Random 1 Flashcards
15 yo. C/o sore testicle. Pain, testicle high, transverse, absent cremasteric reflex Dx?
Torsion of the testicle. Pain, testicle high, transverse, absent cremasteric reflex ddx: epididymo-orchitis, torsion of testicular appendix. rx: urgent surgical review
6 yo bib mum. Itchy rash after eating lunch. Now hoarse, croaky voice and cough. Dx? Apart from ABCs, most important part of rx?
Anaphylaxis. 0.01-0.5mg/kg adrenalin IM anterolateral thigh. May need to rpt every 5-10 mins t/f hospital
56 yo. Abdo pain. H/o heavy ETOH, Hep C pos. Signs of chronic liver disease on examination?
spider naevi (>3), palmar erythema, gynaecomastia, caput medusa, ascites, jaundice, asterixis (liver flap).
45 yo Liver disease. abdo pain. Most serious dx? Essential ix for dx? rx?
Spontaneous bacterial peritonitis. ix: positive bacterial culture results and polymorph leucocyte (PML) count >259 cells/mm3 from ascitic tap. rx: IV 3rd gen cephalosporin Long term antibiotic prophylaxis with bactrim.
Red flags for acute abdo pain in 20yo woman?
ectopic pregnancy appendicitis perforated viscous PID DKA Malignancy eg. ovarian cancer
3 yo boy. Awoke with dyspnoea. Barking cough Inspiratory stridor increased work of breathing +/- fever +/- wheeze Dx? Rx?
Croup rx: Minimal handling Mild- Mod: prednisone 1mg/kg stat and second dose next day. Must be free of stridor before d/c severe: Hospital. nebulised adrenaline and IV dexamethasone
68 yo man. Progressive dyspnoea. Sleeps on 3 pillows. h/o MI and stent. HT. CXR: enlarged heart Echo: LVEF 25%. mitral regurg. Dx? Rx:
Heart failure. salt restrict ACE - I B blocker Frusemide, spironolactone digoxin
37 yo woman. SOB and chest pain this AM. Risk factors for PE? What is the Wells score? When is a D-Dimer indicated?
Risks for PE: previous PE/DVT Recent immobilisation/surgery malignancy pregnancy smoking oestrogen based medications inherited thrombophilia Wells score used to predict likelihood of PE Use D-Dimer if low pre-test probability. Neg D-Dimer and Low Wells score (4 or less) excludes PE
60 yo caucasian man. Abdominal obesity (Waist circumference 95cm), high triglycerides, HT Dx? Rx?
Metabolic syndrome. Abdominal obesity PLUS any 2 of: High triglycerides Low HDL HT (>= 130/85) High BSL >=5.6 or dx T2DM Rx: Lifestyle: - quit smoking, reduce ETOH - normal BMI and waist - Mediterranean diet - low salt - Exercise Medications for HT and lipids as per CVD risk calculator
24 yo uni student. H/o glandular fever. 6 months of tired and fatigue every day. Normal examination. Dx? How to exclude alternative dx? Rx?
Chronic fatigue Syndrome Recommended ix for fatigue (NICE guidelines) Úrinalysis FBC LFT TSH ESR. CRP BSL Creatinine Calcium Coeliac screen CK Ferritin (young people only) Rx: CBT and graded exercise. Nil evidence for meds or alternative meds
42 yo woman. 4 yrs worsening lethargy, generalised body aches, poor sleep. H/o severe viral illness and divorce 5 yrs ago. Burning quality to pain and intermittent paraesthesia. Dx? Red flags? Rx?
Fibromyalgia. Red flags: older age at onset. weight loss, night pain, focal pain, fevers and sweats, neuro fearures, h/o malignancy Rx: Pt education, exercise, psychology, Meds: antidepressants (amitriptyline, duloxetine) SNRI milnacipran only medication on TGA for fibromyalgia Paracetamol and NSAIDs Manage comorbid conditions
43 yo woman. H/o coeliac. 6 months fatigue. Weight gain, poor appetite. Constipation. dry skin. Anaemia, hyponatraemia. Dx? Tests to confirm?
Hypothyroidism raised TSH, Low T3, T4 Check UECs to rule out Addisons as treatment of hypothyroidism can lead to adrenal crisis Anti-thyroid peroxidase = hashimoto Nil USS unless nodules or goitre
33 yo. Bilateral ptosis, muscle weakness. Sits forward with elbow on desk, supporting chin with hand. Dx? Rx?
Myasthenia gravis. Autoimmune Acetylcholine receptors attacked by antibodies Neurologist.
33 yo diffuse goitre TSH 12 (0.3-5.0) T4 2 (11-23) T3 3 (3.5-6.7) Dx? Which further ix necessary?
Hypothyroidism Anti thyroid peroxidase = hashimotos, most common cause in western countries +/-USS - some say only USS if nodule, some say if goitre or nodule
30 yo. Hypothyroidism, on thyroxine. Wants to fall pregnant and is concerned about taking medication during pregnancy. What do you advise about hypothyroidism in pregnancy?
Overt hypothyroidism associated with adverse pregnancy outcomes: impaired fetal neurocognitive development (low IQ), low birth weight, miscarriage, stillbirth. (All women) 150ug iodine supplement daily Monitor TSH 4 weekly. Adjust thyroxine as soon as pregnancy confirmed, usually 25-30% increase
45 yo woman. nervous, intolerant of heat, palpitations, weight loss, fine tremor. Sinus tachy on ECG. Dx?
Hyperthyroidism
38 yo woman, tachycardia, goitre, returned with bloods: TSH editing issue, won’t save.
Thyrotoxicosis due to Graves disease B blocker Antithyroid meds: carbimazole, propylthiouracil. Radioactive iodine, thyroidectomy (after imaging) Propylthiouracil preferred in pregnancy. Wait 6 months after radioactive iodine before pregnancy (men 4 months for turnover of sperm production)
40 yo on carbimazole for Graves. Has mouth ulcer, fever and sore throat. Dx?
Agranulocytosis. (Neutrophil count. Risk with carbimazole and ptu. Advise pt to stop med and see Dr if sx infection.
40 yo, just confirmed hashimotos. What dose of thyroxine would you start? How often would you monitor?
Final dose of thyroxine is usually 1.6mcg/kg or 50-200mcg/day. Start 50mcg (lower, 25mcg in elderly), increasing every 2 wks. Recheck TSH 6 wks (T4 has long half life)
7 yo. Recently started wetting the bed. Mum thinks is due to drinking too much past few weeks. Also weight loss. Dx?
T1DM random bsl urgent refer
65 yo T2DM. Just started sulphonylurea. 4kg weight gain. Why? How to manage?
Insulin and sulphonylureas can cause hypoglycaemia and increase weight. Hypo = eating more = more weight If low BSL advise 15g fast acting carb, wait 15 mins, recheck BSL, if still low, 15g slow acting carb
70 yo T2DM. HT high chol. Vision deteriorating over past 4 months. fundus photo and optical coherence tomography scans show: retinal haemorrhages, hard exudates extending to fovea, cystic macular oedema Dx? DDx? Rx?
Diabetic macular oedema fovea involved = significant vision issues. ddx. cataract, macular degeneration Argon laser photocoagulation, more recently intravitreal anti-VEGF agents. Fenofibrates (recent TGA for diabetic retinopathy).
DSM V diagnosis of Specific Learning Disorder (eg. dyslexia) ?
learning difficulties >6 mths despite extra help academic skills significantly below peers symptoms manifest in school age (sometimes adults) Intellectual disability, vision/hearing impairment, mental/neuro disorders and psychosocial ruled out
3 yo. 3 months dry cough, laboured breathing. fhx atopy and asthma Dx? Initial rx?
Asthma Pt/family education, triggers, non smoking, GPMP, asthma plan etc. Meds: reliever (salbutamol) 6 inh via spacer prn preventer: montelukast or ICS eg fluticasone 50mcg bd (rinse mouth)
Definitions of asthma 0-5yrs: symptom free for at least 6 wks at a time ? Symptoms more than once every 6 wks on average but nil sx between flare ups
- Infrequent intermittent asthma 2. frequent intermittent asthma
Asthma in 0-5yo Daytime sx more than once per week but not every day AND/OR Night time symptoms more than twice per month but not every week?
Mild persistent asthma
Asthma in 0-5yo Any of: Daytime symptoms daily nightime sx more than once per week symptoms sometimes restrict activity or sleep?
Moderate persistent asthma
Asthma in 0-5yo Any of: Daytime symptoms continual night time sx fequent flare ups frequent Symptoms frequently restrict activity or sleep?
Severe persistent asthma
Mum with child with anaphylaxis to peanuts and egg, now pregnant with second child, wants to know how to reduce risk of this child developing anaphylaxis?
No smoking BF Earlier introduction of foods (4-6 months) - note guidelines still say exclusive BF 6 mths. Point is NOT to delay introduction of potentially allergenic foods. Cooked foods initially
Recurrent abdo pain, improved with defecation and alternating diarrhoea and constipation. Dx? Rx? Red flags?
Irritable bowel syndrome (IBS) Rome III criteria for Functional gastrointestinal disoder: a variable combination of chronic or recurrent GI symptoms, such as diarrhoea, constipation, abdo pain, not explained by structural or biochemical abnormalities. rx: low FODMAPs red flags: anaemia, bleeding, weight loss
21 month old. GCS 8/15. Poorly perfused. Unwell with resp infection for prev 24 hours. Metabolic acidosis, BSL 1.6, Na 134, K 5.5. hyperpigmentation of buccal mucosa. Dx? Rx?
Addison Disease - Adrenal crisis UECs, BSL, Serum cortisol, ACTH and 24 hrs utinary cortisol. Urgent ED resuscitation IV hydrocortisone, dextrose
Risks for T2DM?
AUSDRISK: Age >40 Overweight or obese Fhx Male Ethnicity HT Smoking h/o GDM or prev high BSL Fruit and vege intake Physical activity waist measurement (diff range for Aboriginal TSI)
52 yo man. T2DM 17 yrs. 5 days midfoot swelling. Initially painless but now pain after walking. Nil recent trauma Nil fever or other jt swelling. o/e: swelling medial midfoot. Minimal tenderness. Warm, inflamed with bounding pedal pulses. Dx? DDx Rx?
Charcot’s neuroarthropathy DDx: sprain, gout, cellulitis, osteomyelitis. Rx: EMERGENCY Refer multidisciplinary high risk foot clinic Total casting of foot for pressure offloading, immobilisation. ?duration based on clinical assessment, may be 3-6 months Check feet tinea, breaks in skin
Non medical rx migraine?
Quiet, dark room during attack. Avoid triggers - cheese, chocolate, citrus, etoh Improving sleep Regular meals caffeine cessation relaxation biofeedback stress management CBT weight loss exercise
Medical rx migraine?
Acute: simple analgesics and antiemetics. Triptans eg sumatriptan nasal spray
Avoid opiates
Prophylaxis: amitriptyline, pizotifen and propranolol.
Dx and Rx gout?
xray, Jt aspiration for crystals and mc/s (exclude septic jt). NSAID steroid inj urate lowering: allopurinol 100mg daily, titrating up every 4 wks until Serum Urate
Ix for delirium?
medication review Urinalysis & MC/S CXR UEC BSL FBC ESR, CRP
Vertigo plus diplopia, dysarthria, dysphagia, weakness, or numbness?
Vertebrobasillar stroke.
Recurrent vertigo
Benign paroxysmal positional vertigo (BPPV) Rx: Epley or semont manouvres
nausea, vomiting, vertigo. NO HEARING LOSS
Vestibular neuronitis. most common cause: viral infection of vestibular nerve
nausea, vomiting, vertigo AND hearing loss
labyrinthitis
Hearing loss, tinnitus, vertigo, imbalance, headache, facial weakness or numbness
acoustic neuroma
70yo post menopausal bleeding DDx? Ix?
endometrial atrophy benign endometrial hyperplasia benign endometrial polyps uterine fibroids endometrial carcinoma Ix: TV ultrasound. Endometrial thickness >4mm requires biopsy
Risk factors endometrial cancer?
Prolonged use of unopposed oestrogen therapy Tamoxifen use Hereditary non-polyposis colorectal cancer obesity and diabetes nulliparity late menopause, early menarch PCOS
28 yo woman. Obese, headaches few months, mild blurred vision. papilloedema ddx?
Benign intracranial hypertension. Needs opthalmology r/v
Female >50 yrs new bilat shoulder and hip girdle pain Raised ESR/CRP
Polymyalgia rheumatica 16-21% of patients have GCA
Age >50yrs new onset localised headache temporal artery tenderness +/- decreased temporal artery pulse ESR >=50 Positive temporal artery biopsy
Giant cell arteritis vision loss in up to 20% Oral steroids - average 2 yrs or steroid sparing - methotrexate, cyclosporin, azathioprine
14 yo. Non traumatic knee pain 6 wks. Very active.
Dx?
ddx?
Osgood-schlatter (most common) - osteochondrosis of the patellar tendon insertion onto tibial tubercle. Conservative rx, avoid high impact
Ddx:
Osteochonral defect
Meniscal tear
patellofemoral instability
synovitis
osteomyelitis and osteosarcoma (both rare)
60 yo chronic pain and tenderness greater trochanter, lateral thigh and buttock.
Dx?
Rx?
Greater trochanteric pain syndrome.
includes: trochanteric bursitis
tendinopathy and tears of gluteus medius and minimus tendons
Iliotibial band disorders
Most common is gluteus medius tear
USS and MRI to dx
rx: NSAID, Ice, weight loss, physio
USS guided steroid inj into greater trochanteric bursa
Tests for shoulder:
impingement or rotator cuff tendinopathy
Hawkins
Neer
empty can
Who is suitable for äctive surveillance”for prostate cancer?
What does active surveillance involve?
When is curative treatment recommended?
Gleasön score 6 (low-risk prostate cancer). (Gleason 7 intermediate risk, Gleason 8 high risk)
PSA <10
non palpable tumour on DRE or small tumour occupying < half of 1 lobe
Active surveillance (delayed curative treatment):
PSA testing every 3-4 months in 1st 2 years, then 6 monthly PSA and DRE
Biopsy at 12 months then every 2-3 years
Triggers for intervention:
progression to higher grade tumour or tumour volume on biopsy
doubling of PSA <3 yrs
change in pt preference
Treatment options for prostate cancer?
Low risk: Active surveillance, radical prostatectomy, external beam radiation, low dose rate brachytherapy
Intermediate and high risk (combinations of):
radical prostatectomy, external beam radiation, high dose radiation brachytherapy, androgen deprivation therapy
50yo. Common causes chronic dyspnoea?
Asthma
COPD
Interstitial lung disease
myocardial dysfunction
obesity/deconditioning
Contraception perimenopause <50?
>50?
<50, keep using contraception until 2 yrs after last period
>50, contraception for 12 months after last period.
No oestrogen contraceptive >50yrs
If over 50 yrs using progesterone only contraception, can have 2 x FSH tests 6 wks apart, if both over 30IU, contraception only required for another 12 months
17 yo boy. Splenectomy following trauma on bike.
Risks?
Management?
Overwhelming post splenectomy infection.
these episodes have a mortality rate of up to 50%
Common causes: Strep pneumoniae (50% of cases)
Hib
Neiserria meningitidis
capnocytophaga canimorsus (dog or cat bites)
Rx: Daily abx for at least 2 years post splenectomy (amoxil or phenoxymethypenicillin)
Lifelong:
education
Emergency antibiotic supply at signs of infection - fevers, shivers
vaccinations
travel advice/animal handling
medic alert bracelet and utd vaccine card
Severe eye pain
Nausea and vomiting
Headache
Blurred vision and/or seeing haloes around lights (Haloes and blurred vision occur because the cornea is swollen.)
Profuse tearing
Hazy cornea
irregular, semidilated pupil
Red eye
tender and tense to palpation
Acute angle closure glaucoma
urgent refer
Red eye:
Rapid onset of eye pain
decreased vision
photophobia
Risk factors:
Contact lens wear (Note the type of lens, wearing time, and type of disinfection system.)
Trauma (including previous corneal surgery)
Use of contaminated ocular medications
Decreased immunologic defenses
Aqueous tear deficiencies
Recent corneal disease (herpetic keratitis, neurotrophic keratopathy)
Structural alteration or malposition of the eyelids
Bacterial keratitis
urgent refer
can be fungal or amoeba
Sudden painless vision loss.
Relative afferent pupillary defect
DDx:
Sudden painless vision loss (monocular) that usually lasts seconds to minutes, up to 2 hours. Vision returns to normal
Dx:
Rx:
Central retinal vein occlusion - + abnormal red reflex
Central retinal artery occlusion
Transient Ischaemic attack (Amaurosis Fugax)
As for TIA - Urgent refer. carotid doppler, echo, Bloods, thrombophilia screen. Start aspirin.
Risk factors for Obstructive sleep apnoea (OSA)?
Risks of OSA?
Male
Middle age
Obesity
Upper airway obstruction (eg tonsils)
High waist to hip ration
increased neck circumference
medications
ETOH
Also associated with diabetes, HT and smoking
Risks of OSA:
HT
Cardivascular disease
overweight/obesity
MVA
neurocognitive impairment
Restless legs
Risk factors?
Conditions associated?
Rx?
Risk factors
iron deficiency
Pregnancy
End stage renal failure
Drug induced (tricyclics, SSRI, dopamine antagonists - metoclopramide, lithium)
More common in patients with MS and Parkinson’s
Rx:
non med: Stretches, compression stockings, exercise
abstinence from nicotine, ETOH, caffeine
Distraction techniques
review meds
treat iron deficiency - may need to treat to symptom relief, up to ferritin 300
Medications: Dopaminergic: pramipexole, levodopa
DSM V criteria for major depressive disorder?
Pervasively depressed mood and/or marked loss of interest or pleasure, unexplained by personal circumstances PLUS 4 or more of the following for at least 2 weeks:
Marked change in weight or appetite
Insomnia/hypersomnia nearly every day
Psychomotor agitation/retardation nearly every day
Fatigue/loss of energy nearly every day
feelings of worthlessness, excessive/inappropriate guilt
indecisiveness or diminished concentration
feelings of hopelessness
thoughts of death, suicide ideation/attempt
Diagnosis GDM?
Risk factors?
Complications of GDM?
75g GTT 26-28 wks. Fasting BSL 5.1 - 6.9 . 1 hour >= 10.0. 2 hour 8.5 - 11.0
Risk factors: Age, BMI >30, Ethnic group, Fhx GDM or DM, Prev GDM, Prev macrosomia
Complications: PET, polyhydramnios (PROM, unstable lie, cord prolapse, abruption, PPH, stillbirth
Shoulder dystocia, instrumental delivery, LSCS,
Macrosomia/IUGR, diabetes, obesity, jaundice in baay
