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GP- Common presentations Flashcards

1
Q

What signs are specific for Graves’ disease when assessing hyperthyroidism?

A
  • Thyroid acropatchy
  • Exophthalmos
  • Opthalmoplegia
  • Pretibial myxoedema
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2
Q

What Ix are required for suspected hypothyroidism?

A
  • TFTs
  • Anti-TPO and thyroglobin Abs
  • US
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3
Q

What Ix are required for suspected hyperthyroidism?

A
  • TFTs
  • TSH-R antibodies
  • Nuclear scan
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4
Q

Signs and symptoms of hypothyroidism?

A
  • Fatigue
  • Sleepiness
  • Cold intolerance
  • Weight gain
  • Muscle aches
  • Bradycardia
  • Constipation
  • Menstrual irregularities
  • Dry skin
  • Coarse or brittle hair
  • Oedema, especially periorbital
  • Xanthelasma
  • Difficulty with concentration and memory
  • Onycholysis
  • Myxoedema coma: profound hypothermia, bradycardia, skin and facial changes
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5
Q

Signs and symptoms of hyperthyroidism?

A
  • Fatigue
  • Insomnia
  • Heat intolerance, excessive sweating
  • Weight loss
  • Weakness, proximal myopathy
  • Palpitations, tachycardia/AF
  • Diarrhoea
  • Oligomenorrhoea
  • Warm and moist skin
  • Hair loss
  • Nervousness, emotional lability
  • Poor concentration
  • Dyspnoea
  • Hyper-reflexia (brisk) and muscle spasm
  • Lid lag, retraction, thyroid stare and exophthalmos
  • Goitre
  • Onycholysis
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6
Q

What is a “cold” thyroid nodule?

A

Either cancer or cyst

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7
Q

What is a “hot” thyroid nodule?

A

Nodule that secretes T3/T4

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8
Q

What pathogens commonly cause UTIs?

A
  • E. Coli
  • Proteus
  • Enterococcus
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9
Q

What pathogens commonly cause typical CAP?

A
  • S. pneumoniae

- Hib

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10
Q

What pathogens commonly cause atypical CAP?

A
  • Mycoplasma
  • Chlamydia
  • Legionella
  • S. aureus
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11
Q

What pathogens commonly cause meningitis (adults and children >2mo)?

A
  • N. meningitidis
  • S. pneumoniae
  • Hib
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12
Q

What pathogens commonly cause meningitis in children?

A
  • S. pneumoniae
  • GBS
  • Listeria monocytogenes
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13
Q

Who do you screen for T2DM?

A

Every 3 years from

  • 40yo and above
  • Or 18yo if Aboriginal
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14
Q

Presentations of T2DM

A
  • On screening
  • Polyuria, polydipsia, weight loss (uncommon)
  • Blurred vision
  • Paraesthesias
  • Fatigue
  • Skin and candidal infections
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15
Q

Risk factors for T2DM

A
  • FHx of DM
  • Hx of GDM
  • CVD risk factors: BMI, HTN
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16
Q

Diagnostic Ix for T2DM

A
  • OGTT >11.1mmol/L (2hr)
  • Fasting BG >7mmol/L
  • HbA1c >6.5%
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17
Q

What monitoring is required every 6 months in T2DM?

A

SNAP, BMI, BP, HbA1c

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18
Q

What monitoring is required every 12 months in T2DM?

A

Eye and foot exams, kidney assessment

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19
Q

What monitoring is required every 24 months in T2DM?

A

Retinal screening, lipid assessment

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20
Q

What are the Mx options for T2DM?

A
  • Screen for and manage complications and CVD risk
  • Lifestyle changes: weight loss, diet/exercise, smoking and alcohol
  • Monotherapy: metformin (sulphonylurea 2nd)
  • Dual therapy: metformin + sulphonyluyrea (2nd = DPPIV inhibitor or GLP-1 agonist)
  • Triple therapy: metformin + sulphonylurea + DPPIVi/GLP-1
  • Insulin (± metformin): basal then bolus
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21
Q

Complications of T2DM

A
  • Microvascular: nephropathy, retinopathy, delayed wound healing, erectile dysfunction
  • Macrovascular: IHD, HTN, PVD, CVA
  • Cellular: neutrophil dysfunction, peripheral neuropathy, NASH
  • Autonomic: labile BP and postural hypotension, incontinence, gastroparesis, N+V
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22
Q

What symptoms should prompt urgent colorectal referral?

A

> 40 yo with unexplained wt loss + abdo pain
50 yo with unexplained rectal bleeding
60 yo with FeD anaemia or change in bowel habit
Positive faecal occult blood test

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23
Q

What are the abnormal blood results (PTH, ALP, Vit D, Ca, P) in osteoporosis

A

Normal PTH, normal Ca & P +/- low Vit D, tend to have high ALP (increased with increase # risk)

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24
Q

What is Rx for chlamydia? What are screening guidelines?

A

High dose azithromycin or doxycycline

All sexually active people b/w 15 - 29 should be screened with urine PCR annually
Also screen if any current UTI, partner with symptoms or > 2 partner in a year

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25
Q

What is Rx for gonorrhoea?

A

High dose azithromycin and cephalosporin

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26
Q

What are the clinical features of OA?

A

Joint pain with movement - usually improves with rest (may not in severe disease)
Crepitus on joint movement
Bony swelling
Bony tenderness on palpation (esp. joint line)
Bony enlargement or deformity
Reduced range of movement
Morning stiffness or ‘gelling’ after prolonged inactivity - time is less than in inflammatory arthritis (

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27
Q

What are red flags of joint pain?

A 
Inflammatory symptoms (swelling, warmth, redness)
Constitutional symptoms 
Sudden onset 
Nocturnal pain
Pain which does not improve with rest 
Recent trauma 
Morning stiffness > 30 minutes 
Loss of function
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28
Q

What are risk factors/possible causes of OA?

A

Hx of injury/trauma to joint
Significant physical activity - overuse, high impact
Genetic - esp. when affecting small joints of hands
Overweight/obesity
Increasing age
Female gender
Muscle weakness - muscles contributing to joint stability & function
Proprioceptive defects

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29
Q

What is the pattern of joint involvement in OA?

A

Small joints of hands - DIP & PIP involvement (spaces MCP)
1st MCP and IP joints (thumb) & 1st MTP (toe)
Weight bearing joints - knees, hips, spine
Usually doesn’t affect elbow, wrist or ankle

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30
Q

What are XRAY features of OA?

A

Loss of joint space (asymmetrical)
Osteophytes
Subchondrial sclerosis
Subchondrial cysts

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31
Q

How should you diagnose OA?

A

Clinical diagnosis which generally doesn’t require other Ix

Do not need to routinely XRAY - perform if red flags, severe impairment, to grade/identify severity of disease or initial diagnosis of HIP
XRAY features have poor correlation with symptoms (except in advanced disease)

If need to exclude inflammatory cause - ESR, CRP, Anti-CCP (ACPA), RF

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32
Q

What are important lifestyle factors to assess in initial diagnosis of OA?

A

Impact on function (occupational, ADLs, leisure), mood, sleep
Psychosocial/Yellow flags contributing to chronic pain - i.e. attitudes to recovery
Level of physical activity
Treatments previously tried and their effectiveness

33
Q

What is the treatment for OA?

A
  1. Lifestyle measures
    - Weight loss, exercise programs, psychological strategies to manage pain (i.e. CBT), consider physio referral, education on self-management & support groups
  2. Simple analgesia +/- adjuvant topical treatments in short term (NSAIDs, capaicin - may provide some short term relief ~10days)
  3. Consider short term NSAID use (must consider risks, if increased GIT risk co-prescribe PPI)
  4. Consider intra-articular corticosteroid injection for short term benefit i.e. if travelling, particular event/task (can provide benefit for 4-12 weeks, should not be done >4/year)
  5. Consider adjuvant complementary non-pharm techniques (may have some minimal evidence, but don’t harm) i.e. accupuncture, TENS

Glucosamine and chondriton don’t have consistent evidence for benefit so should not be recommended

34
Q

What are the normal and diagnostic values for T2DM?

A

Optimal 4 - 6.1
Impaired GT 6.1 - 6.9

Diagnostic
Random fasting >7
Random non-fasting >11
OGTT > 11.1 at 2 hours

35
Q

Clinical features and risk factors of cataracts

A

Opacity/clouding of lens
Myopic shift - vision improves with pin hole
Loss of red reflex
Normal pupil response
May have halos around vision (more so at night)
Glare sensitivity, difficulty driving at night
Colours less bright
Usually bilateral

Risk factors - increasing age, steroids, myopia, diabetes, FHx, intra-ocular infection or trauma, HTN, increased alcohol

36
Q

Clinical features & risk factors of open-angle glaucoma

A 
gradual, painless vision loss 
Peripheral vision effected - visual field defect - often bump into things 
Raised IOP > 21mmHg
Usually asymmetrical (can be bilateral)
Increased cup-disc ratio

Risk factors - diabetes, steroids, increasing age, HTN, graves disease, FHX

37
Q

Clinical features & risk factors of macular degeneration

A

Most common cause of blindness
Bilateral - one eye usually more effected
Gradual loss of central vision
Central scotoma - bits missing i.e. when reading
Lines appear bent or wavy - distortion on amsla grid

Can be wet or dry

  • Wet 10%, worse prognosis, choroidal neovascularisation, good treatment if early
  • Dry 90%, no specific/good treatment, drusen (yellow) spots +/- pigmentation changes

Risk factors - increasing age, HTN, female, caucasian, smoking

38
Q

What ECG leads correspond to anterior, inferior & lateral infarction and their corresponding arterial supply

A
  1. Anterior
    V1 - V4
    LAD
  2. Lateral
    aVL, Lead I, V5 - V6
    Circumflex
  3. Inferior
    aVF, Lead II - III
    RCA
39
Q

What increases the probability of a diagnosis of asthma in children?

A 
Hx recurrent or persistent wheeze 
Difficulty breathing 
tight chest
cough 
Hx or FHx allergies
FHx asthma 
Consistent clinical response to inhaled bronchodilator 
Symptoms worse at night or early morning 
Associated with triggers
40
Q

What investigations can be performed to support diagnosis of asthma in young children?

A

Spirometry - if able to, usually older than 4-5 yrs
Allergy testing - can help with trigger avoidance and prognostics
Bronchial provocation test if diagnosis unclear
CXR not routinely recommended

41
Q

What are the different patterns of asthma in children 0-5 yrs vs. 6+ yrs?

A
  1. infrequent intermittent - flareups >6 weeks apart (no symptoms between)
  2. persistent, intermittent - symptoms more than once every 6 weeks but no symptoms between

3a. Mild persistent - one of daytime symptoms >once/week or night time symptoms >2 month
* FEV1 >=80%

3b. moderate persistent - any of daily daytime symptoms, night time symptoms >once/week or symptoms sometimes restrict activity/sleep
* FEV1

42
Q

What are the indications for preventer medication in children

A

Consider in frequent intermittent or any persistent asthma patterns

Trial medication and review in 2-4 weeks 
1st line = sodium cromoglycate (1-2), montelukast (2+) 
2nd line (if no response) = low dose ICS
43
Q

What should an asthma management plan for children include?

A
  1. Written and tailored to the child
  2. Medication and instructions for preventer/maintenance therapy
  3. Triggers to avoid, what to do before exercise
  4. Signs that help parent determine the severity of the symptoms and instructions on Rx for each case (i.e. how to adjust Rx)
  5. Signs for when to seek medical advice
  6. Danger signs to seek urgent medical advice and appropriate action to take
44
Q

How are severity of acute asthma symptoms defined in children?

A

Mild/moderate - can walk and talk in full sentences

Severe - can’t talk in full sentences, visible breathlessness and increased work of breathing, sats 90 - 94%

Life-threatening - altered conscious state/collapsed, cyanotic, poor respiratory effort, sats

45
Q

What is the acute Rx of asthma in children?

A
  1. commence salbutamol therapy with spacer (use mask if very young or O2 driven nebuliser if can’t breath with spacer or life-threatening asthma only)
    - can give every 20-30 minutes in mild-severe
    - continuous in life-threatening
  2. Titrate O2 to maintain sats at least 95%
  3. Arrange ICU transfer if life-threatening
  4. Add ipratropium bromide every 20 mins if still no effect
  5. Systemic steroids in first hour (oral or IV) - avoid if
46
Q

What is the CHA2DS2-VASc score?

A 
Age: 65-74yo = 1, >75yo = 2
Stroke/TIA Hx = 2
DM = 1
Prior MI/vascular disease = 1
HTN = 1
CHF/LV dysfunction = 1
Female = 1
47
Q

What is the HASBLED score?

A 
All worth 1:
Age >65yo
Abnormal renal function (dialysis/transplant)
Abnormal LFTs (cirrhosis, 3x ULN)
Hx of major bleeding
History of labile INR
Alcohol use (>8 per week)
Currently taking NSAID or antiplatelet
48
Q

Adverse effects and contraindications of metformin?

A

C/I = renal impairment (GFR

49
Q

What are the abnormal blood results (PTH, ALP, Vit D, Ca, P) in osteomalacia

A

Low Vit D, low Ca and P, normal PTH, high ALP

50
Q

What are the abnormal blood results (PTH, ALP, Vit D, Ca, P) in hyperparathyroidism

A

High PTH, increased Ca, low P, increased ALP

51
Q

What are the abnormal blood results (PTH, ALP, Vit D, Ca, P) in Paget’s disease

A

Normal PTH, normal Ca and P, markedly increased ALP

52
Q

MOA and adverse effects of sulphonylureas

A

MOA = increase insulin secretion

A/E:
Weight gain
Hypoglycaemia
Anorexia, nausea, diarrhoea
Rashes
Blood dyscrasias
53
Q

MOA and A/E of acarbose

A

MOA = inhibit digestion of CHO

A/E:
Flatulence, bloating
Rare liver abnormalities

54
Q

MOA, C/Is and A/E of glitazones

A

MOA = sensitive liver and peripheral tissues to insulin

C/Is = mod-sev HF, risk of bladder cancer

A/E:
Increased subcutaneous fat
Anaemia
Increased # risk
Increased LDL
55
Q

MOA and A/E of DPP4 inhibitors

A

MOA = increase levels of incretins

A/E:
Nasopharyngitis
Headache
URTI Sx

56
Q

MOA and A/E of GLP-1 agonists

A

MOA = activate GLP-1 receptor

A/E:
N+V
Pancreatitis (rare)
Weight loss

57
Q

MOA, C/I and A/E of SGLT2 inhibitors

A

MOA = prevent renal absorption of glucose

C/I = renal impairment

A/E:
Weight loss
Increased UTIs
Aggravate dehydration

58
Q

Salbutamol, Terbutaline

  1. Class
  2. Mechanism of action
  3. Available routes of delivery
  4. Side effects
A
  1. Short acting B2 adrenoreceptor agonist
  2. Induces bronchial smooth muscle relaxation - limited systemic effect
  3. Inhaler +/- spacer, nebuliser, oral
  4. Tachycardia, tremor, hypokalaemia (very high doses)
59
Q

Ipratropium

  1. Class
  2. Mechanism of action
  3. Available routes of delivery
  4. Side effects
A
  1. Short-acting muscarinic receptor antagonist
  2. Reduces parasympathic nerve activation (via ACh-MR path), thus reducing bronchoconstriction
  3. Inhaler, nebuliser
  4. Dry mouth, throat irritation
60
Q

Salmeterol, eformoterol

  1. Class
  2. Mechanism of action
  3. Available routes of delivery
  4. Side effects
A
  1. Long-acting B2-adrenoreceptor
  2. Persistent low level activation of ARs, reducing constrictor binding, thus net resting bronchodilator tone
  3. combination with ICS or turbuhaler & accuhaler individually
  4. Tolerance can occur, tremor, palpitations, headache

Improves QOL, symptoms and reduces frequency & severity of exacerbations in COPD

61
Q

Fluticasone, Budesonide

  1. Class
  2. Mechanism of action
  3. Available routes of delivery
  4. Side effects
A
  1. Inhaled corticosteroids
  2. Decreased recruitment of inflammatory mediators and SMC - reduces remodelling (longer term) and inflammation and hyper-responsiveness (short-medium term)
  3. Combined with LABA or indivudally
  4. Dysphonia, oral thrush
62
Q

Use of SAMA vs. SABA in COPD and Asthma

A

SABA 1st line to SAMA
SAMA ? increased risk CVD
Can be used in combination

63
Q

Tiotropium

  1. Class
  2. Mechanism of action
  3. Available routes of delivery
  4. Side effects
A
  1. Long-acting muscarinic antagonist (LAMA)
  2. persistent reduction of parasympathic nerve activation - reduced bronchoconstriction
  3. Individually (spiriva inhalers) for COPD
  4. Dry mouth, throat irritation

Largely used for COPD, can be used to control asthma if on hgih dose ICS+LABA

Improves QOL, symptoms and reduces frequency & severity of exacerbations in COPD

64
Q

Use of LAMA vs. LABA in COPD

A

Both same benefits in improving QOL, symptoms & reducing frequency & severity of exacerbations

Response is individual

Can be used in combination

65
Q

Hypoglycaemia Mx in DM

A

Rule of 15s:
15 grams of a quick acting CHO
Wait 15 minutes and repeat BGL check
If not rising, add another quick acting CHO
If patient’s next meal is >15 minutes away, provide a longer acting CHO
Test glucose again during the next 2-4 hours

66
Q

GORD red flags

A 
Dysphagia, odynophagia
Unexplained weight loss
Persistent vomiting
Haematemesis, malaena
Signs of anaemia

REFER TO ENDOSCOPY IF PRESENT

67
Q

GORD lifestyle Mx

A

Weight loss
Avoid exacerbating foods, eg/ spicy foods, citrus, fatty foods, caffeine, chocolate
Avoid lying down after meals or late evening meals
Reduce tobacco and alcohol consumption
Avoid exacerbating medications, eg/ anticholinergics, b-blockers, benzos, NSAIDs, opioids

68
Q

What DDx need to be excluded in order to Dx fatty liver disease?

A

Excess alcohol consumption
Chronic viral hepatitis, autoimmune hepatitis, haemochromatosis
Thyroid and coeliac disease

69
Q

Headache red flags

A 
Sudden onset, awoken from sleep
Thunderclap nature
Confusion, with drowsiness and/or vomiting
Fever or neck stiffness
Seizures or personality changes
Morning vomiting
Associated cerebral Sx
Persistent neurological Sx
Provoked by Valsalva (eg/ coughing)
Aggravated by posture change
70
Q

Mx of cluster headache

A

Subcutaneous sumatriptan or O2

Prevention = verapamil

71
Q

Mx of migraine

A

Analgesics
Anti-emetic if severe nausea or vomiting
If above fails, use triptan or an ergot alkaloid

72
Q

PMR Mx

A

Oral corticosteroids with response in 24-72 hours

73
Q

Back pain red flags

A 
Age 50yo
Progressive symptoms (>12w) despite treatment
Cancer 
Unexplained weight loss
Immunosuppression
Prolonged use of steroids
Intravenous drug use
Urinary tract infection
Pain that is increased or unrelieved by rest
Tearing nature of pain, associated with pulsatile abdominal mass
Fever
Significant trauma related to age
Bladder or bowel incontinence or pain
Urinary retention (with overflow incontinence)
Night pain
Worsening pain
74
Q

Back pain yellow flags

A

Belief that pain is harmful or potentially severely disabling
Fear-avoidance behaviours and reduced activity levels
Tendency to low mood and withdrawal from social interactions
Drug seeking behaviours

75
Q

Clinical features of malaria

A

Cyclical and persistent fever (>2w)
Jaundice, hepatosplenomegaly
Viral Sx: headache, nausea, malaise, diarrhoea

LONG to INT IP

76
Q

Clinical features of dengue fever

A 
Maculopapular rash (after fever)
Splenomegaly, thrombocytopaenia
Viral Sx: headache, joint/muscle aches, anorexia, abdominal pain, N+V, malaise

SHORT IP

77
Q

Clinical features of typhoid fever

A 
Maculopapular rash (chest and stomach)
Hepatosplenomegaly
Viral Sx: cough, sore throat, abdominal pain, constipation/diarrhoea

INT IP

78
Q

Ix for fever in a returned traveller

A

FBE, UEC, LFTs
Viral hepatitis serology
Thick and thin films

MD3 (21 decks)

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