therapist and ophthalmologist. Any further process regarding driving private or commercial depends on expert opinions from these disciplines.
A 39-year-old woman presents with second episode of seizure within one week. An EEG confirms the diagnosis of epilepsy. She is started on carbamazepine. She asks you when she can drive again. Which one of the following would be the correct answer?
A. Six months.
B. Four weeks.
C. She cannot drive as long as she is on carbamazepine.
D. She can drive as long as she is on carbamazepine.
E. She cannot drive for five years.
A. Six months.
If a patient is diagnosed with epilepsy for the first time, a conditional license may be considered by the driver licensing authority subject to at least annual review, taking into account information provided by the treating doctor as to whether the following criteria are met:
- The patient has been treated for at least six months
- There have been no seizures in the preceding six months
- If any seizures occurred after the start of treatment, they happened only in the first six months after starting treatment and not in the last six months
- The person follows medical advice, including adherence to medication
For this patient, who has been diagnosed with epilepsy for the first time, a limitation of six months and she cannot drive non-commercial vehicles during this period.
When treatment with an anti-epileptic drug is started in a previously untreated person, sufficient time should pass to establish that the drug is effective before driving is recommenced. However, effectiveness cannot be established until the person reaches an appropriate dose.
For example, if a drug is being gradually introduced over three weeks and a seizure occurs in the second week, it would be premature to consider the drug ineffective. The standard allows seizures to occur within the first six months after starting treatment without lengthening the required period of seizure freedom. However, if seizures occur more than six months after starting therapy, a longer seizure-free period is required. For commercial drivers, the default standard applies.
Example: if a patient has a seizure three months after starting therapy, they may be fit to drive six months after the most recent seizure (nine months after starting therapy). However, if a person experiences a seizure 8 months after starting therapy, the default standard applies and they may not be fit to drive until 12 months after the most recent seizure.
A 37-year-old epileptic man seeks advice regarding driving. He was diagnosed with epilepsy five years ago and was started on carbamazepine; however, he experienced intermittent seizures despite treatment. Three months ago, carbamazepine was switched to phenytoin. He has not had any seizures since then. Which one of the following would be the most appropriate advice regarding driving a non-commercial vehicle?
A. He cannot drive for three months.
B. He cannot drive for six months.
C. He cannot drive for one year.
D. He cannot drive for two years.
E. He can never drive.
C. He cannot drive for one year.
All patients with seizures and epilepsy should avoid driving non-commercial vehicles for 12 months and commercial vehicles for 10 years as default standards.
NOTE - There are circumstances under which these periods may be subject to reduction. Some of these circumstances are listed in the following table
This patient does not fulfill any of the above criteria to be subject to an exception to the general rules; therefore, he should not drive a non-commercial vehicle for at least 12 months after his last seizure, provided that no seizures occurred during the preceding 12 months.
A 23-year-old woman presents for advice regarding driving after a first-time generalised seizure. She had episodes of sudden spasms and twitching of muscles in the past few years. Which one of the following would be the most appropriate advice regarding driving a non-commercial vehicle?
A. No driving for six months.
B. No driving for three months.
C. No driving for one month.
D. She cannot drive anymore.
E. No driving for 12 months
A. No driving for six months.
All patients with seizures and epilepsy should avoid driving non-commercial vehicles for 12 months and commercial vehicles for 10 years as per default standards for patients with seziure. However, there are circumstances under which theseperiods may be subject to reduction.
These circumstances are listet in the following table: -see table below
Those who experience first-time seizure are exceptions to the general rule. They should not drive non- commercial vehicles for six months and commercial vehicles for five years. Thereafter, a conditional driving license for non-commercial vehicles may be considered by driving authority subject to at least annual review, if there has been no seizures (with or without treatment for at least six months).
A 42-year-old epileptic man, who had intermittent seizures despite being on treatment with sodium valproate, was switched to carbamazepine one month ago. Since starting the medication, there has been no seizure. Which one of the following would be the most appropriate advice regarding driving a non-commercial vehicles for him?
A. He can never drive.
B. He can drive after six months of seizure-free period.
C. He can only drive after 12 months of seizure-free period.
D. He can drive after 10 years of seizure-free period.
E. He can drive now.
C. He can only drive after 12 months of seizure-free period.
The scenario describes a case of chronic seizure. Generally, patients with seizures and epilepsy should not drive non-commercial vehicles for 12 months and commercial vehicles for 10 years as default standards after the last episode of their seizures, unless their condition is one of the exceptions for them different limitations is applied. These conditions are listed in the following table:
(Picture on page 1677)
This patient fulfills none of the above-mentioned condition; therefore, general rule applies for him: he should not drive non-commercial vehicles for 12 months.
An 85-year-old man presents to your clinic for annual check to renew his driver’s license. He has long-standing history of hypertension which is well-controlled on antihypertensive medications. Which one of the following is the investigation you should conduct before you issue a certificate?
A. Visual acuity.
B. Mini-mental status exam.
C. Blood sugar.
D. Cholesterol.
E. Liver function tests
A. Visual acuity.
Individuals, who have blood pressure consistently greater than 200 systolic or greater than 110 diastolic (treated or untreated), are not fit to hold an unconditional driving license for non-commercial vehicles. The threshold for commercial vehicles is 170 mmHg and 100 mmHg for systolic and diastolic blood pressure, respectively.
A conditional license may be considered by the driver licensing authority subject to periodic review, taking into account the nature of the driving task and information provided by the treating doctor as to whether the following criteria are met:
- Blood pressure is well controlled; AND
- There are no side effects from the medication that will impair safe driving; AND
- There is no evidence of damage to target organs relevant to driving.
As far as driving is concerned, eyes are the most important end-organ potentially affected by chronic hypertension. Those with hypertension are at risk of hypertensive retinopathy and impaired vision. For that reason, examining the visual acuity will be the most crucial investigation before a certificate is issued for driving license renewal in this patient.
Which one of the following is the best predictor of obesity and its associated risks?
A. Body mass index (BMI).
B. Waist circumference.
C. Mid arm circumference.
D. Waist-to-hip ratio.
E. BMI and waist circumference together.
D. Waist-to-hip ratio.
BMI is advocated by World Health Organization (WHO) as the epidemiological measure of obesity; nevertheless, BMI is a crude index that does not take into account the distribution of body fat, resulting in variability in different individuals and populations. For example, individuals with the same BMI may have different ratios of body fat to lean mass. A muscular athlete may have the same BMI of a less muscular person. Women have more body fat than men at equal BMIs and people lose lean tissue with age so an older person will have more body fat than a younger one with same BMI.
Waist circumference has been recommended as a simple and practical measure for indentifying overweight and obese patients, but it does not take into account body size and height.
Waist-to-hip ratio (WHR) has been suggested as the preferred measure of obesity for predicting cardiovascular disease, with more universal application in individuals and population groups of different body builds. This parameter reflects abdominal (central) fat which is strongly associated with ischemic heart disease, hypertension and type II diabetes mellitus. In terms of predicting obesity-related mortality, WHR is more reliable than BMI and waist circumference together. Waist circumference alone comes next and BMI alone last.
You are asked to give advice regarding breast cancer to a 37-year-old woman who has come to your clinic with concerns about the disease. Her mother was diagnosed with breast cancer at the age of 60 years. She is asymptomatic and her clinical examination is normal. Which one of the following is the next best step in management?
A. She should start mammography now and every two years until the age of 74 years.
B. She should start ultrasonography now and every two years until the age of 74 years.
C. She should perform six-monthly self-breast examination.
D. She should start mammography now and then yearly until the age of 74 years.
E. Reassure her.
E. Reassure her.
Woman with family history of breast cancer in one first-degree relative older than 50 years are considered to be at slightly elevated risk above the normal population for breast cancer. For these women, two-yearly screening mammography starting from the age of 50 is the currently recommended screening; therefore, reassurance for now would be the most appropriate action. This woman however, should be advised that she should start mammography from the age of 50 years.
In general population, breast cancer screening is aimed at asymptomatic women aged 50-69 years; however, all women between 40 and 74 are eligible to enter the program if they wish.
Mammography is not recommended for women younger than 40 years due to dense breast tissue. Other modalities such as ultrasound or MRI can be used as alternatives if indicated.
Risk Level:
- Slightly elevated risk: Family history of breast cancer in one first-degree relative older than 50 years.
Screening Recommendations:
- Age 50-69: Biennial (every two years) mammography screening is recommended.
- Age 40-74: Women can opt for screening if desired.
Younger Women:
- <40 years: Mammography is not recommended due to dense breast tissue. Ultrasound or MRI may be considered if indicated.
A 45-year-old woman with a family history of breast cancer in one first-degree relative older than 50 years.
-
What is the recommended action?
- A) Start annual mammography now
- B) Reassure and start biennial mammography at age 50
- C) Start annual MRI screening now
- D) Immediate ultrasound screening
- E) Genetic testing for BRCA mutation
- Why not A): Annual mammography is not necessary.
- Why not C): MRI is not routinely recommended without higher risk.
- Why not D): Ultrasound is not standard for screening.
- Why not E): Genetic testing is not indicated for slightly elevated risk.
A 42-year-old woman without any family history of breast cancer wants to know if she is eligible for screening.
-
What should you advise?
- A) She should wait until age 50
- B) She can opt for biennial mammography screening now
- C) She should start annual MRI screenings
- D) She needs immediate mammography screening
- E) She should get genetic testing for breast cancer
- Why not A): She is eligible to start now if she wishes.
- Why not C): MRI is not routine for the general population.
- Why not D): Immediate screening is not necessary without symptoms or high risk.
- Why not E): Genetic testing is not needed without a family history.
A 35-year-old woman with concerns about breast cancer.
-
What is the best screening modality for her?
- A) Mammography
- B) Ultrasound
- C) MRI
- D) No screening until 40
- E) Annual physical exam only
- Why not A): Mammography is not effective in women under 40 due to dense breast tissue.
- Why not C): MRI can be considered but is not the first-line screening tool.
- Why not D): She may need screening based on individual risk.
- Why not E): Additional imaging may be necessary beyond physical exams.
A 50-year-old woman with a family history of breast cancer in her mother diagnosed at 55.
-
What is the recommended screening frequency?
- A) Annual mammography
- B) Biennial mammography
- C) Annual MRI and mammography
- D) No screening needed
- E) Genetic testing only
- Why not A): Annual mammography is not necessary for slightly elevated risk.
- Why not C): MRI is not routinely indicated.
- Why not D): Screening is needed.
- Why not E): Genetic testing is not the primary recommendation.
A 35-year-old woman with a strong family history of breast cancer (mother and sister diagnosed before 50).
-
What is the appropriate screening recommendation?
- A) Annual mammography starting now
- B) Biennial mammography starting at age 50
- C) Annual MRI starting now
- D) Genetic counseling and possible testing
- E) No screening needed until symptoms appear
- Why not A): While annual screening may be needed, genetic counseling is the first step.
- Why not B): She is at higher risk and may need earlier screening.
- Why not C): MRI may be considered, but after genetic counseling.
- Why not E): Screening is necessary due to high risk.
A 45-year-old woman presents with a palpable breast lump and no prior history of breast cancer screening.
-
What is the most appropriate next step?
- A) Reassure and start biennial screening at 50
- B) Immediate mammography and ultrasound
- C) Wait 6 months and re-evaluate
- D) Annual MRI screening
- E) Genetic testing for BRCA mutation
- Why not A): Immediate action is needed due to symptoms.
- Why not C): Delaying evaluation is inappropriate.
- Why not D): MRI is not the first step for symptomatic evaluation.
- Why not E): Genetic testing is not the first step; imaging is required.
A 50-year-old woman with a BRCA1 mutation.
-
What is the recommended screening protocol for her?
- A) Biennial mammography only
- B) Annual mammography and MRI
- C) No screening needed until symptoms appear
- D) Monthly self-breast exams only
- E) Annual ultrasound only
- Why not A): Biennial screening is not sufficient for high-risk individuals.
- Why not C): Regular screening is crucial for early detection.
- Why not D): Self-breast exams are not enough.
- Why not E): MRI and mammography are preferred for high-risk screening.
A 52-year-old woman with no family history of breast cancer and normal previous mammograms wants to know if she can extend the interval between screenings.
-
What should you advise?
- A) Annual mammography
- B) Biennial mammography
- C) Extend screening interval to every 3 years
- D) No further screening needed
- E) Switch to MRI screening
- Why not A): Annual screening is not necessary for average risk.
- Why not C): Extending to every 3 years is not recommended.
- Why not D): Screening is still needed.
- Why not E): MRI is not indicated for average-risk screening.
Julian, 35 years old, presents to your office for breast cancer screening after she found out that one of her maternal aunts was diagnosed with breast and ovarian cancer at the age of 40 years. Which one of the following would be the most appropriate advice for her?
A. Two-yearly mammography.
B. Two-yearly ultrasound.
C. Genetic risk screening.
D. Referral for BRCA gene screening.
E. Six-monthly self-breast examination.
C. Genetic risk screening.
Here’s a simplified explanation of the information:
Who is at increased risk of breast and/or ovarian cancer due to a gene mutation (mostly BRCA1 and BRCA2)?
- People with many relatives who have had breast (male or female) or ovarian cancer.
- Relatives who were diagnosed with cancer at a young age.
- Relatives who have had both breast and ovarian cancer.
- Relatives who have had breast cancer in both breasts.
- People of Ashkenazi Jewish ancestry.
How common are inherited genetic mutations in breast cancer?
- 5-10% of all breast cancers are caused by inherited genetic mutations.
- BRCA1 and BRCA2 mutations are the most significant ones for hereditary breast and ovarian cancer.
What should primary care providers do?
- They should use screening tools to identify women with a family history that might suggest an increased risk of harmful mutations in breast cancer genes (BRCA1, BRCA2).
- These tools are questionnaires that help estimate a person’s likelihood of developing breast or ovarian cancer or having a faulty gene mutation.
What is FRA-BOC?
- FRA-BOC is a widely used screening tool in Australia for assessing breast and ovarian cancer risk.
- It’s available from Cancer Australia: FRA-BOC Tool.
What happens if a woman has a positive screening result?
- She should receive genetic counseling.
- If advised during counseling, she should undergo BRCA testing.
For Julian, using a screening tool like FRA-BOC is the best next step. If she is found to be at high risk, she should be referred for genetic counseling and testing.
The following groups are at increased risk of breast and/or ovarian cancer due to a gene mutation (mostly BRCA1 and BRCA2):
**Multiple relatives affected by breast (male or female) or ovarian cancer
**Young age at cancer diagnosis in relatives
**Relatives affected by both breast and ovarian cancer
**Relatives affected with bilateral breast cancer
**Ashkenazi Jewish ancestry
Of all breast cancers, 5-10% are caused by inherited genetic mutation. BRCA1 and BRCA2 mutation are the most important causes for hereditarily increased risk of breast/ovarian cancer. It is recommended that primary care provider screen high-risk woman with screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1, BRCA2). These screening tools are questionnaires used
by the health provider to take into account the family history of the person, and estimating the likelihood of developing breast and/or ovarian cancer in future, or whether they are high risk for having a faulty gene mutation.
FRA-BOC is one of the most commonly used screening tools in Australia for this purpose. FRA-BOC is available from: https://canceraustralia.gov.au/clinical-best-practice/gynaecological-cancers/fra-boc/evaluate
Women with positive screening results should receive genetic counselling and, if indicated after counselling, BRCA testing. For Julian, genetic risk assessment using screening tools such as FRA-BOC is the most appropriate next step. Referral for pretest counselling and genetic testing is an appropriate option once she is found to be at high risk.
You are working in a rural area. A 4-year-old Somali boy is presented to you by his mother for polio vaccine. He has received 3 doses of oral polio vaccine (OPV) at 2, 4 and 6 months of age back at his country with the last dose being given approximately 3 years ago. You only have injectable polio vaccine available in your office. Which one of the following would be the best appropriate management?
A. Check his immune status.
B. No further vaccination is needed.
C. Refer him to another clinic.
D. Give the injectable polio vaccine.
E. Try to find oral polio vaccine for him.
D. Give the injectable polio vaccine.
Injectable Inactivated polio vaccine (IPV) is the polio vaccine currently in use in Australia, and is given intramuscularly. Oral polio vaccine (OPV) is no longer in use in Australia. OPV nd IPV are interchangeable. Children, who have been started on OPV should complete their polio vaccination schedule using IPV (IPOL®) or IPV-containing vaccines.
IPV (IPOL) or IPV-containing vaccines are recommended for infants at 2, 4 and 6 months of age. The 1st dose of an IPV-containing vaccine can be given as early as 6 weeks of age.
If the 1st dose is given at 6 weeks of age, the next scheduled doses should still be given at 4 months and 6 months of age. A booster dose of IPV (IPOL®) or IPV-containing vaccine is recommended at 4 years of age. This is commonly provided as DTPa-IPV, which can be given as early as 3.5 years, but if DTPa-IVP is not available, IPV alone is used.
The only absolute contraindications to IPV (IPOL®) or IPV-containing vaccines are:
**Anaphylaxis following a previous dose of any IPV-containing vaccine
**Anaphylaxis following any vaccine component
A 30-year-old woman is concerned about breast cancer because her mother was diagnosed with breast cancer at the age of 48 years. Clinical examination of the breast is normal. Which one of the following would be the most appropriate advice for her?
A. Mammography yealy from the age of 40 years.
B. Mammography every 2 years from 50 to 74 years.
C. Refer to a surgeon.
D. Refer for genetic studies.
E. Reassure her that she is not at increased risk of breast cancer
A. Mammography yealy from the age of 40 years.
With a first-degree relative affected by breast cancer diagnosed before the age of 50, this woman is considered as having moderate risk for breast cancer. For such patients yearly screening mammography starting from the age of 40 is the best advice to give.
(Option B) Mammography every 2 years is the most appropriate recommendation for general population and those with just slightly increased risk above average for breast cancer.
(Option C) Referral to a surgeon would have been indicated if a diagnosis of breast cancer was established.
(Option D) Referral for genetic testing is an acceptable step for those women who are likely to have a predisposition for familial forms of breast/ovarian cancer. Referral for genetic testing should be considered once screening tools raise suspicion against strong risks of such cancers.
(Option E) Although this woman is not in high-risk category and is categorized as having moderate risk, reassuring is not appropriate because she needs a more extensive surveillance program for breast cancer than general population
A 67-year-old woman presents to your clinic for advice regarding reducing the risk of shingles infection after her husband was diagnosed with ophthalmic shingles 3 days ago. He had a vesicular rash on his face involving the eye, for which he was referred to an ophthalmologist for consultation. She wants to know if she should be vaccinated. She clearly remembers that she had chicken pox at the age of 12 years. Which one of the following is the most appropriate advice for her regarding herpes zoster prophylaxis?
A. Vaccination at this age will not benefit her.
B. Vaccination is indicated if she develops clinical shingles.
C. Vaccination will reduce her risk of infection regardless of her previous exposure.
D. A varicella serology testing is required for further decision making.
E. With the childhood history of chicken pox, she will not benefit from vaccination.
C. Vaccination will reduce her risk of infection regardless of her previous exposure.
- VZV is a DNA virus and part of the herpes virus family.
- Primary Infection: Known as varicella or ‘chickenpox’.
- Reactivation: Known as herpes zoster (HZ) or ‘shingles’. This happens when dormant VZV reactivates in nerve cells.
- 5th Cranial Nerve (CN V): Causes herpes ophthalmicus.
- 7th Cranial Nerve (CN VII): Causes Ramsay-Hunt syndrome.
- Unilateral Vesicular Rash: Appears in a specific nerve distribution (dermatome).
- Prodromal Phase: Occurs 48 to 72 hours before the rash, with symptoms like headache, photophobia, malaise, itching, tingling, or severe pain.
- Rash Duration: 10 to 15 days.
- Common Complication: Post-herpetic neuralgia (PHN), which is pain persisting for more than 3 months after the rash.
- Other Complications: Include eye problems, neurological issues, skin infections, scarring, and pneumonia. Disseminated HZ can affect the whole body, especially in immunocompromised individuals.
- Type: Live attenuated vaccine.
- Purpose: Prevents HZ in people over 50 years old.
- Effectiveness: Contains a higher viral titer to boost immunity in adults.
- Not for Treatment: Does not treat established HZ or PHN, only for prevention.
- Recommendation: A single dose for adults 60 years or older, regardless of childhood vaccination status or previous chickenpox infection.
- Routine Use: Not recommended for people under 50 years old, and routine use in people aged 50–59 is not generally recommended.
- VZV causes chickenpox initially and shingles upon reactivation.
- Shingles manifests as a painful rash and can have severe complications.
- Zostavax® is used to prevent shingles in older adults but does not treat it once it occurs.
- Vaccination is recommended for those 60 years and older.
This summary makes it easier to understand the connection between VZV, its reactivation, and the role of the Zostavax® vaccine in prevention.
Varicella-zoster virus (VZV) is a DNA virus and a member of the herpes virus family. Primary infection with VZV is known as varicella or ‘chickenpox’. Herpes zoster (HZ), or ‘shingles’, is caused by reactivation of latent VZV, which typically resides dormant in the dorsal root or trigeminal nerve ganglia following primary infection. Cranial nerves most commonly involved are 5th cranial nerve (CN V) and 7th cranial nerve (CN VII) resulting in herpes ophthalmicus and Ramsay-Hunt syndrome, respectively.
Reactivation of VZV causing HZ is thought to be particularly due to a decline in cellular immunity to the virus, and presents clinically as a unilateral vesicular rash in a dermatomal distribution in most cases. A prodromal phase occurs 48 to 72 hours prior to the appearance of the lesions in 80% of patients. Prodromal symptoms may include headache, photophobia, malaise, and an itching, tingling or severe pain in the affected dermatome. In most patients, HZ is an acute and self-limiting disease,
with the rash lasting 10 to 15 days. However, complications can occur, especially in older adults.
Post-herpetic neuralgia (PHN), the most frequently faced and debilitating complication of HZ, is a neuropathic pain syndrome that persists or develops after the dermatomal rash has resolved. By definition, PHN is established when pain persists for longer than 3 months after the onset of the rash.
Other complications may occur, depending on the site of reactivation. These include ophthalmic disease (such as keratitis and chorioretinitis), neurological complications (e.g. meningoencephalitis and myelitis), secondary bacterial skin infection, scarring and pneumonia. Rarely, disseminated HZ may develop, with widespread vesicular rash, and visceral, central nervous system and pulmonary involvement. Disseminated disease is more common in people who are immunocompromised.
Dermatomal pain without the appearance of rash is also documented (zoster siné herpéte).
Zostavax® is a live attenuated vaccine formulated from the same VZV vaccine strain (Oka/Merck) as the registered varicella (chickenpox) vaccine Varivax®, but is much more potent (on average, at least 14 times). This higher potency is owed to higher viral titer in Zostavax, and is required to elicit a boost in immune response of adults who usually remain seropositive to VZV following primary infection, but have declining cellular immunity with increasing age.
Zostavax® is used for the prevention of HZ in people>50 years of age. It is important to note that the registered varicella vaccines are not indicated for use in preventing HZ in older people and Zostavax is not indicated for use in younger people who have not been previously immunized or infected with VZV. Zostavax® is used solely for prophylaxis in a potentially-exposed asymptomatic patient. It has no therapeutic effect on established HZ infection or PHN; therefore, not indicated once infection develops. However, if given prophylactically, it can reduces the risk of HZ and PHN.
(Option A) A single dose of Zostavax® is recommended for adults ≥60 years of age who have not previously received a dose of it regardless of their childhood VZ vaccination status. Routine serological testing prior to vaccination is not indicated.
(Option D) Zostavax® is given regardless of a history of previous varicella (chickenpox) infection; therefore, inquiring about previous chicken pox infection is not required.
Routine population-based use of zoster vaccine in persons aged 50–59 years is not recommended. Although the incidence of HZ in persons 50–59 years of age is higher than in younger age groups, and zoster vaccine seems effective in those 50–59 years of age, the likelihood of developing PHN and other complications of HZ is lower in this age group than in those ≥60 years of age. People aged 50–59 years who wish to protect themselves against HZ can be vaccinated; however, the duration of efficacy, and need for a booster dose at a later age, is not yet determined. The routine use of vaccine is not recommended for those younger than 50 years.
A 29-year-old woman presents to your clinic at 14 weeks pregnancy for consultation regarding smoking cessation. She tried to give up smoking when she found out she is pregnant but she failed. She is worried about her baby’s wellbeing and wants to quit smoking. Which one of the following is the most appropriate management option for her?
A. Nicotine replacement therapy.
B. Non-nicotinic chewing gums.
C. Bupropion.
D. Varenicline.
E. Advise that she smoke less cigarettes.
A. Nicotine replacement therapy.
Smoking in pregnancy is the most important preventable cause of a wide range of adverse pregnancy outcomes. Smoking causes obstetric and fetal complications. Furthermore, there is growing evidence that harms can extend into childhood and even adulthood. Unfortunately, most smokers who become pregnant continue to smoke, and most of those who quite relapse after delivery.
Pregnancy is a window of opportunity for health professionals to help smokers quit. Women are motivated to protect their baby’s health, and quitting smoking during pregnancy reduces the risk of complications.
Interventions during pregnancy are modestly effective and assist 6 in every 100 smokers to quit. Many light smokers quit without assistance when they find out they are pregnant. The remaining smokers may need more intensive treatment.
The Australian Smoking Cessation guidelines recommend that pregnant smokers first try to quit with behavioral counselling and support as the first-line treatment. Smoking should be addressed at every GP visit during pregnancy in view of its serious health impact. Counselling in pregnancy produces a 4%-6% increase in the quit rate, compared with no counselling.
Nicotine Replacement Therapy (NRT) should then be considered if the patient is unable to succeed without it. NRT should be used under the supervision of a qualified health professional.
Intermittent, short-acting forms of NRT such as the lozenge or mouth spray are recommended to deliver a lower total daily nicotine dose. However, this may result in under-dosing and reduced effectiveness. The guidelines also advise that if patches are used they should be removed at bedtime.
Although guidelines recommend the smallest effective dose of nicotine, larger doses or even combination therapy may be required. Adequate doses to relieve cravings and withdrawal symptoms, and a full course of at least 8 weeks treatment are supported. The risks and benefits of NRT during pregnancy should be explained without making the patient unduly concerned.
There is no evidence of increased rates of miscarriage, stillbirth, admission to neonatal intensive care unit (NICU) or neonatal death between NRT and control groups. There is currently insufficient evidence to determine whether NRT is safe in pregnancy, but available data and expert opinion suggest it is less harmful than continuing to smoke.
This patient should be started on counselling and support (not an option). NRT should be considered if the patient requires it.
Australian Smoking Cessation Guidelines recommend against the two prescription medicines for smoking cessation, varenicline and bupropion during pregnancy and breastfeeding.
NOTE - Quitting smoking before conception or in the first trimester results in similar rates of adverse pregnancy outcomes compared with non-smokers; however, quitting at any time during produces health benefits. Quitting before pregnancy also allows the use of full range of pharmacotherapies
A 72-year-man presents to your practice for assessment. He does not smoke and has no history of diabetes mellitus or cardiovascular disease. On examination, he has a blood pressure of 172/100 mmHg, confirmed with a second reading. On blood tests, he has a total cholesterol level of 6.2 and HDL of 1mmol/L. According to the following chart which one of the following is his absolute cardiovascular risk?
A. 10-15%.
B. 16-19%.
C. 20-24%.
D. 25-29%.
E. ≥30%
D. 25-29%.
Assessment of cardiovascular disease (CVD) risk on the basis of the combined effect of multiple risk factors (absolute CVD risk) is more accurate than the use of individual risk factors because the cumulative effects of multiple risk factors may be additive or synergistic. In Australia, 64% of the adult population have 3 or more modifiable risk factors. Since CVD is largely preventable, an approach focusing on comprehensive risk assessment will enable effective management of identified modifiable risk factors through lifestyle changes and, where needed, pharmacological therapy.
Absolute risk is the numerical probability of a CVD event occurring within 5 years expressed as a percentage. For example, if one patient’s risk is 15%, he/she could be told he/she has a 15% chance of having a CVD event within the next 5 years.
In Australia, the following charts are used for calculation of absolute CVD risk in any given patient. The risk percentages are extracted from Framingham Risk Equation (FRE). It takes into account the following variables for calculation of absolute CVD risk:
- Age
- Gender
- Smoking
- Systolic blood pressure
- Total cholesterol to HDL ratio
NOTE - Different rules apply to diabetic versus nondiabetic individuals and Aboriginal and Torres Strait Islanders.
These charts are used as follows:
Identify the chart relating to the person’s sex, diabetes status, smoking history and age. The charts should be used for all adults aged 45 years or over (and all Aboriginal and Torres Strait Islander adults aged 35 - 74 years) without known history of CVD, and not already known to be at clinically determined high risk. On the chart, choose the cell nearest to the person’s age, systolic blood pressure (SBP) and total cholesterol (TC):HDL ratio. The color of the cell that can be the person falls into
provides their 5 year absolute cardiovascular risk level. People who fall exactly on a threshold between cells are placed in the cell indicating higher risk. For those older than 74 years, calculate as if they are 74.
This patient is male, non-smoker and 72 years. The part of the chart that should be used for risk calculation is shown in the following picture:
Hypertension is the most important preventable risk factor for which one of the following conditions?
A. Coronary artery disease.
B. Peripheral arterial disease.
C. Renal arterial disease.
D. Ischemic stroke.
E. Atrial fibrillation.
D. Ischemic stroke.
Although hypertension is a risk factor for all of the given to some extent, it remains the most important modifiable risk factor for stroke and intracerebral hemorrhage (ICH). The risk of stroke increases progressively with increasing blood pressure, independent of other factors.
Hypertension is the cause of stroke in >50% cases worldwide. Most estimates for hypertension indicate a relative risk of approximately 4 when hypertension is defined as systolic blood pressure ≥160mmHg and/or
diastolic blood pressure ≥95mmHg.
Hypertension and hypertensive heart disease results in development of left ventricular hypertrophy and diastolic dysfunction that are important risk factors for atrial fibrillation accounting for 20% of cases.
Hypertension is also a major risk factor for coronary artery disease (CAD), and treatment of hypertension reduces the risk of a coronary artery disease by one-third; however, the most important reversible risk factor for CAD is hypercholesterolemia and cigarette smoking. Cessation of cigarette smoking is the single most important preventive measure for coronary artery disease. Moreover, smoking has the highest association with peripheral arterial disease.
Which one of the following risk factors is most signficant for ischemic stroke?
A. Hypercholesterolemia.
B. Smoking.
C. Obesity.
D. Type 2 diabetes mellitus.
E. Hypertension.
E. Hypertension.
All of the given options can be potential risk factors for ischemic stroke; however, hypertension is associated with the highest risk. Hypertension is the cause of stroke in >50% cases worldwide. Most estimates for hypertension indicate a relative risk of approximately 4 when hypertension is defined as systolic blood pressure ≥160mmHg and/or diastolic blood pressure ≥95mmHg. The following table compares the relative risk of different preventable risk factors for stroke: - See table below.
NOTE - Age is the single most important risk factor for stroke. For each successive 10 years after age 55, the stroke rate more than doubles in both men and women. Stroke incidence rates are 1.25 times greater in men, but because women tend to live longer than men, more women than men die of stroke each year. Obesity is associated with elevated vascular risk in population studies. Furthermore, it has been associated with glucose intolerance, insulin resistance, hypertension, physical inactivity and dyslipidaemia.
(Option A) Hypercholesterolemia seems to act in a complex fashion and does not directly act as a risk factor; however, it is an important modifiable risk factor for coronary artery disease.
(Options B and C) Smoking and obesity are associated with relative risks of 1.5 and 1.5-2.0 respectively.
(Option D) Diabetes mellitus is associated with a relative risk of 1.8-3.0.
A 46-year-old man presents to your clinic for a routine check-up. He runs a butchery, and is an smoker. Sometimes, he also uses cocaine and cannabis at parties. On examination, he has a blood pressure of 135/95 mmHg. His BMI is 29. Which one of the following is the most significant risk factor for developing coronary artery disease in this patient?
A. Obesity.
B. Cannabis.
C. Age.
D. Cocaine.
E. Cigarette smoking
E. Cigarette smoking
Major traditional risk factors for cardiovascular diseases are:
**Hypercholesterolemia (high LDL)
**Smoking
**Hypertension
**Diabetes mellitus
Other traditional risk factors include:
**Family history of premature coronary artery disease in a first-degree relative (female<65 years; male<55 years)
**Low physical activity
**Obesity
Of the options, smoking is a major risk factor for coronary artery disease (CAD). People who smoke more than 20 cigarettes a day have a 2- to 3-fold increase in total incidence of heart disease. Continued smoking is a major risk factor for recurrent heart attack. Cessation of cigarette smoking is the single most important preventive measure for CAD.
Although family history of premature heart disease (male< 55 years and female< 65 years), low level of physical activity, and obesity are considered risk factors for CAD, these factors work through major risk factors to a large extent.
Age, by itself, is not a risk factor unless other major risk factors are present. The incidence of CAD increases after the age of 45 years in men and 55 in women.
A 60 year-old man presents to your clinic for a routine medical check-up. He smokes 45 cigarettes a day, and drinks 10 standard drinks daily. He has a body mass index (BMI) of 32 kg/m2. He wears seat-belt almost 60% of the times when he drives.
He is motivated to follow lifestyle modification advice. Which one of the following is the most significant advice for prevention of cardiovascular disease and premature death in this patient?
A. Smoking cessation.
B. Reduction of alcohol intake.
C. Wearing seatbelt all the time when he drives.
D. Weight reduction.
E. Regular exercise.
A. Smoking cessation.
By far, the most common cause of coronary artery disease (CAD) is atherosclerotic changes of coronary arteries. The most common underlying cause is hypercholestrolemia (high LDL). Smoking is also strongly associated with increased risk of cardiovascular diseases, and its cessation is considered the most effective lifestyle modification to prevent cardiovascular events (more than lipid modification). In a patient with coronary artery disease, quitting smoking is associated with a 36%
reduction in mortality.
Although family history of premature heart disease (male < 65 and female < 55), low level of physical activity and obesity are considered risk factors for coronary artery disease, these factors exert their effects in the presence of major risk factors.
(Option B) This patient should also be advised to reduce alcohol consumption to a maximum of 2 standard drinks (one for women) with 2 alcohol-free days every week. This measure is beneficial for general health but does not have a specific effect on cardiovascular status as does smoking cessation.
(Option C) Wearing a properly-adjusted seatbelt reduces the risk of mortality by 50%; however this reduction is related to trauma and severe injuries, not to cardiovascular diseases.
(Option D) Blood pressure and body weight are directly related. For every 1kg reduction in weight, the systolic blood pressure will drop by 1mmHg. Weight reduction is particularly beneficial if the patient has insulin resistance and/or hyperlipidemia. Weight reduction, however, is not as effective as smoking cessation in improving cardiovascular risk.
(Option E) Regular exercise increases high-density lipoprotein cholesterol and reduces body weight, and contribute to improved cardiovascular status, but not as smoking cessation does.
TOPIC REVIEW
Major traditional risk factors for coronary artery disease (CAD) are as follow:
**Hypercholesterolemia (high LDL)
**Smoking (especially smoking cigarettes)
**Hypertension
**Diabetes mellitus
Other traditional risk factors include:
**Family history of heart disease (premature)
**Low level of physical activity
**Obesity
A 62-year-old man presents for ‘absolute cardiovascular risk’ assessment. His past medical history includes type 2 diabetes mellitus for which he is on metformin 500 mg 12-hourly and gliclizide 60 mg daily. Laboratory studies show an albumin/creatinine ratio of 5mg/mmol. Which one of the following options is correct regarding this scenario?
A. Inform him that he is already in high risk group for cardiovascular disease and do not need risk calculation.
B. Perform absolute risk calculation for him now and 2-yearly.
C. Reassure him.
D. Start him on insulin.
E. Increase the dose of his medications.
A. Inform him that he is already in high risk group for cardiovascular disease and do not need risk calculation.
Assessment of cardiovascular disease risk on the basis of the combined effect of multiple risk factors (absolute CVD risk) is more accurate than the use of individual risk factors, because the cumulative effects of multiple risk factors may be additive or synergistic. In Australia, 64% of the adult population have 3 or more modifiable risk factors. As CVD is largely preventable, an approach focusing on comprehensive risk assessment will enable effective management of identified modifiable risk factors through lifestyle changes and, where needed, pharmacological therapy.
Absolute cardiovascular risk assessment should be conducted at least every 2 years in all adults aged 45 years or older who are not known to have CVD or to be at clinically-determined high risk. Calculation of the absolute risk requires information on the patient’s age, sex, smoking status, total and HDL cholesterol, systolic blood pressure and if the patient is known to have diabetes or left ventricular hypertrophy.
Absolute risk calculation is not indicated if:
The patient has current or history of cardiovascular disease e.g. stroke, transient ischemic attack (TIA), ischemic heart disease (IHD), or peripheral arterial disease (PAD).
The patient is already clinically-determined high risk:
- Diabetes and age >60 years
- Diabetes with microalbuminuria (>20 µg/min or urine albumin:creatinine ratio (UACR) >2.5 mg/mmol for males, >3.5 mg/mmol for females)
- Moderate or severe CKD (persistent proteinuria or estimated glomerular filtration rate (eGFR< 45mL/min/1.73 m2)
- Previous diagnosis of familial hypercholesterolaemia (FH)
- SBP ≥180 mmHg or diastolic blood pressure (DBP) ≥110 mmHg
- Serum total cholesterol >7.5 mmol/L
- Aboriginal or Torres Strait Islander peoples aged over 74 years
With diabetes and age of 62 (>60) on one hand and an albumin/creatinine ratio of 5mg/mmol (>2.5mg/mmol), this patient has 2 conditions that categorizes him as clinically-determined high risk; therefore, risk calculation is not required.
(Option B) He does not need absolute cardiovascular risk assessment now or any other time because he is already clinically-determined high risk.
(Option C) Reassurance of a patient who high-risk for CVD is not wise.
(Options D and E) There are no pointers in the scenario towards inadequacy of diabetes treatment; hence, increasing the dose of the current medications or commencement of insulin appears irrelevant.
A 47-year-old man presents for cholesterol check. He smokes 20 cigarettes a day. On examination, he has a blood pressure of 140/90 mmHg. Among the blood tests performed, a cholesterol level of 5.5 mmol/L is remarkable. Which one of the following would be the most appropriate advice for him at this stage?
A. He should start statins.
B. He should start antihypertensive medications.
C. He should be involved in a smoking cessation program.
D. His cholesterol level should be checked in 3 months.
E. He should start regular exercise and diet.
C. He should be involved in a smoking cessation program.
By far,** smoking is the single most modifiable risk factor for coronary artery diseases (CAD)**. Smoking is associated with a 2- to 3-fold increase in CAD. Smoking cessation alone reduces the risk of CAD by 32%; therefore, advice against smoking and encouraging the patient to actively participate in a smoking cessation program will be the most appropriate step.
Adopting a healthy lifestyle including regular exercise and diet is also important for reduction in CAD risk but smoking remains the most important factor. The patient’s blood pressure is at the cut-off point for hypertension. Presently, antihypertensive medications are not indicated.
The target cholesterol level is < 4mmol/L. With a cholesterol level of 5.5 mmol/L, this patient should initially be advised to start regular exercise and a healthy diet. Statins as first-line medications for hypercholesterolaemia are indicated if diet and exercise fail to lower the cholesterol levels in 3-6 months.
Which one of the following measures is of most importance in reducing the prevalence of trachoma infection in a susceptible community such as indigenous Australians?
A. Childhood vaccination.
B. Prophylactic use of tetracycline.
C. Avoidance of community bathing.
D. Regular hand and face washing.
E. Eradication of mosquitoes.
D. Regular hand and face washing.
To reduce the prevalence of trachoma infection, the strategy defined and implemented by the World Health Organization (WHO) should be followed. This strategy is called SAFE that stands for surgery, antibiotics, facial hygiene (cleanliness) and environmental factors.
- Surgery is used to correct the entropion before it leads to permanent damage to the cornea.
- Azithromycin is the antibiotic of choice in this strategy and is given, in oral form, to family members with active trachoma.
- Facial hygiene is achieved through regular hand and face washing.
- Environmental factors should be addressed by improving water supply, better community hygiene and dust and fly control.
Among the following measures surgery and antibiotics are used for treatment not prevention; hence they have no effect on prevalence. The most important measure, which with proper education will significantly reduce the prevalence of the disease, is regular hand and face washing.
(Option A) There is no effective vaccine against Chlamydia trachomatis.
(Optipn B) Tetracycline is not used for prophylaxis or treatment of Chlamydia. Azithromycin is the drug of choice for such purposes.
(Option C) Chlamydia trachomatis is spread via direct contact e.g. from mother to the child. Avoidance of community bathing does not seem to have a significant impact on the prevalence.
(Option E) Trachoma is transmitted by flies not mosquitoes; therefore, eradication of mosquitoes would not be an effective measure
In a randomized controlled trial (RCT) conducted to study the effect of aspirin on prevention of coronary artery events among diabetic smokers, the results in the two arms of the study are as follows: - See table below.
Which one of the following is the relative risk of not using ASA?
A. 1%.
B. 2%.
C. 100%.
D. 200%.
E. 50%
D. 200%.
In statistics and epidemiology, relative risk or risk ratio (RR is the ratio of the probability of an event occurring in an exposed group to the probability of the event occurring in a non-exposed, comparison group.
Of 100 diabetic smokers who are on aspirin, 1 person has developed a coronary event. So the incidence of coronary event in this group is 1% [1/(1+99)x100], while the incidence of coronary events in the group taking placebo instead of aspirin is 2% [2/(2+98)x100].
In this scenario the exposure is taking aspirin. Exposed group has a 1% chance of developing a coronary event versus 2% in those who do not take aspirin.
The RR is then calculated by dividing the odds of the condition in the exposed group (1%) by that of the non-exposed group:
RR= P(exposed) / P(non-exposed) : RR=1% / 2%=0.5
Here, the RR indicates that the odds of developing a coronary event in those diabetic smokers who are on aspirin is half compared to those on placebo. In other words, those who are on aspirin has a 50% risk reduction. Inversely, those who are not taking aspirin are twice as likely to develop a coronary event compared to those who are taking it. So the RR. This means that not taking aspirin is associated with a 200% increase in incidence of coronary events.
Peter, 33 years of age, is concerned about colon cancer because his father had it at the age of 49 and his elder brother at the age of 46 years. He denies any symptoms such as rectal bleeding, altered bowel habits or those related to anemia. Which one of the following would be the most appropriate advice for him regarding colon cancer screening?
A. Screening with FOBT 2-yearly from the age of 50 years.
B. Screening with FOBT 2-yearly from the age 40 years.
C. Screening with yearly FOBT starting from now.
D. Screening with colonoscopy 5-yearly from the age of 50 years.
E. Screening with colonoscopy 5-yearly starting from now.
B. Screening with FOBT 2-yearly from the age 40 years.
Recommendations for colorectal cancer screening is based on individual risk. The risk categories, criteria, and recommended screening program for colorectal cancer currently in use in Australia (recently updated) is outlined in the following table: - See table below.
Peter has two first-degree relatives diagnosed with colorectal cancer. With this in history, he falls in category 2, and requires FOBT testing 2-yearly from the age of 45 years until 49, and colonoscopy every 5 year from the age of 50 years.
Patricia is a 28-year-old sex worker, working in a licensed brothel. She is in your office for sexual health assessment and receiving a sexual health certificate. In consulting her, which one of the following is the correct advice?
A. She needs to perform vaginal and anal swabs every 12 months.
B. She should be screened for chlamydia and gonorrhea using a mid-stream urine every 3 months.
C. She should be screened for hepatitis C infection every 12 months.
D. She should be screened for chlamydia and gonorrhea using high vaginal swabs every 3 months.
E. She should be screened for syphilis every 12 months.
D. She should be screened for chlamydia and gonorrhea using high vaginal swabs every 3 months.
This question asks about requirements by law in order to renew a license for sex work practice. Requirements for such issue is different from current guidelines by the RACGP and STI guidelines in Australia. Based on clinical guidelines, it is recommended that high risk individuals for STIs (such as sex workers) undergo screening every 12 months; however, these guidelines advise that state legislations should be followed regarding the intervals of such tests for legal matters such as issuance or renewal of a sexual health certificate for sex workers. Based on current legislations in Australia, sex workers require to be screened for STIs quarterly (every 3 months) to have their licenses renewed.
Legislations for STI screening are in accordance with the Public Health and Wellbeing Act 2008. Based on this act, sex workers are required to undergo the following tests and measures every 3 months:
Blood tests:
- Syphilis Antibody
- HIV Antigen/Antibody
- Hepatitis B core antibody and surface antibody (HBcAb and HBsAb)
- Hepatitis A antibody (where appropriate)
Swabs (Women):
- Chlamydia (High Vaginal Swab)
- Gonorrhea (High Vaginal Swab)
- Trichomoniasis (High Vaginal Swab) (only at first presentation or if the woman is a contact of infection)
- Cervical Screening when required as per policy
- Gonorrhea (pharyngeal)
- Chlamydia (pharyngeal)
Genital Examination (Women):
- Vulval examination is performed at each visit to exclude visible lesions of genital wart or genital herpes
- A speculum examination is not routinely performed on asymptomatic women unless they require a cervical screening
- A speculum examination should be considered if the woman is symptomatic, has experienced a condom break/slip, or they have a retained sponge/tampon/condom.
Gonorrhea and chlamydia testing for Male Sex Workers:
- As per the policy - Screening of Asymptomatic Men for Sexually Transmitted Infections by Sexual Health Nurses.
- Men must also undergo a genital examination to exclude visible lesions of genital warts and genital herpes.
Provision of vaccinations:
vaccinations should be advised, when appropriate against:
- Hepatitis B
- Hepatitis A
Based on current legislation, the only correct option would be high vaginal swabs for chlamydia and gonorrhea testing using Nucleic acid amplification test (NAAT) every 3 months.
(Option A) Vaginal swabs should be performed every 3 months for renewal of sex work certificate. Anal swabs are required only if there has been anal sex.
(Option B) If instead of high vaginal swabs, a urine sample is considered, the specimen used should be a first catch urine, not midstream urine.
(Option C) Screening for hepatitis C is not routinely required unless there is a high risk for such infection, e.g., injection drug users.
(Option E) Although testing for syphilis is required in sex workers, the interval proposed by law is 3 months, not 12 months.
TOPIC REVIEW
As a general practitioner, you are trying to follow the current Australian guidelines to reduce the incidence of HIV infection in your community by administration of Pre-exposure prophylaxis (PrEP) to those who are at risk. Which one of the following is in need for PrEP?
A. Commercial sex workers.
B. Intravenous drug users.
C. Men who have sex with men.
D. Female partner of an HIV-positive man with undetectable viral load.
E. HIV-positive male partner of a female.
C. Men who have sex with men.
PrEP is used to significantly reduce the risk of HIV transmission in the community using antiretroviral drugs, usually tenofovir/ emtricitabine, in people who are HIV negative but at a significantly increased risk of HIV infection.
One important point to consider is that PrEP is used in those who are currently HIV negative as means of prophylaxis; therefore, those who are already HIV positive do not require PrEP and should be referred for HIV prescription.
The following groups are considered to be at “high risk” if they had these risks in the previous 3 months, or if they foresee these risks in the upcoming 3 months. For such patients, PrEP is recommended: - See table below.
Of the options, only men who have sex with men (MSM) are high-risk for HIV Infection and require PrEP.
(Option A) Commercial sex worker are usually on routine STI follow-up programs and do not require PrEP merely for their carrier. However, once they have any of the high-risk conditions as outlined in the above table, they will require PrEP.
(Option B) Unless the intravenous drug user is not sharing needles with an HIV-positive individual or with MSM of unknown HIV status, PrEP is not indicated.
(Option D) As long as a man has undetectable viral load and take precautionary measures such as use of male condoms, PrEP for his female partner is not indicated as the risk of transmission is extremely low.
(Option E) Prophylaxis aims to prevent the infection. Once a person is HIV infected, prophylaxis has no point, and treatment with antiretroviral regimens should be started
