Rural GP Formative Flashcards
A two month old infant presents with a birth mark on the neck. Examination reveals a cavernous haemangioma (strawberry naevus).
What is the most appropriate management?
- A: Injection of sclerosing fluid into the haemangioma
- B: Local radiotherapy.
- C: Reassurance that specific treatment is not required
- D: Total surgical excision
- E: Vascular laser therapy
= C: Reassurance that specific treatment is not required.
This skin lesion often starts to regress after 12 months of age but it may take up to age 7 years to completely disappear. Treatment is generally not indicated.
A 56 year old male presents with gradual painless loss of hearing in the right ear. There is no history of noise exposure and he has been well recently. He often clears his ears with a cotton bud.
What is the most likely diagnosis?
- A: Chronic otitis media
- B: Otitis externa
- C: Otosclerosis
- D: Perforated tympanic membrane
- E: Wax
= E: Wax
The most likely cause is he has pushed ear wax deeper into the ear canal where it has totally occluded the canal and has produced hearing loss.
A 51 year old female is distressed to have learned that her younger sister has breast cancer at the age of 48 years. What best describes her risk and the most appropriate surveillance?
- A: Her risk is increased and she should have ultrasound with every mammogram
- B: Her risk is markedly increased and she should consider prophylactic bilateral mastectomies
- C: Her risk is moderately increased and she should have screening mammograms every year
- D: Her risk is not markedly increased and she should have screening mammograms every two years
- E: One sibling with breast cancer does not change the patient’s risk and she should have mammograms
= C: Her risk is moderately increased and she should have screening mammograms every year
- Her risk is increased and she should have screening mammograms every year. If it is assumed that the female’s sister developed her breast cancer below the age of 50 years this places the patient at a moderately increased risk of breast cancer (4% of the female population). However, best practice guidelines (RACGP ‘Red Book) advises that the patient requires yearly mammograms from 50 - 69 years of age.
A 58 year old male attends your general practice complaining of ‘a strange feeling’ in his upper chest that has been present for several days. During examination, you find that he is in atrial fibrillation, which is confirmed by ECG. This finding has not been noted before. The examination is otherwise normal.
What is the most important initial management step?
- A: Arrange for a cardiology consultation
- B: Arrange for a Holter monitor to record his rhythm over a 24 hour period
- C: Commence anticoagulant medication
- D: Commence treatment with digoxin
- E: Undertake thyroid function tests
= C: Commence anticoagulant medication.
- He has atrial fibrillation and is thus at risk of embolic stoke. This type of stroke is usually severe and therefore he needs prompt anticoagulation before anything else is done.
A four year old boy’s parents are concerned about his poor language development. Further inquiry reveals that he did not behave like his sibling did when being cuddled or during play. He would tend to rock back and forth for long periods. What is the most probable diagnosis?
- A: Asperger’s syndrome
- B: Autism
- C: Learning disorder
- D: Major depression
- E: Mental retardation
= B: Autism
The history of poor communication skills combined with stereotypical repetetive movements in this young boy is highly suggestive of autism.
Transient ischaemic attacks (TIAs) most commonly resolve in:
- A: 5 seconds
- B: 5 minutes
- C: 5 hours
- D: 24 hours
- E: 5 days
= B: 5 minutes
Nearly all TIAs resolve by five mins.
A 22 year old male comes into the surgery. He gives a one-hour history of suddenly feeling breathless. On auscultation of the chest there are no breath sounds or adventitial sounds on the left side. The area is hyper-resonant to percussion.
What is the most likely diagnosis?
- A: Bronchiectasis
- B: Emphysema
- C: Lobar pneumonia
- D: Pleural effusion
- E: Pneumothorax
= E: Pneumothorax
The history and examination are typical for collapsed lung i.e.
Pneumothorax
A shearer presents with a dark bluish blister on his thumb.
What is the most likely diagnosis?
- A: Blue naevus
- B: Keratoacanthoma
- C: Orf
- D: Q fever
- E: Scabies
= C: Orf
A bluish nodule/blister in a shearer is most likely Orf, a pox virus infection, generally self-resolving and needing no treatment
A rural GP in her country surgery receives a phone message that a farmer has become trapped in a grain bin. What is the most appropriate advice the GP should give over the phone to the people at the scene?
- A: Get bystanders to cut a hole in the bin at ground level
- B: Get bystanders to tip the bin on its side
- C: Get bystanders to turn on the auger
- D: Put a metal sheet in the grain downhill of the victim’s face
- E: Turn off any ventilator
= D: Put a metal sheet in the grain downhill of the victim’s face.
Put a metal sheet in the grain downhill of the victim’s face. The rescue of a person in a grain silo who is being suffocated or engulfed by grain is difficult and dangerous. All actions that increase the outflow of grain will endanger the patient’s life. Surrounding the patient with sheet metal or other grain proof sheeting in order to dig out the surrounding grain and thus lift out the worker is advised.
What advice should be given to a farmer to avoid power take off (PTO) injuries?
- A: Avoid short circuiting the starter motor
- B: Avoid wearing tight clothes
- C: Monitor multi-part guards
- D: Use rollover protective structures (ROPS)
- E: Wear a seat belt
= C: Monitor multi-part guards.
Power take offs are spinning shafts usually on the rear of tractors.
They cause injury by entrapping clothing and dismembering limbs. They should be covered at all times with guards.
A 65 year old farmer presents with a skin lump on his forearm. It has been present for three weeks and is increasing in size. On examination, it is non-pigmented and papular with a plug in the centre. What is the most likely diagnosis?
- A: Basal cell carcinoma
- B: Dermatofibroma
- C: Keratoacanthoma
- D: Neurofibroma
- E: Solar hyperkeratosis
= C: Keratoacanthoma.
The clue to this diagnosis is the rapid growth (present for only 3 weeks) and the plug in the centre which is almost pathognomonic for a keratoacanthoma.
A 62 year old female presents with a rash on the left side of her chest. A diagnosis of herpes zoster is made. Which statement regarding herpes zoster is incorrect?
- A: Following the initial rash there is crusting and separation of scabs
- B: Is associated with intense erythema with papules in affected skin
- C: Is associated with unilateral patchy rash affecting one or more contiguous dermatomes
- D: Once the skin lesions develop, there is no further risk of infection
- E: Rash is preceded by several days of radiating pain with hyperaesthesia
= D: Once the skin lesions develop, there is no further risk of infection. The skin lesions are vesicles which contain herpes zoster virus.
These are highly infectious.
A 31 year old female presents to your practice complaining of a rash on her forehead, cheeks, nose and chin. The periorbital areas are spared. There are some telangiectasia and pustules in the rash. What is the most likely diagnosis?
- A: Acne rosacea
- B: Perioral dermatitis
- C: Pityriasis rosea
- D: Seborrhoeic dermatitis
- E: Systemic lupus erythematosis
= A: Acne rosacea.
The distribution, presence of telangiectasia is characteristic of acne rosacea, which in some cases may have pustules as well.
A 15 year old high school student who has been your patient since she was an infant, comes to you asking for a prescription for the contraceptive pill. She says that her parents do not know of this visit and she is emphatic that she does not want her parents to know of this consultation. She seems confident that her parents would not support her request but she says that her aunt has said it is fine to use the pill. Which of the options is correct to the question, ‘Would you prescribe the pill?’
- A: No - as she is technically a minor and cannot be treated without parental consent
- B: No - because she has confirmed that it is against her parents’ wishes
- C: Yes - because she has enlisted the support of an adult relative
- D: Yes - but only once you are satisfied that she is mature and competent
- E: Yes - prescribing the pill for a 15 year old is legal
= D: Yes - but only once you are satisfied that she is mature and competent.
- Between the ages of 14 - 16 years a minor can be considered an adult for the purposes of the consultation if the doctor considers her mature and competent. This is also known as ‘Gillick’ competence.
A 36 year old bus driver has an acute exacerbation of chronic low back pain. He is prescribed a combination analgesic containing paracetamol 500 mg and codeine 30 mg. The dose recommended by his GP is two tablets, three times a day. Which side effect is it most important to advise the patient about?
- A: Anaphylaxis
- B: Constipation
- C: Dependence
- D: Drowsiness
- E: Rash
= D: Drowsiness.
Although the codeine will cause constipation it will also cause drowsiness in some people. As this male drives a bus he should be warned about this important potential side effect.
- A: Acromegaly
- B: Addison’s disease
- C: Anorexia nervosa
- D: Carcinoid syndrome
- E: Conn’s syndrome
- F: Cushing’s syndrome
- G: Diabetes insipidus
- H: Diabetes mellitus
- I: Hyperparathyroidism
- J: Hyperthyroidism
- K: Hypoparathyroidism
- L: Hypothyroidism
- M: Phaeochromocytoma
- N: Zollinger-Ellison syndrome
= F: Cushing’s syndrome. These symptoms collectively are those of Cushing’s syndrome.
- A: Acromegaly
- B: Addison’s disease
- C: Anorexia nervosa
- D: Carcinoid syndrome
- E: Conn’s syndrome
- F: Cushing’s syndrome
- G: Diabetes insipidus
- H: Diabetes mellitus
- I: Hyperparathyroidism
- J: Hyperthyroidism
- K: Hypoparathyroidism
- L: Hypothyroidism
- M: Phaeochromocytoma
- N: Zollinger-Ellison syndrome
= I: Hyperparathyroidism.
Muscle pain, constipation, abdominal pain, thirst and frequent micturition are strongly suggestive of hypercalcaemia due to hyperparathyroidaemia.
- A: Acromegaly
- B: Addison’s disease
- C: Anorexia nervosa
- D: Carcinoid syndrome
- E: Conn’s syndrome
- F: Cushing’s syndrome
- G: Diabetes insipidus
- H: Diabetes mellitus
- I: Hyperparathyroidism
- J: Hyperthyroidism
- K: Hypoparathyroidism
- L: Hypothyroidism
- M: Phaeochromocytoma
- N: Zollinger-Ellison syndrome
= B: Addison’s disease.
Vomiting, abdominal pain with hyperkaelamia is suggestive of low serum cortisol with electrolyte abnormalities i.e. in this case Addison’s disease.
- A: Asthma
- B: Bronchiolitis
- C: Carcinoma of the lung
- D: Chronic obstructive pulmonary disease
- E Collapsed lung
- F: Congestive cardiac failure
- G: Croup
- H: Fibrosing alveolitis
- I: Inhaled foreign body
- J: Lobar pneumonia
- K: Pleural effusion
- L: Pneumothorax
- M: Pulmonary embolism
- N: Tuberculosis
= B: Bronchiolitis
- The prodromal illness and the clinical findings of hyperinflation, tachypnoea and fine widespread inspiratory crackles on inspiration are strongly suggestive of bronchiolitis caused by RSV.
- A: Asthma
- B: Bronchiolitis
- C: Carcinoma of the lung
- D: Chronic obstructive pulmonary disease
- E Collapsed lung
- F: Congestive cardiac failure
- G: Croup
- H: Fibrosing alveolitis
- I: Inhaled foreign body
- J: Lobar pneumonia
- K: Pleural effusion
- L: Pneumothorax
- M: Pulmonary embolism
- N: Tuberculosis
= H: Fibrosing alveolitis. (Syn. Idiopathic pulmonary fibrosis) is suggested in this question by the age and sex of the patient, progressive shortness of breath, dry cough, clubbing and fine bibasal crackles.
- A: Asthma
- B: Bronchiolitis
- C: Carcinoma of the lung
- D: Chronic obstructive pulmonary disease
- E Collapsed lung
- F: Congestive cardiac failure
- G: Croup
- H: Fibrosing alveolitis
- I: Inhaled foreign body
- J: Lobar pneumonia
- K: Pleural effusion
- L: Pneumothorax
- M: Pulmonary embolism
- N: Tuberculosis
= M: Pulmonary embolism. The histroy of recent inactivity and sudden onset of sharp chest pain associated with shortness of breath raises a strong possibility of pulmonary embolism. This would be significantly large to cause shortness of breath.
- A: Asthma
- B: Bronchiolitis
- C: Carcinoma of the lung
- D: Chronic obstructive pulmonary disease
- E Collapsed lung
- F: Congestive cardiac failure
- G: Croup
- H: Fibrosing alveolitis
- I: Inhaled foreign body
- J: Lobar pneumonia
- K: Pleural effusion
- L: Pneumothorax
- M: Pulmonary embolism
- N: Tuberculosis
= A: Asthma.
Paroxysmal episodes of shortness of breath during exercise in an 11 year old are suggestive of exercise induced asthma.
- A: Asthma
- B: Bronchiolitis
- C: Carcinoma of the lung
- D: Chronic obstructive pulmonary disease
- E Collapsed lung
- F: Congestive cardiac failure
- G: Croup
- H: Fibrosing alveolitis
- I: Inhaled foreign body
- J: Lobar pneumonia
- K: Pleural effusion
- L: Pneumothorax
- M: Pulmonary embolism
- N: Tuberculosis
F: Congestive cardiac failure
- She has congestive cardiac failure mainly affecting the left ventricle as she has signs of fluid in her lungs (bilateral basal crackles) and a non elevated JVP. In time LV failure may progress to RV failure so the patient has biventricular failure.
