To Remember Flashcards
Corticosteroid for face, axillae and groin
Hydrocortisone 1% ointment topically once daily until skin completely clear
Steroid for widespread low grade inflammation of trunk/limbs
If more severe or in flexures
Triamcinolone acetonide 0.02% topically daily until skin clears
Mometasone furorate 0.1% ointment topically until skin clears
Steroid for fingers, lichenified wrists/ankles
Mometasone furorate 0.1% ointment topically until skin clears
Steroid for scalp dermatitis
Mometasone furorate 0.1% lotion topically once daily until skin is clear
Evidence based falls prevention strategies (5)
Balance exercises for 2 hours/week
vitamin D supplementation to achieve a level of >60nmol/L
Psychoactive medication withdrawal
Home occupational therapy assessment for home modifications as indicated
Optimise vision
Risk factors for chronic kidney disease (9)
- Diabetes mellitus
- Cardiovascular disease
- Hypertension
- Obesity
- smoking
- history of acute kidney disease
- ATSI
- family history of kidney failure
- Age >60
What investigations to do if confirmed abnormal eGFR (9)
Urine ACR confirmatory ECU FBE ESR CRP Fasting lipids Fasting glucose Urine mcs for dysmorphic red cells, casts and crystals KUB ultrasound
Neonatal jaundice exam (7)
- alertness
- signs of infection
- dehydration
- poor weight gain/weight loss >10% of birth weight
- birth trauma - cephalhaematoma, significant bruising
- Level of icterus
- hepatosplenomegaly
History for neonatal jaundice (5)
- <48 hours - suggests haemolysis
- > 3 days more likely pathological
- weight loss >10% of birthweight
- Maternal blood group and viral serology
- Family history of haemolytic disease (ABO, G6PD, spherocytosis)
- dark urine or pale stools (biliary obstruction)
Investigations for neonatal jaundice
- Serum bilirubin split into unconjugated and conjugated bilirubin
- FBE/film/Reticulocyte count (haemolysis)
- Blood group and direct antibody test (haemolysis)
Management of neonatal jaundice
- if conjugated bilirubin >15%, dark urine or pale stool- refer gastro/ED (biliary atresia)
- if unwell -> ED
- If haemolysis - discuss with haematologist
- If in treatable range or borderline -> ED
- If prolonged jaundice >2 weeks/>3 weeks preterm without obvious cause - urine mcs, reducing substances, TFT, G6PD
- ensure baby feeding well and arrange follow up
Causes of unconjugated hyperbilirubinaemia (8)
- physiological jaundice - should resolve in 2 weeks (3 weeks in preterm)
- breastmilk jaundice - may continue for many weeks
- sepsis - usually unwell, check urine
- Haemolysis from ABO, rhesus incompatibility - early onset
- bruising/cephalohaematoma -> red cell destruction
- GIT obstruction or ileus e..g pyloric stenosis
- Prematurity
- hypothyroidism (screened in newborn screening test)
Presents day 2 - 2 weeks of age, often begins on face and spreads to affect trunk and limbs. Palms and soles not usually affected. Combination of erythema to us macules, papules, as pustules. TYpically lasts several days
Erythema toxicum neonatorum
Classification criteria for PMR (need 4 points)
Mandatory criteria
- Age =/> j50
- Bilateral shoulder aching
- Abnormal CRP or ESR
Additional criteria
- Morning stiffness >45mins (2 points)
- Hip pain or reduced ROM (1 point)
- Negative RA or anti-CCP (2 points)
- Absence of peripheral synovitis (1 point)
- Ultrasound findings: various findings can add an extra point
Ultrasound findings of bilateral shoulder abnormalities or abnormalities in one shoulder and hip significantly improve sensitivity and specificity
Biochemical evidence of cirrhosis (4)
- thrombocytopenia
- low albumin
- prolonged PT
- prolonged INR
SNAP for osteoporosis prevention
- no smoking
- 1300mg ca per day and adequate safe sun exposure
- no more than 2 standard drinks/day
- weight bearing activity 2-3 times a week moderate - vigorous intensity
- maintain healthy BMI
When there is concern of osteoporotic spinal fracture which imaging modality is recommended?
Non contrast CT
3 behaviours indicative of pain
- Facial expressions - frowning, sadness, grimacing
- Body language - guarding, rigidity, fidgeting, pacing, altered gait
- Vocalisations - crying out, pain noises, moaning, groaning, verbal aggression
Non-pharmacological managementof pain
CBT Physiotherapy/regular exercise Education about source of pain Emotional support Ensuring warm and comfortable, reducing lighting and surrounding noise Heat Walking devices Massage
What are the 5 steps to mental wellbeing
- Be active
- Keep learning
- Be giving to others - acts of kindness can improve mental health
- Take notice - be mindful of the present moment
- Stay connected
Management of anxiety disorder
Psycho education re nature of anxiety, its purpose and how it can present
Psychological treatment - CBT
SSRIs
Suicide assessment questions
Suicidal thinking Plan Lethality Means to carry out plan Past history of attempted suicide Suicide of a family member
DSMV-5 criteria for schizophrenia
Hallucinations
Delusions
disorganised speech
Grossly disorganised or catatonic behaviour
Negative symptoms e.g. diminished emotional expression
+
Impairment of work, interpersonal relations or self-care for a significant period
Last for a continuous period of 6 months
Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out
Non-pharmacological prevention of falls (10)
- Postural hypotension managment
- address under nutrition
- Manage incontinence
- Manage visual impairment
- Manage hearing impairment
- Exercise program to improve strength, balance, endurance and flexibility
- Tai chi
- refer to PT for mobility assisting devices
- Refer to podiatrist for appropriate footwear
- Refer to OT for home assessment and environment modifications
Pharmacological prevention of falls (6)
- Deprescribe where possible, including pharmacist review of medication where appropriate
- reduce/cease psychotropic drugs
- Review medications with dehydrating effect - diuretics/laxatives
- Vitamin D supplementation if deficient
- ensure B12 sufficient
- Manage other medical conditions
Post fall assessment (5)
- History, PMHx, mechanism, mobility levels
- identify sites of injury
- Examine vision, gait, balance and lower extremity joint function
- Neuro exam
- Cardiovascular exam including postural BP
Signs of frailty
- Unintentional weight loss >4kg in past year
- Self-reported exhaustion
- Weakness (reduced grip strength)
- Slow gait speed
- Low physical activity
Reversible causes of incontinence (7)
Delirium Infection Pharmaceuticals Psychological Excess fluid Restricted mobility Stool impaction
Basic investigations for incontinence
Urine MCS
Bladder chart over 3 days
Portable bladder scan for measurement of post-void residual - residual >100 may require ix
Or KUB USS
Side effects of oxybutinin (4)
Dry mouth
Constipation
Urinary retention
Cognitive impairment
Steps to help family care for family member with dementia
- refer to geriatrician for consideration of cholinesterase inhibitor - memantine
- Refer to My Aged Care for assessment for home domestic assistance and home care packages
- discuss advanced care directives
- Discuss enduring power of attorney
- Discuss enduring guardianship
- Refer to dementia support groups
- Discuss respite care services
Information to give - signs and symptoms of dementia
- time course and prognosis
- sources of financial and legal advice and advocacy
- medicolegal issues including driving
- how to join a support group
- information regarding
- Alzheimer’s Australia, Carers Australia, Aged Care Assessment Teams and My Aged Care
Differential diagnosis of cognitive decline, changed behaviour (4)
Dementia
Depression
Delirium
Drugs
Who is at risk of cystic fibrosis
Northern European or Ashkenazi Jewish Ancestory
Family history of CF/CF mutation
Partner affected or known carrier
Partner from Northern European / Ashkenazi Jewish ancestory who are consanguineous
Men with infertility secondary to congenital absence of vas deferens
Test couple for carrier status preconception or in first trimester
Who is at risk of fragile x
Children or adults of either sex with:
Developmental delay including disability of unknown cause
Attention hypersensitivity disorder
Speech and language problems
Social and emotional problems such as aggression or shyness
History of premature menopause <40
Adults with ataxia, balance problems and Parkinsonism
Relative with fragile X mutation
Who is at risk of haemoglobinopathies
Southern European African Middle Eastern Chinese Indian subcontinent Central and southeast Asian Pacific Islander New Zealand Maori South American Caribbean Some North Western Australian and NT ATSI
At risk of familial hyper cholesterol anemia and what to do (6)
Premature IHD men <55, women < 60 First degree relative with hx of same TC >7.5mmol/L LDL cholesterol >4.9mmol/L First degree relative with hx of same Tendon xanthomata or arcus cornealis age <45
-> assess probability using Dutch Lipid Clinic Network criteria
Offer referral to lipid disorders clinic of Dutch Lipid Clinic Network score =/>3
Who is at risk of hereditary haemochromotosis and what to do
All first degree relatives of person homozygous for C282Y or compound heterozygous C282Y/H63D -> >18 yo HFE gene analysis, transferrin sat and ferritin. If has above test all first degree relatives Consider in Chronic fatigue Arthritis ED Early menopause HCC Cardiomyopathy Liver disease -> serum ferritin and transferrin saturation
Family history screening questionnaire (9)
- IHD before age 60
- Diabetes
- Melanoma
- Bowel cancer before age 55
- More than 1 relative with bowel cancer at any age - first and second degree relatives*
- Prostate cancer before age 60
- Ovarian cancer
- Breast cancer before age 50
- More than one relative on the same side with breast cancer at any age. *
Children, siblings, parents, grandchildren, nieces, nephews, aunts, uncles, grandparents
Preventative counselling advice age 14-19
- Assess for risky behaviours
- Promote oral health
- Ask about smoking and provide strong anti-smoking message
- Use models of care that facilitate transition of patients with chronic health conditions/disability from paediatric services to primary care with access to adult specialist care
When and how often to screen for falls risk. What to ask. (3)
From age 65. Annually or 6 monthly if at increased risk
- Have you had 2 or more falls in the last 12 months
- Are you presenting following a fall
- Are you having difficulty with walking or balance
Assessment of falls history (10)
- Detailed history of fall inc fear of falling
- Polypharmacy
- Impaired gait, balance and motility
- Foot pain, deformities, unsafe ;footwear
- Home hazards
- Bifocal or multifocal glasses
- Incontinence
- Recent d/c from hospital
- Chronic illness such as stroke, Parkinson, MS，impaired cognitive impairment/demetia
- Vitamin D deficiency
Assessment of falls exam (7)
1. V/A including cataracts 2 reduced a visual fields 3. Muscle weakness] 4. Neuro impairment 5. Cardiac dysrhythmias 6. Postural hypotension 7. Six metre walk, sit to stand
If impairments following a fall
- GPCOG
- Activities of daily living and home assessment by OT
- Falls risk assessment tools
- If unsteady - gait and mobility assessment by physiotherapist
Falls risk interventions
- Prescribe or refer for home exercise or community exercise program targeting balance which may include strength and endurance must specifically challenge balance and be done for 2 hours per week
2.
Works in abattoir Fevers, sweats, chills, LOW Headache Fatigue Athralgias Myalgia Abnormal LFTs ?diagnosis
Q fever
What is Q fever?
Zoonotic disease
Gram negative Coxiella burnetii
Transmitted by domestic ruminants
Treatment for acute Q fever
Doxycycline 100mg bd
DDx for Q fever
Ross river virus Barmah first virus Dengue Epstein Barr virus Legionella Psittacosis Flu CMV Mycoplasma Leptospirosis Brucellosis
What complications can result from Q fever
- Chronic Q fever
- Post Q fever fatigue syndrome
- Endocardititis
- chronic granulomatous hepatitis
- osteitis/osteomyelitis
- alcohol intolerance
How to use 5-fluorouracil for actinic keratosis
- apply with gloves, thin layer to whole area once or twice daily
- Continue treatment until there is a marked inflammatory response - stage of ulceration
- initial therapy usually 3-4 weeks
How to counsel for 5-fluorouracil use
- side effects include, reddening, pain, itch, burning, stinging, crusting, blistering, sores, peeling, cracking
- less common side effects - hyperpigmentation/hypopigmentation, scarring
- get redness after 3-5 days and peeling, blistering and cracking and development of sores after 11-14 days.
- Healing takes 1-2 months
- avoid sun exposure
- avoid contact with mouth, eyes, nostrils
What are the essential steps for treating hepatitis C? (12)
- Serology positive -> PCR, genotype,
- HCV treatment history - regimen and response
- Potential for non-adherence
- EtOH history (risk factor for cirrhosis)
- Check drug-drug interactions
- Pregnancy discussion
- BMI - NAFLD is a risk factor for cirrhosis
- Signs of chronic liver disease
- FBE - low platelets suspect portal hypertension
- LFTs and INR: low albumin, raised bilirubin and raised INR suggest cirrhosis
- HBV, HIV and HAV serology. If hbv and hbv negative - immunise. Refer if HBV or HIV pos
- Cirrhosis assessment - fibroscan or APRI score (<1). If present refer
Pneumonia vs acute bronchitis. What suggests pneumonia?
Sats <95% HR >100 Temp >37.8 Creps, poor air entry, bronchial breath sounds and dullness to percussion Rigours Pleuritic chest pain Tachypnoea at rest
Pneumonia vs acute bronchitis what suggests bronchitis
- Fever usually subsides within a few days
- unlikely to have rigours, tachycardia or tachypnoea at rest
- wheeze
- creps that resolve with coughing
Treatment of CAP
- Decide if needs to go to hospital
- tachycardia, tachypnoea, hypotension, sats <92%
- acute onset confusion
- multilobar involvement
- blood lactate >2mmol/L
- social circumstances, age, comorbidities, able to take oral meds
- OR CRB65 = acute confusion, RR =/>30, BP<90/60, age =/>65. 0 don’t admit, 1-2 consider, 3-4 urgent admission
Empiric treatment for CAP
And in rural communities
If mycoplasma or chlamydophila suspected
Amoxicillin 1g PO 8 hourly.If improved after 2-3 days treat for 5 days. If slow clinical response treat for 7.
Procaine benzylpenicillin 1.5g IM daily. Length of treatment same.
Doxycycline 100mg bd or clarithromycin 500mg bd
R/v within 24 hours. If not improving assess if needs hospital or start combination therapy
Define low severity CAP in children
- minimal tachypnoea
- no tachycardia
- O2 =/>95%
Treatment low severity CAP in children
- consider performing respiratory virus PCR (difficult to differentiate viral)
- amoxicillin 25mg/kg 8 hourly for 3 days
- reassessment 48-72 hours
Wet cough lasting > 4weeks in children
Protracted bacterial bronchitis
Clinical features of protracted bacterial bronchitis
- must be wet cough for 4 weeks
- cough is isolated symptoms and child is otherwise well
- “rattly” sound on examination
- present day and night. Worsens when changing posture
- coughing symptoms can cause SOB but this is not present at other times.
DDx for chronic cough
- protracted bacterial bronchitis
- exposure to cigarette smoke
- asthma
- postviral cough
- retained inhaled FB -sudden onset, often child eating
- pertussis, lung abscess, TB
- congenital airway abnormalities
- chronic Lung disease - clubbing , chest wall deformity, abnormal growth
Treatment of protracted bacterial bronchitis
- amoxicillin + clavulanate PO 12 hourly for 2 weeks
- if improves confirms diagnosis - continue 2 week course
- if doesn’t resolve after 2 weeks continue for 2 more weeks
- if still not resolved or gets recurrence refer
Acute bronchitis symptoms
- cough +/- sputum
- dyspnoea (not usually at rest)
- wheeze
- chest discomfort or pain due to frequent coughing
- nasal congestion
- headache
- fever
DDx for acute bronchitis and what distinguishes them
- pneumonia - persistent fevers, tachypnoea, tachycardia, hypoxia, rigors, hypotension
- influenza
- pertussis - paroxysmal cough/recent exposure
- asthma
- heart failure - pitting oedema, weight gain
Approach to management of acute bronchitis (9)
- Exclude pneumonia (CXR not indicated) and consider ordering respiratory virus and pertussis NAAT
- Reassure acute bronchitis is a self-limiting condition and over 90% over cases are caused by a virus. Severity does not indicate need for antibiotics
- Ask about expectation for antibiotics
- Explain antibiotics are of no benefit and have potential harms
- Explain cough last 2-3 weeks, 90% resolved by 4 weeks but occasionally last for 8 weeks. This is frustrating
- Symptomatic management
- ? Answer questions
- Ask to return if symptoms take more than 3 weeks to resolve, earlier if fever persists or symptoms worsen or new symptoms develop
- If cough lasts > 8 weeks investigate for chronic cough
Red flags for cough
- Haemoptysis
- > 20 pack years
- > 45 year old with new/changed cough or cough with voice disturbance
- Prominent dyspnoea esp at rest or at night
- Substantial sputum production
- Hoarseness
- Systemic symptoms
- Complicated GORD
- Feeding difficulties - choking/vomiting
- Recurrent pneumonia
Rosacea triad
- facial erythema
- telangiectasia
- sterile acneiform papules, pustules and nodules (but no comodones)
Rosacea history
- typically fair skinned
- often initially starts with prolonged flushing
- face feels hot, stings, burns, itches
- face sensitive to topical products
- half develop ocular rosacea - blepharoconjunctivitis - itching, burning, dryness, FB sensation with erythema and swelling of eyelid
- severe cases get enlarged sebaceous glands and connective tissue changes -> bulbous rhinophymatous nose
Non-drug treatment for rosacea
- minimise factors that cause flushing - emotional stress, change in temp, hot or spicy foods, etOH, baths, calcium channel blocker
- avoid most skin care products.
- Avoid sun exposure. Use low irritant sunscreen
- emollient soap free cleanser
- green tinted foundation to mask telangestasia.
- avoid topical steroids - not helpful and can cause severe rebound flare
Drug treatment mild rosacea
Metronidazole cream 0.75% topical once or twice daily
If topical unsuccessful add oral therapy
Drug treatment for more severe rosacea
Metronidazole 0.75% cream topically once or twice daily
Doxycycline 50-100mg orally once daily for up to 8 weeks and repeat as required. If no response after 4 weeks consider therapy with minocycline
(50-100mg once daily for up to 8 weeks and repeat as required.)
If rosacea recurs within a month try doxy or minocycline 50 mg daily or alt days for 6-12 months
If not effective refer for consideration of isotretinoin
Telengectasia - brimonidine
When counselling for medication use what points do you make?
- Why patient is taking the medication/effect of not taking it.
- Effect of immediately ceasing the medication vs slow weaning
- Need for follow up/monitoring treatment efficacy
- Short term adverse effects
- Long term adverse effects
How to manage haemochromotosis
- Therapeutic venesection
- Regularly monitor ferritin (guide venesections
- Advise first degree relatives should be tested
- If ferritin >1000uI/L refer top specialist with interest in iron overload
How to treat hidradenitis suppuritiva
- Quit smoking
- Normal BMI
- Avoid tight fitting clothing
- 1% Clindamycin solution applied topically to both axillae twice daily for three months
- Consider anti-androgenic OCP
If moderate - Oral antibiotics
- Intralesional corticosteroid injection/oral corticosteroids
8.biologics - Consider referral for moderate - severe cases to dermatologist
Tests to diagnose secondary amenorrhea (4)
- Beta HCG
- TSH
- PRL
- FSH
Another reason - hypothalamic amenorrhea due to excessive exercise/diet/stress
How to diagnose premature ovarian insufficiency
2 elevated FSH 4-6 weeks apart after >4 months of irregular periods/amenorrhea
Acute bacterial prostatitis treatment
Trimethoprim 300mg daily for 2 weeks
Complications from acute bacterial prostatitis (6)
- Acute urinary retention
- Prostatic abscess
- Sepsis
- Chronic bacterial prostatitis
- Formation of a fistula
- Osteomyelitis of spine
List long term aspects of managment of COPD
- regular review to monitor his pulmonary function/progress
- Encourage regular physical activity 30 minutes on most days of the week.
- Referral to pulmonary rehab
- Referral to a dietitian to maintain a normal BMI
- Develop a COPD action plan to treat exacerbation rapidly
- influenza immunisation
- pneumococcal immunisation
- pharmacist home medication review
- discuss referral to a COPD patient support group
- Screen for co-morbidities commonly associated with COPD - depression, anxiety, osteoporosis, coronary artery disease, lung cancer
Counselling specific to varenicline.
- most common side effect is nausea
- Abnormal dreams are a common adverse effect
- may be helpful to combine with short acting nicotine replacement therapy to help with cravings.
- Varenicline has been shown to double the chances of long term smoking cessation
- need to be enrolled in a smoking cessation support program to be eligible for pharmaceutical benefit subsidy
- will need to return after the 4 week starter pack for continuation of the 8 week continuation pack
- using for a total of 24 weeks has been shown to decrease risk of relapse
Clinical exam looking for secondary causes of hypertension or end organ damage
- pulse/rate/rhythm/character
- JVP
- evidence of cardiac enlargement - displaced apex beat, added heart sounds
- Evidence of cardiac failure
- Evidence of arterial disease - bruits, aortic aneurysm, absent femoral pulses, radio-femoral delay
- polycystic kidneys
- retinal haemorrhage, papilloedema, tortuosity, arteriovenous nipping, exudates,
- evidence of Cushing syndrome or thyroid disease
- obesity
Initial investigations for patients newly diagnosed with hypertension- u
- urine dipstick for blood - send for microscopy if positive
- urine ACR
- fasting glucose
- fasting lipids
- EUC with eGFR
- Haemoglobin or heamatocrit
- 12 lead ECG for AF, LV hypertrophy, evidence of previous ischaemic heart disease
- if CKD - renal artery duplex ultrasound (fibromuscular dysplasia in young women)
- if diabetes, vascular bruit, older age, smoker - ABI
- if treatment resistant/low K - aldosterone/renin ratio
- if suspect phaeochromocytoma - 24 hour urine catecholamine
Lifestyle risk factors for hypertension
- 30 minutes moderate intensity physical activity on most/all days of the week + strengthening activities on at least 2 days/week
- normal BMI, waist <94cm males, 80cm females
- total fat 20-35% of energy, total saturated + trans fat < 10% of energy intake, <6g/d salt or <4g for secondary prevention, 5+2
- smoking
- etOH
Steps to increasing antihypertensives
- Add low dose first line drug
- If not on target after 3 months add low dose other first line drug
- If not on target after 3 months increase dose of one of these drugs to max dose, then increase other drug
- If not on target after 3 months add 3rd drug
- Refer
Always check compliance, secondary hypertension, sleep apnoea, undisclosed use of etOH, recreational drugs or high salt diet
Management of anaphylaxis (10)
- 000
- Lay patient flat or allow to sit if breathing difficult
3.Adult give 0.5ml 1:1000 adrenaline IM into mid lateral thigh
Child give 0.01ml/kg 1:1000 adrenaline IM into mid lateral thigh - Repeat adrenaline every 5 minutes as needed
- Remove allergen - flick out insect stings, freeze ticks with liquid nitrogen
- Monitor pulse, BP, RR, pulse oximetry
- give oxygen and airway support if needed
- Obtain IV access in adults and hypotensive children
- If hypotensive give IV saline 20ml/kg bonus and consider additional wide bore cannula
- For persistent wheeze give salbutamol and oral prednisolone
Red flags for Austism Spectrum Disorder (5)
Does not babble or coo by 12 months old
Does not gesture by 12 months of age
Does not say single words by 16 months of age
Does not say 2 word phrases on their own by 24 months of age
Has any loss of any language or social skill at any age.
History for elucidation of hearing loss (6)
- excessive ear wax
- associated tinnitus (impacted wax/ otosclerosis)
- chronic high levels of noise exposure (noise induced hearing loss)
- ototoxic medications (drug induced hearing loss)
- family history of hearing loss (otosclerosis)
- history of regular cold water exposure (exostoses)
Distinguish perioral dermatitis from atopic dermatitis
- usually popular but may be pustular
- commonly affects chin, paranasal area and lower eyelids. May be unilateral
- unlike atopic dermatitis leaves clear rim around the lips
- Topical corticosteroids can cause perioral dermatitis, even after long term use
- also caused by occlusion by cosmetics and creams
- if trigger can be identified and removed and it is not concerning to patient treatment may not be necessary
- if caused by topical corticosteroid, stop therapy and treat with simple emollient and cold compress
- if treatment needs treat as for rosacea with oral antibiotics (can try topical but may irritate the skin)
Redback spider evonomation
- Radiating pain to draining LN/chest/abdomen/back
- Unusual distribution of diaphoresis e.g. isolated to affected limb
3, Headache - NAND V
- Hypertension
Irritability/agitions - Muscle twitches/fasciculation
- Fever
- Priapism
Modular BCC excision margins
2-3mm
General measures for atopic dermatitis (6)
- Avoid environmental triggers e.g. grass
- Loose cotton clothing
- Soap free washes
- Short 2-3 minute baths
- Luke warm baths
- Twice daily emollients
Snake bite first aid (7)
- Apply a pressure immobilisation bandage to the right leg
- Do not wash or clean the wound
- Monitor airway/breathing
- Splint right leg
- Immobilise the patient/bring transport to the patient
- Transfer directly to hospital
- Keep patient calm
Burns early management (6)
1- cool running water for 20 minutes 2- debride blisters 3- dress in Acticoat = nanocrystalline silver dressing 4- rest and elevate for 48 hours (prevent oedema) 5 - frequent oral rehydration 6 tetanus 7. r/v at 48 hours 6 consult burns unit if > 10% BSA
Describe superficial epidermal burn
- dry erythematous skin, no breaks
- sensation intact
- normal cap refill
- Heals within 7 days
- no scarring
e. g. sunburn
Describe superficial dermal burn
- pale pink, blister
- very painful
- blanches
- heals within 14 days
- risk of pigment change
Describe deep dermal/full thickness burn
- red and fixed stained, white/black/leathery
- sensation absent or reduced
- does not blanch
- healing >21 days
- high risk of scarring
Define minor burn in adults and children
adults - <10% BSA
children < 5%
but some superficial burns this size will be difficult to manage in gp due to dressing requirements and pain management
Indications for referral to burns unit (7)
- associated with inhalation injury
- > 10% BSA
- special areas - face/hands/major joints/genitals/feet
- full thickness burns >5% BSA
- electrical burns
- chemical burns
- circumferential burns
complications of sinusitis (6)
- preseptal cellulitis
- orbital celluitis
- cavernous sinus thrombosis
- osteomyelitis
- meningitis
- encephalitits
6 Ps for ischaemia (or compartment syndrome
- pain (exacerbated by stretching)
- pallor
- pulselessness
- paralysis
- paresthesia
- perishingly cold.
suspect if #, burn, prolonged immobilisation, coagulopathy
Palpable distal pulses and intacts cap refill does not exclude compartment syndrome
Management of metabolic complications associated with PCOS (6)
- Assess cigarette smoking
- Regularly assess BMI and waist circumference
- moderate intensity exercise for 30mins/day most days
- Measure lipid profile 2 yearly
- Measure BP annually for every visit if BMI >25kg/m2
- HbA1c yearly
Causes of postmenopausal vaginal bleeding (8)
- vaginal atrophy
- cervical cancer
- cervical polyp
- atrophic endometritis
- endometrial carcinoma
- endometrial hyperplasia
- endometrial polyp
- urethral caruncle
Abnormal bleeding in pre/perimenopausal woman
- History
- exam - speculum and pelvic, CST, chlamydia
- FBE, consider TSH, PRL, coags
- If no anaemia and no prolonged amenorrhea - try conservative management. Otherwise TVUS for endometrial thickness
- premenopausal >12 or >4 peri -> refer for endometrial biopsy, otherwise conservative management
- if not controlled refer
Abnormal bleeding in postmenopausal
- History including if on tamoxifen
- FBE, CST, chlamydia
- if on tamoxifen - TVUS and refer for endomerial bx
- all others - TVUS. endometrial thickness 4 or less - GP surveilance but if continues refer. 5 or more or focal lesions- refer
Long term managment of COPD (12)
1- regular review to monitor pulmonary function
2. regular physical activity
3. Pulmonary rehab
4. maintain healthy BMI
5. written action plan to treat acute exacerbtions rapidly
6. check annual influenza immunisation is up to date
7 check pneumococcal immunisations are up to date
8. Pharmacist home medication review
9. referral to COPD patient support group
10. screen for comorbidities associated with COPD - osteoporosis, coronary artery disease, lung cancer, anxiety, depression
11. medication adherence
12. inhaler technique
causes of abducens nerve palsy
V giant cell arteritis, microvascular ischaemic nerve palsy, cerebral aneurysm, cavernous sinus thrombosis I post viral mononeuritis, mastoiditis N SOL N migraine, MS D I idiopathic C A MS T trauma E Diabetic mononeuropathy most likely trauma, microvascular ischaemia, idiopathic
Causes for delerium in cancer patient
- brain mets
- hypercalcaemia of malignancy
- side effect of opioids
- hyponatraemia secondary to siadh
- uncontrolled pain
+ the usual ones
management when someones cancer is getting worse
- explain findings the show disease progression
- enquire as to whether she would like to discuss prognosis
- complete advanced care directive
- refer to palliative care service
- ensure pain relief adequate
- cease unnecessary drugs
- respite care
- PEPSI cola - physical needs, emotional needs (?depressed) personal needs, social support, information/communication, control, out of hours, late, after
History for erectile dysfunction (9)
- sexual history
- smoking
- hypertension
- diabetes
- pelvic conditions (neurovascular disease, injury, surgery)
- prostate disease
- medication (antihypertensives, anticholinergic, antidepressant, antipsychotic)
- recreational drug use
- depression
Exam for erectile dysfunction
- BP and cardiovascular assessment
- BMI, waist circumference
- Genitals - penile plaques - peyronie’s disease, small testes - hypogonadism
- lack of androgenisation
Investigations for erectile dysfunction (3)
- HbA1c
- Lipid profile
- morning testosterone
4.
Reversible causes of erectile dysfunction (3)
- low testosterone
- medication induced
- psychogenic
Treatment for erectile dysfunction (3)
- optimise risk factors and related comorbidities as appropriate
- SNAP, avoid recreational drugs
- BP, lipid and DM control
- assess for cardiovascular disease - Treat reversible causes
- medication induced
- psychogenic - consider psychotherapy
- low testosterone - phosphodiesterase 5 inhibitor
- tadalafil 10mg at a time before sexual activity that the patient has found to be optimal. Max one dose daily. Can increase to 20 mg according to efficacy and tolerability
If taking regularly can take 2.5-5mg daily
contraindications to phosphodiesterase 5 inhibitors
- unable to climb 20 steps in 15 seconds
- taking nitrates
common side effects for phosphodiesterase inhibitors
- facial flushing
- headache
- dyspnoea
- nasal congestion
- dizziness
- backpain (tadalafil)
how long after a dose of tadalafil should you not give nitrates
5 days. 24 hours for other phosphodiesterase 5 inhibitors
Red flags for head and neck cancer (neck mass)
- Mass present for > 2 weeks
- recent voice change
- dysphagia or odynophagia
- ipsilateral otalgia, nasal obstruction or epistaxis
- loss of weight/appetitie
neck mass exam
- exam mass
- cutaneous lesions
- anterior rhinoscopy
- oral cavity inspection and palpation
- oropharyngeal inspection for ulceration, masses
- tonsil enlargement or asymmetry
investigations for patient at risk of head and neck cancer
- contrast enhanced CT neck
- FNA
Ancilliary investigations (if malignancy unlikely or first line investigations don’t yield a diagnosis) may be done
Refugee health assessment
FBE - eosinophils - intestinal lparasites, strongyloides, schistosomiasis
Mantoux - latent TB
Strongyloides serology
Varicella >14 and no history of natural infection
If from Sudan add
Schistosomiasis serology
Malaria thick and thin film and rapid detection test in within 3 months or 12 if febrile
What should I order if I get a positive rectal swab for chlamydia
Lymphogranuloma venereum NAAT
Treatment of Osgood Schlatter (osteochondrosis and traction apophysitis at inferior attachment of patella ligament
sports as tolerated
modify activities to reduce pain
ice for 20 minutes after activity
physio for quad stretching and strengthening
general measures for atopic dermatitis (6)
- avoid environmental triggers
- loose cotton clothing
- soap free washes
- short 2-3 minute baths
- luke warm baths
- BD emollients
50 year old preventative activities (11)
- SNAP
- BMI and waist circumference
- BP
- fasting lipids
- calculation of absolute cardiovascular risk
- calculation of diabetes risk (AUSDrisk)
- FOBT, mammography, cervical screening
- # risk
- flu vaccine history
- diphtheria, tetanus pertusis
- skin cancer risk reduction education
- SNAP and BMI, waist
- BP, fasting lipids, CVD risk assessment
- ausdrisk
- vaccinations - flu and diphtheria, tetanus, pertussis
- cancer - fobt, mammography, CST, skin cancer risk reduction education
- # risk
How to provide a teenage friendly healthcare environment (6)
- provide a welcoming environment with adolescent friendly posters in the waiting room
- Ensure easy access to inexpensive consults
- Provide online bookings
- Provide clarity regarding confidentiality
- Ensure care is non-judgemental
- Provide information that is aimed at teenagers
Points to discuss around future unintended pregnancy (4)
- Enquire sensitively about pregnancy intention
- Enquire sensitively about contraceptive beliefs
- Encourage use of LARCs
- Educate re emergency contraception
how to treat well demarcrted erythremetous scaly lesions scalp
=psoriasis
Scalp - mometasone furorate 0.1% lotion topically once daily until clear
Once controlled add coal tar based shampoo - don’t wash off immediately, use daily then when controlled 2x/wk + slowly withdraw steroid
If thick scale - LPC 6% + salicylic acid 3% in aqueous cream bd
If not controlled - daivobet 50/500 mcg/g gel daily until skin is clear
treat well demarcated erythematous scaly lesions on trunk and limbs
=psoriasis
LPC= liquor picis carbonis = coal tar solution
LPC 6% + salycylic acid 3% ointment bd for 1 month
If needed add mometasone furoate 0.1% ointment daily until skin is cleared
pleuritic chest pain, worse when lying flat, eased by leaning forward, SOB, fever
diagnostic criteria?
pericarditis most common cause - idiopathic need 2 of: 1. pericarditic chest pain 2. pericardial rubs 3. new widespread ST elevation or PR depression 4. pericardial effusion
ECG changes of acut pericarditis
sinus tachy, widespeard ST elevation and PR depression with reciprocal changes in aVR
Treatment for acute pericarditis
Colchicine:
70kg or more = 500microgram bd for 3 months/<70kg 50microg daily
PLUS EITHER
aspirin 750mg 8hourly for 1 -2 weeks then decrease by 250-500mg every 1-2 weeks then stop OR
ibuprofen 600mg orally 8 hourly for 1-2 weks then decrease the dose by 200-400mg every 1 or 2 weeks to stop
RESTRICT EXERCISE
be guided by symptoms resolution and inflam markers
causes of pericarditis
V- I- viral most comon, bacterial N- consider in lung, breast, haem malignancies D - Idiopathic, iatrogenic C A autoimmune Traumatic inc post MI E uremic - kidney impairment
soft heart sounds
elevated JVP
hypotension
cardiac tamponade
+ pulsus paradoxis
Investigations for pericarditis 5
- ecg
- cxr
3 inflammatory markers - troponin (+ve in 30%)
- transthoracic echo
Management of pericarditis
hospital if:
1. fever >38
2sub acute course - symptoms over several days without clear cut acute onset
3 large pericardia effusion
4 cardiac tamponade
5. failure to respond within 7 days to aspirin of NSAIDs
DDX for pericardititis (5)
PE aortic dissection penumothorax peumonia MI If dx unclear -> ED
erythema nodosa investigation
most commonly due to streptococcal infection and sarcoidosis 1. FBE 2. ESR 3. Biochem 4. Streptococcal serology 5 throat swab 6. CXR
erythema nodosum causes
I - strep, TB, Yersinia N - lymphoma, leukaemia D - I - OCP, idiopathic C T A sarcoidosis, ulcerative colitis, Crohn disease E
causes of erythema multiforme 3
tx
HSV reactivation
Mycoplasma pneumonia
drugs
remove triggers
emollient
mometsdone furoate 0.1% for 2 wks
onychomycosis rx
comfirm with mcs
oral terbinafine for 6 weeks for fingers and 12 weeks for toes
new nail takes up to 9 months to grow
what is valvular AF
moderate or severe mitral valve stenosis or a mechanical heart valve
FOOSH
Tenderness distal to Lister’s tubercule (dorsal distal radius)
REduced ROM of wrist
Reuced grip strength
scapholunate dislocation
Morton’s neuroma
Interdigital neuroma really a mechanimcal entrapment enuropathy
metatarsalgia due to mechanical nerve cirritation to the digital nerve in the web space
complin of toe numbness and pain in forefoot
5-10 year old with limp
1 transient hip synovitis
2 acute myositis
3 DDH
4 Perthes disease
0-4 yo limp
- transient hip synovitis
- acute myositis
- DDH
- Toddler fracture
> 10 yo with limp
- stress fracture and sprains
- traction apophysitits (Osgood Schlatter, - tibial tuberosity, Severs - calcaneus
- slipper upper femoral epiphysis
Limping child history
- limp >7d
- history of trauma
- Pattern of severity of pain and limp severe localised joint pain
- change to urinary or bowel habit
- Fnctional limitations inability to walk/weight bear
- nocturnal pain and symptoms
- systemic symptoms fever/night sweats/chills/rigors/ rash
- constitutional symptoms - loss of weight/lethargy/fatigue/anorexia
- recent viral infection (acute myositits or transient synovitits)
Petechiae/purpura/ecchymosis (consider HSP, malignancy/haematological cause)
