Semester C Flashcards
Beryl is a 73-year-old lady who is concerned about a lesion that has been slowly growing on her face over the last 3 months. It commenced as a small “pimple” like lesion but now looks like this:
https://acrrm.instructure.com/courses/546/files/40861/preview
She has never had anything like this before but has previously had some small scaly lesions “frozen” off when she lived in Queensland, where she grew up and lived until she was 70 years old. She now lives with her daughter in South Australia. Her other medical history includes type 2 diabetes, hypertension and hyperlipidaemia.
The most likely diagnosis is:
A. Nodular basal cell carcinoma (BCC)
B. Squamous cell carcinoma
C. Keratoacanthoma
D. Amelanotic melanoma
A. Nodular basal cell carcinoma (BCC)
BCC’s are the most common human cancer; nearly as common as all other human cancers combined! BCCs are a locally invasive skin tumour. The main characteristics are:
Slowly growing plaque or nodule
Skin-coloured, pink or pigmented
Varies in size from a few millimetres to several centimetres in diameter
Spontaneous bleeding or ulceration
Very rarely a threat to life
There are several distinct clinical types of BCC including nodular BCC
Most common type of facial BCC
Shiny or pearly nodule with a smooth surface
May have central depression or ulceration, so its edges appear rolled
Blood vessels cross its surface
BCC
Image source and reference: DermNetLinks to an external site.
Keratoacanthoma is a skin lesion that erupts in sun-damaged skin and may start at the site of a minor injury. It initially appears as a small pimple or boil but with a solid core filled with keratin (scale). It grows for a few months then it may shrink and resolve by itself. As it cannot be clinically reliably distinguished from more severe forms of skin cancers, keratoacanthomas are usually treated surgically.
keratoacanthoma
keratoacanthoma
keratoacanthoma
Image source and reference: DermNetLinks to an external site.
Amelanotic melanoma is a form of melanoma in which the malignant cells have little to no pigment and being classically described as ‘skin-coloured’. Truly amelanotic melanomas, lacking all pigment, are rare. Most are red, pink, or erythematous. The borders may be well- or ill-defined. Patients and clinicians may not be alert to suspect non-pigmented lesions as melanoma and so amelanotic melanomas are often misdiagnosed.
amelanotic melanoma
amelanotic melanoma
amelanotic melanoma
You explain your diagnosis to Beryl and then move on to discussing management.
What is the most appropriate way of treating this BCC?
A. Electrocautery
B. Cryotherapy using liquid nitrogen
C. Excision biopsy
D. Fluorouracil cream
C. Excision biopsy
Excision biopsy is the only treatment modality that will give a definitive diagnosis as well as permanent cure.
Shave, curettage, and electrocautery are generally only used for low-risk tumours on trunk and limbs.
Cryotherapy is only used for very small, thin, low-risk tumours and Beryl’s looks quite raised and nodular.
Fluorouracil cream is only used for actinic keratoses or thin intraepidermal lesions such as Bowen’s disease
Tim is a 58-year-old man whose wife has made him an appointment to look at a lesion on his back which has been growing. He is unsure how long he has had it as he can’t see it and it doesn’t cause him any symptoms.
His younger brother (56 years old) was diagnosed with a melanoma five years ago but he is unsure what type it was.
Tim is otherwise well and has no other medical history and takes no medications. He is an ex-smoker of five years having smoked 20 per day for 35 years. He consumes three standard alcoholic drinks per day on average.
You examine him and find this lesion which measures 8 x 6 mm:
The most likely diagnosis is:
A. Malignant melanoma
B. Compound melanocytic naevus
C. Seborrheic keratosis
D. Squamous cell carcinoma
C. Seborrheic keratosis
Seborrhoeic keratosis is a harmless warty spot that appears during adult life as a common sign of skin ageing. They can be solitary or multiple with some people having hundreds of them and they can also be referred to as SK, basal cell papilloma, senile wart, brown wart, wisdom wart, or barnacle.
Seborrhoeic keratoses are extremely common with an estimated over 90% of adults over the age of 60 years have one or more of them. They occur in males and females of all races, typically beginning to erupt in the 30s or 40s but are uncommon under the age of 20 years. Seborrhoeic keratoses can arise on any area of skin, covered or uncovered, with the exception of palms and soles and mucous membranes.
Seborrhoeic keratoses have a highly variable appearance:
Flat or raised papule or plaque
1 mm to several cm in diameter
Skin-coloured, yellow, grey, light brown, dark brown, black or mixed colours
Smooth, waxy or warty surface
Solitary or grouped in certain areas, such as within the scalp, under the breasts, over the spine or in the groin
An acquired melanocytic naevus, or mole, is a common benign tumour, usually appearing during childhood and adolescence. Sun exposure is a causative factor, particularly in childhood. Lesions evolve with age, and many melanocytic naevi eventually regress, and the number of naevi decreases over the age of 50 years.
Classification of common acquired naevi is based primarily on the location of nests (e.g. junctional, compound, dermal or combined naevi) leading to features that are often clinically recognisable. Dermatoscopy is also useful in classifying naevi, particularly when there are atypical clinical features raising suspicion for melanoma.
Rhonda is a 42-year-old lady who has had 2 BCC’s removed in the past from her ear and nose usually standard surgical excision techniques. She has an extensive past history of sun exposure from long hours tanning on the beach as a teenager. Whilst the previous surgery has produced minimal scarring, a friend has told her about Moh’s surgery and she would like to explore this option.
Moh’s surgery:
A. Is a technique where thin layers of cancer containing skin are progressively removed and examined until only cancer free tissue remains
B. Is named after Dr Angus Moh who pioneered the surgery in the 1980’s
C. Involves standard surgical removal of the lesion only, without margin excision, which is then sent away for histological examination and followed by further surgery at a later date if cancer containing tissue remains
D. Stands for “Methodical over Haste”
A. Is a technique where thin layers of cancer containing skin are progressively removed and examined until only cancer free tissue remains
Mohs surgery, developed in 1938 by a general surgeon, Frederic E. Mohs, is microscopically controlled surgery used to treat common types of skin cancer. It offers extremely high cure rates and maximal preservation of healthy tissue. During the surgery, after each removal of tissue and while the patient waits, the tissue is examined for cancer cells. That examination dictates the decision for additional tissue removal. Mohs surgery allows for the removal of a skin cancer with very narrow surgical margin and a high cure rate of between 97% and 99.8% for primary BCC. It can also be used for SCC, but with a lower cure rate.
Cathy is a 32 year old G1P1 who has come to see you for a routine 6-week postnatal check. Her pregnancy was uneventful and she had an emergency LUSCS at 39 weeks for fetal distress during the first stage of labour. Baby George was a healthy 3450g boy who is developing normally in every respect. He is exclusively breast fed and always happy according to Cathy, who is loving motherhood. She has a question however about hair loss in herself. She has noticed for the last 4 weeks that she seems to be losing excessive amounts of scalp hair. It’s not enough to have caused any bald spots but she is concerned about it. You suspect telogen effluvium is the cause.
You advise Cathy that:
A. Telogen effluvium begins during pregnancy
B. As her case is related to pregnancy, she will have permanent hair loss
C. Telogen effluvium is common and affects between 40-50% of women
D. She will need a blood test to measure FBC, thyroid function and iron levels
C. Telogen effluvium is common and affects between 40-50% of women
Telogen effluvium presents as sudden onset diffuse hair shedding triggered by a number of factors including pregnancy and coming on 1-5 months following completion of the pregnancy. It is uncommon for it to begin during pregnancy with the most common period of hair loss occurring approximately three months after delivery. It affects between 40-50% of women. During pregnancy up to 60% of hair that is in the growth state may enter into the telogen resting state. The hair loss is temporary, and hair loss returns to normal within six to twelve months.
If no clear trigger found, workup should consist of complete blood picture, thyroid function and serum ferritin measurement
Sue is a 36-year-old woman who has no significant past medical history and takes no medications. She presents with a problem with her left 1st toenail which she has had for some months. She ignored it at first but after a month or so tried some cream from the chemist, she can’t remember which. None of her other nails (toes or fingers) are affected and she has no rashes anywhere else. She has tried going to 100% cotton socks and has also occasionally used Betadine on it. This is her toe:
thickened, crumbly and discoloured nails, no rash
The most likely diagnosis here is:
A. Fungal nail infection
B. Psoriasis
C. Onychgryphosis
D. Eczema
A. Fungal nail infection
Whilst all of these conditions can cause thickened, crumbly and discoloured nails, the lack of any other rashes would generally exclude psoriasis and eczema, and onychgryphosis is an age-related process so usually presents in the elderly.
Sarah is a 19-year-old lady who has been allergic to Penicillin since early childhood. She reacts with a generalised urticarial skin rash with weals and wheeze.
Weals:
A. Are characterised by a lack of surrounding erythema
B. Never last more than 12 hours
C. Always maintain a fixed shape once they appear
D. Can affect any site of the body
D. Can affect any site of the body
A weal (or wheal) is a superficial skin-coloured or pale skin swelling, usually surrounded by erythema that lasts anything from a few minutes to 24 hours. Usually very itchy, it may have a burning sensation and they tend to be distributed widely and can affect any part of the body. They can be a few millimetres or several centimetres in diameter and each weal may last a few minutes or several hours and may be round, or form rings, a map-like pattern or giant patches. Weals also can change shape during their clinical course.
Emma is a 15-year-old girl who presents with quite severe facial acne which she has had for around 12 months now. She has presented with her mother. She has tried Duac (benzoyl peroxide + clindamycin) and Differin (adapalene) creams as well as general skin care products (moisturisers etc). Her mother has heard that antibiotics may help.
Which is true of the use of antibiotics in teenage acne?
A. Amoxycillin is the best first line therapy as there is less long-term resistance associated with this compared to other antibiotics
B. Usually results will be seen in 1-2 weeks and duration of therapy is generally 1-2 months
Correct!
C. Doxycycline or Minocycline are the preferred first choice agents
D. Are not to be used in conjunction with benzoyl peroxide topical agents
C. Doxycycline or Minocycline are the preferred first choice agents
Antibiotics work by controlling the skin bacteria (P. acnes) that contributes to acne plus a possible anti-inflammatory action as well. They have been used in acne management for decades; however, with increasing concerns of antibiotic resistance, there is a trend to use shorter courses of usually three to six months. There may not be any visible results for at least a month post commencement and the minimum course is 3 months. Using antibiotics with topical benzoyl peroxide can reduce bacterial resistance. The more common antibiotic tablets/capsules in use include doxycycline (e.g. Doxy, Doryx, Vibratabs) and minocycline (e.g. Minomycin). Erythromycin may be used in younger patients and pregnancy. If one antibiotic doesn’t improve the acne, it may be worthwhile changing the dose or class of antibiotic however, Amoxycillin and the other Penicillins tend to be ineffective. As always there are contraindications and side effects to consider and any prescription should look at the benefits vs risk.
After 6 weeks, if the acne has not responded:
in males, try a different antibiotic listed above (doxycycline, minocycline or erythromycin) for 6 weeks
in females, try a different antibiotic listed above for 6 weeks or add or change to a COCP and/or spironolactone
refer the patient to an expert for oral isotretinoin.
Raj is a 19-year-old British tourist who is backpacking his way around Australia and has come to see you with an intensely itchy rash on his trunk, hands, feet and genitals which he has had for around a week. He has been moving towns every 4-5 days and living in mostly backpacker accommodation, some of which have been a “bit dodgy” when it comes to cleanliness. He has no significant past history, no allergies and takes no regular medications. He has tried Calamine lotion, anti-histamines and “Soov” cream (Chlorhexidine Gluconate) for the itch, none of which have really helped. He saw a doctor in the last town who put him on 5 days of Prednisolone at 50 mg per day thinking it may have been contact dermatitis. He has just arrived in town in the last few days and you think he may have scabies.
Which of the following is correct about scabies:
A. Crusted scabies generally affects young, healthy individuals
B. Scabies is transmitted by droplet infection
C. Scabies burrows never involve the genitals
D. The itch generally comes on 4-6 weeks after transmission of the mite
D. The itch generally comes on 4-6 weeks after transmission of the mite
Scabies is transmitted mostly by skin to skin contact although there have been reports of people catching it from bedding and clothing. The itch comes on 4-6 weeks after transmission and the genitals are quite a common place to be affected. Crusted scabies (previously known as Norwegian scabies) generally affects elderly people or those with other co-morbidities including malnutrition, immune deficiency, intellectual deficit and neurological disease.
Niall is a 22-month-old boy who, 14 days ago, developed a high fever, conjunctivitis and a dry, fissured tongue. He saw another GP in the practice who diagnosed a viral illness and advised Panadol, fluids etc. His father has brought him in again as he is still irritable and anorexic and, although his eyes have stopped weeping, they are still red. You diagnose Kawasaki disease based on the clinical presentation.
At what stage of Kawasaki disease is young Niall?
A. Subacute
B. Acute
C. Terminal
D. Late Stage
B. Acute
Kawasaki disease has 3 distinct stages:
• acute stage (1-11 days)
• subacute stage (11-30 days)
• late stage (beyond 30 days)
By both time frame and clinical symptoms Niall is in the subacute stage.
Ayla is a 4-year-old girl whose parents are concerned that she was bitten on the leg by a tiger snake in the garden of their property approximately 60 minutes ago. They heard her cry out and turned to see a 1 metre snake moving away from her. They immediately applied a pressure immobilisation bandage (PIB), splinted the leg with a wooden garden stake and drove her straight to hospital, being a drive of around 45 minutes. You have seen Ayla, who is asymptomatic, and whose initial laboratory tests (CBP, EUC, CK, Coags) are normal. Appropriate management for Ayla from here would be:
A. Admit for 24 hours, leave PIB in situ for that time and repeat bloods before sending home
B. Remove PIB and send her home after a further 1 hour of observations if all well
C. Remove PIB, repeat bloods at 1, 6 and 12 hours and admit for 12-24 hours
D. Remove PIB, repeat bloods at 4 hours and send home if they are ok and all is well
C. Remove PIB, repeat bloods at 1, 6 and 12 hours and admit for 12-24 hours
Asymptomatic snake bite victims should be admitted for at least 12 hours with bloods at close monitoring of blood tests during that time. The PIB can be removed after the patient has been fully assessed, the first set of bloods are normal and as long as the patient has remained asymptomatic.
Shaun is a 3-year-old boy, weighing 14kg who has ingested 200mg (4 x 50mg) of his mother’s Amitriptyline tablets. The toxic dose of this medication for Shaun would be:
A. 140mg
B. 210mg
C. 50mg
D. 500mg
B. 210mg
The toxic dose of the tricyclic antidepressant Amitriptyline in children is 15mg/kg = 210mg for him.
The major effect of overdose is cardiotoxicity with life threatening dysrhythmias, often refractory to treatment, which primarily result from blockade of inactivated fast sodium channels.
Sam is a 23 year old who has presented to your rural facility after taking an intentional overdose of paracetamol, 12g (500mgx24) 3 hours ago. He is asymptomatic. The most appropriate management is to:
A. Discharge with advise to return if symptoms develop
B. Offer activated charcoal
C. Commence a 20 hour infusion of acetylcysteine and admit him locally
D. Commence acetylcysteine and arrange transfer to a hospital with pathology service
C. Commence a 20 hour infusion of acetylcysteine and admit him locally
He has taken more than 10g of paracetamol therefore does require acetylcysteine, and local admission with review for symptoms at 20 hours is recommended by the updated guidelines. https://www.mja.com.au/system/files/issues/212_04/mja250428.pdfLinks to an external site. He would definitely need transfer if he had ingested >=30g of >=500mg/kg. He has presented more than two hours post ingestion so the window for activated charcoal at this dose has passed. Discharge home for this ingestion dose is inappropriate as NAC needs to be commenced.
Jim is a 79 year old who presents with weakness and shortness of breath for the past 3 hours. In the resuscitation bay, his heart rate is noted to be 45 with a blood pressure of 85/55. IV access is obtained and a small IV fluid bolus (500mL) of normal saline is commenced. His ECG shows complete heart block. The next most appropriate management step is to:
A. Administer adrenaline 50mg IV
B. Administer an initial dose of atropine 0.3mg IV, repeated every 3 to 5 minutes as needed
C. Administer an initial dose of atropine 0.6mg IV, repeated every 3 to 5 minutes as needed
D. Administer an initial dose of atropine 1.2mg IV, repeated every 3 to 5 minutes as needed.
C. Administer an initial dose of atropine 0.6mg IV, repeated every 3 to 5 minutes as needed
In the absence of reversible causes, atropine remains the first-line drug for acute symptomatic bradycardia where there are no immediately obvious reversible causes. The initial dose of 0.5 to 0.6mg IV can be repeated every 3 to 5 minutes up to a maximum dose of 1.8mg. Doses of atropine <0.5mg may paradoxically result in further slowing of the heart rate. Atropine is to be used cautiously in the presence of acute coronary ischemia or myocardial infarction as increased heart rate may worsen ischemia or increase the zone of infarction.
External cardiac pacing should be commenced if IV fluids and atropine fail to improve the patient’s clinical state.
Frank is an 83-year-old long term patient of yours who has been brought in to your clinic by his daughter following a collapse at home this morning. He described feeling very dizzy when he went to get out of bed, sat himself back on the bed and called for his daughter who has driven him into the clinic. Your nurse has taken him into the treatment room and has performed a basic set of observations (BP 100/60, PR 30 regular, RR 16, afebrile) and an ECG:
HR 30, sinus bradycardia
You perform an assessment of the airway, breathing and circulation whilst your nurse obtains IV access. What is the next most appropriate step?
A. Perform transcutaneous pacing
B. Give a dose of atropine 0.5mg IV, repeated every 2 minutes as needed up to a total of 3.0mg
C. Give a dose of atropine 0.5mg IV, repeated every 3-5 minutes as needed up to a total of 3.0mg
D. Commence a dopamine infusion
C. Give a dose of atropine 0.5mg IV, repeated every 3-5 minutes as needed up to a total of 3.0mg
In the absence of reversible causes, atropine remains the first-line drug for acute symptomatic bradycardia. The initial dose of 0.5 mg IV can be repeated every 3 to 5 minutes as needed to a total of 3.0 mg. Doses of atropine of <0.5 mg may paradoxically result in further slowing of the heart rate. Atropine is to be used cautiously in the presence of acute coronary ischemia or myocardial infarction as increased heart rate may worsen ischemia or increase the zone of infarction.
Atropine is only a temporising measure and Frank will need transcutaneous pacing, however administering atropine first will give you and your team time to prepare for pacing.
Ellie, a 12 year old patient on your rural hospital ward has been admitted for IV antibiotics for a buttock abscess, she was diagnosed with Type 1 Diabetes 12 months ago. She behaves abnormally after her lunch, not recognising familiar faces and running around the room, before appearing to fall asleep on her bed. The nursing staff perform a finger-prick BSL and it reads 1.7. What is the best treatment option out of the following:
A. Oral glucose
B. Glucagon 0.5mg IV
C. 2mL/kg bolus of 10% dextrose
D. Glucagon 0.5mg IM
C. 2mL/kg bolus of 10% dextrose
Rationale: Oral glucose is not the best option for this situation where the patient is unlikely to be able to co-operate (and therefore swallow), and from the stem appears to be unconscious, even if a buccally-absorbed glucose gel were available.
Glucagon can be given intravenously (IV) or intramuscularly (IM), however, this patient will weigh more than 25kg so should be given 1mg rather than 0.5mg. Presumably, this patient has an intravenous cannula in situ for the administration of her antibiotics, so this should be used to administer the IV dextrose.
10% dextrose can be made by putting 50mLs of 50% dextrose into 500mL of 5% dextrose.
Glucagon 1mg IV was not listed as an option but would be entirely appropriate to administer initially whilst drawing up the 10% dextrose, and would be the preferred option if the patient did not have an IV cannula. Response to this should occur within 10 minutes.
You are working in a remote community when Ken, a 55-year-old farmer with atrial fibrillation, presents to you in general practice complaining of an episode of 30 minutes of slurred speech that occurred the day before and his since resolved. The nearest stroke unit is a 2-hour plane flight away. Which of the following is the first step in your management:
A. Perform ABCD² score to determine urgency of investigation
B. Commence anticoagulation due to delay in specialist access
C. Refer him immediately to the nearest stroke unit
D. Perform an ECG
C. Refer him immediately to the nearest stroke unit
A widely used tool to quickly assess a patient’s risk profile in TIA is the ABCD2 tool (Links to an external site.) Links to an external site..
However, studies have indicated that ABCD² and its more recent adaptations (e.g. ABCD³ (Links to an external site.) Links to an external site.) classify an important proportion of TIA patients with atrial fibrillation and symptomatic carotid stenosis in the “low risk” category, potentially exposing them to detrimental treatment delays and risk of recurrent ischaemic events. The Australian Clinical Guidelines for Stroke Management recommend against the use of the ABCD² score in isolation to determine the urgency of investigation in TIA patients.
Ken has atrial fibrillation, which is one of the criteria that can be used to identify patients who require immediate hospital referral in settings where GPs would benefit from diagnostic aid and where specialist review may be delayed by more than one day. Ken’s ABCD² score is actually 2 (low-risk).
The GP can use any one of the following criteria to identify patients who require immediate hospital referral in this context:
ongoing focal neurological symptoms,
>1 TIA over past 7 days,
presence of atrial fibrillation,
patient treated with anticoagulants or
ABCD2 score >3.
If the most likely diagnosis is truly TIA then urgent investigation is required (even if a risk stratification score such as ABCD2 suggests “low risk”).
Anticoagulants require brain imaging before initiation.
An ECG is an important part of the initial assessment, however, Ken is already known to have atrial fibrillation and the priority is to arrange transfer for specialist care.
Hannah is a 31 year old G1P0 with a BMI of >30kg/m2 who presents to you at 28 weeks gestation for an antenatal appointment. She complains of a headache over the past two days and feels nauseous. Her blood pressure is 155/91 and you note 2+ protein in her urine dipstick. The next most appropriate step in her management is to:
A. Commence Nifedipine (SR) 20 to 30mg daily
B. Arrange transfer to the nearest maternity unit for a CTG
C. Order bloods including full blood count, LFTs, urea and creatinine
D. Order a 24-hour urine collection
B. Arrange transfer to the nearest maternity unit for a CTG
Rationale: Hannah’s presentation is concerning for pre-eclampsia. Severe hypertension, headache, epigastric pain, visual disturbances, oliguria, nausea, vomiting and reduced fetal movements, are ominous signs requiring urgent admission and management in a woman more than 20 weeks gestation, as does any concern about fetal wellbeing. Hannah has nausea, a headache and hypertension with proteinuria, which is enough to make a decision that she needs urgent admission and management at a maternity unit.
Whilst the investigations listed are important, these can be arranged in an inpatient context and are not the immediate priority.
Antihypertensive therapy is likely indicated but further work-up needs to be performed before this is initiated, and treatment in an outpatient setting would not be appropriate.
Andrew is a 26 year old male who has presented with a unilateral painful red eye after mowing the lawn, of sudden onset. He has hyphaema and a distorted pupil. The nearest ophthalmology centre is approximately 150km away. What is the best mode of transport for his retrieval?
A. Road ambulance
B. Pressurised jet/turboprop aircraft
C. Unpressurised piston aircraft
D. Rotary wing (helicopter)
A. Road ambulance
Rationale: Andrew’s history and examination are concerning for a penetrating eye injury. Penetrating eye injury is one of the clinical reasons for a low altitude transfer, as residual air or other gases left within the orbit can cause severe damage on expansion. Boyle’s Law affects any gas inside the body; hence as the pressure drops with air transport, the gases will expand. Ground transport avoids this expansion.
The effects of altitude are a major consideration for aeromedical transfers. Even the airline standard cabin pressure is equivalent to around 2000m above sea level, and this is sufficient to cause expansion of gas by a factor of 1.4, which can certainly be clinically significant. Most fixed-wing aircraft are capable of being pressurised to counter this effect, but some smaller fixed-wing aircraft and all helicopters are unpressurised.
Logan is a 79 year old man brought in by ambulance to your rural ED with confusion, abdominal pain and diarrhoea. He has a temperature of 35.4C with a heart rate of 108, blood pressure 85/55, SpO2 90% on room air, RR 22 and capillary refill of 4 seconds.
What is the most appropriate management step?
A. Measure the serum lactate
B. Obtain blood cultures
C. Administer oxygen as part of breathing assessment
D. Check bedside blood glucose level
C. Administer oxygen as part of breathing assessment
Rationale – Logan is in undifferentiated shock, which is most likely septic shock. Whilst all of the options listed are appropriate management steps in sepsis, an ABCD approach would dictate that assessing breathing and administering oxygen would be prioritised over the other three options, which all fall under ‘circulation’.
Craig’s wife Sonia has come to see you, without her husband’s knowledge, to discuss his mental health and other issues.
During the discussion, the issue of domestic violence comes up. She describes frequent, almost daily, arguments at home in the last 12 months that are becoming more frequent, and occasionally he has slapped her across the face when he is angry and has had too much alcohol to drink. He is very apologetic immediately afterwards and blames the alcohol. He has never harmed or abused the children in any way.
Your next step is to:
A. Report Sonia and Craig’s domestic violence to the police
B. Make a report to the Child Abuse Report Line (CARL)
C. Explore Sonia’s wishes about whether she wants to make a police report
D. Explain to Sonia that laws relating to violent assault are 100% consistent across all states and territories
C. Explore Sonia’s wishes about whether she wants to make a police report
It is not mandatory to report all cases of DV to police. The NSW Department of Health recommends in its Domestic Violence Policy discussion paper that health workers notify the police where the survivor has serious injuries such as broken bones, stab wounds, lacerations or gunshot wounds. Wherever possible, the victim should be informed when a decision is made to inform the police.
(Reference: Reporting domestic violence to the police - SAFER (a resource to help Australian churches deal with domestic and family violence) (saferresource.org.au) Links to an external site..)
It is not mandatory to report all cases to CARL unless there is a threat or suspicion of a threat to the children. If there is concern regarding the immediate welfare of children in such situations, then it should certainly be reported straight away with consideration of immediate police notification as well.
Barring any extreme circumstances such as those examples above, then the victim has the right not to report the perpetrator to the police. The GP can encourage this but without placing undue pressure on the victim however, the GP’s main role here is one of support and referral to appropriate other support services as appropriate.
Whilst the basic laws relating to violent assault are consistent across Australia, there are subtle differences especially in relation to family violence intervention orders.
Craig’s employer has asked that he undergo a urine drug screening test before returning for his next rostered shifts at the mine. Craig has come to you for this but would like to know more about it. He is particularly concerned about benzodiazepines as he took one of his partners Valium last night as he couldn’t sleep.
What factor from the following list can affect the length of time that a test can detect a benzodiazepine in the body?
A. Patient hydration levels
B. Co-use with alcohol to mask the detection of the benzodiazepine
C. All benzodiazepines are eliminated from the body over the same time course
D. Co-use with amphetamines to mask the detection of the benzodiazepine
A. Patient hydration levels
There are a number of factors that affect the detection of drugs in urine testing and they include:
the drug used
body mass
hydration levels
the acidity of the urine
how long ago the person took the drug
Urine testing kits have a varied range of drugs that can be tested depending on the brand. Some drugs will not show up in standard bedside urine testing e.g. psychedelic drugs including LSD and mescaline are very difficult to test for, if not impossible.
If the person being tested is dehydrated, then the test will be more strongly positive.
The shorter acting benzodiazepines (e.g. temazepam) are eliminated more quickly than the longer acting (e.g. diazepam) and will therefore show up for a shorter time in urine testing (up to 5 days detectable for temazepam vs up to 10 days for diazepam).
Co-using other drugs to try and mask a positive result for the drug being tested for is generally not effective.
John, 38 years old and a friend of Craig’s, has applied for a job as a FIFO after hearing about the remuneration on offer and is here for a pre-employment medical. He has been unemployed for 12 months and informs you that he really needs this job to help him and his young family financially as they are really struggling. He has even calculated that, if he can stick at being a FIFO for 5 years, it would set him up in a really good financial position as it would allow him to pay off his mortgage and car loan.
He does suffer from asthma and type 1 diabetes, both of which he would like to be kept secret from his future potential employer as it may interfere with his employment prospects. He has signed a full consent for the examining doctor to inform the employer of any findings in the history or examination arising from the pre-employment medical.
Do you, as the examining doctor:
A. Only document what you consider to be relevant
B. Leave out the issues from the report that John has asked you not to disclose
C. Fudge the report totally as you feel sorry for John and his family’s financial plight
D. Disclose all of John’s medical conditions to the employer
D. Disclose all of John’s medical conditions to the employer
When a patient signs a consent to allow an employer information on his medical information, then the doctor concerned is obliged to disclose that information on request. Patients need to understand that it is the ethical and legal responsibility of the doctor to do that.
John did not get the position he applied for and he is still out of work. It is now a further 6 months on and John comes to see you again. His family has lost their home due to inability to pay the mortgage and they are living with his wife’s parents.
He says he feels hopeless and useless as he can’t provide for his family. He is consuming more alcohol and is very moody at home. He is having difficulty sleeping, his appetite is poor, and he has no energy or drive to do anything, sometimes spending the whole day in bed so he doesn’t have to “face the world”.
You diagnose him with depression and enquire regarding thoughts of self-harm.
What factor from this history is recognised as high risk for suicide in Australian society?
A. Male gender
B. Being married
C. Anglo-Saxon background
D. Living with extended family
A. Male gender
According to RACGP’s Red Book - Suicide Links to an external site. attempted suicide is a higher risk in the following factors:
mental illness, especially mood disorders, and alcohol and drug abuse
previous suicide attempts or deliberate self-harm
male
young people and older people
those with a recent loss or other adverse event
patients with a family history of attempted or completed suicide
Aboriginal and Torres Strait Islander peoples
widowed
living alone or in prison
chronic and terminal medical illness
in the 12 months following discharge from a psychiatric hospital
women experiencing intimate partner violence
lesbian, gay and bisexual people
John is 17 years old and presents to your GP clinic with scrotal pain. It came on suddenly an hour ago and has been getting worse. There is no history of recent trauma, fevers, or urinary symptoms. He is not sexually active.
On examination his vital signs are within normal limits. He has a very tender erythematous right scrotum and absent cremasteric reflex. It does not transilluminate. It is hard to palpate the testes but it appears horizontally located. Elevation and support of the scrotum (Prehn’s sign) increases his pain.
Your most likely differential diagnosis is:
A. Hydrocoele
B. Testicular torsion
C. Epididymo-orchitis
D. Urinary tract infection
B. Testicular torsion
His signs and symptoms are classical for testicular torsion. There is no transillumination to suggest hydrocele. There are no symptoms suggestive of infection. Prehn’s sign relieves pain in epididymo-orchitis but tends to increase pain in torsion. See this guideline from RCH MelbourneLinks to an external site. for more information.
It is Tuesday morning at your GP clinic. Eighteen-year-old Pat has presented to you with acute groin pain. From history and examination, you have a high suspicion that Pat has testicular torsion. Your clinic is 75km from your referral hospital. You have a private imaging company next door who are able to perform ultrasounds.
Your next best action would be to:
A. Perform a urine dipstick to exclude UTI
B. Order an urgent ultrasound
C. Give some analgesia and wait for that to take effect before further action
D. Send to the tertiary hospital for urgent surgical review
D. Send to the tertiary hospital for urgent surgical review
A patient with suspected testicular torsion should be urgently seen by a surgeon. Delay in transfer can result in permanent damage to the testicle. Although it would be good to give analgesia and exclude infection, it is imperative to urgently transfer a patient with suspected torsion in order for the testicle to be saved. Waiting for an ultrasound will cause unnecessary delay.
James is a 37-year-old truck driver. He presents to your GP clinic with pain in the right scrotum for 3 days on and off but worse in last 4 hours. He does sometimes feel a stinging when he urinates. He has not noted a discharge from his penis. He admits to having unprotected sexual intercourse while he is on the road.
On examination he has a temperature of 38.5 degrees. He has a swollen, erythematous right scrotum. There is generalized tenderness but more in the posterolateral aspect of the testes. His scrotum does not trans-illuminate and cremasteric reflex is present.
The most likely diagnosis is:
A. Urinary tract infection
B. Testicular torsion
C. Epididymo-orchitis
D. Hydrocoele
C. Epididymo-orchitis
The history of unprotected sex along with fever and painful tender scrotum suggest epididymo-orchitis. A simple urinary tract infection does not sufficiently explain his testicular swelling or erythema. His symptoms are more than one would find with hydrocele, plus there is no trans-illumination. Testicular torsion usually does not present with fever and the time course does not fit with torsion.
Bill, a 65-year-old local CEO comes to see you with a 5-month history of worsening nocturia, frequency, urgency, difficulty initiating urination, difficulty directing the urinary stream and post void dribbling. These symptoms are affecting his sleep, his work, and other daily activities. His International Prostate Symptom Score (IPSS) score is 19 (moderately symptomatic). He has not noticed any blood in his urine, has not had any UTIs, incontinence or episodes of urinary retention, and his other medical history is unremarkable. Abdominal examination is normal, and you can feel a smooth enlarged prostate on DRE (digital rectal examination). Initial bloods, MSU and renal tract ultrasound investigations are normal.
After discussing treatment options with Bill, what is your recommended initial step in management?
A. Lifestyle advice
B. Commence Duodart®
C. Complementary treatments
D. Urology referral
B. Commence Duodart®
Treatment of LUTS (lower urinary tract symptoms) is mostly determined by bother of symptoms, effect on quality of life (QoL) and whether any complicating features are identified.
Patients with low IPSS and minimal bother may elect for conservative management (watchful waiting and lifestyle advice) while those with increasing IPSS (>8) and/or bother may benefit from a trial of medical therapy or surgery.
Surgical treatment is more effective, but medical therapy may provide adequate symptom relief with fewer and less serious adverse events.
In uncomplicated cases of BPH when the provisional diagnosis is clear, medical therapy can be easily instituted in the primary care setting.
As a selective alpha-blocker relieves symptoms more rapidly than a 5alpha-reductase inhibitor, consider combination treatment when the prostate is enlarged (volume >30–40mL) and rapid relief of troublesome symptoms is required. Combination treatment is shown to be more beneficial and durable than monotherapy.
The combination of α-blocker (tamsulosin) with 5 α-reductase inhibitor (dutasteride), is available in Australia as Duodart® on the PBS (streamlined authority) for men with moderate to severe BPH and LUTS.
Jim, a 55-year-old mechanic comes to see you for a general health check-up. His older brother has just been diagnosed with prostate cancer and he is asking to have the ‘prostate cancer blood test’. He does not have any LUTS (lower urinary tract symptoms) and is otherwise generally well. After appropriately counselling Jim, you agree to order a PSA as part of his routine bloods.
Your reasoning for this is because, according to current Australian guidelines you should;
A. Routinely offer PSA screening to all men from age 50 - 70
B. Offer PSA screening to all men who request it at any age
C. Offer PSA screening to men aged 45 - 69 with increased risk of prostate cancer who request it every 2 years after appropriate counselling
D. Offer PSA screening to men aged 50-69 who request it every 2 years after appropriate counselling
C. Offer PSA screening to men aged 45 - 69 with increased risk of prostate cancer who request it every 2 years after appropriate counselling
Prostate specific antigen (PSA) testing remains controversial both in Australia and internationally.
Screening of asymptomatic (low-risk) men for prostate cancer by prostate specific antigen (PSA) testing is not recommended because the benefits have not clearly been shown to outweigh the harms.
Offer evidence-based decisional support to men considering whether or not to have a PSA test, including the opportunity to discuss the benefits and harms of PSA testing before making the decision.
For men at average risk (i.e. no family history) of prostate cancer who have been informed of the benefits and harms of testing and who decide to undergo regular testing for prostate cancer, offer PSA testing every 2 years from age 50 to age 69.
For men whose risk of prostate cancer is estimated to be at least 2.5–3 times higher than average due to the presence of risk factors (e.g. a brother diagnosed with prostate cancer, particularly if younger than 60 years at diagnosis), and who decide to undergo testing after being informed of the benefits and harms, offer testing every 2 years from age 45–69 years.
For men younger than 50 years who are concerned about their risk for prostate cancer, have been informed of the benefits and harms of testing, and who wish to undergo regular testing for prostate cancer, offer testing every 2 years from age 45 to age 69 years.
Harold, a 62-year-old local farmer comes to see you for blood test results. He initially presented with a 3-month history of worsening difficulty passing urine. He described his symptoms as mild and non-bothersome but was worried there could be a serious cause. Harold has a history of hypertension and dyslipidaemia but is otherwise well. After appropriate counselling and discussion about risks and benefits of PSA testing at his last appointment, Harold decided to have a PSA done. Harold’s total PSA result is 5.9 ng/mL and DRE (digital rectal examination) today is normal.
What is your management plan?
A. Watchful waiting
B. Repeat total PSA in 1-3 months and measure free-to-total PSA percentage
C. Refer to Urology for prostate biopsy
D. Measure PSA velocity and doubling time
C. Refer to Urology for prostate biopsy
Many patients who present with LUTS do so because they are concerned about prostate cancer. The benefit-to-harm ratio of using PSA to investigate men with LUTS is unclear so it is important for GPs to discuss the harms and benefits of PSA testing with their symptomatic patients in order for them to make an informed decision.
If PSA results in a man with LUTS show that he could have prostate cancer, he should be offered urology referral for consideration of a core biopsy of the prostate.
A total PSA threshold of 4.0 ng/mL has traditionally been used as the criterion for prostate biopsy.
The ‘PSA testing and early management of test-detected prostate cancer’ guidelines mention repeating total PSA in 1-3 months and measuring free-to-total PSA when the initial result is abnormal, however these guidelines are not relevant to Harold as he has symptomatic LUTS and his symptoms are unstable (i.e. worsening).
Measuring PSA velocity, PSA doubling time or PSA change require at least three or four total PSA measurements separated by several months. For men with total PSA levels already above the threshold, the delay in obtaining these PSA dynamic parameters may cause both anxiety and the possibility that the cancer will spread during that period.
Pablo is a 23-year-old man who has taken a year off his university studies to come to Australia on a working visa to be a farm hand on a large cattle station in Central Queensland. He attends your rural hospital emergency department with a fever, headache, and cough, as well as aching muscles and joints. His liver function tests return abnormal.
Vaccination history for which of the following conditions is the most important to enquire about in your assessment of Pablo?
A. Influenza
B. Q fever
C. Legionella
D. Pneumococcal
B. Q fever
Explanation: Q fever infection is most often associated with the livestock industry, with cattle, sheep and goats considered to be the main source of C. burnetii infections in humans. It can present as a mild influenza-like illness, and vaccination is recommended in at-risk individuals including farm workers. There is no vaccination available for Legionella.
Samuel is a 30-year-old shearer who attends your rural general practice complaining of an increasingly unsightly skin lesion on the dorsum of his left index finger. It has been present for 2 weeks, is mildly tender on palpation, and there are no other lesions. He denies any fever or chills.
He saw one of your colleagues last week who swabbed the lesion and commenced him on flucloxacillin for presumed cellulitis. Samuel’s lesion has showed no improvement on the flucloxacillin. The bacterial swab returned unremarkable.
Picture: Orf
What is the most appropriate management advice for Samuel today?
A. Prescribe a second course of oral flucloxacillin
B. Refer Samuel to the rural hospital for IV flucloxacillin
C. Reassure him that the lesion will self-resolve. Advise him to cover it when at work
D. Treat the lesion with cryotherapy
C. Reassure him that the lesion will self-resolve. Advise him to cover it when at work
Explanation: Samuel has orf, also known as ecthyma contagiosum and scabby mouth disease. It is a benign, self-limited occupational viral infection associated with exposure to sheep and goats. Secondary bacterial infection can occur.
Mavis, a healthy 50-year-old Aboriginal woman attends your rural general practice for her annual Aboriginal health check. Mavis is a non-smoker. She happily informs you that she is the healthiest member of her family, with no medical conditions and she takes no regular medications.
You review her immunisation history particularly in relation to her pneumococcal vaccination status. She has not received a 13vPCV or 23vPPV vaccine before.
Which of the following pneumococcal vaccinations will you offer Mavis today?
A. 13vPCV
B. 23vPPV
C. Mavis does not require a pneumococcal vaccination today
D. Mavis does not require a pneumococcal vaccination until she turns 65
A. 13vPCV
Explanation: Mavis is a healthy Aboriginal adult aged 50 years and above, and is recommended by the National Immunisation Program to have 2 doses of 23vPPV vaccine given at least 5 years apart, with the first dose given at 50 years of age. Where the individual hasn’t received a 13vPCV dose prior, they should receive this dose first, then commence the 23vPPV schedule 12 months later.
Rosie is a 6-year-old Aboriginal girl who is brought in to see you at your general practice by her Aunty. Rosie’s presenting complaint is intensely itchy skin. She was sent home from school today when her teacher suspected Rosie might have scabies.
You diagnose scabies and decide to prescribe permethrin cream for Rosie. You advise Rosie’s Aunty that family members and the school should be notified of the diagnosis so that any affected contacts can be examined and also receive treatment.
Which of the following outlines the correct treatment regime for Rosie’s scabies?
A. Permethrin 5% cream for 1 application only
B. Permethrin 5% cream for 2 applications, 1 week apart
C. Permethrin 25% cream for 1 application only
D. Permethrin 25% cream for 2 applications, 1 week apart
B. Permethrin 5% cream for 2 applications, 1 week apart
Amanda is a 51-year-old lady requesting bowel cancer screening. You note from her family history that her mother was diagnosed with bowel cancer in her 60s. Which of the following is the correct advice on the bowel cancer screening that is indicated for Amanda?
A. She should have a FOBT every year until age 74
B. She should have a FOBT every 2 years until age 74
C. She should have a colonoscopy every 2 years until age 74
D. She should have a colonoscopy every 5 years until age 74 and consideration of low dose 100mg aspirin daily
B. She should have a FOBT every 2 years until age 74
Amanda falls in Category 1/A (average or slightly higher than average risk) in terms of colorectal cancer risk based on her family history with one relative with colorectal cancer diagnosed at age 55 or older. Note that if Amanda’s mother was diagnosed with bowel cancer at the age of 54 or less, then she would fall into Category 2/B and the answer would be to have a colonoscopy every 5 years until age 74
Reference: National Health and Medical Research Council Clinical Practice Guidelines for the Prevention, Early Detection and management of Colorectal
Sarah is 9 weeks pregnant. She and her husband, Ryan, undergo reproductive carrier screening. Both are found to be carriers of cystic fibrosis and hence increased risk of having a child affected by the respiratory condition. Which of the following options are available to them to manage this risk for Sarah’s current pregnancy:
A. Using a donor sperm or egg
B. Using a donor embryo
C. Chorionic villous sampling or amniocentesis
D. Testing embryos produced by In vitro fertilisation by preimplantation genetic diagnosis
C. Chorionic villous sampling or amniocentesis
The alternative answers are incorrect as they are only able to avoid an affected child if done pre-conception.
Based on the provided information, which of the following patients warrant assessment for risk of Familial Hypercholesterolaemia using the Dutch Lipid Clinic Network Criteria?
A. Bill, a male, whose mum died from a MI at age 65
B. Michael, a male who has just been discharged from hospital after a MI at age 54
C. Helen, a female, whose Low-density lipoprotein (LDL-C) is 2mmol/L
D. Jane, a female, whose total cholesterol (TC) is 7mmol/L
B. Michael, a male who has just been discharged from hospital after a MI at age 54
Only Michael meets the screening criteria (male aged less than 55 years with premature coronary artery disease)
Olivia is a 55 year old female with no co-morbidities who presents for a check-up. She is concerned about having a heart attack or stroke in the future. She is a non-smoker and has no significant family history of cardiovascular disease. You calculate her absolute 5 year cardiovascular risk to be low at 1%.
You decide to:
A. Perform screening using coronary artery calcium score
B. Perform screening using an exercise stress test.
C. Perform screening using a carotid duplex ultrasound
D. Reassure Olivia that she is at low risk of developing cardiovascular disease in the next 5 years.
D. Reassure Olivia that she is at low risk of developing cardiovascular disease in the next 5 years.
Rationale: One of the RACGP’s Choosing Wisely Australia Recommendations is Don’t screen asymptomatic, low-risk patients (<10% absolute 5-year CV risk) using ECG, stress test, coronary artery calcium score, or carotid artery ultrasound. - Choosing wiselyLinks to an external site.
Major risk factors for vascular disease include older age, male sex, hypertension, smoking, dyslipidaemia and diabetes. Calculators using cardiovascular risk factors are widely available to determine a patient’s individual risk for a vascular event. The additional information obtained by screening asymptomatic adults at low risk for a vascular event, via a resting ECG or stress test, is very unlikely to alter risk stratification or reduce overall events related to coronary artery disease. The potential harms of these tests have been found to equal or exceed the potential benefits in this population.
In the absence of clinical trial data demonstrating an overall benefit, coronary artery calcium score is also not recommended in this population (National Vascular Disease Prevention Alliance (NVDPA) guidelines.
Similarly, screening with carotid duplex ultrasound in low-risk patients results in many more false-positive than true-positive results. This in turn leads to a significant number of unnecessary angiographies or surgical procedures, with the attendant risks of stroke, myocardial infarction and death.
A family from Afghanistan are booked in to see you for refugee health assessments. The father, aged 42 was in offshore detention for 5 years. He has now been reunited with his wife aged 38 and children aged 11 and 14 who have recently arrived in Australia. You are aware that the family have likely experienced or been exposed to trauma.
The following is true regarding trauma when conducting health assessments for refugees:
A. You should never ask about trauma as it can cause distress for the patient
B. Patients with psychological sequelae from past trauma usually present with mood changes
C. Patients are often forthcoming with this information
Correct!
D. Consider asking about past trauma only if appropriate and there is adequate time for response
D. Consider asking about past trauma only if appropriate and there is adequate time for response
Rationale:
It is rare for a patient to disclose a history of psychological trauma. Talking about past experiences can be psychologically beneficial. The knowledge that the patient has endured certain experiences due to their country of origin or transit is generally sufficient for you to orient your care. However psychological and psychosomatic symptoms may persist and acknowledgement of their causes may be required for ongoing management.
Consider asking about past trauma only if appropriate and there is adequate time for response.
Some useful questions are:
• Some people have had bad things happen to themselves and their families. Has anything happened to you or your family that could be affecting your health or the way you are feeling now?
• Do you have any problem I can help you with today that is a result of something that happened in the past?
Abia, aged 35 comes to see you with her daughter Saarah, aged 10. They have both recently arrived in Australia from Syria as refugees and you are seeing them for refugee health assessments. During the assessment you enquire about their
vaccination history. Abia says she is pretty sure both she and Saarah received all of their usual childhood vaccines but she has no documentation of this.
Regarding immunisations for Abia and Saarah;
A. From what Saarah has told you, you can assume they are both fully vaccinated so don’t require any further vaccines.
B. Newly arrived refugees in Australia have usually not had any prior vaccinations so they must all be given a full course of the standard vaccines available in Australia.
C. Refugees are usually immune to common vaccine preventable illnesses due to past exposure so do not need routine vaccines.
D. Abia and Saarah will both need to have a catch up vaccine schedule planned. Checking serology may be helpful to assist with this process.
D. Abia and Saarah will both need to have a catch up vaccine schedule planned. Checking serology may be helpful to assist with this process.
Children and adults entering Australia as migrants or refugees, or seeking asylum should (but do not always) have their vaccination status assessed and should (but do not always) receive appropriate catch-up vaccination. Migrants from resource-poor settings — especially refugees or people seeking asylum — may be incompletely vaccinated according to the Australian schedule and may have incomplete records of vaccination.
If a migrant, refugee or person seeking asylum has no valid documentation of vaccination, they should start a catch-up schedule.
Serological testing before vaccination is not routinely recommended. However, it may be needed for:
* migrants, refugees and people seeking asylum from hepatitis B–endemic countries to detect current or past hepatitis B infection (also see Hepatitis B)
* female migrants, refugees and people seeking asylum of child-bearing age to identify women who are seronegative for rubella and need vaccination (see Rubella)
Frank is an 82-year-old man who presents to you with a one-month history of burning in his right calf when he walks down to the local shop to get his newspaper and cigarettes every morning. It seems to be getting worse and coming on after shorter distances but is always relieved with rest.
His past medical history includes type 2 diabetes, hypertension and controlled atrial fibrillation for which he is anticoagulated with apixaban.
Which of the following is true?
A. Frank is probably experiencing intermittent claudication
B. This is not intermittent claudication as this always causes crampy pain and not burning
C. This is most likely representative of acute limb ischaemia
D. You should tell Frank to stop exercising as it could be harmful
A. Frank is probably experiencing intermittent claudication
Intermittent claudication can present as pain, cramping and/or burning and classically comes on during exercising and is relieved by rest. Acute limb ischaemia will most likely present with the 6 P’s i.e:
Pain
Pallor
Pulselessness
Paraesthesia
Perishingly cold
Paralysis
You should encourage Frank to keep exercising within comfort levels whilst investigating his arterial insufficiency. You should also encourage him to give up smoking!
Frank comes back two months later with an ulcer on his foot which he has had for two to three weeks. It is quite painful especially at night in bed. His intermittent claudication has stabilised but he has to rest three to four times during his daily 400m walk to the local shop. He has been dressing his foot at home with Betadine and Vaseline and covering with clean cloth. He is still smoking!
You diagnose Frank as having an arterial ulcer. You send him off to have his ankle brachial pressure index (ABPI) measured and the result comes back as 0.4.
A reading of 0.4 represents:
A. A normal value
B. Severe arterial disease
C. Mild arterial disease
D. Moderate arterial disease
B. Severe arterial disease
The normal value is 0.92 to 1.3. If the ABPI is less than 0.9, there is likely to be arterial disease. Levels of less than 0.5 indicate severe arterial disease.
Rhonda is a 68-year-old lady who has been brought into your rural hospital emergency department by her husband with back pain. She has a long-term history of lumbar back pain secondary to severe osteoarthritis causing spinal canal stenosis at L3-4, L4-5 and L5-S1 levels. Earlier today she lifted a basket of wet washing and immediately developed severe lower back pain.
On examination she is obese, weighing 110kg (BMI 30) and in obvious distress with pain. She also complains of “pins and needles” around the perineum and perianal areas and weakness of the lower legs (she needed a wheelchair to get her into the ED as she couldn’t walk).
Her other past medical history includes osteoarthritis, hypertension, hyperlipidaemia and diabetes. You suspect acute cauda equina syndrome.
What risk factors does Rhonda have for cauda equina syndrome?
A. Middle age, diabetes, female, obesity
B. Middle age, spinal canal stenosis, obesity
C. Middle age, spinal canal stenosis, female, obesity
D. Middle age, diabetes, osteoarthritis, obesity
B. Middle age, spinal canal stenosis, obesity
Risk factors for cauda equina syndrome are:
Middle age
Obesity
Heavy lifting
Spinal lesions and tumours
Spinal infections or inflammation
Lumbar spinal stenosis
Violent injuries to the lower back (gunshots, falls, auto accidents)
Birth abnormalities
Spinal arteriovenous malformations (AVMs)
Spinal haemorrhages (subarachnoid, subdural, epidural)
Postoperative lumbar spine surgery complications
Spinal «saddle?» anaesthesia
There is no associated risk with either gender or race.
Tahlia is a 19-year-old lady who has fallen off her horse approximately one hour ago and has been brought in to your rural hospital emergency department with altered conscious state. Witnesses describe an initial period of loss of consciousness for around two minutes, then a period of lucidness for around ten minutes, then lapsing into a progressively deeper unconscious state. You assess her Glasgow coma scale (GCS) as around 5, and she has a dilated pupil on her right side which is poorly responsive to light.
Which of these CTs demonstrates the most likely diagnosis?
A. Extradural
B. Subdural
C. Subarachnoid Haemorrhage
D. Normal
ICP produces a diminishing conscious level and causes herniation of the temporal lobe through the tentorial hiatus, compressing the oculomotor nerve, resulting in ipsilateral pupillary dilatation. This may progress to contralateral hemiparesis and brainstem compression, with cardiorespiratory arrest.
Travis is a 28-year-old footballer who attended the local hospital on Saturday after being “dazed for a few seconds” after a knock to the head during the third quarter of a local football match. He denied any loss of consciousness and he played on to the end of the game, but he has no memory of playing the game at all.
His coach has sent him to see you today, Monday, to get a clearance to play next Saturday. Travis is keen to play and says he feels fine apart from a “niggling” headache and feeling very tired since the incident. He is keen to return to training tomorrow and Thursday nights and to play on Saturday.
Your advice to him is:
A. Don’t train this week but will be ok to play on Saturday
B. Resume light physical activity tomorrow then, if feeling OK, can resume full training Thursday and play Saturday even if there are still residual symptoms of headache, tiredness etc
C. Totally rest for 48 hours then can train Thursday night and play Saturday
D. If in doubt, sit it out! Do not resume any physical activity until concussion symptoms are resolved and then it needs to be a graduated return to full physical activity.
D. If in doubt, sit it out! Do not resume any physical activity until concussion symptoms are resolved and then it needs to be a graduated return to full physical activity.
In regard to anorectal anatomy, the dentate line:
A. has no bearing on the clinical presentation. of anorectal disorders
B. is made up of the anal valves that collectively form an irregular circle.
C. is also referred to as the pectoral line.
D. is located in the upper (or internal) anus.
B. is made up of the anal valves that collectively form an irregular circle.
The dentate (or pectinate) line is important because it tells you the origin of the pathology and determines the clinical presentation. It forms the junction between the upper (or internal) and lower (or external) anus.
Marlene is a 45-year-old lady who presents with perianal pain and swelling for 3 days. On examination she has a swelling and redness around the perianal area and a palpable lump. You diagnose a perianal abscess. Which of the following is true of this condition?
A. It never presents with anything other than local symptoms
B. They generally don’t require drainage and respond to conservative measures such as antibiotics
C. They generally only involve Staph or Strep bacteria
Correct!
D. The procedure of draining either perianal or ischiorectal abscesses should be in the realm of a rural generalist
D. The procedure of draining either perianal or ischiorectal abscesses should be in the realm of a rural generalist
Perianal abscess can occasionally present as a patient with generalized sepsis and needs to be treated accordingly. They generally DO require drainage and certainly drainage of perianal and ischiorectal abscesses is within the realm of rural generalists however, intersphincteric and supralevator are more complex and should be referred for specialist colorectal care. Perianal abscesses usually involve enteric organisms (gram negative and anaerobic).
You are doing your regular weekly nursing home consulting session when the staff ask you to see Beryl, an 85-year-old lady, as they are concerned about an anal lump that was only discovered this morning after a bowel action. Beryl suffers from advanced Alzheimer’s dementia and is bed bound. On examination there is an obvious rectal prolapse protruding approximately 3-4 cm from the anus itself.
In regard to rectal prolapse:
A. It is more common in males with a 6:1 ratio
B. It only occurs in the elderly
C. It should be initially managed with gentle digital pressure to try and reduce the prolapse
D. It should be left alone as there are no complications and spontaneous resolution is likely
C. It should be initially managed with gentle digital pressure to try and reduce the prolapse
Rectal prolapse is more common in females with a 6:1 female to male ratio. It can occur in all age groups including children and can have significant complications including mucosal ulceration and necrosis of the rectal wall. Whilst spontaneous resolution can occur in children it is very unlikely in the elderly.
Mr Franz a 62 year old gentleman with a 25 pack year smoking history presents to your practice complaining of haematuria on follow up of his investigations you find he he has a glomerular haematuria with macroalbuminuria. Your initial management would include:
A. Watchful waiting and repeat the tests in three months time
B. Referral/telehealth with a Nephrologist
C. Referral/telehealth with a Urologist for a cystoscope
Correct!
D. Referral/telehealth with a Nephrologist and a Urologist for a cystoscope
D. Referral/telehealth with a Nephrologist and a Urologist for a cystoscope
A is incorrect - True haematuria is a red flag for urological cancer and requires active management. Waiting for three months could result in an unacceptable delay to diagnosis and treatment.
B, C and D - Mr Franz needs to be referred to a nephrologist because you have found a renal cause for his haematuria. However, because Mr Franz has a true haematuria, so he should also be referred for cystoscopy in case there is a second urological cause found for his haematuria (the incidence of concurrent disease is about 3%).
A 55 year old woman with a family history of TCC and a personal history of working with alanine dyes presents with a two month history of macroscopic haematuria. Your initial dipstick test results shows a large amount of blood, moderate leucocytes and nitrates. Your next step in management is:
A. Treat for a UTI and then repeat initial screening
B. Refer to a Urologist for a cystoscopy based on her risk assessment
C. Arrange for Blood tests including FBC, ELFTS and Coagulation profile and a Urinalysis microscopy and culture and sensitivity
D. Arrange a CTU
A. Treat for a UTI and then repeat initial screening
A - correct. Asymptomatic urinary tract infection (UTI) is the most common cause of haematuria (Yeoh et al) . Cystoscopies come with an inherent risk of bladder perforation. If all patients with haematuria caused by UTI’s had a cystoscopy there would be needless morbidity associated with this. The other work up tests for haematuria are also expensive and may be unnecessary. Hence checking for UTI and treating it prior to invasive or expensive testing makes logical and ethical sense.
B - incorrect. Referral to the urologist for a cystoscopy is made when there is true haematuria found in the absence of a UTI
C - incorrect. It is true that the tests mentioned are made for work up of haematuria including FBC,ELFTS, coagulation profile, urinalysis, microscopy and C and S. However, these should only be performed if the patient does not have a urinary tract infection
D - incorrect. A CTU is performed only if the cystoscopy (+/- retrograde pyelogram +/- urine cytology) is negative.
