GP Flashcards

Question

What is the management of acne?

Answer 1

Infected eczema Staphylococcus aureus = "impetiginisation" Soak off crusts Topical mupirocin or oral fluclox

Answer 2

Herpes simplex virus = "eczema herpeticum" Admit to hospital

Answer 3

Pompholyx eczema Pompholyx is a common type of eczema affecting the hands (cheiropompholyx), and sometimes the feet (pedopompholyx). Same treatment as normal eczema

Answer 4

Discoid eczema

Answer 5

Asteatotic eczema Common on legs of older people Same treatment as normal eczema

Answer 6

Lichen simplex is a localised area of chronic, lichenified eczema/dermatitis. It is usually somewhat linear or oval in shape, and markedly thickened. It is intensely itchy. Lichen simplex is often solitary and unilateral, usually affecting the patient’s dominant side. **Potent steroids**

Answer 7

Infections are probably associated with at least 90% of cases of EM. In order of frequency: HSV 1 Mycoplasma pneumonia Other viruses Medications are an uncommon cause.

Answer 8

**Maculopapular skin lesions forming plaques** Few to hundreds of skin lesions erupt within a 24-hour period. The lesions are first seen on the backs of hands and/or tops of feet, then spread along the limbs towards the trunk. Mildly itchy or burny Lesions typically have 3 zones (red rim, clearance zone, and central blister or erosion)

Answer 9

**For the majority of cases, no treatment is required as the rash settles by itself over several weeks without complications.** Treatment directed to any possible cause may be required such as oral aciclovir (not topical) for HSV or antibiotics (e.g. erythromycin) for Mycoplasma pneumoniae. Supportive care: * oral antihistamines or topical steroids for itch * mouthwashes containing local anaesthetic and antiseptic reduce pain and secondary infection in patients with involvement of the oral mucosa **Prognosis** Erythema multiforme usually resolves spontaneously without scarring over 2-3 weeks for the EM minor form, and up to 6 weeks for EM major. However it often recurs.

Answer 10

**In non-remote community settings:** Suspect S. aureus as the pathogen. For localised skin sores, use: mupirocin For multiple skin sores or recurrent infection, use: di/flucloxacillin 500 mg **In remote community settings in central and northern Australia** Suspect S. pyogenes as the pathogen. benzathine penicillin

Answer 11

Treatment is not always required, but if so consider referral for potent and ultrapotent topical steroids.

Answer 12

Lichen Planus

Answer 13

Pityriasis rosea We think there may be a viral cause but no-one knows It will clear up in 6-12 weeks. Dark discolouration of skin may take longer to resolve. It doesn't normally reccur but it can. If itchy you can use topical corticosteroid ointment or calamine lotion

Answer 14

Psoriasis - Guttate subtype

Answer 15

Streptococcal tonsillitis and other infections Injuries such as cuts, abrasions and sunburn Obesity Smoking Excessive alcohol Stressful event Medications such as lithium, beta blockers, antimalarias, NSAIDs Stopping corticosteroids

Answer 16

Red, scaly plaques with well-defined edges and symmetrical distribution – usually not itchy.

Answer 17

**Pustular psoriasis** Usually on hands/feet Often without usual plaque psoriasis May be painful or "burning"

Answer 18

No good data on the prevalence of psoriatic arthritis in patients with psoriasis, circa 10% **Patients with psoriasis have 2-3x cardiovascular risk of patients without psoriasis!**

Answer 19

Rosacea is a common persistent eruption of unknown aetiology. It is characterised by central facial erythema, visible blood vessels and acneiform papules and pustules. It is typically chronic and persistent with a fluctuant course.

Answer 20

**General management** * Apply cool packs if severe * Minimise factors that cause flushing or irritation (see aetiology) * Sun protection plus sun avoidance measures are essential * Use an emollient soap-free cleanser, combined with a low-irritant sunscreen to reduce irritation * Some people may use a green-tinted foundation to mask erythrotelangiectatic features **Topical therapy – for mild erythema and inflammatory lesions** * 2% sulphur in aqueous cream tds OR * Metronidazole gel bd OR * Azelic acid gel OR * Clindamycin 1% solution bd OR * Erythomycin 2% gel bd Long-term maintenance with topical metronidazole is often used to control rosacea and prolong remissions. **Systemic antibiotics – for more severe cases or when topical therapy unsuccessful** * Doxycycline 50 to 100mg daily * Erythromycin 250 to 500 mg twice daily * Minocycline 50 to 100mg daily

Answer 21

The prominent clinical feature of scabies is itching. It is often severe and usually worse at night. The pruritus is the result of a delayed type-IV hypersensitivity reaction to the mite, mite feces, and mite eggs.

Answer 22

Permethrin 5% cream (adult and child 6 months or older) Apply topically to dry skin from the neck down, paying particular attention to hands and genitalia. Apply under the nails using a nailbrush. Leave on for a minimum of 8 hours (usually overnight) and reapply to hands if washed. Application time may be increased to 24 hours if there is a history of treatment failure. Repeat treatment in 7 days

Answer 23

Resolution in 85% of patients within 4-6 weeks. Generally good and patients may spontaneously recover even without medication. Related to severity of lesion and more favourable if some recovery or progress seen within 3 weeks of onset.

Answer 24

Space occupying lesion --\> facial twitch or spasm CVA --\> other signs of stroke, not limited to CN VII Ramsay Hunt Syndrome --\> look for vesicles on ear Otitis Media --\> otoscopy

Answer 25

**Basics** Eye care for patients who have impaired eye closure Use of short term (10 days) oral corticosteroids (60 mg/ day) within 72 hours after the onset of symptoms. Antiviral agents if viral etiology is suspected but only in conjunction with corticosteroids.- contentious **Place and person** GP managed Referral to neurologist in cases of new or worsening symptoms or incomplete recovery after 3 months. **Investigate and confirm diagnosis** Assess and exclude other possible identifiable causes **Non-invasive management** Psychological counselling and physiotherapy **Definitive management** Specialists may do surgical nerve decompression if fails to recover. Electrical nerve stimulation to promote motor recovery. Both have limited evidence **Long term** Follow up 1-2 weeks after onset to monitor effect of medications and eye care.

Answer 26

Cataracts Age related macular degeneration Chronic open angle glaucoma Diabetic retinopathy

Answer 27

Branch or central retinal vein occlusion Branch or central retinal artery occlusion CVA/TIA Giant Cell Arteritis Retinal detachment Optic neuritis Migraine

Answer 28

Benign and self limiting Apply heat and massage twice a day Avoid antibiotic ointments Incision and curettage is second line treatment Prevention by managing any associated blepharitis

Answer 29

No easy cure Lid hygiene --\> warm compresses for 5-10mins bd If severe try oral tetracycline for 2-3 months

Answer 30

**Key features** Gritty red eye Purulent discharge Clear cornea **History** Purulent discharge which causes the eyelashes to stick together in the morning Starts on one eye and spreads to the other (usually) Hx of contact with a person that has similar symptoms **Examination** Bilateral mucupurulent dischange with uniform engorgement of all of the conjunctivial blood vessels Non-specific papillary response **(larger fleshy swellings on the inside of the eyelid)** Fluorescein staining is negative

Answer 31

Limit the spread by avoiding close contact with others Use of separate towels and good ocular hygiene Many cases resolve spontaneously within 5 days; however, symptoms can last up to 14 days if untreated. A 'delayed prescription' approach is appropriate. **Mild cases** Saline irrigation of the eyelids and conjunctiva Antiseptic drop such as propamidine isethionate 0.1% **More severe cases** Chloramphenicol 0.5% eye drops 1-2 hourly for 2 days Decrease to 4 times daily for another 7 days Chloramphenicol 1% eye ointment at night **Specific organisms** Pseudomonas use topical gentamicin and tobramycinN. gonorrhea use appropriate systemic antibiotics

Answer 32

Low salt diet + diuretic Vestibular rehab Prochlorperazine maleate (stemetil): 5-10 mg orally every 6-8 hours when required Do not use stemetil long term --\> will stop the brain accommodating to a labyrinthine upset

Answer 33

**Severe vertigo that lasts for days** Acute inflammation of the vestibular nerve Cause unknown Young or middle aged adults Incapacitating sustained (non-positional) vertigo Sudden onset Very unwell and lie still in bed Nausea and vomiting No tinnitus or deafness

Answer 34

Reassurance and explanation Stemetil should be given only in the first few days After 2-5 days steady resolution usually occurs over a period of 6 to 12 weeks

Answer 35

BPPV Meniere's disease Vestibular neuronitis

Answer 36

Treponema pallidum

Answer 37

Rare in Australia High-risk sexual activity and previous STIs increase the risk

Answer 38

**Early syphilis** primary (chancre), secondary (rash or condylomata lata) or latent syphilis (asymptomatic) of less than two years duration exist based on serology results **Late latent syphilis** Latent syphilis has existed for two or more years or of indeterminate duration, in the absence of neurosyphilis and other symptoms and signs of disease **Tertiary syphilis** where cardiovascular involvement and neurosyphilis is present.

Answer 39

Secondary syphilis is caused by haematogenous spread of infection. This leads to a widespread vasculitis. * Non-itchy, reddish/brown skin rash + mucous membrane lesions. * Systemic symptoms inc fever, pharyngitis, headache and arthralgia * **condylomata lata** (clusters of soft, moist lumps in skin folds of the anogenital area)

Answer 40

**Condylomata lata**, is a cutaneous condition characterized by wart like lesions on the genitals. They are generally symptoms of the **secondary phase of syphilis**, caused by the spirochete, **Treponema pallidum**.

Answer 41

One third of people who have latent syphilis will go on to develop tertiary syphilis - approximately 3 to 15 years after the initial infection. There are three different forms: ``` gummatous syphilis (15%) - soft tumours on bone/liver/skin neurosyphilis (6.5%) - dementia/paresis/seizures/apathy cardiovascular syphilis (10%) - aortic aneurysms ```

Answer 42

**Public health** * Syphilis infection (Group C disease) must be notified in writing within five days of diagnosis. * Advice to cease sexual activity until treated **Contact tracing** * For primary syphilis, Trace sexual contacts for the last 3 months. Such contacts should be treated as for the case, even if their serology is negative. * For secondary syphilis, this period should be extended to 6 months * For early latent syphilis, to twelve months. * For late latent syphilis, any sexual partners and also children of infected women should be evaluated. **Early syphilis (less than 2 years' duration)** benzathine penicillin 1.8 g IM, as a single dose **Late latent syphilis (asymptomatic syphilis of longer than 2 years' duration, or of unknown duration.)** benzathine penicillin 1.8 g IM, once weekly for 3 weeks **Tertiary syphilis (syphilis of longer than 2 years' duration, or of unknown duration, with cardiovascular, central nervous system or skin and bone involvement.)** Expert advice is essential. benzylpenicillin 1.8 g IV, 4-hourly for 15 days.

Answer 43

**HSV1 – First infection** * high fever * sore throat * pharyngeal oedema * Generalised muscle pain * Rigors * Cervical lymphadenopathy * Sometimes splenomegaly **Recurrences** * 6-48 hours of pain/burning/tingling * Vesicles then form, crust and heal within 10 days * Systemic manifestations rare

Answer 44

**All patients** * Symptomatic simple analgesia * Consider 2% topical lidocaine * Pt education * Avoid sexual contact when lesions present * 100% use of condoms * Lifelong infection, could have contracted long ago * Lack of serious sequelae for most people **Minor episode (oral)** Aciclovir 5% cream topically, 5 times per day (every 4 hours while awake) for 4 days at the first sign of recurrence **Severe episode** Aciclovir 400 mg orally, 5 times daily for 7 days **Long term suppressive treatment** Aciclovir 400 mg orally, 12-hourly for up to 6 months **Disseminated visceral involvement: pneumonitis, hepatitis, or CNS involvement (meningitis or encephalitis)** Admit to hospital IV acyclovir

Answer 45

Smoking Sexual activity (lifetime number of partners) HIV and immunosuppression OCP use for \>5years

Answer 46

Whilst chlamydia is usually asymptomatic, it is much more common than gonorrhea so in a patient with urethral discharge chlamydia is still more common than gonorrheoa! It could also be HSV

Answer 47

**Infections of the cervix, anus and throat usually cause no symptoms.** **Men** * Urethral discharge 2 – 10 days after unprotected sex * Dysuria * Men who have sex with men * Hx of STD * Multiple sexual partners * Inconsistent condom use **Women** Most women who are infected with gonorrhoea have _no symptoms or vague symptoms that mimic common UTI._ Women with gonnorrhoea are just as at risk of developing serious complications from the infections regardless of the presence or severity of symptoms. The initial symptoms or signs that women MAY experience, include: * Dysuria * Vaginal discharge * Vaginal bleeding * Dyspareunia

Answer 48

**The 5 P’s** 1. Partners * How many? * Male/female/both? * Regular or random? 2. Practices * Frottage/oral/vaginal/anal? * Drugs used? 3. Previous STIs 4. Prevention of STIs 5. Prevention of Pregnancy

Answer 49

**Public health** * Gonococcal infection (Group C disease) must be notified in writing within five days of diagnosis. * Advice to cease sexual activity until treated * Contact tracing Sexual partners of individuals with gonorrhoea should be examined and investigated then treated empirically. **Definitive management** Ceftriaxone: 250mg IM as a single dose It is recommended that all patients with a suspected or confirmed diagnosis of gonorrhoea be treated for Chlamydia if it has not been excluded. As a practical matter, Chlamydia is treated routinely in patients with gonorrhoea. Azithromycin: 1 g orally as a single dose **Long term** Repeat diagnostic method if want to see if infection has cleared.

Answer 50

PID Infertility Epididymitis Reactive arthritis

Answer 51

**Normally asymptomatic but may have Cervical/Urethral discharge** Age 25 years Multiple sex partner/new sex partner History or prior STD Abnormal vaginal bleeding Dysuria

Answer 52

**First pass urine – NAAT (nucleic acid amplification test)** Culture of urethral discharge Also test for gonorrhea, syphilis, HIV and Hep B

Answer 53

**Public health** * Chlamydia infection (Group C disease) must be notified in writing within five days of diagnosis. * Advice to cease sexual activity until treated **Contact tracing** Sexual partners of individuals with chlamydia should be examined and investigated then treated empirically. **Definitive management** Azythromycin 1g as a single dose OR Doxycycline 100mg BD for 7 days **Long term** patients should be re-tested 3-4 months after the initiation of antibiotics

Answer 54

**50% asymptomatic** White-to-grey discharge adherent to the vaginal mucosa Dysuria Vaginal pruritis Previous episodes Dyspareunia Vulvodynia

Answer 55

Amsel criteria

Answer 56

Treatment of sexual partners is not required For symptomatic patients, use: metronidazole 400 mg orally, 12-hourly for 5 days OR metronidazole 0.75% vaginal gel, 1 applicator full intravaginally, at bedtime for 5 nights

Answer 57

Mastalgia Nausea Fluid retention Abdominal bloating Headaches Chloasma

Answer 58

Risk of decreased bone density with prolonged use \>5 years Weight gain up to 2 kg per year Delay in return to fertility up to 9 month

Answer 59

1/3 amenorrhoea 1/3 intermittent bleeding 1/3 heavy bleeding --\> consider removal

Answer 60

Intermenstrual bleeding first 6 months then at least 90% reduction in blood loss and many have amenorrhoea.

Answer 61

Amenorrhoea occurs usually by 3rd injection Small % have heavy bleeding

Answer 62

Improved acne Reduced endometriosis and fibroids risk Reduced menorrhagia, dysmenorrhea, PMT Reduced ovarian and endometrial cancer risk

Answer 63

35 years if smoker At menopause if non smoker

Answer 64

8 in 100 women who have unprotected sex one time during the fertile part of their cycle will become pregnant. If these 100 women take ECP about 1 will become pregnant Only 1 in 1,000 women who have an IUD put in after having unprotected sex will become pregnant.

Answer 65

**You have up to 72 hours after unprotected sex to take the ECP.** **You have up to five days after ovulation to have an IUD fitted.** The ECP is most effective at preventing pregnancy (95% effective) if taken within 24 hours of unprotected sex. Within 25 to 48 hours, the effectiveness falls to 85%, and within 49 to 72 hours it is only 58% effective.

Answer 66

Foreign body Earwax Otitis externa Otitis media Cholesteatoma Perforated membrane Trauma Eustachian tube dysfunction Otosclerosis

Answer 67

**Cochlear --\> CN VIII --\> Auditory cortex** Presbycusis Noice induced Menierres Acoustic neuroma Stroke

Answer 68

Do Rinne test Medical emergency and needs high dose steroids early (Prednisolone 1mg/kg up to 60mg daily) Refer to specialist Overall recovery rates are 50-65% If it recovers, usually within 2-4 weeks In some patients, the hearing loss is permanent

Answer 69

**LUDWIGS ANGINA - MEDICAL EMERGENCY** **Mortality = 8%** A serious, potentially life-threatening cellulitis of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheotomy.

Answer 70

**Basics** * Secure the airway! * Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway. * Prevent the development of septic shock and multi-organ failure — give antibiotics early. **Place and person** * Notify ENT, anaesthetics and ICU. * Admit to ICU **Investigate and confirm diagnosis** * Do not delay treatment whilst waiting for investigations. **Definitive management** * Antibiotics * Metronidazole 500mg IV every 12 hours AND * Benzylpenicillin 1.2g IV every 6 hours * Steroids: * Dexamethasone IV * Intensive care * 1:1 nursing * Continuous RR, ETCO2, invasive BP and ECG monitoring * Fluid resuscitation * Indwelling catheter \*For patients with non-immediate hypersensitivity to penicillin: Cephazolin 1g IV every 8 hours. For patients with immediate hypersensitivity to penicillin: clindamycin 450 mg IV every 8 hours

Answer 71

Defined as rapid onset diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. It is a form of cellulitis that involves the skin and subdermis of the external auditory canal with acute inflammation and variable oedema. Acute diffuse otitis externa (swimmer's ear) often occurs following skin maceration of the external ear canal from water exposure. Pseudomonas aeruginosa and/or Staphylococcus aureus are commonly isolated from cultures.

Answer 72

**_RAPID ONSET_** ## Footnote Clinical features * Itching at first * Pain (mild to intense) * Fullness in ear canal * Scant discharge * Hearing loss Signs * Oedema (mild to extensive) * Tenderness on moving auricle or jaw * Erythema * Otorrhoea (offensive if coliform) * Pale cream ‘wet blotting paper’ debri – C. albicans * Black spores of Aspergillus nigra

Answer 73

**Basics** Simple analgesia **Place and person** N/A **Ix** Culture swab **Management** * The external ear canal must be kept as dry as possible for \>2 weeks after treatment * Remove discharge or other debris from the ear canal by dry aural toilet, not by syringing with water. * For bacterial infection: * Dexamethasone 0.05% + framycetin 0.5% + gramicidin 0.005% ear drops * 3 drops in affected ear tds, for 3-7 days * For fungal infection * Triamcinolone acetonide 0.1% + neomycin sulfate 0.25% + gramicidin 0.025% + nystatin * 3 drops 3tds for 3-7 days * The tragus should be pumped for 30seconds after instillation by pressing on it repeatedly, within the limitation of any pain. * Systemic antibiotic therapy provides no additional benefit to topical therapy, unless there is fever, spread of inflammation to the pinna, or folliculitis.

Answer 74

AOM can be either viral or bacterial (or mixed) in origin, but regardless of cause, it is usually self-limiting (60% of children treated with placebo became pain-free in 24 hours, and spontaneous resolution of AOM occurs in approximately 80% of children).

Answer 75

Viral URTI that will self-resolve

Answer 76

Acute otitis media Perforation of the tympanic membrane with otorrhoea

Answer 77

Generally, conservative management with simple analgesia Adults with otitis media --\> conservative management Indications for Amoxycillin * * Sick child with fever * Vomiting * Red-yellow bulging TM * Discharge * Loss of TM landmarks * Persistent fever and pain after 3 days of conservative approach * Bilateral AOM

Answer 78

rhinovirus, coronavirus, adenovirus

Answer 79

**Catarrhal stage (7-14 days)** * Anorexia * Rhinnorrhoea * Conjunctivitis/lacrimation * Dry cough **Paroxysmal stage (about 4 weeks)** https://www.youtube.com/watch?v=AIVt3e5EVtc * Paroxysms of severe coughing with inspiratory ‘whoop’ * Vomiting (after coughing) * Coughing mainly at night * Lymphocytosis **Convalescent stage** Chronic cough which may last for weeks

Answer 80

**Basics** ABC **Place and person** If younger than 6 months – hospitalization School exclusion until at least 5 days of antibiotic use **Investigate and confirm diagnosis** Nasopharygeal aspirate FBE, IgA serology CXR – to exclude pneumonia **Non-invasive management** Good ventilation Avoid emotional excitement or distress Avoid overfeeding during paroxysmal stage **Definitive management** Antibiotics minimize transmission but do not effect course of disease Azithromycin 500 mg 5 days OR Trimethorpim and sulfamethoxazole 7 days OR Clarithromycin 7 days **Prophylaxis** Same treatment as above for household and other close contacts if commenced within 3 weeks of onset of cough in the patient **Prevention** Acellular pertussis is part of the immunization schedule Initial protection 2, 4 and 6months Booster (dTpa) 4 years 10-15 years Parents or household contacts of newborns

Answer 81

Fever, flank pain, nausea

Answer 82

* Frequent sexual intercourse * Urinary tract infections (UTI) * Diabetes Mellitus * Stress incontinence * Foreign body in urinary tract (calculus, catheter) * Anatomical/functional urinary abnormality * Immunosuppressive states (HIV, transplantation, chemotherapy, corticosteroid use) * Pregnancy * Hospital acquired infection * History of urinary tract infection in childhood

Answer 83

**Bedside tests** Urine dipstick --\> Pyuria (pus in the urine) is always present in pyelonephritis, bacteriuria, haematuria **Bloods and urine** Urine culture – _WBC casts is diagnostic_ Blood cultures FBE – leuckocytosis ESR/CRP **Imaging** -Not needed to confirm diagnosis but may identify cause Renal ultrasound/CT may aid in diagnosis of hydronephrosis from a stone or obstruction

Answer 84

Staghorn calculi are composed of struvite (magnesium ammonium phosphate) and are usually seen in the setting of infection with urease producing bacteria (e.g. Proteus, Klebsiella, Pseudomonas and Enterobacter). Urease hydrolyses urea to ammonium and increase in the urinary pH.

Answer 85

**Bedside Tests** Urine dipstick test - may be +ve for leukocytes, nitrates, blood **Bloods and urine** Urine Microscopy - may be +ve for WBC, RBC and Bacteria Serum calcium, phosphate, uric acid, bicarbonate UEC **Imaging** Plain abdominal xray - approx 80% of stones contain calcium which can be seen on xray CTKUB 99% of stones are visible using this method For Monash exams the INITIAL AND GOLD STANDARD Ix for urolithiasis is CTKUB not AXR U/S Can show some stones and uteric dilatation Useful in pregnant women, young women or unstable patients in whom exposure to radiation is undesirable

Answer 86

**Stone analysis** To determine the chemical composition of the stone The stone is either extracted from surgery or passed by the patient **Parathyroid levels** As a possible cause of calcium-containing stones Hyperparathyroidism --\> hypercalcaemia à calcium stones **Urine microscopy** Amino acid / cysteine levels As a possible cause of cysteine stones **24 hour urine monitoring** should be ordered once the patient is stone free measure volume, pH, creatinine, sodium, calcium, oxalate, uric acid, citrate Helps in determining underlying metabolic cause or aetiology for nephrolithiasis

Answer 87

## Footnote D/C home on "push fluids" (drinking a lot orally to try to pass the stone) Medical expulsive therapy (MET) may also help to pass the stone Tamsulosin (alpha blocker --\> smooth muscle relaxation) Nifedipine (calcium channel blocker --\> smooth muscle relaxation)

Answer 88

\>6mm Extracorporeal shock wave lithotripsy (ESWL) Ureteroscopy Percutaneous nephrolithotomy (PCNL)

Answer 89

**Basics** Education, conservative treatment **Place and person** GP managed, if symptoms persist or worsen refer to orthopaedic/ hand surgeon **Investigate and confirm diagnosis** Nerve conduction study **Non-invasive management** ``` Weight loss (if overweight) Wrist splinting esp at night Ultrasound physiotherapy tx Oral glucocorticoids (short term use only!) Corticosteroid injections into the carpal tunnel region ``` **Definitive management** Surgical decompression * Open * Endoscopic Wide variation in success rates and complications for both

Answer 90

**NO CAST** Non-union Open fracture Compromise neurovascular Articular fracture Salter harris III IV V Trauma

Answer 91

rotavirus, MMR, varicella

Answer 92

TDAP - pertussis component tetanus and diphtheria and bordatella pertussis

Answer 93

**Fever, pharyngitis, lymphadenopathy** (94%, usually posterior cervical chain) **and fatigue** Sometimes splenomegaly

Answer 94

Prognosis is typically good for this self-limiting infection. The vast majority of patients recover uneventfully and develop immunity to control the latent infection. Usually, most symptoms will r**esolve in one to two weeks, although fatigue and malaise may persist for months.** Death can occur rarely from airway obstruction, splenic rupture, neurological complications, haemorrhage (thrombocytopaenia) or secondary infection.

Answer 95

Measles There is no specific treatment of measles except for supportive care, but the disease can be prevented by a live virus vaccine. **Immediately notify DoH, isolate for \>4 days after rash onset.** Complications of measles occur more often in immunocompromised and poorly nourished individuals and include pneumonia, laryngotracheitis, otitis media, and encephalitis.

Answer 96

Similarly to malaria, the most important clue is travel to measles-endemic area or exposure to individual with measles in an unvaccinated person. Other key features include: Fever Cough Coryza Conjunctivitis **Koplik’s spots Maculopapular rash**

Answer 97

Measles has Koplick spots Investigations: Measles IgM and IgG serology

Answer 98

Mumps is an acute, self-limited, viral syndrome. It is spread by respiratory droplets, and, before the advent of the mumps vaccine, it affected school-aged children commonly. Classically, mumps causes swelling of the parotid glands; the involvement of other salivary glands, meninges, gonads, and pancreas is also common. **Management** * 5 days of isolation at home * Supportive care * Mumps (Group B disease) must be notified in writing within five days of diagnosis. * School exclusion: exclude for nine days or until swelling goes down, whichever is sooner. **Complications** The more serious complications of mumps, such as meningitis, encephalitis, and orchitis, may occur in the absence of parotitis, which can delay accurate diagnosis of the clinical syndrome.

Answer 99

**Basic** Education and reassurance **Place and person** GP managed **Investigate and confirm diagnosis** * FBE * UEC (rule out renal osteodystrophy) * LFTs (rule out chronic liver dz) * CMP (Hypocalcaemia? Primary hyperparathyroidism (high Ca, low phosphate)) * Parathyroid hormone levels * Vit D levels * TSH (hyperthyroidism?) * Serum and urine electrophoretogram and immunoelectrophoretogram (multiple myeloma) * Anti-TTG and IgA (coeliac) * DEXA scan **Non invasive** * Quit smoking, reduce alcohol * Calcium and vitamin D * Weight bearing exercise * Physio and OT to prevent falls **Definitive** Indications for pharmacotherapy: * Minimal trauma fracture * \>70 yrs and T score -3.0 or lower * T score less than -1.5 and prolonged steroids Options: * Bisphosphonates: * Aledronate, oral, weekly, up to 10 years * Zoledronic acid, IV, yearly for 3 years * SERM – Raloxifene * Monoclonal antibody – Denosumab * Teriparatide (PTH analogue) * Strontium ranelate What do you need to know about bisphosphonates: * Significantly reduces the risk of # and complications of OP * Do not eat or drink before taking the drug * Take once a week, standing up with a full glass of water. * Take the tablet whole, do not crush or chew. * Remain standing up for 30mins after taking. * Do not eat, drink or lie down for 30 mins after taking * Risks * Oesophageal irritation * Upper GI ulcers * Musculoskeletal aches and pains * Osteonecrosis of the jaw (rare) * Atypical femoral stress fractures (rare) * Delays bone healing if there is a #

Answer 100

**1) Is the HTN primary or secondary?** ABCDE * Apnea, Aldosteronism * Bruits / Bad Kidneys * Catecholamines, Cushings, Coartation, Calcaemia * Drugs * Corticosteroids * OCP * Decongestants (pseudoephedrine) * ETOH * NSAIDs * Oestrogen * Psych drugs – MAOi, Lithium, Clonidine * Endocrine (hyperthyroidism) **2) How bad is has it been? - assess for end organ damage** * Heart * LVH (ECG, TTE/TOE) * Kidneys * Albumin:creatnine * Protein:creatnine * eGFR * Eyes * Fundoscopy * Vascular * Auscultate for bruits * U/S or angiogram **3) How bad might it be in the future? - assess overall CV risk**

Answer 101

**HOMESICK** ## Footnote Headache / Hypertension Obesity Medications (some antivirals/ABx) Embolism / Thrombus / Clotting disorders Stroke IHD Cancer (Breast, Endometrial) Kids (ie. parity) / Breastfeeding

Answer 102

* Could it be **cancer**? * Pain not relived by bed rest * Weight loss * Age * Hx or FHx of prostate, breast of lung ca * Could it be **cauda equina**? * Bladder/bowel symptoms * Saddle parasthesia * Bilateral parasthesia in limbs * Could it be **spinal stenosis**? * Pain in legs when walking but relieved by sitting * Age \>65 * No pain when seated * Could it be **AnkSpond** * Morning stiffness * Improves with exercise * Onset * Slow onset * Could it be a **fracture**? * Point tenderness * **Trauma** * Age \>50 * Osteoporosis or use of corticosteroids Signs and symptoms of **neurocompressive** lower back pain * Pins & needles and/numbness * Muscle weakness * Positive straight leg raise and/or slump test * Sharp, lancinating leg pain * Leg pain \> LBP * High irritability and flares of pain and activity limitation

Answer 103

* Weight loss + exercise * Analgesia * Physio referral * Monitor

Answer 104

* FBG ≥7.0 mmol/L (on two separate occasions) * 2 hour postprandial ≥11.0 mmol/L on OGTT (on two separate occasions) * HbA1c ≥6.5% (48 mmol/mol) (on two separate occasions) - ALTHOUGH THIS ISN'T CURRENTLY FINDED BY MEDICARE

Answer 105

**What’s caused it?** Determine if their HT is essential or secondary **How bad is has it been?** Assess for end organ damage **How bad might it be in the future?** Assess overall CV risk

Answer 106

ABCDE ## Footnote Apnea, Aldosteronism Bruits / Bad Kidneys Catecholamines, Cushings, Coartation, Calcaemia Drugs Endocrine (hyperthyroidism)

Answer 107

**‘CODE NO’ (+ psych drugs)** ## Footnote Corticosteroids OCP Decongestants (pseudoephedrine) ETOH NSAIDs Oestrogen Psych drugs – MAOi, Lithium, Clonidine

Answer 108

**Heart** •LVH (ECG, TTE/TOE) **Kidneys** •Albumin:creatnine •Protein:creatnine •eGFR **Eyes** •fundoscopy **Vascular** •Auscultate for bruits •U/S or angiogram

Answer 109

**Epidemiological / Anthrolpological Risk Factors** * Female * Older age * Early-onset menopause / menopause * Low BMI * Immobilisation **Lifestyle Risk Factors** * ETOH * Smoking * Low calcium intake * Low vitamin D intake * Inadequate sun exposure **Medications / Disease Processes Risk Factors** * Steroids * Anti-convulsants * HRT (protective) * *Endocrine disorders:* \*Cushings \*HyperPTH \*Hyperthyroidism * *Other disorders:* \*CKD \*CLD \*MM \*Hysterectomy

Answer 110

A **T score** is the number of standard deviations from the BMD of a young healthy adult (30 y.o.) A **Z score** is the number of SDs you are from the BMD of someone your age and sex. *A T score is used in the diagonsis of osteopenia / osteoporosis*

Answer 111

DEXA scan T score between -1 and -2.5 = osteopenia Z score less than -2.5 = OP

Answer 112

OA Fracture Deformity

Answer 113

**_'MR PPP MMM'_** ## Footnote **M**alacia (Adults) / **R**ickets (Paeds) - *vitamin D not mineralizing bone* **P**orosis / Penia - *osteoclastic reabsorption of bony architecture* **P**agets - abnormal osteoclasts, intense resorption of bone **P**arathyroidism - primary, secondary **M**alignant invasion - (think of hexagon: thyroid, breast, lung, kidneys, prostate) **M**GUS **/ M**M **M**edication - steroids, anti-convulsants

Answer 114

Labratory Tests * Serum Vit D * CMP * UEC * LFT * PTH * TFT * Urinary cortisol (if cushings suggestive on history) * urine / serum proetin electrophoresis (if MGUS / MM suggestive on history) Imaging * xray of painful site * DEXA scan

Answer 115

Basics Place & Person **Ix and Confirm Diagnosis** FRAX Risk Ax Tool - gives a 10 year probabilty of major osteoporotic fracture **Definitive Management** * Lifestyle / Non-Pharmacological * cessation of ETOH * cessation of smoking * weight bearing activitiy * dietary chanages - calcium and vitmamin D * Pharmacologial * Bisphosphonates * Raloxifene * Antibody - denosumab * Calcium & Vitamin D * Endocrine (HRT, PTH) * Strontium ranelate **Referral** * Physiotherapy - falls and balance classes * OT - gait aids * repeat DEXA every 2 years?

Answer 116

Bisphosphonates inhibit osteoclastic activity. They can be given as a weekly tablet or yearly IV (Zoledronic acid). The AE of bisphosphonates are oesophagitis are: * oesophagitis / gastritis * osteonecrosis of the jaw (also for denosumab) * atypical fractures of the femoral neck You should tell the patient * If taking oral - have the tablet once / week in the morning whilst sitting up, and don't eat / drink or lie down for at least 30 minutes afterward * If taking either oral or IV, visit your dentist prior to commencement and have done any major dental work which needs doing * Ensure you are well hydrated prior to IV infusion, you will require some testing (of Ca, Vit D, eGFR)

Answer 117

poor renal function if this is the case --\> denosumab

Answer 118

6 monthly SC injection Osteonecrosis of the Jaw Atypical fractures

Answer 119

women, usually younger post-menopausal women **with spinal OP**, especially in those with a high breast-Ca risk. it is a SERM. It has the same AE as other HRT, but it REDUCES the risk of breast cancer. It also can **exacerbate vasomotor symptoms**. It has been shown to increase spinal BMD but not femoral neck or elsewhere.

Answer 120

a PTH analogue when given in a pulsatile fashion (daily SC injections) it increases BMD it can only be prescribed by a specialist it only increases vertebral BMD, not femoral

Answer 121

Strontium, which has the atomic symbol Sr and the atomic number 38, belongs to the group II in the periodic table of the elements, just beneath calcium. Because its nucleus is very nearly the same size as that of calcium, the body easily takes up strontium and incorporates it into bones and tooth enamel in the place of calcium

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