General Presentations Flashcards
1
Q
What are red flag signs or symptoms in lower back pain?
(9)
A
History of cancer
Age > 50 or < 15
Known Osteoporosis or high fracture risk
Fevers > 38/night sweats
Use of IV drugs
urinary retention
urinary incontinence/bowel incontinence/saddle anaesthesia
Lower limb weakness/paralysis
prolonged morning stiffness (Ank spond) + <40yo + 3months of sx
2
Q
Management for mechanical lower back pain.
A
Ibuprofen
Referral to physio for active treatment program
Advise not to have prolonged bed rest
Return to work as soon as possible
Can use massage therapy
Advise to trial Yoga or Taichi or Pilates
Long term 5-10% weight loss
3
Q
Treatment for PMR - dosing.
A
prednis(ol)one 15 mg orally, daily for 4 weeks; then reduce daily dose by 2.5 mg every 4 weeks to 10 mg daily; then reduce daily dose by 1 mg every 4 to 8 weeks to stop
4
Q
For GCA, without evolving visual loss, list two steps of management. dosing if required.
A
- Urgent referral to ophthalmologist for treatment to prevent visual loss
- Start prednisolone 40-60mg, orally, for a minimum of 4 weeks
(3. Can start aspirin 100mg to prevent vascular thrombus)
If having visual loss will need IV glucocorticoids in hospital
5
Q
Up to one third of abdominal pain presenting to GPractice has no cause.
Apart from surgical causes, what are non-abdominal causes of abdominal pain?
(6)
A
PE
MI
Pneumonia
Anxiety/depression
Lumbar spine pathology
Pelvic Pathology: ectopics ,ovarian torsion, fibroids, PID
6
Q
In the elderly person with abdominal pain, what two things should you consider as serious diagnoses?
A
Mesenteric Artery occlusion
Leaking AAA
7
Q
What Imaging can you use to investigate Abdominal pain?
A
Right Upper Quadrant–> U/S
Right lower quadrant –> CT with IV contrast
Left Lower quadrant–> CT with oral and IV contrast
Suprapubic–> U/S
Right or Left lower quadrant pain in child bearing age females or pregnancy related concerns –> Abdominal U/S for LLQ or TVU/S for suspected ectopics or other pelvic pathology
8
Q
In a frail elderly person with abdominal pain, who appears unwell, what is the appropriate management?
A
Consider sepsis, perforation, ischemic bowel.
answer: CT and hospitalisation
9
Q
In a 56 year old patient with flank pain and haematuria
1 What is the most likely diagnosis
- What is the diagnosis not to be missed
- What should you do
A
- Renal stone
- Ruptured AAA
A ruptured AAA can tamponade and cause a normotensive BP. So you might not pick it up.
Secondly the AAA can irritate the ureter and cause haematuria - A new presumed diagnosis of “kidney stones,” in someone aged over 50 should prompt imaging of the Aorta.
10
Q
Aside from imaging, what investigations may you consider for abdominal pain?
A
- EUC
- FBC for infection
- CRP for inflammation
- LFTs- liver
- Lipase- pancreatitis (can be falsely elevated with mesenteric ischemia)
- urine MCS
- Urinanalysis
- Pregnancy test
- (ECG) if suspecting cardiac
- Fasting BGL or any BGL - ?DKA
- Venous Blood gas for lactate. ?ischemic bowel
11
Q
Explain the appropriateness of imaging for different types of LBP?
A
- non specific LBP. unless red flags. do not image. If > 6 weeks then consider XRAY first line. If red flags MRI is preferrable
- Symptomatic Lumbar disc herniation. This is when a disc causes pain, usually radicular sharp and shooting. Radicular pain alone is not a red flag, but if combined with weakness, numbness or parasthesia then yes it is. If > 6 weeks then consider MRI.
- Symptomatic spinal canal stenosis. Usually bilateral pain from back (or not) to hips. Usually aggravating by walking (psuedoclaudication). This case definitely IMAGE. with MRI.
12
Q
What is the most common cause for chest pain?
A
Musculoskeletal causes
Isolated MSK issues (costochondritis, lower rib pain syndrome)
Rheumatological Diseases: fibromyalgia, RA
Non-rheumatological systemic disease: Cancer/mets, Osteoporotic fracture, Sickle Cell disease (Rare)
13
Q
What to ask regarding sleep patterns specifically?
A
Usual Bed time
Shift work
Time taken to fall asleep when lights out
Rough duration and amount of wakenings
Time patient gets out of bed
Any triggers that wake the patient
14
Q
What can impact a patient’s sleep?
A
Too much Caffiene
Alcohol
Nicotine
Exercise before bed
Period of stress/anxiety/depression
Television in the room
Pets/kids interrupting
15
Q
When would you order a PSN (polysomnograph) for sleep?
A
Suspicious of Sleep Apnoea, treatment resistant insomnia, sleep related movement disorder and parasomnias
16
Q
What are the components of CBT used for insomnia?
(4)
A
- Stimulus Control
(removing all wakening triggers; phones, TVs, computers, light sources. And excluding sleep from living room) - Sleep Restriction
- Relaxation techniques (imagery, biofeedback, mediation, hyponosis)
- Sleep hygiene
- Cognitive therapy
17
Q
Medications that can be used for insomnia?
A
Melatonin- helps more with sleep onset time and delayed sleep phase disorder
2 mg orally, 60 to 120 minutes before bedtime for an initial period of 3 weeks then review. Melatonin may be continued for an additional 10 weeks.
Temazepam 10 to 20 mg orally, 30 minutes before bedtime for the shortest possible duration; preferably not on consecutive nights and for less than 2 weeks.
Zolpidem MR 5 to 10 mg orally, at bedtime for the shortest possible duration; preferably not on consecutive nights and for less than 2 weeks
18
Q
What points do you raise with a person when discussing sun protection?
A
Use sun protection when UV is > 3
Use of shade
Wide brimmed, legionnaire or bucket style hats
Protective clothing
Sunglasses
Use sunscreen with SPF > 30
Avoid the sun at peak times of the day
19
Q
Is there a screening for skin damage?
A
No specific recommendation
Ask patients to be self aware and familiar with their skin as well as be alert of new lesions
Anyone at high risk should have 3-6 monthly checks.
High risk: past/family history, sun damage, solarium use, fair skin/red hair, easily burnt, extensive sun exposure
Advise anyone over 10 to be sunsmart (not screening)
20
Q
Risk factors for hip and knee Osteoarthritis? (3)
A
age
joint injury
obesity and overweight
21
Q
How can you can clinically diagnose knee Osteoarthritis?
(6)
A
If patient is >45 years
Activity related pain
Stiffness < 30 minutes in the morning
Crepitus on active ROM
Bony enlargement
No detectable warmth
22
Q
What is the role of imaging with regards to Hip and Knee OA?
A
The diagnosis is clinical and imaging is not needed.
If other pathology is suspected then order imaging or if diagnosis is vague
Imaging for OA follow-up is recommended only if there are unexpected rapid progression of symptoms or change
in clinical characteristics that need to be confirmed (eg increasing severity of OA)
23
Q
In management of hip or knee OA, what has strong recommendations?
only 2
A
- Land based exercises: walking and muscle strengthening exercise
- Weight management for BMI < 25
24
Q
what are some conditional recommendations for management of hip and knee OA?
(up to 11)
A
- CBT best combined with exercise
- Stationery cycling or hatha yoga can be offered to some persons
- Aquatic exercises. can be offered. Can refer to an exercise physiologist
- Massage therapies
- Adjunctive stretching therapies
- Topical heat application
- Assisted walking devices to help with mobility
- TENS
- NSAIDs short courses
- Duloxetine (no TGA approval)
- Corticosteroid injection
25
What not to do (in terms of treatment) for hip/knee OA?
evidence base: strongly not recommended.
(5)
1. opioids of any form
2. doxycycline
3. Strontium ranelate
4. IL inhibitors
5. Arthroscopic lavage
26
What are red flag features for neck pain and why?
(5)
1. Significant trauma: MVA - disruption of the cervical spine
2. History of RA (atlanto-axial disruption)
3. Infective symptoms: meningism, fever, history of drug use
- abscess, meningitis, mycotic aneurysms
4. Neurology (of upper motor neuron problems) :
- Cervical cord compression, demyelinating process
5. Ripping/tearing neck pain sensation - arterial (carotid/vertebral dissection)
6. Concurrent chest pain/cardiac features - MI
27
Acute neck pain is classified as _______ _____ ______. (Length of time)
The prognosis is generally _______.
under 6 weeks,
Good
28
What are the sub-acute and chronic definitions for neck pain?
Acute < 6 weeks
Sub acute 6 weeks to 6 months
Chronic > 6 months
29
What are two important predictors of chronic neck pain prognosis in whiplash injuries?
1. Initial severity of the pain
2. If there is a compensation claim simultaneously
30
Somatic neck pain can be superficial or deep.
Superficial pain from the skin is usually sharp and well defined.
Deep somatic pain is usually dull and achy, and more generalised.
Neither of these are 'radicular pain'
what are causes of deep somatic neck pain?
1. Spondylosis (though this can be difficult to diagnose at the cause as XRAY findings and level of pain don't correlate well)
2. Discogenic. prolapse of the nucleus pulposus
3. Facet joint pain
4. Myofascial pain
31
What is radicular pain?
pain that radiates along a sensory distribution.
Usually sharp and cutting and has parasthesia or dysathesia.
32
Causes of radicular neck (or even lower back) pain?
(2 main groups)
spondylotic myelopathy - degenerative changes that narrow the spinal canal, resulting in neurological compromise.
Cervical radiculopathy- causes are predominantly degenerative and include foraminal stenosis, such as those imparted by osteophyte encroachment from spondylosis. Another common cause includes posterolateral cervical disc herniation, compromising abutting exiting nerve roots
33
What are yellow flags?
yellow flags are psychosocial factors that are predictive of chronicity and disability with regard to any disease.
34
What are they yellow flags with regard to neck pain?
(4)
1. Attitude that the spinal pain is potentially severely disabling
2. Social or financial problems
3. Reduced activity levels
4. Presence of a compensation claim
Addressing some of these yellow flags may help to reduce the risk of acute neck pain progressing to sub-acute and even a chronic temporal pattern
35
What to note on examination of the neck in neck pain?
(3 main points)
Inspection - posture, scars, muscle bulk, symmetry
Palpation - midline tenderness (could be sinister)
Neurological exam- movement and sensation of the upper limbs
36
What are indications for imaging (with an MRI) for neck pain?
(6)
1. Age > 50 with new symptoms
2. Systemic features: weight loss, fevers/night sweats, anorexia
3. Infection risk (IVDU, immnosuppressed)
4. Moderate to severe pain lastin g> 6 weeks
5. neurological findings
6. History of malignancy
37
With neck pain, if there is associated extremity pain (due to nerves involved) that is worse than the neck pain itself, other than an MRI, what else could you consider?
A nerve conduction study
38
Management for non-critical causes for neck pain?
(3)
1. Poor evidence but essentially manual therapy/physio for the neck
2. Non opioid analgesics in the short term
3. Addressing yellow flags (psychological barriers) in regards to the neck pain
39
When can a GP refer for MRI with regards to neck pain?
when patient is > 16 y.o and concerned about cervical radiculopathy
also 16+ and for cervical trauma however, CT is better and recognising fractures- but if worried about ligaments or spinal cord this can be done.
40
what is the chronological classification of a cough?
(3)
acute < 3 weeks
Sub acute 3-8 weeks
Chronic > 8 weeks
41
What are the red flags with regards to a cough?
(up to 7)
1. Haemoptysis
2. Smoker
a. 20 pack year history with a new cough
b. > 45 yo with new cough or altered voice
3. Prominent dysponoea at night
4. Hoarseness
5. Systemic features (weight loss, appetite loss, fever, oedema, vomiting)
6. GORD with associated weight loss, haematemesis or melena, dysphagia or odophygia
7. GORD not responding to treatment
8. LRTI - recurrent
9. Abnormal respiratory exam or CXR
42
When do you suspect pertussis with regards to a chronic cough?
Cough longer than 3 months
Paroxysms of coughing (coughing fit)
No fevers
Coughing to the point of needing to vomit
Inspiratory Whoop
43
What are the most common causes of a chronic cough?
-Post viral cough
-GORD
-Asthma
-Upper airway cough syndrome (post nasal drip or perceived post nasal discharge)
The bottom three make up 90% of the causes for chronic cough.
44
what is acute bronchitis?
Acute cough of less than 14 days duration and at least 1 other symptom of a respiratory infection:
such as symptoms of URTI, sore throat,
sputum production, dyspnoea, wheeze, chest
pain, for which there is no other explanation.
45
What management is recommended/ not recommended for acute bronchitis?
1. Do not prescribe antibiotics
2. Does not need a CXR on suspicion of acute bronchitis alone
3. Reassure that it is self limiting
4. Educate that it can take 8 weeks to settle / set realistic expectation of time frame
5. Set a review in 3 weeks if no improvement at all, or worseninng
6. CAN use inhaled fluticasone propionate in those who DO NOT smoke. Only this steroid was studied.
46
What are some general management options including medications (no dosing required) in dealing with a chronic cough?
(4)
1. Avoid triggers: exposure to cold dry air, smoking and air pollution
2. Vocal hygiene- helps reduce laryngeal irritation.
3. Use an active cycle of breathing for sputum clearance
4. Inhaled steroids - only really useful if the person has asthma.
47
After initiating therapy for weight loss, when should you first plan a follow up?
2 weeks ideally
48
what is the most recent statistics on overweight and obesity in Australia?
25% of children in Australia are either overweight or obese (17% overweight + 8 % obese)
67% of adults are either overweight or obese (1/3 of all adults were overweight, 1/3 were obese and 1/9 of all adults are severely obese).
49
What is the 5 A's framework?
Ask
Assess
Advice
Agree
Assist
50
What is important when trying to encourage behaviour change, be it smoking cessation or weight loss, etc. ?
Use patient centered language
e.g. instead of Ask as the first step in the 5As, maybe "seek permission"
Use a person centered approach
Acknowledge the important of a strong therapeutic relationship
Recognising that using the 5A approach, when asking and assessing the patient may not be ready to move onto the next steps of advise/agree/assist
51
What are approved pharmacotherapies for weight loss?
1. Phentermine
2. Contrave (bupropion/naltrexone)
3. Orlistat (this is the only TGA approved and PBS funded medication for weight loss)
4. Saxenda (Liraglutide).
52
What is the general tGA requirements for all current approved weight loss pharmacotherapy?
if BMI> 30 or BMI between 27-30 with weight related complication (HTN, diabetes, lipids)
(For phentermine BMI of >25 with related morbidity is ok. )
53
Under what condition should Saxenda be discontinued beyond 12 weeks?
According to the tGA
Treatment with Saxenda should be discontinued after 12 weeks on the 3.0 mg/day
dose if a patient has not lost at least 5% of their initial body weight.
54
What comprises of the "Top Ten Tips" for weight control
(10)
Keep to your meal routine
Go for reduced fat
Walk off the weight: approx 10000 steps a day or 60-90 minutes of moderate intensity exercise
Pack a healthy snack (beware of sugar content in yoghurts, muesli and fat content in cheese)
Learn the labels
Caution the portions (don't heap food on a plate)
Up on your feet (reduce sedentary behaviour, at the least 10 minutes of walking/being up every 1 hour)
Think about beverages. choose water first
Focus on your food, don't eat on the go or infront of the TV
Don't forget vegetables
55
What are the main points to note in examination when assessing head injury?
(6)
1. Gaze disturbances
2. Pupillary reflexes
3. Gross motor and sensation in the limbs
4. Postural instability: gait, rombergs test
5. Auditory processing. (observe how they respond)
6. Neurocognitive: basic orientation Time, place, person, what they were doing at the time. "MADDOCKS QUESTIONS" - very sport specific.
56
What is the recommended time frame for return to school / work activities in a young person after a concussion?
1. Acute rest phase 2 days minimum up to- 5 days
Shouldn't need more than 3 days off school
No cognitive activity for 2-3 days. Complete cognitive rest at home including screen/TV time
Move onto next stage if no headache for a full day
2. Relative rest phase 5-7 days
Might still be symptomatic but can tolerate at least 30 minutes of concentration. Build up to 3 half days. no sport in recess
3. Graduated exertion phase 7-14 days
No medications needed to treat concussion related symptoms. Return to full school program by the end of it.
57
When can a young person return to sport after a concussion?
What is the likely fastest time to return to full game play if initially symptomatic?
concussion being defined as mildly symptomatic minor head injury.
They can only return to sport after returning to school.
Sport progression:
6 steps, with 24 hours between each step after that.
day 1- no rest
day 2 -light aerobic
day 3 - sport specific exercise no overhead or lifting
day 4 - non contact sport drills
day 5 -full contact practice
day6- full contact sport / return to normal
Going back to a full cognitive load at school can take up to 14 'school' days.
Only after this can they start the sports progression. Which can take 7 days.
58
What are high risk groups that need antibiotics for a sore throat?
patients aged 2 to 25 years from populations with a high incidence of acute rheumatic fever (
Those with existing rheumatic fever
Those with scarlet fever
Also recommended for patients with severe symptoms of pharyngitis (eg patients requiring hospitalisation, patients with severe throat pain or dysphagia
59
What should be done prior to any antibiotic administration?
A throat swab PCR and bacterial MCS
(2 swabs)
60
What is a recommended time from for follow up for a sore throat, if symptoms are not improving, with or preferably without antibiotics
3-7 days or sooner if worsening
61
Empiric antibiotic for a sore throat?
Phenoxymethylpenicillin 500mg, orally, 12 hourly for 10 days
(child 15mg/kg up to 500mg)
Do not use amoxicillin as it is too broad spectrum
62
If a patient is unlikely to adhere to a 10 day course of antibiotics for a sore throat what can be done?
IM Benzathine penicillin as a single dose
63
For A sore throat what medication can be given instead of penicillin if there is ...
a. a delayed non severe reaction to penicillin?
b. a severe penicillin reaction?
a. Cephalexin 1gram 12 hourly, orally, for 10 days.
(Child: 25mg/kg up to 1g)
b. Azithromycin 500mg, daily orally for 5 days
(child 12mg/kg up to 500mg)
64
What are 5 steps you can take in shared decision making about antibiotics?
1. Reassure that condition is unlikely to change much with antibiotics e.g. sore throats usually don't respond any faster (maybe 1 day difference)
2. Explore their ideas and concerns about it
3. Give options for treatment. e.g. expectant, analgesia, anti-inflammatory, antibiotic
4. Risks and benefits of the antibiotic: side effects- diarrhoea, resistance.
5. Make a decision
65
What are clinical features of a GAS throat infection?
(5)
Fever > 38
Tender Cervical lymphadenopathy
Tonsillar exudate
ABSENCE of a cough
Rhinorrhoea or nasal congestion
66
What is scarlet fever?
What is the recommended treatment?
It is a common cause of a sore throat in those aged 5- 15 years old.
Usually caused by streptococcus pyogenes.
Has a distinct rash.
Treatment is primarily supportive. Does not need antibiotics unless patient is in a high risk group (in another question).
67
In a severe sore throat, not responding to simple analgesia, what can be used?
dexamethasone 0.15 to 0.6 mg/kg (max 10 mg) oral/IV/IM as a single dose
or
prednisolone 1 mg/kg (max 50 mg) oral as a single dose
68
After a sore throat caused by an EBV infection, what 2 specific points of advice is needed?
1. Fatigue can last for months
2. Avoid contact sports for about 4 weeks (as EBV can cause spleen enlargement and predisposes to rupture)- still rare and occurs in 0.5% of cases.
69
What tests, and why, should you order when suspecting EBV as a cause for a sore throat?
Need a serology for EBV detection not a throat swab PCR
Also order FBC with blood film to detect for haemolytic anaemia if for some reason the spleen is affected.
70
What are some red flag clinical features that may require hospitalisation for a sore throat
1. Drooling
2. Muffled voice
3. trismus (restricted jaw ROM)
4. Neck swelling
5. Stridor
6. Respiratory distress
7. unilateral throat pain
8. Signs of airway compromise
9. Signs of septic shock
71
What are specific sore throat conditions that NEED HOSPITAL
Acute epiglottitis
Retropharyngeal abscess
SEVERE EBV infection
SEVERE croup
Peritonsillar abscess and peritonsillar cellulitis
Pharyngeal diphtheria
72
What are adjuvant treatments for neuropathic pain?
(3)
Gabapentinoids
TCAs
SSRIs, SNRIs
73
From the following list, which medications can be considered for treating neuropathic pain
A. Anti-epileptics:
B. Cannabinoids
C. Topical capsaicin
D. Clonidine
E. Ketamine
F. Lidocaine systemic or topical
A. gabapentinoids can be, others like carbemazepine can be used in trigeminal neuralgia, lamotrigine to only used by specialists
B. Cannabinoids are currently only indicated for spasticity in MS. Otherwise there is no evidence for use and is not currently recommended. Also products have no clear pharmaceutical profile and are not regulated
C. Capsaicin (low dose) can be used for MSK pain. but is no better than placebo for chronic neuropathic pain. Higher dose capsaicin has some efficacy but is not licensed for use in Australia- would need the special access scheme
D. Clonidine. Specialist only
E. Ketamine. Does work. Not licensed for use in Australia.
F. Lidocaine systemic - can be used. but preferably by practitioners experienced with use. Best for post operative or cancer pains
Lidocaine topical - is useful. used for post herpetic neuralgia. Easy to use for elderly or frail patients.
73
From the following list, which medications can be considered for treating neuropathic pain
A. Anti-epileptics
B. Cannabinoids
C. Topical capsaicin
D.
74
What is the drug of choice for acute neuropathic pain?
A gabapentinoid.
e.g.
Pregabalin. 25-75mg, orally, at night initially increasing to twice a day over 3-7 days. Continue to increase dosing every 3-7 days up to a max of 600mg (total) a day.
Gabapentin 100mg- 300mg, orally at night. Same instructions, max dose: 3.6 grams
75
What are second line options for neuropathic pain?
SNRIs
e.g duloxetine 30mg, oral, in the morning up to 120mg (day), increase every 7 days
or venlafaxine 37.5mg orally, daily, increasing every 7 days up to 225mg.
TCAs
e.g Amitriptyline 5- 12.5mg, orally, at night, increasing as needed every 7 days up to a total of 150mg at night.
76
What findings on history/exam identifies neuropathic pain
(4)
1. Pain description as shocks/burning
2. Allodynia or hyperalgesia on examination
3. Motor or sensory deficits in the painful area
4. consistency between the area in which the pain is experienced and the innervation area of the affected neural structure.
77
What and when is treatment for this indicated?
This is Shingles. Reactivation of herpes Zoster virus.
treatment is indicated if
adults and adolescents who present within 72 hours of onset of rash,
And for all
immunocompromised adults and adolescents (including those with HIV infection) regardless of duration of rash.
78
What is first and second line treatment for anti-virals to treat shingles?
Famciclovir 500 mg, orally, 8 hourly for 7 days. (10 days duration for immunocompromised)
(better at preventing post herpetic pain)
Second line, and if in children or pregnant women:
Aciclovir 800mg (20mg/kg), orally, 5 times a day for 7 days.
79
Post herpetic pain is common after a shingles infection. What can be used for mild pain?
lidocaine 5% patch, up to 3 patches applied at the same time to the painful area (after shingles has healed). Wear for up to 12 hours, followed by a patch-free interval
Do not apply to broken skin
80
What can be used for moderate to severe pain if you have utilised paracetamol, NSAIDs and topical patches?
prednisolone 50 mg orally, in the morning for 7 days
81
For severe shingles pain, when you've exhausted the topical lidocaine, paracetamol, NSAIDs and prednisolone, what else can be done?
In this case it is reasonable to consider an opioid short term.
Tramadol or Tapentadol IR
both: 50-100mg, orally, 4-6 hourly as needed (max 400mg/day)
Pregabalin or Gabapentin are also appropriate.
82
Non pharmacological management of hypertension?
(7)
1. Regular aerobic exercise 150 minutes / week moderate intensity
2. Smoking cessation
3. Reducing alcohol
4. Moderate sodium restriction
5. Healthy diet such a mediterranean diet
6. Weight reduction
7. Treatment of OSA
83
What are three first line drug classes for treating hypertension?
ACEi, or ARBs
Dihydropiridine CCB (amlodipine, lercandipine)
Thiazide and Thiazide like diuretics (HCT)
84
Give dosing instructions for an ACEi and ARB for blood pressure?
Perindopril arginine 5- 10mg, orally, daily
Perindopril erbumine 4-8mg, orally, daily
Candersartan 8-32mg, orally, daily
Irbesartan 150-300mg, orally, daily
Telmisartan 40-80mg, orally, daily.
85
When is it advisable to START anti-hypertensive medication?
when there is a high cardiovascular risk > 15%
If there is a moderate risk 10-15% but any of:
family hx of premature CVD
ABTSI
BP raised consistently >160/100
If there is a low risk (<10%) but BP is consistently > 160/100mmHg even with lifestyle advice.
86
If one BP drug doesn't work at the initial dosing what should be done next?
First add another low dose of another drug
If still not adequate then increase strength of one of the two drugs
If still not adequate add a low dose of third drug
87
what are secondary causes of hypertension?
(5)
Chronic Kidney Disease
Renal Artery Stenosis
Thyroid disease
Adrenal disease specifically primary hyperaldosteronism.
OSA
88
What should you do for a person with a BP of 190/100 but are not symptomatic?
Does not need emergency treatment
Assess for risk factors and send to hospital if indicated (e.g. coaguloatphy, CKD, aneurysms, recent vascular procedures)
No urgency to start a new drug until investigated
Investigate for secondary causes
Follow up in a few days maximum
For BP >220/140 send to E.D for work up and management.
89
Investigations for BP > 180/100
LFTs
EUC + kidney function
Urinanalysis
ECG
?U/S renal arteries or CT angio (better option)
90
What are systemic cause of bilateral oedema?
Allergic reaction to drugs or other
Cardiac disease
Hepatic Disease
Renal Disease
Poor protein absorption/intake
Pregnancy
OSA
91
What are localised (or unilateral) causes of pitting odema?
Cellulitis
DVT
Compartment syndrome
Lipedema (accumulation of fluid in adipose)
Lymphoedema - post surgery, tumour, trauma, radiation
92
Describe three things you are seeing on examination that support venous insufficiency?
Varicose veins in the feet
Venous stasis ulcer
Haemosiderin deposition
93
For this condition , what antibiotic would you use?
No systemic features, no ulcers or penetrating lesions.
What about if delayed non severe reaction to penicillin?
Or if severe penicillin reaction?
Phenoxymethylpenicillin 500mg, oral, 6 hourly, 5 days.
Or
Cephalexin 500mg, oral, 6 hourly, 5 days
If severe reaction
Clindamycin 450mg oral, 8 hourly, 5 days
94
For Cellulitis with an ulcer or penetrating lesion, what empiric antibiotic should you chose?
Or if staph. aureus is suspected
Second line if non severe reaction to penicillin?
flucloxacillin or dicloxacillin 500mg, oral, 6 hourly, 5 days.
Second:
Cephelaxin 500mg, oral, 6 hourly, for 5 days
95
What dietary advice should be given to those with raised cholesterol?
1. Replace transfats altogether in the diet
2. Reduce intake of saturated fat
3. Increase soluble fibre intake
4. Introducing plant sterol-enriched milk, margarine or cheese (this is the most effective measure at reducing LDL)
96
What medication can you start if initial statin therapy is not enough to lower cholesterol?
What would you start if triglyceride elevation was the primary concern?
1. Ezitimibe 10mg, oral daily
2. Fenofibrate, oral, daily dosing (depends on eGFR but if > 60 then 140mg)
PLUS fish oil equivalent of 2-4 mg of OMEGA-3 Fatty acids, oral, daily
97
What is the DLCN criteria? What can contribute to points?
Dutch lipid Clinical network diagnostic criteria for familial hypercholesterolemia.
patient with premature CAD 2points
Acrus corneileus 4 points
Tendon Xanthomata 6 points
LDL > 8.5 6 points
LDL 6.5-8.5 is 4 points
You need MORE than 8 points for a definite diagnosis and between 6-8 for a probably.
98
What is a coronary calcium score and who should get it?
It is a CT scan of coronary arteries that looks at calcium deposition.
Usually for those who have low CVD risk but with risk factors (over 40 and ABTSI, 40-60 with diabetes, family history of premature CAD), or for those with an intermediate CVD risk (10-15%).
Most useful in guiding statin therapy.
99
What structure/algorithm can you use to help assess a pigmented skin lesion when using a dermatoscope?
When might this structure/algorithm not be useful?
"Chaos and Clues"
This begins by looking at symmetry, however some symmetrical lesions can still be malignant. So don't always rely on this.
100
Which pigmented lesions, that appear symmetrical should be considered for a biopsy?
1. a changing lesion
2. any lesion on head or neck with a dermatoscopic grey appearance
3. A NODULAR pigmented lesion
4. Any pigmented acral lesion
101
What are the 8 "clues" when assessing a pigmented lesion?
1. Eccentric structureless area
2. Thick reticular lines or branches
3. Grey or blue structures
4. Black dots or clods, peripherally
5. Radial lines, psuedopods or segmental lines
6. White lines
7. Polymorphous vessels
8. Acral ridge lesions or chaotic nails
102
Which "clues" are these showing?
1. eccentric structureless
2. Blue clods
5a and b. Radial central lines
6. White lines
7. Polymorphous vessels
103
Is this a suspicious pigmented lesion?
Yes.
It is "chaotic" i.e. not symmetrical.
104
Screening the general population for B12 deficiency is not recommended.
Which groups of people might you consider testing?
(7)
1. Those with small intestine or gastric resections
2. Bowel disease: Inflammatory bowel disease, tapeworm.
3. Use of metformin > 4 months
4. Use of a PPI or antihistamine (H2 blockers) > 12 months
5. Those aged over 75
6. Vegans or strict vegetarians
7. Alcohol abuse (inadequate intake)
105
What foods have b12?
fish, meat, dairy products, fortified cereals and supplements.
106
Vitamin B12 deficiency affects __(a)___ systems, and sequelae vary in severity from mild fatigue to severe __(b)___ impairment.
Symptoms typically include being easily __(c)__ with exertion, palpitations, and skin __(d)__.
Bone marrow suppression is common and potentially affects all cell lines, with megaloblastic anemia being most common.
Neurologic manifestations are caused by progressive demyelination and can include ___(e)__ ____, areflexia, and the loss of ___(f)___ and vibratory sense.
Dementia-like disease, including episodes of __(g)__, is possible with more severe and chronic deficiency.
a. multiple
b. neurological
c. fatigued
d. pallor
e. peripheral neuropathy
f. proprioception
g. psychosis
107
What are the most likely causes of fatigue?
(4)
1. Depression/Anxiety
2. Stress (work related, family etc)
3. Post viral infection
4. sleep related disorders (including: OSA, insomnia, shift work)
108
What are SERIOUS causes of fatigue?
(6)
1. Malignancy
2. Anaemia - this is not a disease itself. So it might be something as benign as poor iron intake or as sinister as a malignancy
3. Cardiac arrhythmias
4. HIV, Hep C
5. Occult bacterial infection
6. Haemochromatosis
109
Apart from the 4 most common causes of fatigue (depression, stress, sleep, osa, and post-viral) and the more serious causes (arrhythmias, malignancy, anaemia, HIV, HH), what are some endocrine and metabolic related causes?
(4)
1. Diabetes mellitus
2. Hypothyroidism
3. Renal failure
4. Metabolic conditions (very vague)
also coeliac disease and OSA (though that falls under sleep)
110
What are red flag features, when faced with a presentation of fatigue?
Think about the serious causes
1. Lymphadopathy HIV? Lymphoma?
2. Unintentional weight loss - various
3. Fever- infection
4. SOB- arrhythmia or pulmonary infection, heart failure, COPD
5. Recent onset or progression of cardiovascular, gastroenterological, neurological or rheumatological symptoms: HH, RA, SLE
6. Abnormal bleeding anywhere
111
What would you examine in someone presenting with tiredness/fatigue/lethargy?
(9)
1. Vital signs
2. Body habitus, weight, WC
3. General appearance ?anaemic ?jaundice ?dehydrated
4. Mental health questionnaires
5. Cardiovascular respiratory
6. Abdominal - massess
7. Lymphadenopathy
8. thyroid exam
9. OSA assessment includes, neck and waist circumference and ESS
112
Initial investigations appropriate for lethargy?
(7)
1. FBC
2. EUC
3. LFT
4. ESR/CRP
5. Fasting BGL
6. TSH
7. Ferritin
can order others depending on clinical suspicion
example urine ACR for kidney disease or MCS or PCRs for infections, imaging if exam indicates the need.
113
What are important points to elicit on history of haemoptysis?
(9)
1. Associated SOB
2. Associated weight loss
3. Associated fevers
4. Work exposure e.g. asbestos, wood dusts, silica
5. Environmental exposure to high air pollutants.
6. Chest or shoulder pain
7. Hoarseness of voice.
8. Active or passive smoking
9. family history of lung cancer
114
What is 'conservative' management for haemorrhoids?
And which grades of haemorrhoids does it apply to?
1. Relieving constipation. Usually by increasing fibre intake.
2. Can use mild laxatives
3. Avoid medications that cause constipation e.g. codeine.
This works best for first degree haemorrhoids, but is applied to all four degrees of haemorrhoids
115
What are the grades of haemorrhoids, and their treatments?
Grade 1. Bleeding, with no prolapse
Grade 2. Bleeding and prolapse that reduces after defecation
Grade 3. Bleeding and prolapse that has to be manually reduced. Painful if large .
Grade 4. irreducible prolapse. Usually thrombosed.
Treatment on flowchart
116
What are the two main aspects of symptomatic management for this?
1. Avoiding constipation: fibre, stool softeners
2. Local anaesthetic topical application
3. Local GTN Application- advise not to get onto normal skin and expect a headache. Alternatively a topical calcium channel antagonist (diltiazem can be used)
117
What is the first line treatment, for cellulitis without systemic features. Non purulent but rapid spreading.
First line
phenoxymethylpenicillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days
If delayed and non severe hypersensitivity
cefalexin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days.
If immediate or severe hypersensitivity
clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 8-hourly for 5 days
118
For purulent cellulitis (eg associated abscess, furuncle), or if S. aureus is suspected based on clinical presentation (eg penetrating trauma, associated ulcer) what can you use:
dicloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days. (or flucloxaxillin)
For delayed non severe hypersensitivity
cefalexin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days.
For immediate or severe hypersensitivity
trimethoprim+sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly for 5 days
119
What is the STOPBANG questionnaire used for?
What does it compromise off?
(1)
(9)
It is used to SCREEN for Obstructive sleep apnoea (OSA).
S- snoring
T- tiredness
O- observed aponoas
P- high blood pressure
B- BMI > 35
A- Age > 50
N- neck circumference > 40cm
G- gender, male
A score of 3 or more can indicate OSA
Though the MBS rebate requires a score of at least 4 for a sleep study.
The higher the cut off value the more specific the test is, but the less sensitive.
120
What to address with a patient, when managing obstructive sleep apnoea?
(5)
1. Workplace and driving safety
2. Obesity if relevant (usually is)
3. Hypertension
4. Adenotonsillar hypertrophy
5. Depression
121
When a sleep study returns it usually comes back with an AHI and P90, for assessment of severity.
What do these measure, and what are the cut offs
(2)
(2)
AHI- apnoea hypoapnoea index.
apnoea; The amount of time not breathing > 10 seconds,
hypoapnoea; reduction in airflow for > 10 seconds causing a saturation dip or waking from sleep
usually anything > 5 events is diagnostic
> 15 events is usually severe
P90- time of total sleep spent with oxygen saturations dipping below 90%.
1-5% can indicate OSA
>5% is usually severe
122
The following symptoms might indicate?
-morning headaches
-dry throat
-poor concentration
-reduced libido
-fatigue
Obstructive sleep apnoea
