Semester D Flashcards
Amber is a 21-year-old with known Addison disease of 2 years standing. She has been unwell in the last 2 days with sore throat and rhinorrhoea. She now presents in Addisonian crisis.
In regard to immediate therapy:
A. She should be commenced on IV antibiotics as the first priority
B. She should have IV Hydrocortisone commenced immediately
C. In the absence of vomiting, oral Prednisolone is the preferred mode of steroid administration here
D. She should be treated with oral rehydration to maintain euvolemia
B. She should have IV Hydrocortisone commenced immediately
Amber needs IV Hydrocortisone as a priority and then generally over the next 24 hours. IM Hydrocortisone and oral Prednisolone are not the first line management here. Antibiotics may be considered for bacterial infection, where indicated, but are not the immediate priority.
Mrs SP, 86 years of age, is a nursing home resident who was admitted to hospital following an unwitnessed fall. She had been feeling unsteady on her feet for the past week, but her mental state and vital signs were normal, and there were no neurological deficits on examination. Her past medical history included osteoporosis, hypertension, gastro-oesophageal reflux disorder (GORD) and depression. She is on multiple medications, including Escitalopram, Telmisartan, controlledrelease Oxycodone/Naloxone for chronic back pain, Oxybutynin for urinary urge incontinence, Simvastatin, Pregabalin for sciatica, Esomeprazole and Denosumab injections for osteoporosis.
A diagnosis of hyponatraemia secondary to SIADH was made.
In regard to SIADH:
A. Medications are an uncommon cause
B. Patients are always hypotensive reflecting a hypovolaemic state
C. Causes a hypotonic hyponatraemia with euvolaemia
D. Corrected by hypertonic saline infusion
C. Causes a hypotonic hyponatraemia with euvolaemia
SIADH is a euvolaemic state hence patients do not display hypotension or other symptoms of cardiovascular compromise (in the absence of course of any other co-morbidities that may cause this!). Medications are a very common cause and there is a long list of medications that can contribute to this. It is generally corrected by water restriction alone.
Which one the following tests are correct? (Pick more than one)
A. A negative DST ( Dexamethasone Suppression Test) can exclude Cushing disease
B. A negative Growth Hormone measurement does not exclude Acromegaly
C. Non functioning pituitary adenomas do not cause hormonal symptoms
D. MRI is the imaging of choice for pituitary pathologies
E. Prolactin should be checked in women , presenting with secondary amenorrhea
A, B, D, E
Non functioning adenomas may grow and eventually cause hypopituitarism.
How many hormones does the Pituitary gland secrete?
A. 7
B. 8
C. 9
D. 10
E. 11
The correct answer is 9.
TSH, ACTH, GH, LH, FSH and Prolactin from anterior segment.
ADH and Oxytocin from posterior segment
Melanocyte-Stimulating Hormone from intermediate part.
David, 45 year old presents with moon facies, marked fatigue, hypertension with excess fat pad on the back of the neck. His MRI reveals a pituitary tumour. What would you expect his results to reveal?
A. Increased ACTH and Increased Cortisol
B. Decreased ACTH and Decreased Cortisol
C. Increased ACTH and decreased Cortisol
D. Increased Catecholamines
A. Increased ACTH and Increased Cortisol
David has Cushing’s disease and so you would expect increase ACTH and cortisol.
Cushing’s disease is due to a tumour on the pituitary gland (pituitary adenoma): the tumour releases excessive amounts of ACTH and in direct response, the adrenal glands overproduce cortisol.
On the other hand Cushing’s syndrome (hypercortisolism or hyperadrenocorticism) refers to the endocrine disorder caused by elevated cortisol levels in the body due to any cause (e.g. pituitary, adrenal or ectopic).
An adrenal cause of Cushing’s syndrome would cause High cortisol and Low ACTH.
Thus Cushing’s syndrome is the umbrella term for several disorders, including Cushing’s disease, which is one of the specific causes of Cushing’s syndrome.
A decrease in serum calcium levels (hypocalcemia) leads to: A. Increase dietary calcium absorption from intestines
B. Increase in parathyroid hormone (PTH)
C. Increases Calcium release from the bone
D. Stimulates renal calcitriol production
E. All of the above
E. All of the above
Calcium haemostasis is important to learn about: read more here Calcium Homeostasis · Part One (litfl.com)Links to an external site. and Physiology, Calcium - StatPearls - NCBI Bookshelf (nih.gov)
Samantha, 34 yo presents with anxiety, weight loss and weakness. You perform some blood tests and her TSH <0.01 with elevated Free T4 and T3.
What would be the most useful blood test to confirm a diagnosis of Graves?
A. Thyroid peroxidase (TPO) antibody
B. Erythrocyte Sedimentation Rate
C. Thyroglobulin (Tg) antibody
D. Thyroid Stimulating Hormone (TSH) receptor antibody
E. Reverse T3
D. Thyroid Stimulating Hormone (TSH) receptor antibody
Samantha has the classic triad of symptoms for hyperthyroidism. TSH receptor antibody will be positive in 90-99% of Grave’s Disease. A radionuclide thyroid scan would also be a useful further investigation which would demonstrate homogenous uptake.
A 32 year old female is 9 weeks pregnant. She presents with palpitations, tachycardia and weight loss despite increased appetite. Her TSH is <0.01, with a high free T4.
Which of the following treatments would be most appropriate for this patient?
A. Propranolol
B. Prophythiouracil
C. Carbimazole
D. Radioactive Iodine
E. Potassium Iodide
B. Prophythiouracil
Prophythiouracil is the preferred option for treatment of hyperthyroidism in the first trimester as carbimazole has been associated with congenital abnormalities. Radioactive iodine therapy is contraindicated in pregnancy as it crosses the placenta and is taken up by the baby’s thyroid gland. Beta blockers can be used to treat significant palpitations and tremor but should be used sparingly due to concerns regarding impaired fetal growth with long term use. Potassium iodide is use as an emergency treatment for thyroid storm.
Trent is a 42 year old who has been on metformin and empagliflozin for his diabetes for the past 8 months. He presents with abdominal pain, nausea and vomiting and Kussmaul breathing.
His BSLs are 11 and ketones are 1.8. He has signs of moderate dehydration. What is the most appropriate diagnosis?
A. Thyroid Crisis
B. Euglycemic ketoacidosis
C. Hyperosmolar hyperglycemic state
D. Acute hypoglycemic event
E. Multiple endocrine neoplasia syndrome
B. Euglycemic ketoacidosis
“Euglycaemic ketoacidosis refers to ketosis and acidosis in the presence of normal blood glucose levels (or
minor elevations of blood glucose levels) in symptomatic patients. This rare condition is more likely to occur in
patients with type 1 or type 2 diabetes who are pregnant, patients on a low-carbohydrate diet or using SGLT2i,
or patients who have just undergone surgery” Management-of-hyperglycaemia.pdf (racgp.org.au) Links to an external site.
For further information see:
Samuel, a 23yo male, presents with weight gain and nocturia. He has no significant medical history but his father & grandfather had diabetes.
Examination is unremarkable other then a BMI of 29. HBA1c is 8.1% and there is no proteinuria or ketones on urinalysis. Antibody screen is negative.
What type of diabetes does Samuel most likely have?
A. MODY
B. LADA
C. Type 2 DM
D. Type 1 DM
E. Secondary diabetes
A. MODY
Features of MODY include young onset, autosomal dominant inheritance, onset in at least 1 family member at <25 years of age, absence of autoantibodies and ketosis, and not necessarily requiring insulin.
When to consider a diagnosis of MODY at the presentation of diabetes: aetiology matters for correct management | British Journal of General Practice (bjgp.org) Links to an external site.
Maturity onset diabetes of the young (MODY) | Diabetes UK Links to an external site.
Yvonne is a 30-year-old G2P1 woman who sees you in the GP rooms at 11 weeks’ gestation to review her first trimester screening blood results. Her HCV Ab result is positive. You repeat the test and order an HCV RNA PCR to confirm the result. Which of the following points of advice is correct regarding the management of HCV in pregnancy?
A. Women should be advised to avoid sharing of personal care items to reduce potential transmission of Hepatitis C to others
B. Women can be safely treated with antivirals during pregnancy
C. Caesarean section has been shown to reduce perinatal transmission rates compared to vaginal birth
D. Breastfeeding is discouraged
A. Women should be advised to avoid sharing of personal care items to reduce potential transmission of Hepatitis C to others
Effective Hepatitis C treatments are available but they are not safe or recommended during pregnancy. Caesarean section has not been shown to reduce perinatal transmission rates. Breastfeeding is encouraged unless there is bleeding/cracking of the nipples.
Mandy is a 22-year-old G1P0 woman who is 22 weeks’ pregnant. She sees you in the GP rooms with a 24-hour history of an itching and burning sensation of her vulva. She has not experienced this before. You take a swab that confirms your suspected diagnosis. What is the recommended management? Please select the BEST answer.
A. Oral acyclovir 400mg TDS for 5-10 days
B. Oral acyclovir 400mg TDS for 5-10 days, then from 36 weeks’ gestation until delivery
C. Oral acyclovir 400mg TDS until delivery
D. Supportive care only. Nil antiviral therapy is indicated
B. Oral acyclovir 400mg TDS for 5-10 days, then from 36 weeks’ gestation until delivery
As per eTG, an initial genital herpes infection should be treated with a 5-10-day course of an antiviral such as acyclovir. ASID recommends the consideration of suppressive antiviral therapy from 36 weeks until delivery.
Craig is an 85 yo male with a long term indwelling urinary catheter (IDC). He was reviewed at home by the community nursing team this morning who noticed that the urine was cloudy. They were concerned that he may have a urinary tract infection, so they have collected a sample of urine from the IDC collection bag and brought it to the clinic for you to action. You have spoken on the phone to Craig who reports that he is feeling generally well with no fevers and a normal appetite
The next best step is to:
A. Send the catheter urine sample for m/c/s and prescribe cephalexin 500mg bd
B. Send the catheter urine sample for m/c/s and await results
C. Change the catheter and prescribe cephalexin 500mg bd
Correct!
D. Change the catheter and collect a new urine sample to send for m/c/s
D. Change the catheter and collect a new urine sample to send for m/c/s
Laura is a 24yo who has a telehealth appointment for scripts for her regular oral contraceptive pill and asthma medication. Whilst she is on the phone, she reports that she has actually noticed a cough and runny nose for the past few days since making the phone appointment, and would like you to prescribe her the ‘usual antibiotic’ that she uses when she has a cough. She is currently not short of breath, and hasn’t required increased use of her salbutamol reliever.
Which of the following is the best advice to provide Laura on the phone today?
A. An antibiotic will interfere with her combined oral contraceptive pill
B. You can prescribe a ‘delayed script’ for an antibiotic to take if her cough worsens
C. There is no indication for prescribing an oral antibiotic at this time
D. You can prescribe an antibiotic, but would need to review her in person first
C. There is no indication for prescribing an oral antibiotic at this time
Which of the following does not commonly cause ongoing problems with chronic fatigue?
A. Q fever
B. Ross River Fever
C. Queensland tick typhus
D. Epstein-Barr virus
C. Queensland tick typhus
Answer C – rickettsial infections tend to respond rapidly to antibiotic treatment, residual symptoms are rare.
Which of the following does not respond to oral doxycycline?
A. Q fever
B. Scrub typhus
C. Melioidosis
D. Leptospirosis
C. Melioidosis
Answer C – melioidosis is typically a severe infection and requires high dose IV antibiotic therapy. PO doxy will not be adequate
Which of the following can cause disseminated infection in a vulnerable host?
A. Echinococcosis
B. Brucellosis
C. Strongyloidiasis
D. All of the above
D. All of the above
Answer D – they can all cause disseminated disease in various different forms, but disseminated strongyloid has the highest mortality
Development of a Jarish-Herxheimer reaction is typically associated with commencing treatment for which infection?
A. Leptospirosis
B. Strongyloides
C. Melioidosis
D. Spotted fever
A. Leptospirosis
Answer A – leptospirosis, though it can be seen with any spirochaete infection and is more common with syphilis
A young family come in to see you for travel advice. Sam, aged 24 is 20 weeks’ pregnant and generally well, her husband Alex aged 25, and their 3yo son Jonah who are both also otherwise well. All of their routine vaccinations are up to date. None of them have received any travel vaccines previously. They have seen a really good deal for flights and accommodation for 5 nights at a resort in Fiji. They haven’t been able to travel for a couple of years due to Covid and are keen to have a holiday before their next child is born. They are hoping to leave in 2 weeks.
What is the most appropriate medical advice to give them regarding their planned trip?
A. They should not travel as the risk of complications while travelling in the second trimester of pregnancy is too high
B. Sam and Alex should consider travelling but leaving Jonah at home with grandparents as he is too young for any travel vaccines and the risk of illness is too high
C. They do not need to take any medication for Malaria prophylaxis for this destination
D. You warn them against travel as there is not enough time for them to complete the courses of recommended travel vaccines for this destination before they go
C. They do not need to take any medication for Malaria prophylaxis for this destination
Rationale:
Fiji is a low risk destination for Malaria and prophylactic medication is not usually advised. Mosquito and other insect bite prevention measures are still important however.
Travel during pregnancy is considered safest in the second trimester
Jonah is old enough to have recommended travel vaccines for this destination including Hep A and Typhoid vaccines. Other food and water borne illness prevention measures should also be discussed.
Sam, Alex and Jonah are up to date with routine vaccines and the only additional travel related vaccines recommended for this trip would be Hep A and Typhoid vaccines. As they are not planning to leave for 2 weeks, there is enough time for them all to have the first dose of these vaccines, and this will provide adequate cover for this trip.
Lorna is a 53 year old Aboriginal woman presenting to you in your remote Aboriginal community outreach clinic today with a 2 week history of productive cough and fever. You consider TB as part of your differential diagnosis.
The most appropriate investigation to request in order to confidently diagnose or exclude active TB in this case would be:
A. CXR and sputum M/C/S with AFB (three samples)
B. Sputum M/C/S and AFB (3 samples)
C. Serum Quantiferon Gold (IGRA test)
D. CXR
A. CXR and sputum M/C/S with AFB (three samples)
Rationale:
Tuberculosis can be difficult to definitively diagnose, so the guideline-based approach is to start with CXR and three separate sputum collections (at least one of which should ideally be first thing in the morning, and each at least 8 hours apart) sent for M/C/S and AFB. Further investigation is very commonly needed.
CXR changes in TB can be non-specific or not present, and it can be difficult to distinguish between changes of active and latent TB on CXR
CT chest is not likely to add any further or specific diagnostic information for TB, and will likely be difficult to arrange due to your remote location
A positive Quantiferon Gold (IGRA test) will not be able to distinguish between active and latent TB in this case, and a negative result does not exclude active TB
If sputum is positive for AFBs this is most likely diagnostic of TB. Sputum culture is the most sensitive test for active TB. Induced sputum may be needed.
In our case study, Arnold suffered from a cerebellar infarct. This condition typically:
A. Produces a waddling type gait
B. Is always easily diagnosed on CT scan
C. Can be missed on both clinical examination and CT scan
D. Is the most common area of the brain to be affected by ischaemic stroke
C. Can be missed on both clinical examination and CT scan
A cerebellar infarct classically produces an ataxic gait and can be difficult to diagnose on CT scan. The clinical signs may be very subtle and therefore may require a high index of suspicion. The commonest artery involved in ischaemic stroke is the middle cerebral artery which supplies parts of the cerebrum and not the cerebellum.
As part of his rehabilitation, Arnold had an ADL assessment. In regard to ADL assessments?
A. ADL stands for Activities of Daily Leisure
B. An ADL assessment evaluates an individual’s level of independence and function in relation to personal care, leisure, and social activities
C. An ADL assessment evaluates an individual’s level of independence and function in relation to personal care only
D. An ADL assessment is not involved with trying to return a person to pre-disability function
B. An ADL assessment evaluates an individual’s level of independence and function in relation to personal care, leisure, and social activities
An ADL (Activities of Daily Living) assessment evaluates an individual’s level of independence and function in relation to personal care, leisure, and social activities. ADL assessments are used to help reduce the impact of impairment caused by injury and illness, and to facilitate the earliest return to pre-disability functions.
Frontal lobe syndrome:
A. is a broad term used to describe the damage of higher functioning processes of the brain such as motivation, planning, social behaviour, and language/speech production
B. aetiology is always from some form of neurodegenerative disease
C. has no effect on personality
D. CT is the preferred imaging modality over MRI
A. is a broad term used to describe the damage of higher functioning processes of the brain such as motivation, planning, social behaviour, and language/speech production
Frontal lobe syndrome can be caused by numerous conditions including trauma, cerebrovascular disease and tumours as well as neurodegenerative conditions. Personality changes is one of the major symptoms and MRI is the preferred imaging modality as it is more specific and sensitive than CT.
Which is the most common type of headaches?
A. Tension headaches
B. Migraine headaches
C. Cluster headaches
D. B and C
A. Tension headaches
The most common type of headache is tension headache, or tension-type headache (TTH). Symptoms include a feeling of pressure or tightness around the head. Women are more commonly affected than men, and this kind of headache often begins during the teen years. TTH may be caused by musculoskeletal problems or stress. Attacks of TTH typically persist for a few hours, but in some cases can last for days. A chronic form of TTH can be disabling.
