Randoms

Question 1

Risk factors for endometrial ca

Answer 1

History of chronic anovulation
Exposure to unopposed oestrogen
Polycystic ovary syndrome (PCOS) associated with chronic anovulation
Exposure to tamoxifen
Strong family history of endometrial or colon cancer (Lynch syndrome)
Nulliparity
Obesity (often with diabetes and hypertension)
Endometrial thickness > 8mm

Question 2

Which tests should a sexually active MSM have 3 monthly

Answer 2

Hep A, B, HIV, Syphilis serology, First pass urine and ano-rectal swab for Chlamydia and Gonorrhea NAAT

If monogamous - yearly

Hep C test yearly only - if IVDU, HIV, or on Prep

Question 3

Post menopausal bleeding - endometrial thickness 4mm or more on T/V ultrasound

Answer 3

Any post menopausal bleed - Refer in 6 weeks to Gynae

If Endometrial thickness greater than 4 mm - endometrial biopsy

Question 4

Perineal tears - long term issues and when to refer?

Answer 4

Long term - dyspareunia, perianal pain, flatal and feacal incontinence

Refer - dyspareunia, severe constipation, faecal incontinence, wound dehiscence

Question 5

Acute management of poisoning in toddler

Answer 5

Call Poisons hotline 1131126, ABC D1- disability - (treat seizures), D2 - Decontaminate - skin, eyes and GIT (with toxicologist cos emesis, activated charcoal and lavage have limited evidence and carry risks) D3 - drug antidotes, E1- ECG E2 - exposure (think about hypo and hyperthermia) E3 - enhanced elimination (urinary alkilisation, multi dose activated charcoal, dialysis)

Question 6

Lethal in 1-3 tabs

Answer 6

Beta blockers, calcium channel antagonists, Sulphonylureas (hypoglycaemia may be delayed up to 8 hours), chloroquine and hydroxychloroquine, ecstasy and amphetamines, tricyclic antidepressants, theophylline

Question 7

Candidal vulvovaginitis - candida albicans vs glabrata

Answer 7

If can tolerate topicals: Topical 1% cotrimazole intravaginal cream one applicator full nocte for 6 nights.
If cant tolerate topicals and not prego - oral fluconazole 150mg stat

For candida glabrata- Boric acid 600mg intravag nocte for two weeks

Question 8

Red flags for hospital admission in Community acquired pneumo?

Answer 8

patients with any of the following parameters need close clinical observation, and are therefore likely to need inpatient management [NB2]:

tachypnoea (respiratory rate 22 breaths/minute or more)
heart rate higher than 100 beats/minute
hypotension (systolic blood pressure lower than 90 mmHg)
acute-onset confusion
oxygen saturation lower than 92% on room air (or lower than baseline in patients with comorbid lung disease)
multilobar involvement on chest X-ray
blood lactate concentration more than 2 mmol/L [NB3].

Question 9

Definition of infertility?

Answer 9

Infertility is defined as the inability to conceive after 12 months of regular, unprotected sexual intercourse and this typically affects 15 - 20% of couples.

Question 10

Causes of male infertility?

Answer 10

Pre-testicular
• Hypogonadotrophic hypogonadism – Kallmann syndrome
• Hyperprolactinaemia
• Pharmacological

Testicular
• Varicocele
• Cryptorchidism
• Testicular cancer
• Radiation
• Chemotherapy or
pharmacological
• Genetic azoospermia or
oligospermia
• Y-chromosome microdeletions
• Klinefelter syndrome
• Environmental
• Infection
• Injury or trauma
• Primary ciliary dyskinesia
• Sertoli cell-only syndrome
• Anti-sperm antibodies

Post-testicular
• Coital
• Pharmacological
• Retrograde ejaculation
• Congenital bilateral absence of
the vas deferens
• Ejaculatory duct obstruction or
seminal vesicle dysfunction
• Vasectomy or Iatrogenic injury to
the vas deferens
• Young’s syndrome
• Nerve injury
• Spinal cord injury
• Retroperitoneal lymph node
dissection
• Systemic disease

Question 11

Elevated lft

Answer 11

Elevated lifts - exclude etoh, viral hep b and c, autoimmune hep, thyroid prob, coeliac, haemochrom
And u/s

Question 12

Nafld criteria

Answer 12

Evidence of fatty infiltration- on u/s MRI or liver biopsy
Exclusion of significant etoh consumption
Exclusion of other causes of steatosis (meds, surgery, metabolic disorders

Question 13

Emergency contraception for a woman?

Answer 13

Levonorgestrel tablets:

1.5mg tablet stat dose taken as soon as possible (within 72 hours of unprotected intercourse)
if this is unavailable, a woman can take 25 tablets of the levongesterel progestin-only mini-pill with another 25 tablets to be taken 12 hours later (50 tablets total)
may have reduced efficacy in women with a BMI > 30
2. Ulipristal acetate tablets (“EllaOne”):

30mg tablet taken orally as soon as possible, up to 5 days following unprotected intercourse
most effective of the oral methods
may have reduced efficacy in women with a BMI > 30 (but less so compared with levonorgestrel)
3. Copper intrauterine device:

the most effective overall method
not affected by body weight
insert within 120 hours of unprotected intercourse without loss of efficacy for 5 days
the only method that will be effective if ovulation has already occurred
Recommencing the oral contraceptive pill or inserting an etonogestrel implant (Implanon) after counselling may be appropriate long-term options to prevent pregnancy but are not appropriate in the short term as emergency contraception.

Question 14

How would you manage a simple ovarian cyst?

Answer 14

Simple cysts will usually resolve within three menstrual cycles and require no investigation.”

This question is assessing knowledge of investigation of a simple ovarian cyst. It is important candidates are aware that simple cysts, in the pre-menopausal period, usually self-resolve within 3 cycles. If the cyst is greater than 5cm, a repeat ultrasound could be performed in 3 months to ensure resolution.

Question 15

Should you organise a CA125 for a pre-menopausal woman? What can it be elevated in?

Answer 15

In addition to ovarian carcinoma, some pelvic pathologies may contribute to an elevated CA125 including endometriosis, pelvic inflammatory disease and uterine fibroids. In the pre-menopausal female CA125 is not a diagnostic or screening test and as such should not be routinely ordered in the general practice setting.

Question 16

How does vulval lichen planus present?

Answer 16

Vulval lichen planus often presents with painless white streaks in a fern-like pattern or with painful ulcers / erosions

Question 17

Eligibility for home Cervical collection?

Answer 17

The new National Cervical Screening Program (NCSP) commenced in Australia in December 2017 and involves screening women aged 25 – 74 years with a 5 yearly HPV test. There are specific eligibility criteria surrounding the use of self-collected vaginal samples which can be seen in the reference below. Eligible people include:

• those who have never participated in the NCSP and are 30 years or over
• those who are overdue for cervical screening by 2 years or more and aged 30 years or over

Question 18

Amsel criteria for diagnosing bacterial vaginosis?

Answer 18

The Amsel criteria can be used to diagnose bacterial vaginosis; three of the following features must be present:

thin, white, homogeneous discharge
vaginal fluid pH more than 4.5
clue cells (epithelial cells covered with small curved coccobacilli and mixed flora) visualised on a wet preparation of a vaginal swab or Gram-stained smear
fishy odour when adding alkali (potassium hydroxide 10%) to discharge.

Question 19

Treatment and important considerations for BV?

Answer 19

Metronidazole orally 2g stat
Clindamycin treatment of choice in pregnant women
Make sure that
Male partners don’t need treatment but female partners should be assessed for BV
Bacterial vaginosis is associated with a 2-3 fold increased risk of acquiring STIs including chlamydia, gonorrhoea, herpes simplex type 2 and HIV infection, and increases the risk of HIV transmission to male partners.

Question 20

Approach to lactational mastitis?

Answer 20

Acute mastitis is usually associated with breastfeeding and is often caused by Staphylococcus aureus. Poor infant positioning, milk stasis and nipple damage are contributing factors. Breastfeeding or expressing milk (manually or via a pump) from the infected breast is safe and should be continued.

If mastitis is not associated with breastfeeding, seek expert advice for management.

In patients without systemic symptoms, increased breastfeeding and gently expressing milk from the affected breast may prevent progression and resolve infection without antibiotics.

In patients with systemic symptoms, or symptoms or signs that have not resolved after 24 to 48 hours of increased breastfeeding and expressing of milk, early antibiotic therapy is important to prevent abscess formation. Combine antibiotic therapy with increased breastfeeding and expressing of milk.

Use:

1
dicloxacillin 500 mg orally, 6-hourly. If symptoms and signs resolve rapidly, 5 days of therapy may be sufficient; otherwise continue treatment for 10 days
OR

1
flucloxacillin 500 mg orally, 6-hourly. If symptoms and signs resolve rapidly, 5 days of therapy may be sufficient; otherwise continue treatment for 10 days.

Question 21

Breast cancer risk reduction?

Answer 21

Current RACGP guidelines for preventive activities in general practice (the ‘Red Book’) advocate for physical activity, adequate folate, a Mediterranean diet, normal body mass index (in post-menopausal women only) and decreased alcohol consumption to reduce breast cancer risk.

In this case it is important for candidates to identify that having one first-degree family member with breast cancer, aged over 50, does not change Roberta’s overall risk category. She is still in the ‘average or only slightly higher risk’ of breast cancer category (i.e. >95% of the female population). Therefore, she should be encouraged to have a screening mammogram every 2 years until the age of 74 years and breast awareness should also be discussed.

Smoking does not have the same correlation with breast cancer as alcohol, and there is no strong or proven direct association with smoking and breast cancer in females.

Question 22

How should a new breast lump be managed?

Answer 22

A triple test with a follow-up appointment is the most appropriate management for a women with a new breast lump. See the Cancer Australia 2017 guidelines referenced below for details. If there are suspicious or malignant breast or nipple changes after having conducted a history and examination, it is recommended to refer to a breast surgeon, preferable with further test results.

The triple test refers to three diagnostic components:

1. medical history and clinical breast examination
2. imaging – mammography and/or ultrasound
3. non-excisional biopsy – core

Question 23

What do you need to know about self collected tests? What happens with a positive result?

Answer 23

The self-collected test only detects HPV and the sample cannot be tested for cervical cell changes. If a woman completes a self-collected HPV test, and higher risk HPV 16/18 is detected, she should be referred for colposcopy and at that visit, the clinician will collect a cervical sample for liquid-based cytology. If HPV (not 16/18) is detected on the self-collected sample, the woman should be advised to return to see you in 6 – 12 weeks for a clinician-collected cervical sample for liquid-based cytology.

Question 24

When to refer esotropia?

Answer 24

Inward turning of the eye, known as ‘esotropia’, is considered normal for infants aged under 3 months if it variable and occurs intermittently. After 3 months of age, this condition needs to be referred semi-urgently for evaluation for strabismus. Constant large turning in of the eye also requires semi-urgent referral, regardless of the age of the infant. Acute onset of constant esotropia at any age requires immediate referral.

Question 25

Pre-referral eye exam in infant?

Answer 25

An appropriate pre-referral eye examination of an infant of this age includes:

checking visual acuity and ocular motility (by seeing if the infant can fix and follow with a light or toy)
checking fundoscopy
checking for absence / presence of the red reflex and white reflex
checking pupillary sizes and reactions

Question 26

Pseudogout presentation and joint aspirate findings?

Answer 26

Acute calcium pyrophosphate crystal arthritis (also known as pseudogout), is the most common cause of an acute monoarthritis in the older patient. It presents as an acutely inflamed joint, mimicking gout. The knee and the wrist are the most commonly affected sites, a point of difference from gout, but the disease may involve other joints and tendons. Acute attacks can be accompanied by fever and leucocytosis, mimicking septic arthritis.

Question 27

Bariatric surgery criteria?

Answer 27

Eligibility criteria for bariatric surgery are primarily based on body mass index (BMI) and the presence of obesity-related complications, including:

individuals with BMI >40 kg/m2
individuals with BMI >35 kg/m2 with one or more obesity‑related complications.

Question 28

Acute gout pharm mx?

Answer 28

indomethacin 50mg QID
OR
colchicine 1 mg orally initially, then 500 micrograms 1 hour later, as a single one-day course (total dose is 1.5 mg).
OR local corticosteroid injection - max of two affected sites

Question 29

Acute management of hypoglycaemic episode

Answer 29

Commence appropriate resuscitation protocols.
Give an injection of glucagon 1 mg intramuscular or subcutaneous if available.
If intravenous access is obtained, glucose 50% – 20 mL intravenous via a securely positioned cannula (optimally the antecubital veins). Use 10% glucose in children, as hyperosmolality has caused harm.
Phone for an ambulance (dial 000) stating a ‘diabetic emergency’.
Wait with the patient until the ambulance arrives.
When the person regains full consciousness and can swallow, they can then be orally given a source of carbohydrate.

Question 30

Signs of red back spider envenomation

Answer 30

Signs of red back spider systemic envenomation can include agitation, lethargy, malaise, hypertension, nausea, vomiting, fever, priapism, patchy paralysis, paraesthesia, fasiculations, muscle spasms, headache and cardiac effects.

Question 31

Scabies management - non remote and remote?

Answer 31

First-line treatment for scabies is topical permethrin 5% cream, which should be applied to the whole body and washed off after eight hours. In central and northern Australia and in infants and the elderly, scabies above the neck is common and in these populations treatment should also be applied to the face and hair (avoiding the eyes and mucous membranes). All household contacts should be treated at the same time.

Flucloxacillin in adults and cephalexin in children (more palatable than flucloxacillin) are the preferred choice of antibiotics in non-remote settings where S. aureus is the most likely pathogen. In remote settings, S. pyogenes is the primary driver of infection, and first line treatment options include short-course trimethoprim-sulfamethoxazole or intramuscular benzathine penicillin G. Trimethoprim-sulfamethoxazole is also recommended if methicillin resistant S. aureus is suspected or proven.

Question 32

Protazoan infection with common presenting symptoms in women include frothy yellow/green vaginal discharge possibly with a foul odour, dyspareunia, dysuria and lower abdominal discomfort.

Answer 32

Trichomonas Vaginalis

High Vag swab for NAAT
Treat with flagyl either 2g PO stat
or 400mg bd for five days
treat male partners presumptively