1
Q
Head lice
A
- no sign of poor hygiene
- launder pillow cases using hot water or hot dryer
- pyrethin based scalp preparation thoroughly cover hair, thorough rinse, combing with fine toothed comb, dry with clean towel- repeat in 7 days
- alternative: conditioner and comb every 2 days until no lice are seen for 10 days,
- if resistent malthion based preparation
- treat family members if affected
- pyrethrin ci if allergy to ragweed, care in asthma
- can return to school day after treatment
- no need to shave of cut hair short
- exclude dermatitis scalp or confuse this with headlice
2
Q
Microcytic aneamia
A
Causes:
- iron deficiency
- Thalassamia
- sideroblastic
- chronic disease (more often normocytic)
- led poisoning.
Do: first iron studies, if iron deficiency arrange colonoscopy and endoscopy! in patients that are middle aged or older. Can start on H2 receptor antagonist while waiting, not necessary. Also do blood film.
3
Q
renal colic investigation
A
- urine dipstick (don’t forget endone seeking)
- culture to exclude infection
- US to rule out obstruction
- abdo x-ray
- GOLD standard: CT non-contrast shows stones not visible in x-ray
- do at least creatinin, urea, serum uric acid and calcium.
- investigate causes : hyperparathyroidism, hypercalcaemia, hyperoxaluria, UTI
- analyse stone
4
Q
Renal/ureteric colic management
A
- pain relief: NSAID is preferable (eg diclofenac 50 mgTDS for one week), opioids or panadene forte acceptable
- strain urine plus analyse
- avoid high fluid intake (increases dialation ureter) acc to murtagh but high fluid intake acc to AMC.
- refer to urologist if high-grade obstruction, not passing in 48 hours, fever/UTI, staghorn calculus, DM-II, single kidney, stone >5mm
- urologist may have to go in and retrieve stone or blast.
5
Q
renal/ureteric colic explain
A
- draw diagram of anatomy bladder, kidney, ureter and urethra
- explain pain might come back again
- explain management and investigations and follow-up in 48 hours or if febrile
- recurrence up to 75%
- reduce anaimal protein, increase fluid intake
6
Q
feacal soiling 2nd to chronic constipation management in child
A
- common
- pr allowed
- start with high dose oral laxatives
- enema
- suppositiries
- gastrointestinal lavage
- maintain regular Bowel motions with laxatives for months and prolonged follow-up
- regular toileting after meals
- fluid and fiber
- treat fissures
- exclude organic causes via hx or investigation and emotional stress
(overflow is liquidification of feaces, masses remain)
7
Q
psoriasis causes
A
- excact eatiology unknown
- inflamation, cell proliferation in epidermis
- triggers: lithium, B-blocker, chloroquine
- ## stress, infections, trauma
8
Q
Psoriasis management
A
- cave arthritis (mostly hands/fingers) and 2nd infections
- emollients
- weak topical corticosteroid
- tars
- keratolytics
- systemic: methotrexate, acitretin or cyclosporin
- phototherapy
- long term management
9
Q
UTI in men management and investigation
A
- dipstick + midstream culture if dipstick +
- trimethoprim 300 mg nocte or cephalexin 500 mg BD 10 days (and adjust according to sensitivity, both ok in penicillin sens), alt amocycillin if no penicillin sens
- ural may be tried (alkalisation urine)
- increase fluid intake
- childeren: inv vesicoureteric reflux
- younfer adults: foreign body bladder, STD
- older adults: calculi kidney, ureter or bladder, prostatitis, bladder polyps or ca, BPH or ca prostate, urethral stricture, TB –> arange US +PSA + creat folowed by CT, and urologist (cystoscopy or voiding cystourethrogram)
10
Q
Bed wetting (nocturnal enuresis) invx/hx
A
- fam hx, major stressors, sibblings, general health, development, growth percentiles
- urine dipstix
- urine MC&S
- growth and percentiles
- blood pressure
- Renal US only if abnormalities above
11
Q
Bed Wetting management without organical problems
A
- empathy and reassurance
- lifting and restrictions of fluids have not been shown to be effective but can be continued if parents wish so.
- Enuresis alarm (conditioning response to release of urine) (available in pharmacy, community health care centres) (may take weeks to be succesfull and months for desired effect)
- succes rate higher if child motivated
- reward system and star chart
- Arginine vasopressin nasal spray when it is improtant to stay dry (school camps etc)
- succes rate amitriptyline is low and can be dangerous
- review 2-3 weeks after start alarm
12
Q
Gout Presentation and risk factors
A
- metatarsophalangeal joint great toe (or other in feet or elsewhere), extremely painfull, red, tender, needle shaped cristals in aspirate (not required)
- elevated urate (can also cause CVD and chronic renal failure)
- longterm can cause destructive arthropathy,
- exacerbated by alcohol and drugs (thiazides, B-blockers, aspirin, niacin, ciclosporin) trauma, seafood, game, oval, shellfish
- associated with metabolic syndrome
- inherited
13
Q
Gout acute management
A
- NSAID eg indomethacin 50-75 mg stat, 50 mg 2 hrs later, 25mg TDS for 48 hours, than 25 mg BD for 1 week.
- alternative prednisolone 25 mg OD for 7-10 days, alternatively colchicine
- increase fluids
- elevate and rest for 24-48 hours
- additional paracetamol if required
- warn for side effects medications
- cease offending drugs, eg stop tiazide and start ACE
- should be improved in 48 hours
- blood for uric acid
- ddx septic
14
Q
gout long term management
A
- adequate water intake
- avoid diuretics or salicylates
- reduce weight
- reduce alcohol
- avoid purine rich food (offal, tinned fish, shell fish and game)
- start allopurinol in recurrent attacks +/- 8 weeks post attack 50-100 mg OD increase to 300 mg (colchicine can be given additionally if attack while starting allopurinol)
- aim to reduce uric acid < 0.4
- review CVD risk profile/ metabolic syndrome: BP, serum lipids, fasting blood sugars, urea, creatinin, electrolytes
15
Q
Benzodiazepam dependence approach
A
- inquire in history of habbit development
- open, non judgemental
- start cut-down with keeping diary, than very slow withdrawal, give information, offer referal to support groups
- know that there is a possibility to report to health department but don’t do this unless everything else failed
- work with patient
- advice on relaxation techniques, CBT etc
- get psych history (can be brief)
- consider changing to longer acting drug to ease withdrawal symptoms
16
Q
Basal cell carcinoma
A
- most common, appr 80% of skin cancers,
- age ussually > 35 yrs
- sun-exposed areas mostly: neck, face, upper trunk, limbs
- central ulceration typical
- can grow slowly over years
- do not metastasise, local spread can cause problems though
- excision with margin, sun protection
16
Q
Benzo dependence withdrawal/risks
A
- withdrawal: anxiety, depressed mood, sleep disturbance, tremor, headaches, physical symptoms anxiety, muscle aches pains and twitching, RISKS: - combination with other sedatives - increased risk car accidents - depression and emotional blunting -
17
Q
clinical features suspicious dysplastic naevi:
A
- large (>5mm) irregular moles
- irregular, ill defined borders, irregular pigmentation, background redness, variable colours
- most are not malignant and will not become malignant but excision is indicated if any diagnostic concerns
18
Q
signs suggestive for melanoma
A
- change in size
- Change in shape
- change in colour
- change in surface
- change in border
- bleeding or ulceration
- itching
- other symptoms
Examine LN!
19
Q
Scabies diagnosis, invx and management
A
- itch, worst at night,
- hands mostly, also flexor side wrists, and rash on abdomen
- can be STD
- worsens by warming hands
- skin scrapings to confirm
- permethrin 5% (overnight) or benzoate emulsion 25%(24 hours) repeat in one week if severe infection
- treat household contacts even if not symptomatic
- wash clothing and bedding hot, leave exposed to sun to dry
- repeat in one week
- avoid close contact until treated
- avoid baths or scrubbing pior to application
20
Q
occupational dermatitis
A
- delayed hypersensitivity
- palmar and dorsal surface of hands
- patch testing dermatologist to confirm
- wash with water, avoid soap
- pat dry after washing
- topical corticosteroids cream for initial control, if severe oral prednisolone to be considered
- oral antibiotics if 2nd skin infection
- emollient agent for further prevention
- cement dermatitis: avoid contact with wet cement, barrier creme before putting on gloves (not if skin is damaged), protective gloves, wash hands after exposure
21
Q
newly diagnosed DM exam and inv
A
Don't forget to ask for Sexual function, vision and sensory problems # exam: BP, weight/BMI, eye sight, neuro exam, consider genital exam if indicated # invx: - office: urineanalysis and random BGL finger - EUC, GTT, urine microscopy and culture (infection and albumin), lipids, ECG, HbA1C, FBE, ESR/CRP
Refer to podologist, dietician, opthalmologist
22
Q
vaccination guidelines and contra-indications
A
contra indication: encephalopathy within seven days of DTP, immediate or anaphylactic reaction, major illness or temp >38.5 at time of vaccination (postpone), immunocompromised children (only live vaccines: MMR, oral polio, rubella, chicken pox), in egg anaphylaxis give in controlled environment and observe for 4 hours. Not ci: family history, prematurity (vaccination should not be delayed), topical or inhaled cortico’s, surgery. (1 or less: 1.000.000 encephalopathy from MMR, 2000:1.000.000 from measles.
paracetamol prior to and post vaccination prevents most side effects
- Birth: Heb B
- 2 months: Heb B, DTPa, Hib, polio, pneumococcal, rotavirus
- 4 months: Heb B, DTPa, Hib, polio, pneumococcal, rotavirus
- 6 months: Heb B, DTPa, Hib, polio, pneumococcal, rotavirus
- 12 months: Hib, MMR, meningococcal C
- 18 months: VZV
- 4 years: DTPa, MMR
- 10-13: Heb B, VZV
- 12-13: HPV
- 10-17 DTPa
23
Q
alopecia areata
A
- unknown aetiology, 20% association with organ-auto-immunedissease, can be associated with major stress event
- resolution 33% in 6 months, 50% in one year. 80% may have relapse. If hair loss remains for years, change of improvement minimal
# Try every therapy for 3-6 months before changing: - potent topical corticosteroid (eg betamethasone dipropionate 0.05%) OD- BD
- intralesional corticosteroid for small areas (eg eye brows, multiple injections usually required)
- topical dithranol OD
- topical minoxidil BD
- oral corticosteroid if topical no effect, tapering down over two months
- referral to dermatologist for topical immunotherapy or ultraviolet phototherapy
24
Glubus histericus - symptoms, invx, managemennt
```
# tightening up of throat, excess salivation, clearing of throat.
- ABSENCE of: dysphagia, hoarseness voice, sore throat, post nasal drip
# do laryngoscopy and pharyngoscopy, endoscopy if in doubt
# usual emotional origin, will resolve spontaneously in most cases
```
exclude (via history or invx) the following DDX:
- GORD
- retrosternal goitre
- carcinoma of paryngopharynx
- oesophageal or cricothyroid web, myasthenia gravis, polymyositis
25
mumps and management of post mumps orchitis
- paramyxovirus
- 50-60% infectivity
- incubation 12-25 days, infectivity from 6 days prior to swelling face until 9 days later
- complications: common: orchitis, aseptic meningitis; rare: encephalitis, arthritis, pancreatitis, ophoritis
orchitis:
- 3-4 days after parotitis is subsiding
- usually unilateral
- subsides over one week
- supportive treatment: paracetamol, rest, support of scrotum, heat packs
- significant atrophy in 50%, sterility is rare and only if bilateral
- does not predispose malignancy
26
OCP prescription
exclude ci:
- DVT /PE, oestrogen dependent malignancy especially breast cancer, active liver disease, cholestatic jaundice in past, unexplained vaginal bleeding, focal migraines
- relative ci: smoking, HT, DM, irregular menses, oligomenorrhoea
do BP, pelvic and abdo exam, Pap smear, breast exam, inspect for hirsutism
if all normal: microgynon 30, monophasic, low dose oestrogen, low failure and breakthrough rate.
- if oligomenorrhoea: triphasic --> less post pill ammenorrhoea
- epilepsy or anti-tb treatment: microgynon 50, other meds increase liver enzyme activity and lead to lower bioavailibity of oestrogen
- hirsutism/ acne/ PCO --> oestrogen dominant pill, like ovulen or diane 35
- breastfeeding, previous DVT, oestrogen problematic in past --> low dose progestogen only pill but 3% fail rate
- follow-up in at least 3 months with bp
- advise no protection against STD's
- explain about missed pill, diarrhoea, breakthrough bleeding, se like breast pain, weight gain, and breakthrough bleeding ussually subside in 1-2 months
- explain when protected
explain risks: dvt, other embolism, mi, cva, no certain link with increased cancer, possible slight increased risk endometrial ca and breast. protective for endometrial ca and certain ovarian
- if missed in week 3, do not have stop week (or do not take placebo)
- 7 days condoms if two missed in twenty or three in thirty. Take pill asap even if together with next
27
Peptic ulcer
- cause: majority H Pylori, NSAID can contribute or solely cause ulcer
- can heal by itself in 70% but often relapse or: bleeding, perforation, gastric outlet obstruction and malignancy (only 2 % and only in gastric ulcer, not in duodenal ulcer
- alcohol and smoking reduces healing but do not contribute to formation of ulcer
- NSAID inhibit formation of protective mucus, H Pylori produces layer around it self to protect from acid which causes break in integrity of mucus layer mucosa
- all patient suspected of peptic ulcer should have endoscopy for diagnosis, confirm if H pylori and biopsy in gastric ulcer
treatment:
- with H Pylori: Proton-pump inhibitor + clarithromycin/amoxycillin + metronidazole for 1-2 weeks. 90% symptoms resolve by 1 week
- no H Pylori only proton pump inhibitor 4-8 weeks
- if duodenal ulcer treatment success can be judged by lack of symptoms and H Pylori breath test, if Gastric ulcer do re-endoscopy
-
28
smoking ceassation
- ask about smoking habits / patterns and earlier attempts and what made them fail. Asses current level of being ready to stop
- if smoking > 20/day or if need cigarette in 30 min of waking up, nicotine replacement likely to be required
- symptoms one can expect: depression, feeling unwell, insomnia, restlessness, irritability, anxiety, reduced concentration, drop in heart rate, increased appetite, cravings. Symptoms worst in first 4 days, residual symptoms reduce in one month, craving in certain situations can remain live long, important not to give in as it easily re-institutes habit.
- aim for total abstinence, not just reducing
- set Quit-by date
- inform others and ask for support
- practise problem solving
- NRT generally cheaper than continuing to smoke, some available on PBS, double change of succes
- gum, remain in mouth with alternative chewing for 30 minutes .risk are ulcers or dyspepsia
- patches can give local skin reaction, slow release, mostly not on PBS
- inhalers
Key: if discussing advice to stop inform patient of all risks and tell them it is up to them to weight the risk and the benefits for them and that I'm here to help them if they like to stop and that other help (eg NRT) is available if they like
29
Hand osteoartritis
- morning stiffness, improves with exercise
- pain exacerbates by activity and improves in rest
- swelling,
- Heberden's nodes and Bouchard nodes (RA has actual joint swelling)
- pain
- limited ROM
- genetic disposition
- aching at base of thumb
- grip and pinching reduced
- function compromised
- ussually DIP (contrary to RA which usually had MCP and PIP)
- rarely involvement of wrist
- usually not tender on exam (contrary to RA)
Do x-ray to confirm:
- joint space narrowing
- subchondral sclerosis
- osteophytes
- subchondral cyst
Management:
- symptomatic: stretching, exercise, weight-loss, heat packs, splinting, OT or PT
- start with panadol, nexr NSAID
- alternative like fish oil no evidence but can try
- surgery extreme
30
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