1
Q
What is Trichomonas Vaginalis?
A
T vaginalis infection is the most common nonviral STD in the world.
Many patients (20-50%) are asymptomatic.
If discharge is present, it is usually copious and frothy and can be white, gray, yellow, or green (the yellow and green colors are due to the presence of white blood cells [WBCs]). Local pain and irritation are common.
2
Q
What are the risk factors of OP?
A
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
3
Q
What is a T score?
What is a Z score?
Which is used for the diagnosis of OP?
What is the other used for?
A
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
4
Q
How do you diagnose OP and osteopenia?
A
DEXA scan
T score between -1 and -2.5 = osteopenia
Z score less than -2.5 = OP
5
Q
what might artefactually increased BMD on a DEXA scan?
A
OA
Fracture
Deformity
6
Q
What are the differential diagnoses of pathalogical fractures?
A
‘MR PPP MMM’
Malacia (Adults) / Rickets (Paeds) - vitamin D not mineralizing bone
Porosis / Penia - osteoclastic reabsorption of bony architecture
Pagets - abnormal osteoclasts, intense resorption of bone
Parathyroidism - primary, secondary
Malignant invasion - (think of hexagon: thyroid, breast, lung, kidneys, prostate)
MGUS / MM
Medication - steroids, anti-convulsants
7
Q
What investigations would you order for someone with a pathological fracture?
A
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
8
Q
Describe your management of OP (which has been diagnosed on DEXA and without any pathalogical fracture)
A
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?
9
Q
What is the mechanism of action of bisphosphonates?
What routes are they given in?
what are the AE of bisphosphonates?
What should you tell the patient?
A
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)
10
Q
when are bisphosphonates contraindicated? what is second line?
A
poor renal function
if this is the case –> denosumab
11
Q
how is densoumab administered and what is its side effects?
A
6 monthly SC injection
Osteonecrosis of the Jaw
Atypical fractures
12
Q
in whom may raloxifene be used when treating OP?
what is it’s MOA?
what is it’s AE?
A
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.
13
Q
what is the MOA of teraperatide and who can prescribe it?
A
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
14
Q
what is the mechanism of action of strontium ranelate?
A
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
15
Q
which STI is usually asymptomatic?
A
chlamydia
16
Q
If a male has uretheral disachrge, what should you test for?
A
Gohonorrhea
Chlamydia (even though usually symptomatic, is more common than gonorrhea)
17
Q
how often should one be screened for chlamydia?
A
yearly from aged 15-30 if they are sexually active
18
Q
how does chlamydia normally present?
A
normally asymptomatic
discharge from penis / vagina
pain during urination
pain during sex
19
Q
What are the complications of chlamydia in men and women?
A
Men
- Epididymitis & Epidydimo-Orchitis; which can lead to
- Infertility
- Reactive Arthritis (more common in men)
Women
- Pelvic inflammatory disease; which can lead to
- Infertility
- Ectopic pregnancy
- Persistent pelvic pain
20
Q
Which STI can cause a reactive arthritis and in which sex?
A
chlamydia
reactive arthritis caused by chlamydia is more common in men than in women
21
Q
What is the management of chlamydia?
A
Basics
Place & Person
Investigate & Confirm Diagnosis
- NAAT: specimen collected by -
- first pass urine
- endocervical swab
- cultured urethral discharge (if present)
Definitive Management
- 1g azithromycin po as a single dose
- Abstain from unprotected sexual intercourse for at least 7 days during and after treatment
- A notifiable disease - must notify DHS within 5 days of diagnosis
Follow-Up
- Contact tracing - advise to dicuss with sexual partners so they can be screened
- Re-test for chlamydia 3-4 months post treatment
22
Q
how do you investigate for chlamydia?
A
NAAT
Method of collection:
- first pass urine
- endocervical swab
- urethral discharge (if present)
23
Q
what is the typical presentation of gohnorrhea in men?
and in women?
A
Man with copious urethral discharge 2-10 days after unprotected sex (although chlamydia is still more common than gonorrhea, so still more likely to be chlamydia).
Women are usually asymptomatic or present with vague symptoms mimicking a UTI.
24
Q
What is required to investigate for gonorrhea?
A
NAAT. Specimen collected by
- Urine (mid stream)
- Endocervical swab
- Rectal swab
- Throat swab
- Culture of discharge
Also investigate for chlamydia if you suspect gonorrhea!
25
what is the definitive management of chlamydia?
what is the definitive management of gonorrhea?
how are these managements potentially related?
Chlamydia = 1g azithromycin po, single dose
Gonorrhea = Ceftriaxone 250mg IM, single dose
If you are treating for gonorrhea, but you haven't ruled out chlamydia - treat for chlamydia as well
26
What is the management of gonorrhea?
Investigate and Confirm Diagnosis
* NAAT, collected by:
* MSU
* Rectal swab
* Pharyngeal swab
* Endocervical swab
* Cultured discharge (if present)
Definitive Management
* IM 250mg ceftriaxone
* Advise to abstain for sex for 7 days?
Follow Up
* Notifiable disease - notify DHS within 5 days
* Contact tracing - treat sexual partners empirically
* Offer eductaion RE safe sexual practises
* Re-investiage 3-4 months after treatment, to ensure complete treatment
* ALSO TEST / TREAT CHLAMYDIA
27
Which STI is described as "the great imitator"?
Syphillus
28
What is the name of the microorganism which causes syphillus?
Treponema pallidum
29
How does primary syphillus present?
A single painless ulcer in the genital area (chancre)
30
What is the pathophysiological progression of syphillus?
Remember Syphillus happens in Stages
* Primary = Chancre
* Secondary = Secondary erruption on skin and mucous membranes (rash) +/- systemic symptoms
* Then long periods of latency
* Teritiary (10-30 years after infection) = late lesions of skin, bone, viscera, cardiovascular and central nervous systems (this is why it's called the great mimcker)
31
How do you investigate for syphillus?
Syphillis EIA (blood test)
32
what is the definitife management of syphilllis?
early (
late (\>2 years or unknown) = IM benzthine penicillin, weekly for 3 weeks
tertiatry syphillis (\>2 years and with skin, bone, CVS or neurological involement) = IV benzylpenicillin
33
What is the overall management of syphillis?
Investigate and Confirm Diagnosis
* Seroloigcal test - Syphillis EIA
Definitive Management
* Early - IM benzathine penicillin, once off
* Late or unknown - IM benzathine penicillin, once per week for 3 weeks
* Tertiary - IV benzylpenicillin for 15 days
* Abstain from sex until completion of treatment
Follow-Up / Other
* Test for other STIs
* Notifiable disease - contact DHS
* Contact tracing
* Retest 3-4 months after completion of treatment
34
what is a common presentation of bacteral vaginosis?
asymptomatic
fishy-smelling vaginal discharge
dysuria
vaginal pruritis
pyspareunia
35
how do you diagnose bacterial vaginosis?
* Clincially
* presence of mucous dishachrge
* fishy smell
* clue cells on micrscopy (culture not required)
* Vaginal pH \>4.5
36
What is the defitive management of bacterial vaginosis?
metronidazole (orally or vaginal gel)
OR clindamycin (orally or vaginal gel)
37
What is the pathophysiology of bacterial vaginosis?
* Reduction in the acid-producing normal flora of the vagina [Lactobacillus]
* Leads to growth of anaerobes and other fastidious microorganisms
38
What types of HPV are oncogenic?
What types are not?
HPV 6 & 11 = not oncogenic (cause geintal warts)
HPV 16 & 18 = oncogenic
39
What else, other than HPV infection, increase ones risk of cervical cancer?
* HPV
* Sexual activity
* Cigarette smoking
* OCP
* Immunosupression
40
What type of epithelium is in the endocervical canal?
What type of epithelium is in the cervix?
What area of epithelium is most likely to become dysplastic when infected by HPV?
endocervical canal = columnar
cervix = squamous
between this is the transitional zone / where there is "cervical ectropion" - this is the area which is most likely to become dysplastic
41
What systems are used to grade dysplastic changes of the cervix?
1. The Bethesda System (SIL system) - which looks at individual cells and their degree of displasia
2. Cervical Intraepithelial Neoplasia system (CIN) - which looks at the degree of dysplasia and the depth of dysplasia
42
When is the Gardasil vaccine currently funded?
Boys and girls aged 12-13 (year 7)
Need to receive the three doses within a year (preferably at 0, 2 and 6 months)
If outside this age range - have to pay for it (most efficacious if haven't already had sex)
43
What types of HPV does Gardisil proect against?
6, 11, 16 and 18
44
At what age is it recommended to first have Pap smears?
How often is it recommended to have them?
Until what age?
18-20 years old, or 2 years after one has first had sex (whichever is later)
(Girls who have had sex earlier than 18 years do not require a Pap smear until they are 18; even if they first has sex at the age of 15).
Current guidelines suggest having Pap smears every 2 years until the age of 70
(Note that women between 50-70 are the most uninvestigaed population)
45
Describe the difference between current guidelines with Pap smears and the new HPV testing which will likely roll out in May 2017
**_Changes_**
**Age commencing cervical screening**
From 18 years to 25 years
**Test performed**
HPV testing instead of Pap smear +/- liquid based cytology
**Equipment used**
Brush as for liquid-based cytology (instead of spatula)
**Frequency of test**
Every 5 years instead of every 2 years
**Exit age**
Between 70-74 years old (instead of 70)
46
47
bacteral vaginosis is potentially serious in what population?
pregnant women
increases the risk of miscarriage
48
49
What is the difference between Chancroid versus Chancre?
***_Chancre_*** = **painless** ulceration most commonly formed during the primary stage of **syphilis**. This infectious lesion forms approximately 21 days after the initial exposure to Treponema pallidum.
***_Chancroid_*** = **painful** ulceration which occurs 3-10 days after contact with Haemophilus ducreyi.
50
What is the typical presentation of HSV?
Multiple painful genital ulcers one to two weeks following exposure to the virus. Can also be associated with a systemic illness.
51
What is the treatment of HSV?
Acyclovir (cream, oral or IV depending on the severity)
52
What are the types of HSV and what do they cause?
HSV 1 = oral herpes
HSV 2 = genital herpes
53
What is the GP management mnemonic?
**DKA EMP REAP**
Diagnosis
Knowledge
Attitudes
Explain
* NORMALISE
* causes
* symptoms
* complications
Management
* Basics
* Place and Person
* Ix and CD
* Defitive Management
* lifestyle
* non-pharm
* pharm
* invasive / surgical
* Prevention / Long Term / Follow Up
Preventative Opportunities
Reinforce
Evaluate the Consultation
Arrange Follow up
Pamphlet / Website!
* A very good website is the better health channel
54
How do you organise your thoughts of prevntative opportunities in GP?
/ what do you say in an OSCE?
SCREEN
SNAP
CV risk
Reproduction
Emotions
Elderly
Neoplasms
**Scripts:**
* Ascertain age.
* Ascertain whether or not they have had the recent test you are going to propose / ascertain when their last GP visit was
* “Now, because you are **x** years old and this is your first visit to the GP in **y** years – there are certain screening tests which are recommended we do every so often, to screen for certain conditions such as ….”*
* “With this is mind, I think it would be wise to organize **a, b and c**, as well as consider the issue for which you have come to see me, today.”*
55
What is the definitive management + follow-up / long term management of psoriasis?
_Lifestyle_
* Avoid skin damage & triggers
* Moisturise
_Pharmacological_
*Topical -* "CC DD"
* intermittent, short term potent **C**ortocistreoids
* **C**alcipatriol (a vitamin **D** analogue)
* **D**ithranol (inhibits DNA synthesis)
*Systemic -* refer to dermatologist
* Oral mathotrextae
* Biological agents - infliimab
_Physical Therapy_
* Phototherapy with UV light
_Follow Up_
* 2 - 3 x increased CV risk with psoriasis
* Psoriatic arthritis
* Eryhroderma
56
What are the complications of psoriasis?
Psoriatic arthritis
Erythroderma
2 - 3 x increased CV risk
Poor self esteem
57
What is the reassurance of eczema and psoriasis you should give patients?
Very common
Don't cause scarring or disfigurment
58
What is the definitive management of eczema?
Lifestyle
* Avoid skin breakdown
* avoid dryness
* avoid heat
* avoid irritants
* Restore skin barrier
* moisturise+++
Pharmacological Treatment
* Topical steroid cream: low, medium or high dose
* If severe refer to dermatologist for oral steroid or immunsuppressive agents eg. methotrexate
*Alternatives / Additions:*
* If want to avoid steroid --\> pimecromilous
* If have an itch --\> anti-histamines
* Wet dressings or occlusive dressings
* If infected --\> antibiotics + oatmeal washes / bleach baths
59
What is the definitive management of acne?
**Lifestyle**
* wash skin
* avoid sun damage
* avoid squeezing lesions
**Topical Treatment: ABC**
* Adapelene (topical retinoid)
* Benzyl peroxide
* Clindamycin (topical antibiotic)
**Oral Treatment: DE**
* Doxycycline [replaces topical clindamycin]
* Estrogren + progesterone [ie. OCP] in females
**Referral**
* For isotretinoin
**Ongoing**
* Psych
60
How do you diagnose T2DM?
**5.5 - 7 - 11**
## Footnote
*Need two positive tests (preferably different)*
Fasting \> 7
Random \> 11
* If first test is uncertain* [fasting: 5.5-7 or random: 7-11] need to refer for 2OGTT [which is like a controlled random]
* Can* refer for HbA1c now? \>6.5% = T2DM
61
What is a relative contraindication to prescribing some an ACEi?
What would you prescribe instead?
angioedema
62
What is glaucoma and what are it's types?
High intraoccular pressure causing death of optic nerve cells.
Open angle glaucoma = poor drainage of aqueous pressure due to dysfunctional drainge by the canal of schlemm
Closed angle glaucoma = poor drainage due to closure of the angle between the cornea and the iris
63
what is seen on opthalmoscopy in gluucoma?
Cupping
Measure the cup:disc ratio
65
What is the typical presentation of open angle glaucoma?
It is asymptomatic!
Patient's may have loss of peripheral vision, but usually won't notice
66
What examination findings are typical of glaucoma?
1. raised pressure
2. cupping on ophthalmoscopy
3. loss of peripheral vision (might have to be measured by a special machine called an automated perimetry)
67
What is the typical presentation of acute glaucoma?
An extremely red and painful eye
+/- N&V
Patients may reoprt seeing halos around lights
68
what are the examination findings of acute angle glaucoma?
Pupil is sluggish and mid-dilated
Slightly cloudy cornea
High pressures
Rock hard eye on palpation
69
What is the treatment of chronic glaucoma?
1. Topical beta-blockers
2. Also topical alpha-agonists, carbonic anhydrase inhibitor (Diamox), and prostaglandin analogues
3. Trabeculectomy
70
What is a cataract?
Any opacity of the lens, regardless of aetiology
(they can occur in different parts of the lens)
71
What are the causes of visual loss?
Gradual Visual Loss [COAD]
* Cataracts
* Open angle glaucoma
* Age-related macular degeneration
* Diabetic retinopathy
Suddent Visual Loss [BRCO]
* Branch retinal vein occlusion
* Retinal detachment
* Central tretinal artery occlusion
* Optic neuritis
Non-eye related causes [TMG]
* TIA
* Migraine
* Giant cell arteritis
72
Which are arteries and which are veins?
Arteries - plaer, thinner
Veins - thicker, darker
73
What type of haemorrhages are seen in diabetic retinopathy?
dot and blot haemorrhages
74
what type of haemorrahes are seen on hypertensive retinopathy?
flame haemorrhages
75
What is the typical presentation of cataracts?
Gradual loss of vision
Reduced night vision
Glare from oncoming traffic
79
What is a cotton wool spot and when do you see it?
ischaemic retina
diabetic retinopathy
80
What is seen on ophthalmoscopy in diabetic retinoathy?
dot and blot haemorrhaes
cotton wool spots (ischaemic retina)
neovascularisation (which occurs in large areas of ischaemia)
hard exudates (lipid accumulation from swelling)
81
What's this?
Red cherry spot
Central retinal artery occlusion
82
What are the three types of retinal detachment?
Rhegmatogenous (the usual type)
Tractional (can happen in diabetics)
Exudative (tumor or something pushing from below)
83
What are the symptoms of retinal detachment? (And the DDx for each)
* Flashing lights
* DDx = migraine and posterior vistreous detachment
* Floaters (look like dark specks that obscure vision - like a swarm of flies)
* DDx = posterior vitreous detachment
* Curtain of darkness coming down
* DDX = TIA
84
what is the typical presentation of age-related macular degeneration?
Older patient
Progressive steady decline in **central vision**
Difficulty in reading (new glasses don't help)
85
Elderly pt, sudden unilateral vision loss.
What are the DDx?
And what are the prognoses of each?
Branch retinal vein occlusion (will resolve spontaneously in 2 months)
Central retinal artery occlusion (requires urgent surgical referral)
87
What is conjunctival injection?
88
What is this and how is it treated?
Dendritic ulcer of HSV
Treated with antivirals
89
What is the clinical presentation of optic neuritis?
Sudden vision loss (central scotoma is classic)
Decreased contrast and color sensitivity
Pain with eye movement
90
What is optic neuritis associated with?
MS
91
What is the management of optic neuritis
Specialist referral
IV steroids
92
What are the examination findings of optic neuritis?
Optic nerve head edema
Relative afferent pupillary defect
93
painful eye in the context of a foreign body?
corneal abrasion
which if infected may lead to corneal ulcer
95
What is this?
Anterior synechia
97
What is the management of a dendritic ulcer on the cornea due to HSV?
antivirals prescribed by opthalmologist
DON'T prescribe steroids
98
What is another name for anterior uveitis?
iritis
99
What is another name for iritis?
anterior uveitis
100
What's this?
What is the epidemiology and typical clinical picture?
**_episcleritis_**
Affects young adults
Moderate ache
Milder symptoms than those experienced by patients with iritis
The conjunctival inflammation is usually localised to one sector
101
What is erysipelas?
Caused by group A strep
involving the upper dermis that characteristically extends into the superficial cutaneous lymphatics.
Tender, intensely erythematous, indurated plaque with a sharply demarcated border. Its well-defined margin can help differentiate it from other skin infections (eg, cellulitis)
102
What is the uvea?
iris, ciliary body, and the choroid
all
connected to each other and are histologically similar
103
What is the aetiology of anterior uveitis?
idiopathy
or associated with rheumatological conditions (HLA-B27)
104
What is the orbital septum?
describe the two types of cellulitis
pre-septal / peri-orbital cellulitis is anterior to the orbital septum
post-septal / orbital cellulits extends behind the septum
105
What is a synechia?
A synechia is an eye condition where the iris adheres to either the cornea (i.e. anterior synechia) or lens (i.e. posterior synechia).
107
What is this?
stye
external hordeolum
108
what is the aetiology of synechia?
Synechiae can be caused by ocular trauma, iritis or iridocyclitis and may lead to certain types of glaucoma.
109
what is the management of anterior uveitis?
requires urgent referral!
Topical steroid drops reduce the inflammation
Topical cyclopentolate (dilate the pupil and break down synechiae)
110
What is the episclera?
The episclera is a thin layer of tissue that lies between the conjunctiva and the connective tissue layer that forms the white of the eye (sclera)
111
what is episcleritis?
What is it's prognosis?
Benign self-limiting condition
Resolves in two weeks without treatment
113
What's this?
Entropion
115
What's this?
What is it's clinical presentation?
What is it's aetiology?
What is it's prognosis?
Large bleed + Painless + Normal vision
May be associated with hypertension or heavy bouts of coughing or straining
Resolves spontaneously within 2-3 weeks
116
What's this slight redness in the corner of my eye?
What treatment is required?
Pterygium
Common in hot climates
Benign fibrovascular growth from the conjunctiva
No treatment required unless growth reaches cornea à refer to ophthalmologist to be peeled back
117
118
What is another name for pre-septal / post-septal cellulitis?
pre-septal = peri-orbital cellulitis
post-septal = orbital cellulitis
120
What is the management of periorbital / orbital cellultis?
**periorbital cellulitis**
often managed with oral antibiotics
**orbital cellulitis**
more serious condition requiring hospitalisation and parental antibiotics
complications such as intraorbital abscess formation may require surgical intervention
121
How do you DDx between episcleritis and scleritis?
**instillation of phenylephrine 2.5%**
the phenylephrine blanches the conjunctival and episcleral vessels but leaves the scleral vessels undisturbed. If a patient's eye redness improves phenylephrine instillation, the diagnosis of episcleritis can be made.
123
What is the difference between a stye (external hordeolum) and a Chalazion (meibomian cyst)
Stye is an infection, red and tender
Chalazion is not tender, and is hard (due to sterile inflammation)
124
What is another name for stye?
external hordeolum
125
What is another name for a chalazion?
mebomiam cyst
126
What is blepharitis
Blepharitis is a chronic eye condition characterised by inflammation of the eyelids.
127
What is the name for inflammation of the eyelids?
Blepharitis is a chronic eye condition characterised by inflammation of the eyelids.
129
What is Trichiasis?
Abnormally positioned eyelashes that grow back toward the eye, touching the cornea or conjunctiva
132
what is photokeratitis?
photokeratitis is akin to a sunburn of the cornea and conjunctiva
133
How do you differentiate between viral and bacterial conjunctivities?
There are no specific clinical signs to differentiate bacterial and viral conjunctivitis.
134
What is the clinical picture fo conjunctivitis?\>
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
135
136
What is a risk factor for retinal detachment?
myopia
137
According to Monash, GPs can easilly treat foreign bodies, but after how long should the patient be reviewed?
In 24 hours
138
What type of stroke is the most common cause of a homnymous hemianopia?
**Posterior** circulation stroke
(but MCA stroke can also cause symptoms)
139
According to John Murtagh, if you diagnose a migraine when should you review the patient?
In 24 hours
If the pain hasn't resoved reconsider the diagnosis
140
What is the first line acute treatment for a migraine?
And what is second line?
Aspirin
Paracetmaol
Ibuprofen
Triptans
Ergot
141
What is used for prophylaxis of migraines?
TCA
B-blocker
Sodium Valproate
Verapamil Sustained Release
142
If someone presents to you (a GP) with acute angle glaucoma, what should you do?
Call an ambulance.
The patient should remain in the supine position as long as possible.
The urge to wear eye patches, covers, or blindfolds should be resisted. By maintaining the conditions that cause pupillary dilation, these articles help perpetuate the attack.
143
Aortic stenosis gives you what type of pulse?
Pulsus parvus et tardus
Small volume pulse
Weak and small pulse
144
What is the classic triad of Mennieres disease?
Vertigo, hearing loss and tinnitus
145
What is the duration of the vertigo attaks in BPPV compared with Menierres disease?
Most attacks of meniere's will last for hours compared to a few seconds in the case of BPPV
146
According to Monash, what is unilateral hearing loss until proven otherwise?
Assume that any unilateral sensorineural hearing loss is caused by an acoustic neuroma until proven otherwise.
147
What Ix do you have to do once you have prescribed someone an ACEi?
UEC
148
When does the "dry cough" appear with an ACEi?
Doesn't have to start striaght away!
149
What is a known adverse effect of TCAs (which isn't one of the usual)?
Intestinal obstruction
150
What type of anaemia might metformin cause?
Megaloblastic
| (B12)
151
What test is commonly listed as positive in sarcoidosis?
ACE levels
152
Why should GPs fluorsceine stain every eye?
And why shouldn't GPs really be prescribing steroid eye drops?
Both answers - HSV!
153
What parasite is associated wth bladder cancer?
Shistosomiasis
154
What is used to diagnose active TB?
What is used to diagnose latent TB?
Which test might be positive is someone has had a TB injection?
* Active = CXR + 3 x sputum samples
* Latent =
* Mantoux (Tuberculin Skin Test) - false positive from BCG test
* Quantiferon Gold [interferon gamma release assays (IGRA)]
* If these are +ve then do CXR to exclude active TB
155
What is the first, second, third and fourth line treatments in hyperlipidaemia (elevated LDL)?
1. statin
2. ezetimibe
3. bile acid binding resin
4. nicotinic acid
(SEB + nicotinic acid is always last line)
156
What is the first, second and third line treatments for hypertriglycerideaemia?
1. fenofibrate
2. fish oil
3. nicotinic acid
157
When would you use nicotinic acid in hyperlipidaemia?
Last line for both LDL and TGs
158
What is the treatment target for total cholesterol?
159
What is the treatment target for HDL?
\>1
160
What is the treatment target for LDL?
161
What is the treatment target for TGs?
162
163
How often and how should you screen for OP?
Assess risk factors in women aged \>45 and men aged \>50 who are of average risk
In women and med of *increased risk / risk factors* refer for DEXA, do not repeat more freuently than every 2 years and only do so if it is likely to change treatment
164
What score do you use to diagnose osteoporosis on DEXA scan?
What are the cut offs?
**T score**
\> -1 is normal
between -1 and -2.5 is osteopaenic
165
What are the risk factors for osteoporosis?
Lifestyle
* smoking
* ETOH
* physical inactivity / immobilsation
* Low Ca and Vitamin D intake
Anthropological
* Female
* Older age
* Low BMI
* Early menopause
Medical
* Steroids
* Anti-convulstandts
* HRT (protective)
* Endocrine
* cushing's
* hyperPTH
* hyperthyroidism
* CKD
* Chronic liver disease
* MM
* Hysterectomy
166
What is Bacterial Vaginosis?
A change in the normal flora within the vagina
* Reduction in Lactobacillus species
* Overgrowth of anaerobic
* Mobiluncus species
* Gardnerella vaginalis
* Atopobium vaginase
* Mycoplasma hominis
167
What is the clinical presentation of Bacterial vaginosis?
* White-to-grey fishy smelling discharge
* Dysuria
* Vaginal pruritis
*
168
What is the Amsel Criteria for Diagnosis of BV?
1. Clinician observed vaginal discharge - thin, white, adherent, homogeneous appearance.
2. Vaginal pH of \>4.5.
3. The presence of “clue cells” on a gram stain or wet prep from a high vaginal swab.
4. Positive amine (whiff) test.
169
Who should be treated for bacterial vaginosis?
* Symptomatic women
* Women having a TOP
* Women having IUDC insertion
* WOmen who are pregnant and have a history of pre-term delivery
170
What is the treatment for Bacterial Vaginosis?
One of the following
* Metroniadazole orally - 5 days
* Metronidazole vaginal gel - 5 nights at bedtime
* Clindamycin - 7 days
* Clindamycin vaginal cream - 7 nights
Not clindamycin cream is oil based and can weaken condoms
171
What are the complication of untreated Chlamydia trachomatis?
Women
* PID
* Ectopic pregnancy
* Infertility
Men
* Epididymitis
* Prostatis
172
What is the treatment for chlamydia trachomatis?
1g of azithromycin as a single dose
173
What organism is responsible for Chlamydia?
* Chlamydia trachomitis
* Gram-negative bacterium
* Obligate intracellular parasite - replicates within the host cell and forms inclusion bodies which then reorganise and rupture within 2-3 days
174
What is the incubation period for chlamydia?
7-21 days
175
How can you investigate chlamydia?
* First pass urine - NAAT
* Culture of urethral discharge
176
How long should people abstain from sexual contact after completion of antibiotic treatment for chlamydia?
At least 7 days
177
What is the causative organism for Gonorrhea?
* Neisseria gonorrhoeae
* Gram negative diplococcus bacteria
178
What is the clinical presentation of Gonorrhea?
**Infections of the cervix, anus and throat usually cause no symptoms.**
**Men**
* Urethral discharge
* 2 – 10 days after unprotected sex
* Dysuria
* Age 15-24
* 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.
179
What is the definitive management for Gonorrhoea?
Ceftriaxone: 250mg IM as a single dose
(Ciprofloxacin can be used as an alternative to ceftriaxone when a sensitive strain has been identified.)
180
What causes genital herpes?
HSV 1 or 2
Oral herpes is caused by HSV 1
181
What is the clinical presentation of genital herpes?
Women
* Genital pain
* Discharge
* Dysuria
* Ulcerative lesions on the vulva, perineum, buttocks and cervix
Men
* Vesicles on the penis shaft or glans
* Urethritis
* Protitis with discharge, rectal pain and tenesmus
* Constipation
* Impotence
* Urinary retention after anorectal intercourse
182
What is the management of Genital herpes?
Basics
* Simple analgesia
* Patient education
* Avoid sexual contact when lesions are present
* Use of condoms
Place and person
* GP
* Hospital admission if disseminated visceral involvement
Definitive managment
* Aciclovir
Long term
* Aciclovir can be used for up to 6 months for long term suppressive treatment
183
What is the causative organism of syphilis?
* Treponema pallidum
* Spirochaete
184
What is a chancre?
A painless ulcer, particularly one that develops on the genitals in venereal disease.
It is the first presentation of primary syphilis
185
What are the stages of syphilis?
* Early syphilis
* Primary
* Chancre
* Secondary
* Rash or condylomata lata
* Latent
* Asymptomatic of less than two years based on serology results
* Late latent
* 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
* Teritary syphilis
* Cardiovascular and neurosyphilis is present
186
What are the symptoms of secondary syphilis?
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)
187
What is the treatment for early syphilis?
SIngle dose of Benzathine penicillin
188
What is the treatment of late latent syphilis?
Once weekly x3 benzathine penicillin
189
What are the types of cataracts?
* Nuclear sclerosis
* Age related
* Cortical
* Aging and diabetes
* Posterior subscapsular
* Steroid use, intraocular inflammation, diabetes, trauma, radiation and aging
190
What is the clinical presentation of a cholesteatoma?
History
* Trauma to or disease of middle ear
* Hearing loss
* Ear discharge resistant to ABx
* Tinnitus
Examination
* Otoscopy typically shows crust or keratin in the attic
191
What are the differentials of sudden vision loss?
* Branched retinal vein occlusion
* Central retinal artery occlusion
* Retinal detachment
* Optic neuritis
* TIA
* Giant cell arteritis
* Migraine
192
When and how does secondary syphillus present?
4-10 weeks after the primary infection
Is caused by haematogenous spread of infection. This leads to a widespread vasculitis.
Secondary syphillus is known for the many different ways it can manifest!
But symptoms most commonly involve the skin, mucous membranes, and lymph nodes. There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles.
193
How do you investigate for syphillus?
Serological testing:
* Reactive non-treponemal test
* rapid plasma reagin [RPR] test
* venereal disease research laboratory [VDRL] test
* Treponema pallidum Particle Agglutination/Haemagglutination (TPPA/TPHA)
* Enzyme Immune Assay (EIA);
194
What is the treatment of gohnorrhea?
Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine
| (PLUS Azithromycin 1g PO, stat)
195
What is the treatment of syphillus?
Benzathine penicillin 1.8g IMI, stat
196
What group of 'reportable diseases' are STIs?
How quickly should the GP notify?
What information is given?
Group C
Within 5 days of diagnosis
Only the patient's initials, post code and DOB
197
How do you test for HIV?
ELISA is the first test (HIV Ag/Ab)
There might be a false negative in the 'Window Period', may need to repeat
Then order the Western Blot
198
199
Vaginal soreness, green / grey bubbling discharge with offensive odor two days after casual sex?
Trichomonas Vaginalis
Year 4C - GP
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