June 8th 2021

Question 1

72F metastatic lung ca, radiotherapy to spinal mets, pain, lives with daughter. behavioural change in last few days, hallucinations, phx: MCI, Htn, hyperC, DMII, COPD, meds: morphine SR 30mg, morphine IR 5mgPRN, metoclopramide, perindo5, atorva80, metformin500, spiriva18, salbutaPRN, afebrile, confused. 8 underlying causes
a,b,f,g, j, k

Answer 1

• occult infection such as UTI
• constipation
• pain
• cerebrovascular accident
• intracranial metastases
• infective exacerbation of COPD
• drug-induced psychosis
• hypercalcaemia
• electrolyte disturbance

Question 2

72F metastatic lung ca, radiotherapy to spinal mets, pain, lives with daughter. behavioural change in last few days, hallucinations, phx: MCI, Htn, hyperC, DMII, COPD, meds: morphine SR 30mg, morphine IR 5mgPRN, metoclopramide, perindo5, atorva80, metformin500, spiriva18, salbutaPRN, afebrile, confused. 4 indications for syringe driver

Answer 2

• dysphagia
• persistant nausea/vomiting
• bowel obstruction
• coma
• poor absorption of oral drugs
• patient preference

Question 3

72F metastatic lung ca, radiotherapy to spinal mets, pain, lives with daughter. behavioural change in last few days, hallucinations, phx: MCI, Htn, hyperC, DMII, COPD, meds: morphine SR 30mg, morphine IR 5mgPRN, metoclopramide, perindo5, atorva80, metformin500, spiriva18, salbutaPRN, afebrile, confused. 4 medications in syringe driver

Answer 3

metoclopramide
clonazepam
morphine
haloperidol
hyoscine butylbromide

Question 4

52F aboriginal, 3/12 hx of fatigue, home with 7 kids, works as cleaner, no PR bleeding/abdo symptoms, no weight loss/night sweats, LMP 2/12 ago, irregular/heavy, has mirena, pmhx: HTN, hyperC, T2DM, BMI 35, 20py, COPD, OA, metformin1gXR, empagliflozin10, perindo5, atorva80, spiriva18, salbPRN, paracetamolPRN, allergies sulpha and penicillins. 7ddx

Answer 4

• obstructive sleep apnoea
• hypothyroidism
• chronic kidney disease
• depression
• iron deficiency anaemia
• cardiomyopathy
• perimenopause
• poorly controlled DMII

Question 5

52F aboriginal, 3/12 hx of fatigue, home with 7 kids, works as cleaner, no PR bleeding/abdo symptoms, no weight loss/night sweats, LMP 2/12 ago, irregular/heavy, has mirena, pmhx: HTN, hyperC, T2DM, BMI 35, 20py, COPD, OA, metformin1gXR, BD, empagliflozin10, perindo5, atorva80, spiriva18, salbPRN, paracetamolPRN, allergies sulpha and penicillins. Hba1C 9.4%, 5 mx, non-pharma and Pharma

Answer 5

• add exenatide IR 5microg/BD subcut
• add sitagliptin 100mg, PO, daily
• dietician referral for diet review
• aboriginal health liaison worker
• weight loss 5-10%
• encourage daily exercise 150min aerobic 2-3 sessions resistance training
• referral to diabetes educator
• referral to podiatrist
• referral to optometrist

Question 6

52F aboriginal, 3/12 hx of fatigue, home with 7 kids, works as cleaner, no PR bleeding/abdo symptoms, no weight loss/night sweats, LMP 2/12 ago, irregular/heavy, has mirena, pmhx: HTN, hyperC, T2DM, BMI 35, 20py, COPD, OA, metformin1gXR, empagliflozin10, perindo5, atorva80, spiriva18, salbPRN, paracetamolPRN, allergies sulpha and penicillins. has diabetic retinopathy, 1 single Pharma agent

Answer 6

fenofibrate 145mg, po, daily if eGFR >60
if eGFR 20-60: 96mg
if eGR 10-20 then 48mg

Question 7

52F aboriginal, 3/12 hx of fatigue, home with 7 kids, works as cleaner, no PR bleeding/abdo symptoms, no weight loss/night sweats, LMP 2/12 ago, irregular/heavy, has mirena, pmhx: HTN, hyperC, T2DM, BMI 35, 20py, COPD, OA, metformin1gXR, empagliflozin10, perindo5, atorva80, spiriva18, salbPRN, paracetamolPRN, allergies sulpha and penicillins. AKI, 3 med changes

Answer 7

• cease empagliflozin
• reduce metformin to 500mg
• cease perindopril short term
• commence insulin

Question 8

4F, brought in my foster mum, behaviour, trouble sleeping, daily tantrums, teacher: difficulty communicating, doesn’t play well, no sig pmhx, no reg meds, 7 ddx

e, j, I(iron studies)

Answer 8

• hearing impairment
• anxiety disorder
• intellectual disability
• obstructive sleep apnoea
• autism spectrum disorder
• attention deficit hyperactive disorder
• early life trauma
• post traumatic stress disorder

Question 9

4F, brought in my foster mum, behaviour, trouble sleeping, daily tantrums, teacher: difficulty communicating, doesn’t play well, no sig pmhx, no reg meds, 8 hx

Answer 9

• snoring at night?
• recurrent ear infections
• social reciprocity- eye contact?
• prenatal exposure to smoking
• birth complications?
• hx of abuse by birth parents?
• perinatal infections?
• hx of known brain injuries?

Question 10

35F, nurse, hep C post needle stick 6/12 ago, chronic hep C, want to conceive, worried about working, husband aware, condoms, no pmhx, PPI PRN, non smoker, ETOH socially. 5 points of discussion

a,b,g,i,j,k,l,q,c, f

Answer 10

• antivirals for cure>90% available for hep C
• need further testing to determine type of Rx
• cease PPIs prior to starting hep C treatment
• continue contraception
• minimise ETOH consumption
• eligible for worker’s compensation

Question 11

35F, nurse, hep C post needle stick 6/12 ago, chronic hep C, want to conceive, worried about working, husband aware, condoms, no pmhx, PPI PRN, non smoker, ETOH socially. successful rx after 12/12, now 7/40, spotting this AM, 5ddx

Answer 11

• ectopic pregnancy
• cervical ectropion
• cervical cancer
• miscarriage
• pelvic inflammatory disease
• uterine fibroids

Question 12

35F, nurse, hep C post needle stick 6/12 ago, chronic hep C, want to conceive, worried about working, husband aware, condoms, no pmhx, PPI PRN, non smoker, ETOH socially. successful rx after 12/12, now 7/40, spotting this AM, 4mx/Ix

Answer 12

• urgent transvaginal ultrasound
• serial bHCGs 48-72 hours apart
• maternal blood group/antibody testing
• review in 48-72 hours