FRACGP 1 > Quiz1 > Flashcards
Quiz1 Flashcards
Which combination of drugs can lead to serotonin syndrome?
Serotonergic drugs
Anti Dep’s: SSRI’s, SNRI’s, MAOInhibitors, TCA’s, Lithium
Valproate
Analgesics and antitussives: Tramadol, fentanyl, Pethidine
Drugs of abuse: Ecstasy, Amphetamines
Herbs: St Johns Wort, Tramadol, Ginseng,
Antiemetics:Metoclopramide, ondansetron
5HT1 Agonists: Sumatriptan
What are the symptoms of serotonin syndrome?
Triad of CNS, autonomic and neuromuscular dysfunction.
Including: tremor, hyper-reflexia, clonus, autonomic instability, agitation, diaphoresis, mydriasis and agitation, progressing onto hyperthermia, delirium, renal failure and, if untreated, death
In a perimenopausal woman when can contraception be ceased?
Cease at age 55
or if amenorrhea for 12 months with Mirena, POP, or implanon = then 2 x FSH levels (six weeks apart) and if both are > 30 advise contraception only needed for further 12 months
What is required to optimise healing of plantar foot ulcers?
Pressure reduction, redistribution of pressure (offloading).
Arterial ulcers should not be debrided until assessed by a specialist and revascularisation considered
Which meds improve outcomes in patients with heart failure and reduced ejection fraction?
ACEInhibs, Bblockers, Aldosterone antagonists, Angiotensin receptor neprilysin inhibiotrs (ARNI)
What condition can ACEInhibitor plus spironolactone predispose a patient to?
Hyperkalaemia
ECG changes: Prolonged PR, loss of p waves, Sine wave, bradycardia
When should travellers be prescribed chemoprophylaxis for travellers diarrhea?
Immunocompromised - dont use longer than three weeks
Healthy travellers - no, just treat early, risk of resistance
What are sideeffects of Sildenafil? (PDE5 Inhibitor)
Headache, dizziness nasal congestion, flushing, dyspepsia
Based on current evidence what non pharmacological management is recommended for osteoarthritis?
Land based exercise, gradually increasing for all people.
CBT - targetted at pain management.
Strong evidence against - platelet rich plasma injection and visco supplementation.
Neutral recommnedations for u/s, patellar taping and shoe orthotics
Ottawa Ankle Rules: A patient with traumatic ankle pain qualifies for ankle radiographs if they have any of the following?
point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus
point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus
inability to weight bear (four steps) immediately after the injury and in emergency department
Ottawa Ankle Rules: A patient with traumatic midfoot pain qualifies for foot radiographs if they have any of the following?
point tenderness at the base of the fifth metatarsal
point tenderness at the navicular
inability to weight bear (four steps) immediately after the injury and in emergency department
Paediatric constipation - whats the management?
- Soften stool - to empty rectum
- Soften the stool - to minimis pain
- Encourage good toileting habits. (Ideally - 5mins, 2-3 times per day after meals/not associated with distractions) praise toileting even when no poo is passed.
Abdo xray shouldnt be routinely performed in GP
Which BP meds are ok in pregnancy?
Labetalol, methyldopa.
Not ACE inhibitors - in second and third trimester can cause fetal renal dysfunction, oligohydramnios and fetal death.
Saba?
Salbuatmol (ventolin/asmol) Terbutaline (Bricanyl)
Sama?
Ipratropium (Atrovent)
Laba?
Salmeterol (Serevent)
Formoterol (Oxis, Foradile)
ICS/LABA?
Fluticasone/salmeterol - Seretide
Budesonide/Formoterol - symbicort
Fluticasone/Vilanterol - Breo
ICS/LABA/LAMA?
Fluticasone/Vilanterol/Umeclidinium
First step in COPD mx?
Saba or Sama
Second step in COPD mx?
Lama or laba
When to add ICS in COPD?
If Fev1 less then 50% predicted
AND 2 or more exacerbations in last 12 months
AND Significant symptoms despite LAMA and LABA therapy
Lama?
tiotropium- spirvia
Umeclinidium - Incruse
Dermatitis Herpetiformis - Which investigations to confirm diagnosis?
Skin biopsy for histopathology
and Direct immunoflourescence (shows Iga deposition i with epidermal transglutaminase complexes in papillary dermis)
Coeliac disease is underlying cause
Rash - extensor surfaces, vesicular, plaques or erythematous papules - associated with diarrhoea, abdo discomfort, bloating (coealiac)
5% 5 Fluorouracil (Efudix) - absolute contraindication in treatment of actinic keratosis?
DPD (dihydropyrimidine dehydrogenase) deficiency
Can cause stomatitis, diarrhoea, neutropenia, neurotoxicity, death
An alternate treatment is Ingenol Mebutate (Picato)
Seborrheic dermatitis - clinical picture and treatment?
Skin has red/salmon patch appearance, flaky surface, concentrates in folds (eg nasolabial fold)
1st line: Topical antifungal and steroid
Also topical ketaconazole shampoo in hair to reduce malassezia load. (normal part of skin flora - implicated in seb Derm)
Who is eligible for an NIP free flu vaccine?
Pregnant women Ppl aged 65 and over ATSI aged 6 months or over Children 6 months to 5 years Ppl aged 6 months and over with medical conditions at risk of severe influenza and it’s complications
Kids and flu Vax?
Must be over 6 months
Anyone with chronic illness over 6 months or kids between 6 months and 5 years are free
Kids aged 6 months to 9 years require two doses of influenza vaccine - at least four weeks apart - in the first year they receive the vaccine. One annual dose is required in following years.
What flu vaccine are available?
Quadrivalent influenza vaccines
QIVs
Who should be screened for DM?
From age 40 years (18years for ATSI) using AUSDRISK
Individuals at high risk - fasting bsl every 3 years
IGT or impaired fasting glucose - 12 monthly fasting BSL
What does the AUSDRISK tool use?
Age Gender Ethnicity FHx - parents/siblings Smoking status HTN (meds for) How often do you eat veg or fruit (every day/not every day) Have you ever been found to have a high BGL (including during illness and whilst well)
Exercise (at least 2.5 hrs phys activity/week - eg 30 mins a day for 5 or more days)
Waist circumference
Targets < 94cm men (<90cm in Asian); <80cm women (Caucasian)
No clear data for Mediterranean/African/Middle east - use Europe data
No clear data for south/Central America- use Asian
ATSI - in Asian data group
Over what period does AUSDRISK calculate risk of developing diabetes?
5 years
Scores:
5 or less - low risk - 1 in 100 will develop DM
6-11 Intermediate risk - 1 in 50
Greater than it equal to 12 - high risk -1 in 14
In addition to AUsDRIsk what are other high risk groups? (With evidence)
Indigenous (10 times higher risk of developing DM) greater than or equal to 35 years
Ppl greater than or equal to 40 with either Obesity (BMI great than or = to 30) and/or HTN
Clinical CV disease
Women with PCOS who are obese
Ppl on antipsychotics
Other high risk groups for DM (more studies needed)?
Women with history of gestation DM Age 55 (greater than or equal to) Age 45 (greater than or equal to) with a first degree relative with T2DM
What are Diagnostic criteria for DM?
HBAIC greater than/equal to 6.5%
Fasting glucose greater than/equal to 7mmol/L
Random glucose greater than/equal to 11.1 mol/L
On a 75g OGTT - fasting 7 or more; or a 2hr 11.1 or more
In Asymptomatic patient - repeat the test (can be positive on two different diagnostics also)
BGL targets for DM
Fasting - 6-7
Post prandial 6-10
Recommended Alcohol intake in DM?
Less than or equal to 2 standard drinks a day (both sexes)
Phys Activity in DM
30/60 mins walking (or equivalent) 5 or more days/week (ideally daily)
Aspirin in DM
Indicated for those with DM with a history of CV disease
Evidence for those who have no history of CV disease is weak
If high risk of DM?
Measure fasting glucose or HBA1c
When can diagnosis of DM be confirmed on one test ?
Aceite unequivocal hyperglycaemia with acute metabolic decompensation or obvious symptoms (poluiria/polydipsia)
Joseph Browne, a 73 year old male, has been referred to your practice for an iron infusion. He has a known history of heart failure with reduced ejection fraction (HFrEF) of 39%, 2 months ago on echocardiogram. A gastroscopy and colonoscopy were reported as normal one month ago.
Taking into account his HFrEF, what would you advise Joseph regarding iron replacement? Choose one (1) option.
IV ferric carboxymaltose should be avoided in patients with an ejection fraction less than 45%.
Oral iron supplements are advised in preference to IV ferric carboxymaltose in patients with HFrEF.
It is safe and strongly advised to administer IV ferric carboxymaltose for iron deficiency in HFrEF.
Oral iron supplements should be trialled first for 6 months in patients with HFrEF prior to administering an iron infusion.
Oral iron supplements should be trialled first for 3 months in patients with HFrEF prior to administering an iron infusion.
The correct answer is: “It is safe and strongly advised to administer IV ferric carboxymaltose for iron deficiency in HFrEF”.
About 50% of patients with heart failure are iron deficient and it is an important prognostic indicator, regardless if the patient is anaemic or not. The current heart failure guidelines emphasise the recommendation of administering IV ferric carboxymaltose when a ferritin level is below 100mcg/L (or when the ferritin is 100 – 300mcg/L and the transferrin saturation is less than 20%). Oral iron is ineffective in normalising iron status in patients in with HFrEF.
Walter is a 55 year old male infrequent attender to your clinic. You note on his file that his past medical history lists an abdominal aortic aneurysm. He tells you it was found about a year ago ‘by accident’ when he had ultrasound for ‘something else’. You review the ultrasound report from 10 months ago and see that the aneurysm measured 3cm at that time. He has no other past medical history on file and is on no medication. He is a smoker with a 30 pack year history and his is blood pressure today is 160/105mmHg.
What are your primary management priorities for Walter and his abdominal aortic aneurysm?
Screen all Walters first degree relatives for aortic aneurysms
Referral for an echocardiogram to exclude aortic root dilatation or ascending arch aneurysm
Optimise cardiovascular risk factors including hypertension, cholesterol and encouraging smoking cessation
Refer Walter to a vascular surgeon for advice on surgical management options
Put Walter on 6 monthly recalls for aneurysm surveillance to monitor size and progression
Optimise cardiovascular risk factors including hypertension, cholesterol and encouraging smoking cessation
Medical management of AAA generally involves cardiovascular risk reduction, including antiplatelet therapy, statin therapy and antihypertensive therapy. This best medical management, however, is generally not intended to limit expansion or reduce the size of the AAA. Managing cardiovascular risk factors is crucial for improving the overall survival of patients and the outcomes of future AAA repair. Smoking cessation should also be advised and encouraged in all patients with known AAA on the basis that it increases life expectancy and reduces morbidity and mortality from aneurysm repair. There is also evidence that smoking is associated with AAA development and increased aneurysm expansion.
Traditionally, familial screening has been recommended for primary relatives over the age of 65 years, but recent evidence suggests that this should also be extended to younger relatives in whom there is clinical evidence of a collagen, elastin or connective tissue disorder.
It is suggested that only patients with a primary presentation of a large AAA should undergo echocardiography to exclude aortic root dilatation and bicuspid aortic valve or ascending arch aneurysm.
Typically surgical intervention has been recommended at thresholds of 5.5cm in men, and 5.0cm in women. However, there seems to be a trend towards earlier intervention before these operative threshold in some countries. Walter may need a vascular surgeon opinion, however, this is not your top-most management priority.
In general, suggested surveillance intervals have been based on rupture risk and expected growth rates, estimated from the size of the aneurysm. No surveillance guidelines have been published or endorsed by the Australian and New Zealand Society for Vascular Surgery (ANZSVS) to date. the 2007 US Society for Vascular Surgery Guidelines would recommend 10 yearly surveillance intervals for a 2.5-3cm aneurysm; while the 2010 European Society for Vascular Surgery (ESVS) Guidelines recommend 24 month surveillance intervals for a 3.0-3.9cm aneurysm.
On further questioning Mark thinks his blood pressure was high a few years ago, but he moved towns and forgot to follow it up. You consider if he may have secondary hypertension. Which of the following statements about secondary hypertension in adults is correct? Choose one (1) option.
Secondary hypertension is more common in those with a family history of hypertension
The most common causes of secondary hypertension in Mark’s age group include: renal parenchymal disease and coarctation of the aorta
The most common causes of secondary hypertension in Mark’s age group include: renal artery stenosis, and renal failure
The most common causes of secondary hypertension in Mark’s age group include: obstructive sleep apnoea and adrenal/endocrine disorders.
Management of the underlying cause will not improve secondary hypertension
The most common causes of secondary hypertension in Mark’s age group include: obstructive sleep apnoea and adrenal/endocrine disorders.
This includes conditions such as: Hyperaldosteronism, thyroid dysfunction, Cushing’s syndrome and pheochromocytoma.
Aetiologies of secondary hypertension are different in children compared to adults. In children (birth-11 years) renal parenchymal disease (eg reflux nephropathy, glomerulonephritis, polycystic kidney disease) and coarctation of the aorta are the most common causes of secondary hypertension. In older adults (65 years and over) atherosclerotic renal artery stenosis and renal failure are the most common causes.
Secondary hypertension is more common in patients without a family history of hypertension. Management of the underlying cause can improve or normalise blood pressure in patients with secondary hypertension.
Bill Cook is a 72-year-old male who presents with fatigue. He has a past medical history of an acute myocardial infarction at age 55. He states that over the last 6 months he has become more tired with normal daily activities. He lives in a 2-storey house and gets breathless when climbing the stairs. He denies any symptoms at rest and can dress himself without feeling short of breath. He states that he has put on 3 kg over the last 3 months and his socks leave quite distinctive marks around his ankles. You arrange an echocardiogram, which demonstrates impaired left ventricular contractile function (LVEF < 40%).
Which of the following medications improves outcomes in patients with heart failure with reduced ejection fraction (HFrEF) Choose one (1) option.
Eplerenone
Verapamil
Frusemide
Bumetanide
Digoxin
The correct response is: Eplerenone
ACE inhibitors, angiotensin II receptor blockers, beta blockers, aldosterone antagonists and angiotensin-receptor neprilysin inhibitors (ARNI) have been shown to improve outcomes in patients with heart failure with reduced ejection fracture (HFrEF).
Miriam White is a 72 year old patient who comes to see you for review following an emergency department visit for her first presentation of rapid atrial fibrillation. She had an echocardiogram performed which showed mitral valve prolapse. Miriam has been commenced on anticoagulation treatment by the hospital. You consider her stroke risk by determining her CHA2DS2-VA score which is 2. Her bleeding risk is low. Her renal function on recent bloods was normal.
What is the most appropriate agent for anticoagulation for Miriam?
Clopidogrel / Aspirin (Actavis) 75mg/100mg orally daily
Warfarin orally daily titrated to INR target range 2 – 3
Aspirin 100mg orally daily
Enoxaparin 1.5 mg/kg subcutaneously daily
Apixaban 5mg orally twice daily
The correct response is: “Abixaban 5mg orally twice daily”
A CHA2DS2-VA score of 2 puts this patient at high risk of a stroke or vascular event and therefore oral anticoagulant therapy is recommended according to the 2018 Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation. Even though Miriam has mitral valve prolapse this is not regarded as “valvular atrial fibrillation” (only moderate or severe mitral valve stenosis or mechanical heart valves fulfil this criteria). The current guidelines recommend treatment with a NOAC (in preference to warfarin) for patients with non-valvular AF where anticoagulation is indicated. The use of anti-platelet agents is not recommended for stroke prevention in patients with non-valvular atrial fibrillation.
Peter, a 62 year old man presents for a check-up at his wife’s insistence as her 65 year old brother has recently had a myocardial infarction. He doesn’t really want to come for review and asks you if you can tell him today if he is at an increased risk of cardiovascular disease. He had some blood tests performed a year ago for an insurance medical.
In deciding if he needs further assessment, which one of the following automatically puts Peter at high risk of cardiovascular disease? Choose one (1) option.
Diastolic blood pressure 100 mmHg
Age > 60 years
eGFR 65 mL/min/1.73m2
Serum total cholesterol 7.2 mmol/L
Systolic blood pressure 180 mmHg
he correct response is: Systolic blood pressure 180 mmHg
Patients with a systolic blood pressure of equal to or greater than 180mmHg are considered at high risk. See the Heart Foundation’s guide to absolute cardiovascular disease risk assessment for a full list of criteria which makes a patient at high risk.
Reference:
National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular risk. 2012. Available from: https://www.heartfoundation.org.au/getmedia/4342a70f-4487-496e-bbb0-dae33a47fcb2/Absolute-CVD-Risk-Full-Guidelines_2.pdf (Accessed May 2020).
A 58 year old man has recently been discharged from hospital following an inferior myocardial infarction that was managed with a drug eluding stent. He presents for a review of his medication. He states although he saw a pharmacist prior to discharge he is confused about his long-term medications and the plan for his ongoing care.
Which of the following statements is correct? Choose one (1) option.
He should be on the lowest possible dose of a statin indefinitely
Vasodilatory beta blockers are recommended if he has reduced left ventricular dysfunction (unless contraindicated)
ACE inhibitors are recommended but have not been shown to improve survival
Only high risk patients should be referred for cardiac rehabilitation following a myocardial infarction
A potassium sparing diuretic is recommended
The correct response is: Vasodilatory beta blockers are recommended if he has reduced left ventricular dysfunction (unless contraindicated).
Cardiac rehabilitation is recommended for all patients hospitalised with Acute Coronary Syndrome. Survival following a myocardial infarction is improved with the use of ACE inhibitors. Unless there is a history of intolerance or a contraindication, patients should take the highest tolerated dose of a statin indefinitely following hospitalisation for Acute Coronary Syndrome.
Reference:
Chew DP et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Heart, Lung and Circulation, 25 (2016):895-951
https://www.heartfoundation.org.au/images/uploads/publications/
Clinical_Guidelines_for_the_Management_of_Acute_Coronary_Syndromes_2016.pdf
Mark Lowe, a 66 year old male, attended your clinic with his wife for his annual diabetes check. Mark has well-controlled insulin-dependent type 2 diabetes mellitus. Your practice recently purchased an ankle:brachial index (ABI), which shows an ABI for Mark of 1.2. His wife, Pam, 58, who is otherwise well with no significant past medical history and no history of smoking, asks if she could book in for an ABI to screen for peripheral vascular disease too.
What is the most appropriate advice to give Pam regarding this investigation?
Pam would benefit from screening for peripheral vascular disease as she is over 50 years of age
Advise Pam that she should have a combined doppler venous ultrasound and ankle:brachial index (ABI) to assess for peripheral vascular disease
Advise Pam that there is insufficient evidence to advocate screening in low risk patients and that she does not require ankle:brachial index (ABI) testing
Pam should undergo a physical examination, with a focus on the absence of pulses, femoral bruit and trophic skin changes as this is more sensitive than ankle:brachial index (ABI) testing.
Advise Pam that there no evidence for ankle:brachial index (ABI) screening in any population groups
The correct answer is: “to advise Pam that there is insufficient evidence to advocate screening in low risk patients and that she does not require ankle:brachial index (ABI) testing.”
Current RACGP guidelines for preventive activities in general practice (the ‘Red Book’) does not advocate for peripheral vascular disease screening with ankle:brachial index (ABI) in low risk or asymptomatic patients. High risk (including diabetes) or symptomatic patients would benefit from an ABI as a diagnostic test. The absence of pulses, femoral bruit and trophic skin changes have a low sensitivity for peripheral vascular disease and ABI is more sensitive.
Sarah is a 23 year old patient who presents complaining of two days of retrosternal pleuritic chest pain which is worse when she is lying in bed. She recalls having a “cold” a few weeks ago but has otherwise been well recently. She denies any fever, cough, sputum, haemoptysis or limb swelling. Sarah takes the oral contraceptive pill but takes no other medications. She has no significant past medical history.
On examination, she appears well perfused and non-distressed but anxious. She has a regular pulse but is mildly tachycardic. Her blood pressure is 120/80mmHg and oxygen saturations are 97% on room air. She has dual heart sounds and her chest is clear. Her calves are soft and non-tender. Her ear, nose and throat examination is unremarkable.
You ask your practice nurse to perform an electrocardiogram which is below. What is the most likely diagnosis? Choose one (1) option.
ECG - widespread ST elevation, PR depression and reciprocal changes in AVR
Inferior ST elevation myocardial infarction
Acute pericarditis
Pulmonary embolism
Pneumothorax
Prolonged QT interval with tachycardia
The correct response is: Acute pericarditis.
The ECG shows the classic signs of acute pericarditis including sinus tachycardia, widespread ST elevation and PR depression with reciprocal changes in aVR. Sarah’s pericarditis is likely due to the viral infection she had a few weeks prior to the onset of her chest pain.
Mary George, a 67 year old female attends your clinic to discuss her husband’s recent ischaemic stroke secondary to previously undiagnosed atrial fibrillation. Mary asks you if she should be checked for atrial fibrillation as she is concerned about her own risk of stroke. She has no symptoms of concern including no palpitations, shortness of breath or fatigue. Mary has no significant past medical history and she takes no regular medications.
Based on current guidelines, what advice about screening do you provide to Mary?
Advise Mary that screening for silent atrial fibrillation is not supported by current guidelines
Advise Mary that screening for silent atrial fibrillation is recommended in patients aged over 65 years
Advise Mary that screening for silent atrial fibrillation is recommended in patients aged over 75 years
Advise Mary that screening for silent atrial fibrillation is recommended in patients aged over 60 years
Advise Mary that screening for silent atrial fibrillation is recommended in patients aged over 70 years
The correct response is: Advise Mary that screening for silent atrial fibrillation is recommended in patients aged over 65 years.
The 2018 Australian atrial fibrillation guidelines recommend opportunistic screening for silent atrial fibrillation in patients aged over 65 years. There is strong evidence to suggest that 10% of ischaemic strokes are related to previously undiagnosed atrial fibrillation.
On examination, his left calf is swollen and tender posteriorly. The left calf’s circumference is 4 cm greater than the right. You suspect a deep vein thrombosis and organise a duplex venous ultrasound of the left lower limb, which confirms the presence of distal deep vein thrombosis.
He is a non-smoker and has never had a previous thrombotic event. There is no family history of thrombophilia. He has no other risk factors for future clots.
How long should this patient be anti-coagulated for? Choose one (1) option.
Therapeutic Guidelines recommends that provoked isolated distal DVTs can be treated for 6 weeks with anti-coagulation as long as the major provoking factor is no longer present. In this case, the major provoking factor was the patient’s recent hospital admission with immobilisation. Note that the duration of anti-coagulation may be different for proximal DVTs, for unprovoked DVTs and for patients with ongoing provoking factors. Details can be found in the reference (eTG).
Bill Weatherill is a 50 year old man who was recently admitted to hospital with an acute myocardial infarction. He was treated successfully with a drug eluting stent and had an uneventful recovery with no arrhythmias. His echocardiogram showed left ventricular ejection fraction of 38%. He comes to see you on discharge from hospital. What combinations of medications is Bill most likely to have been discharged on? Choose one (1) response.
Aspirin, ticagrelor, atorvastatin, carvedilol, fosinopril
Aspirin, clopidogrel, atorvastatin, propranolol, fosinopril
Aspirin, ticagrelor, atorvastatin, carvedilol, spironolactone
Aspirin, clopidogrel, atorvastatin, carvedilol, sacubitril+valsartan
Aspirin, ticagrelor, atorvastatin, carvedilol, ditiazem
The correct response is: Aspirin, ticagrelor, atorvastatin, carvedilol, fosinopril
In general principals, the drug therapy for the secondary prevention of atherosclerotic cardiovascular disease usually consists antiplatelet drug(s) with a of a combination of a statin, an angiotensin converting enzyme inhibitor (ACEI), and unless contraindicated, a beta-blocker.
Following an acute coronary syndrome, dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) is usually recommended for 12 months.
Statin therapy reduces cardiovascular morbidity and mortality in patients with established atherosclerotic CVD, and high dose therapy should be given irrespective of the patient’s lipid levels.
Angiotensin converting enzyme inhibitors (ACEI) prevent cardiovascular events including myocardial infarction, stroke and death in patients with atherosclerotic CVD; these effects may be independent of blood pressure reduction.
While beta-blocker therapy should be started immediately following an acute coronary syndrome (unless contraindicated). Patients with reduced left ventricular systolic function (left ventricular ejection fraction 40% or less) or evidence of ongoing ischaemia (including stable angina) are more likely to benefit from long-term beta-blocker therapy. Use one of the beta blockers shown to be effective in heart failure with reduced ejection fraction (HFrEF) (bisoprolol, carvedilol, metoprolol succinate or nebivolol).
Mark Jones is a 34 year old male who presents to your urban clinic with a 4 hour history of sharp retrosternal chest pain which is made worse by inspiration and radiates to his neck and shoulders. The pain improves when he sits up and leans forward. He denies any cardiovascular risk factors and currently weighs 75kgs. From his notes you can see he had a viral upper respiratory tract infection 1 month ago. He does not have any other medical diagnoses. The nurse hands you his ECG which shows diffuse PR depression and ST segment elevation with upward concavity.
On examination his vital signs are within normal limits and you determine that he is suitable for outpatient treatment.
What is the recommended treatment regime for your suspected diagnosis? Choose one (1) correct answer.
Oral colchicine 500mcg daily for 4 weeks
Oral ibuprofen 600mg three times per day for 2 weeks with gradual taper to cease
Oral colchicine 500mcg twice daily for 3 months PLUS oral ibuprofen 600mg three times per day for 1 week with gradual taper to cease
Oral colchicine 500mcg twice per day for 3 months PLUS oral dexamethasone 8mg twice daily for 2 weeks with gradual taper to cease
Oral aspirin 600mg three times per day for 4 weeks
The correct response is: Oral colchicine 500mcg twice daily for 3 months PLUS oral ibuprofen 600mg three times per day for 1 week with gradual taper to cease.
The diagnosis in the case is Pericarditis.
Patients require hospital admission if a specific treatable cause is identified, or if one of the following risk factors associated with poor prognosis is present:
high fever—over 38o C
subacute course—symptoms over several days without a clear-cut acute onset
large pericardial effusion
cardiac tamponade
failure to respond within 7 days to aspirin or NSAIDs.
Other risk factors to consider include myopericarditis, immunosuppression, trauma and oral anticoagulant therapy.
The treatment of acute pericarditis depends on the cause. Consider specific treatments in patients with connective tissue disorders (immunosuppression), uraemia (dialysis) or purulent pericarditis (antibiotics).
Otherwise, restriction of exercise plus colchicine combined with aspirin or an NSAID, are the mainstays of therapy. Colchicine combined with the anti-inflammatory drug improves remission rates of pericarditis at 1 week and reduces recurrence rates in acute and recurrent pericarditis, compared with anti-inflammatory drug therapy alone. Base the choice of anti-inflammatory drug on patient history of use (contraindications, previous efficacy, or adverse effects), presence of concurrent diseases (if aspirin is being taken as antiplatelet therapy, its use is preferred over other NSAIDs) and clinician familiarity with the drug.
The following are recommended treatments for pericarditis as per therapeutic guidelines:
Colchicine:
-70 kg or more: 500 micrograms orally, twice daily for 3 months
-less than 70 kg: 500 micrograms orally, once daily for 3 months
PLUS EITHER:
-aspirin 750 to 1000 mg orally, 8 hourly for 1 to 2 weeks, then decrease the dose by 250 to 500 mg every 1 or 2 weeks to stop
OR
-ibuprofen 600 mg orally, 8 hourly for 1 to 2 weeks, then decrease the dose by 200 to 400 mg every 1 or 2 weeks to stop.
Aspirin, ibuprofen or an alternative NSAID are usually given for 1 to 2 weeks, with duration guided by symptom resolution and normalisation of markers of inflammation (eg C-reactive protein). The dose of the NSAIDs may be tapered to stop, but it is not essential to taper the dose of colchicine to stop. Reduce the dose of colchicine for patients with kidney impairment.
Betty Smith is a 70 year old female who has newly diagnosed paroxysmal non-valvular atrial fibrillation. She has a history of diabetes and is on perindopril for hypertension. She has no history of falls, stroke / transient ischaemic attack, thromboembolism, heart failure, vascular disease, or liver disease and lives independently in her own home.
When considering stroke prevention for this patient using her CHA2DS2-VA score, which one of the following is most appropriate next step in management? Choose one (1) option.
Begin aspirin
Begin apibaxan
No treatment is required
Begin warfarin
Refer for pacemaker insertion
The correct response is: Begin apibaxan
The 2018 Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation recommends the use of the CHA2 DS2-VA score to assess stroke risk. This patient’s score is 3:
History of hypertension: 1 point
Age 65-74 years: 1 point
Diabetes: 1 point
In patients with non-valvular AF and with no contraindications to anticoagulation, the guidelines recommend:
CHA2 DS2-VA score 2 or more: anticoagulation is recommended
CHA2 DS2-VA score 1: anticoagulation should be considered
CHA2 DS2-VA score 0: anticoagulation is not recommended
Bleeding risk also needs to be taken into consideration when making a decision about anticoagulation.
When anticoagulation is recommended in a patient with non-valvular atrial fibrillation, a NOAC (apibaxan, dabigatran or rivaroxaban) is recommended in preference to warfarin. In patients with valvular AF requiring anticoagulation, warfarin should be used (not NOACs). There is no role for the use of anti-platelet therapy for stroke prevention in patients with non-valvular atrial fibrillation.
A 34 year old male presents with a history of chest pain, shortness of breath and fever. He states the pain is located over the left side of his chest, is sharp in intensity and made worse by inspiration and lying flat. Your investigations confirm a diagnosis of pericarditis.
What is the most common cause of acute pericarditis in Australia? Choose one (1) option.
Medication-induced
Idiopathic
Autoimmune
Bacterial
Tuberculosis
The correct response is: “Idiopathic.” Table 2 in the reference provides a list of the possible underlying causes of pericarditis, with idiopathic being the most common. Viruses are the most common cause of infectious pericardial disease.
Chantelle DeBois, a 63 year old female, presents with worsening congestive heart failure on the background of a previous myocardial infarction at 60 years of age. Her recent echocardiogram last week showed an ejection fraction of 36%, a change from 45% in the year prior. She has pedal oedema to her mid lower leg. Her current medications include perindopril arginine 10mg and frusemide 40mg mane.
Based on current guidelines what medication change should be undertaken to reduce her risk of mortality and morbidity? Choose one (1) option.
Increase frusemide, with additional 20mg orally at midday
Commence spironolactone 25mg orally mane
Commence carvediolol 25mg orally twice daily
Commence aspirin 100mg orally mane
Commence sacubitril+valsartan 49+51mg orally, twice daily
The correct answer is: “Commence spironolactone 25mg orally mane”.
A clear stepwise approach is recommended for the treatment of heart failure with reduced ejection fracture (HFrEF). After the maximum tolerated dose of an ACE-Inhibitor has been used, the next step is to add a mineralocorticoid receptor antagonist (MRA), such as spironolactone. Beta-blockers should only be used once a euvolaemic state is reached. Loop diuretics, such as frusemide, can be used for symptomatic management, but there is no evidence that they reduce mortality or morbidity.
Reference:
Atherton JJ, Sindone A, De Pasquale CG, Driscoll A, MacDonald PS, Hopper I, Kistler P, Briffa TG, Wong J, Abhayaratna WP, Thomas L. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of heart failure 2018. Heart Lung & Circulation. 2018 Oct;27(10):1123-1208. https://www.heartlungcirc.org/article/S1443-9506(18)31777-3/fulltext (Accessed April 2020).
eTG. Heart Failure. https://tgldcdp.tg.org.au/viewTopic?topicfile=heart-failure (Subscription required). (Accessed April 2020).
Michael Bolt, a 64 year old male, presents with a print-out from the internet to your GP rooms. Michael has read online that restricting his sodium intake to less than 500mg a day, can improve his congestive heart failure. He has a known history of congestive heart failure, on the background of atrial fibrillation.
What advice would you give Michael regarding sodium intake? Choose one (1) option.
Michael should restrict his sodium to as low as possible, aiming for 500mg, which would be beneficial to his heart failure.
There is no evidence to support the amount of dietary sodium restriction beyond expert opinion, thus he should aim for less than 6g/day, as per the general population target.
There is no evidence to support the amount of dietary sodium restriction beyond expert opinion, thus he should aim for less than 2g/day, as per the general population target.
Michael should not restrict his sodium in his diet, as this may worsen his atrial fibrillation due to calcium channel changes.
Michael should restrict his sodium to as low as possible, aiming for less than 1g a day, as per the current guidelines.
The correct answer is: “There is no evidence to support the amount of dietary sodium restriction beyond expert opinion, thus he should aim for less than 2g/day, as per the general population target”.
Candidates should be aware that as per the current heart failure guidelines, there is no evidence from meta-analyses and randomised controlled trials that supports a lowered sodium intake in heart failure. As such, national guidelines for the general population of less than 2g per day are advised.
Bill Cook is a 72-year-old male who presents with fatigue. He has a past medical history of an acute myocardial infarction at age 55. He states that over the last 6 months he has become more tired with normal daily activities. He lives in a 2-storey house and gets breathless when climbing the stairs. He denies any symptoms at rest and can dress himself without feeling short of breath. He states that he has put on 3 kg over the last 3 months and his socks leave quite distinctive marks around his ankles. You arrange an echocardiogram, which demonstrates impaired left ventricular contractile function (LVEF < 40%).
Which of the following statements is CORRECT?
Loop diuretics are proven to improve survival outcomes in patients with heart failure with reduced ejection fraction
All patients with heart failure with reduced ejection fraction should be prescribed a Nitrate patch.
Beta blockers may initially worsen symptoms in patients with heart failure with reduced ejection fraction
Aldosterone antagonists have not been shown to reduce hospitalisation rates in patients with heart failure with reduced ejection fraction
Patients with heart failure with reduced ejection fraction should be encouraged to avoid physical activity
The correct response is: “Beta blockers may initially worsen symptoms in patients with heart failure with reduced ejection fraction”
Ryan is a 30 year old man who presents with chest pain for two days. He describes it as a constant sharp pain, worse on deep breathing and coughing, with no radiation.
Ryan is normally fit and healthy. You review his past medical history and see he usually only comes in with coughs and colds. He was seen by a colleague a week ago for a medical certificate when he had a sore throat.
Ryan says he is very active, and has been training for a triathlon, he wonders if he has pulled a chest muscle doing bench press at the gym.
On examination, he is afebrile with a respiratory rate of 20/min and SaO2 98% on room air. Heart sounds are dual. His chest is clear. His ECG shows widespread ST elevation and PR segment depression.
What is the most likely diagnosis? Choose one (1) option.
Hyperkalaemia
Rhabdomyolysis
Musculoskeletal chest wall pain
ST elevation myocardial infarction
Pericarditis
The correct response is: “pericarditis”
The most common cause of pericarditis is idiopathic and viral. Patients often present with pleuritic chest pain which is made worse by deep inspiration and lying supine. A pericardial friction rub may be detected on physical examination but is only seen in about 35% of patients. The typical ECG findings include widespread ST elevation with PR depression. This differs from an acute myocardial infarction where ST elevation is seen in the coronary vascular territory and reciprocal PR depression is usually absent.
61 year old school teacher, Agnes attends your clinic for annual review of her non-valvular atrial fibrillation (AF). She confirms that she is still asymptomatic. Agnes has a history of obstructive sleep apnoea, obesity and hypothyroidism. Her hypothyroidism is well controlled with thyroxine 125mcg daily. Agnes takes no other regular medications. You perform an electrocardiogram which confirms that rate-controlled AF is still present.
What is the most appropriate AF management option for Agnes until your next scheduled review in 12 months’ time? Choose one (1) option.
Commence oral amiodarone
Refer Agnes for a catheter ablation
Commence aspirin and address her risk factors (e.g. obstructive sleep apnoea, hypothyroidism, obesity)
Commence dual therapy with aspirin and rivaroxaban 5 mg orally twice daily
Focus on risk factor control (e.g. obstructive sleep apnoea, hypothyroidism, obesity)
The correct response is: Focus on risk factor control (e.g. obstructive sleep apnoea, hypothyroidism, obesity)
Agnes is at low risk of complications at age 61 years with stable, asymptomatic AF and her CHADS2VA score is 0. It is reasonable to focus on risk factor reduction at this stage. Amiodarone is used for rhythm control and may exacerbate her hypothyroidism. Catheter ablation is not indicated in this setting. There are also significant anaesthetic risks associated with obesity and obstructive sleep apnoea. Aspirin does not have adequate anticoagulant effect in AF. The use of direct-acting anticoagulants such as rivaroxaban is not indicated for a CHADS2VA score of 0. Dual therapy would increase bleeding risks without providing additional anticoagulant protection.
You are a GP in a rural town are looking after Samantha, a 53 year old woman, who has been recently diagnosed with heart failure. She travelled to see a visiting cardiologist in a nearby town who performed an echocardiogram which showed an left ventricular ejection fraction of 35%. The cardiologist has started her on enalapril 2.5mg daily and bisoprolol 1.25mg daily and asked you to titrate these up depending on tolerance. Her recent blood tests show normal renal function. What other medication do you commence Samantha on at this stage to improve her survival and reduce her risk of hospitalisation from her heart failure?
Spironolactone 25mg PO daily
Diltiazem 180mg PO daily
Frusemide 20mg PO daily
Sacubitril + valsartan 49+51mg orally twice daily
Verapamil 160mg PO daily
Spironolactone 25mg PO daily
Drugs that improve outcomes in heart failure with reduced ejection fraction (HFrEF) include angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), beta blockers, aldosterone antagonists and angiotensin-receptor neprilysin inhibitors (ARNI) (eg sacubitril+valsartan). Good quality clinical evidence shows that these drugs improve survival and reduce heart failure hospitalisation.
An ANRI should only be considered in patients with symptomatic heart failure despite optimal therapy with an ACEI or ARB and beta blocker therapy. It is not indicated for Samantha at this stage.
Loop diuretics can be used in patients with heart failure with reduced ejection fraction (HFrEF) to reduce the signs and symptoms of congestion (eg breathlessness, peripheral oedema) and improve exercise tolerance. But there is no high-level evidence that loop diuretics reduce mortality or morbidity.
Negative inotropic effect of non-dihydropyridine calcium channel blockers –verapamil and diltiazem may depress cardiac function. These should be used with caution and do not have evidence for improving morbidity or mortality in patients with heart failure.
Phil is a 62 year old Caucasian man who has returned for a review of his blood pressure. You saw him three months ago for a general check up and his blood pressure was 158/95 at the time. After arranging some bloods, you calculated him to have a moderate cardiovascular risk. He has no family history of premature cardiovascular disease. You counselled him on lifestyle measures to improve his blood pressure and arranged to review him in 3 months time.
At review today, his cardiovascular risk remains unchanged. However you still feel concerned about his blood pressure.
According to the National Heart Foundation of Australia ‘Guideline for the diagnosis and management of hypertension in adults’, which one of the following measurements would indicate that an antihypertensive should be commenced for Phil?
≥ 140/90 mmHg
≥ 150/90 mmHg
≥ 150/100 mmHg
≥ 160/90 mmHg
≥ 160/100 mmHg
According to the National Heart Foundation of Australia Guideline for the diagnosis and management of hypertension in adults: for patients with moderate absolute cardiovascular risk with persistent blood pressure >140mmHg systolic and/or >90mmHg diastolic, antihypertensive therapy should be started.
National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults. 2016. Available at: https://www.heartfoundation.org.au/Conditions/Hypertension (Accessed May 2020)
Francis is a 55 year old man with hypertension and hypercholesterolaemia who had an anterior myocardial infarction last year. His current blood pressure is 130/85. He is taking ramipril 5mg, amlopidine 5mg, rosuvastatin 10mg, aspirin 100mg and omeprazole 20mg. He complains that both his legs are swollen everyday. He denies any shortness of breath on exertion or positional dyspnoea. As well as monitoring his blood pressure and leg swelling, which one of the following is the most appropriate next step?
Cease the amlodipine
Add frusemide at a dose of 20mg orally daily
Increase his ramipril from 5mg to 10mg
Add a thiazide diuretic in the form of indapamide 1.5mg orally daily
Cease rosuvastatin
The most likely cause for his swollen legs is the dihydropyridine calcium channel blocker, amlodipine. You would cease this medication in the first instance and continue to monitor blood pressure and see if the swelling resolved. If further antihypertensives were required, then initiating a different class (ie a thiazide) is likely to help.
Mrs Miriam White is a 72 year old regular patient who is usually well and lives independently with her husband. She presents today with a sudden onset of a ‘fluttering’ in her chest. She reports feeling a bit breathless and denies any chest pain. She has a past history of hypertension (for which she takes Ramipril 5mg daily) and mitral valve prolapse. Your practice nurse has seen her in the waiting room and taken her straight to the treatment room for an ECG.
What rhythm is shown on Miriam’s ECG trace? Choose one (1) option.
Irregularly irregular, absence of P waves, narrow complex tachy
Atrial flutter
Atrial flutter with 2:1 block
Wolff Parkinson White Syndrome
Rapid atrial fibrillation
Sinus tachycardia with peaked QRS complexes suggestive of hyperkalaemia
Rapid AF“Rapid atrial fibrillation”. This ECG shows an irregular narrow complex tachycardia with a rate of 135bpm with loss of P waves and an irregular ventricular response.
Atrial flutter has regular atrial activity and typically produces a rate of 300bpm, or 150bpm in flutter with 2:1 block. Wolff Parkinson White Syndrome usually exhibits a rate >200bpm with wide QRS complexes due to ventricular depolarization in the accessory pathway. Hyperkalaemia usually produces peaked T waves (not peaked QRS complexes). It then progressively causes flattening of the P waves and a prolonged QRS interval.
A 76 year old male presents with fatigue. He states that for the last 6 weeks he had found normal activities difficult and he has intermittent palpitations. He has become more short of breath at rest but denies any chest pain. He is currently on perindopril for his hypertension but has no other regular medications. He has no other past medical history.
On examination, you note that he has an irregularly irregular heart rate. You arrange an urgent electrocardiogram and echocardiogram which confirms he has non-valvular atrial fibrillation.
Which of the following statements is correct? Choose one (1) option.
Valvular atrial fibrillation refers to patients with a mechanical heart valve
Valvular atrial fibrillation refers to patients who have either moderate or severe mitral valve stenosis or a mechanical heart valve
Valvular atrial fibrillation refers to patients who have either moderate or severe mitral valve prolapse or a mechanical heart valve
Valvular atrial fibrillation refers to patients who have either moderate or severe aortic stenosis or a mechanical heart valve
Valvular atrial fibrillation refers to patients who have either moderate or severe mitral regurgitation or a mechanical heart valve
The correct response is: Valvular atrial fibrillation refers to patients who have either moderate or severe mitral valve stenosis or a mechanical heart valve.
This is important to know when deciding upon appropriate therapy for preventing thromboembolism in patients with atrial fibrillation.
Gwen, a 75 year-old female, presents complaining of palpitations with fatigue and shortness of breath over the last few months. She has a past history of hypertension and diabetes. You perform an ECG which confirms atrial fibrillation. Based on this information, what is Gwen’s CHA2 DS2-VA score?
The correct response is: 4
The 2018 Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation recommends the use of the CHA2 DS2-VA score to assess stroke risk. Gwen’s score is 4 which was calculated as follows:
History of hypertension: 1 point
Age ≥75 years: 2 points
Diabetes: 1 point
Jonathon has been commenced on quetiapine as treatment for his bipolar disorder. He presents with a racing heart and you perform a ECG. What does his ECG reveal?
achycardia only
Atrial fibrillation with rapid ventricular rate
Acute ST elevation myocardial infarction
Left bundle branch block
Tachycardia with QT prolongation
The correct response is: Tachycardia with QT prolongation
This is a potential adverse effect of quetiapine. Antipsychotics can increase the QT interval and the risk of arrhythmia and sudden death. It is recommended that patients on long-term antipsychotics have an ECG performed annually (and when clinically indicated).
Rowena is a 52 year old who female presents for her annual health check. She is up-to-date with her mammograms and cervical screening tests. There is no significant past medical history listed in her file. Her recent fasting bloods were unremarkable but you note at her last visit that her resting blood pressure was 155/92 mmHg. You repeat her blood pressure today and once again the reading is slightly elevated at 158/91 mmHg.
Which of the following is correct regarding Rowena’s blood pressure?
The patient has Grade 1 (mild) hypertension
The patient has Grade 2 (moderate) hypertension
The patient has Grade 3 (severe) hypertension
The patient’s blood pressure is normal
The patient has high-normal blood pressure
Answer = The patient has Grade 1 (mild) hypertension
Luke Rein, a 48 year old male, presents to your GP clinic with a 3 day history of intermittent sharp chest pain. He reports the chest pain was worse when lying in bed in last night, with improvement when sleeping upright on his lounge chair. He recalls having a sore throat two weeks ago.
Luke’s body mass index (BMI) is 27, blood pressure is 122/80mmHg, jugular venous pressure is not elevated and heart rate is 65 beats per minute, regular, heart sounds are dual, with no murmur.
After confirming your suspected diagnosis, what three (3) treatment options would you advise Luke to undertake? Choose one (1) option.
Colchicine; aspirin; restriction of strenuous exercise until symptoms have resolved
Aspirin; colchicine; restriction of all exercise for 12 months
Colchicine; prednisolone; exercise as desired
Prednisolone, aspirin; restriction of strenuous exercise for 6 months
Paracetamol; benzyl penicillin; no activity restriction is required
Colchicine; aspirin; restriction of strenuous exercise until symptoms have resolved
A 34 year old male presents with a history of chest pain, shortness of breath and fever. He states the sharp pain is located over the left side of his chest and is made worse by inspiration and lying flat. You perform an electrocardiogram which supports your suspected diagnosis of pericarditis.
What could you expect to see on this patient’s electrocardiogram? Choose one (1) option.
PR depression and diffuse ST elevation which can be followed by T wave flattening and inversion
Loss of the P wave with tall tented T waves
PR elevation and diffuse ST elevation which can be followed by tall tented T waves
PR depression and diffuse ST depression which can be followed by QRS widening
PR depression and diffuse ST elevation which can be followed by peaked T waves
The correct response is: PR depression and diffuse ST elevation which can be followed by T wave flattening and inversion
ECG changes in pericarditis can follow four stages including:
Stage 1: diffuse ST elevation with PR depression with reciprocal changes in aVR (during the first 2 weeks)
Stage 2: resolution of stage 1 with generalised T wave flattening (1 - 3 weeks)
Stage 3: T wave inversion (3 to several weeks)
Stage 4: resolution (several weeks onwards)
Brian is a 67 year old male who presents to see you for review after recently being diagnosed with heart failure with reduced ejection fraction after presenting with a 6 month history of cough and shortness of breath. On examination, you note that he has bilateral fine inspiratory crepitations and mild shortness of breath on exertion. He has significant peripheral oedema to the level of the knees bilaterally.
You discuss his medications with him and then discuss non-pharmacological management. What advice do you provide to Brian regarding fluid restriction and dietary salt intake?
Choose the most appropriate advice.
Brian should consume < 2 grams salt / day and restrict his fluids to < 1.5L / day
Current guidelines do not support specific salt or fluid restriction in heart failure management
Brian should consume < 5 grams salt / day and restrict his fluids to < 2L / day
Brian should consume < 5 grams salt / day and manage his fluids according to his daily weighs
Brian should consume < 1 gram salt / day and restrict his fluids to < 1.5L / day
The correct response is: Brian should consume < 2 grams salt / day and restrict his fluids to < 1.5L / day.
This question is testing your knowledge of the 2018 Heart Failure guidelines. There is no evidence beyond expert opinion to support the amount of sodium intake for patients with heart failure, so the current advice is to apply the National Heart Foundation Australia general population recommendation regarding sodium intake which is < 2g/day.
Regarding fluid restriction, the guidelines recommend:
For patients with overt congestion: restrict to 1.5L fluid / day
If the patient’s weight increases by 2kg over 2 days: recommend GP review (consider a temporary increase in diuretics depending on haemodynamic status, renal function and electrolytes)
Consider a sliding-scale of diuretics for patients who are competent in self-management
Tania is a 50 year old woman who underwent ablative therapy for the treatment of her AV nodal reentry tachycardia 3 months ago. She has had excellent outcome and has ceased all her previous medications which included amiodarone. She presents today though feeling unwell. She describes unintentional weight loss of 5kg in the last month, this is associated with a tremor, and a feeling of weakness. Today she feels like her heart is racing again, and she is worried that the ablation has failed.
What is the MOST likely diagnosis? Choose one (1) from the following list:
Addison’s disease
Anxiety
Chronic Renal Failure
Congestive cardiac failure
Inflammatory pulmonary toxicity
Diabetes insipidus
Diabetes Mellitus
Recurrence of AV nodal re-entry tachycardia
Hepatic Failure
Hyperparathyroidism
Hyperthyroidism
Hypopituitarism
Hypothyroidism
Iron deficiency anaemia
Lymphoma
Multiple Myeloma
Psychosis
This woman is presenting with Amiodarone induced thyrotoxicosis. Amiodarone-induced thyrotoxicosis can develop during long-term amiodarone treatment, or some months after stopping treatment (because amiodarone has a long half-life). It can occur in patients with and without pre-existing thyroid disease. Amiodarone-induced thyrotoxicosis can be related to the high iodine content of amiodarone (type 1 amiodarone-induced thyrotoxicosis), but amiodarone can also directly damage thyroid cells (type 2 amiodarone-induced thyrotoxicosis).
A 58 year old man presents with an episode of severe chest pain at rest, in the context of a 2 week history of exertional chest pain. He has significant cardiac risk factors including hypertension and type 2 diabetes mellitus. He also has a family history of ischaemic heart disease with his father having coronary artery bypass grafting (CABG) at 54 years of age. He is an ex-smoker with a 40 pack year history. The chest pain was located over the left side of his chest and he describes a dull and heavy sensation, associated with shortness of breath and diaphoresis. Electrocardiogram (ECG) demonstrates sinus rhythm with ST elevation in the inferior leads (II, III and aVF). You suspect a myocardial infarction.
Which of the following coronary arteries is most likely occluded in this patient? Choose one (1) option.
Left anterior descending
Left circumflex artery
Right coronary artery
Diagonal arteries
Right marginal artery
The correct response is: Right coronary artery
Approximately 40 - 50% of myocardial infarctions are inferior myocardial infarctions. About 80% of inferior myocardial infarctions are caused by occlusion of the right coronary artery. Less commonly, the dominant left circumflex or a “type III” or “wraparound” left anterior descending artery may be involved. The latter involves an unusual pattern of concomitant anterior and inferior ST elevation.
Reference:
Life in the fast lane. ECG library. Inferior STEMI. https://lifeinthefastlane.com/ecg-library/basics/inferior-stemi/ (Accessed November 2019)
Shingles - test?
Herpes zoster PCR
What is Hutchinson’s sign?
Vesicles of Herpes Zoster on the tip of the nose.
The nasociliary branch of the trigeminal nerve innervates the cornea (Eye) and lateral dorsum and tip of the nose.
Hutchinsons sign precedes opthalmic involvement or Herpes Zoster Opthalmicus.
What are the complications of Herpes zoster?
- Post herpetic neuralgia
- Opthalmic involvement
- Ramsay hunt syndrome (vesicles to external auditory canal and palate AND loss of taste to anterior two thirds of tongue AND facial weakness
- Disseminated zoster
5, Bacterial infections
Management of herpes zoster?
Antiviral
eg. Famciclovir 250mg TDS for 7 days
Analgesia
eg. Paracetamol 1g QID as required
