GP Questions Part 2
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. What would you like to do?
List 2 possible side effects of inhaled steroid use.
- - oral thrush
- - sore throat
- - dysphonia
- - growth stunting (at doses >500mg)
What are 2 ways of monitoring asthma control?
- 1. Level of nocturnal cough
- 2. Peak flow metre (useful for >6yos)
What are the main classes of causative agents of acute gastroenteritis in children? List an example from each class.
- Viruses (70%) - e.g. rotavirus (contributes to 50% of all acute GE hospitalisations of children)
- Bacteria (15%) - salmonella, campylobacter jejuni, escherichia coli, shigella
- Protazoa e.g. giardia lamblia
How do you distinguish, clinically, between viral gastroenteritis and bacterial gastroenteritis?
- Viral: watery diarrhoea without blood, possible vomiting, low grade fever, anorexia, more in Autumn/Winter, Hx of contact
- Bacterial: bloody diarrhoea, mucus in stool, high fever, food/water-borne
What are the indications for admitting a child with acute gastroenteritis?
- Severe dehydration (>7% body weight lost)
- <6 months old
- >8 stools and/or >4 vomits in the past 24 hours
- Carers unable to manage child at home
What children are at increased risk of dehydration with gastroenteritis?
- < 6 months old
- Abnormal gut anatomy
- Hyperosmolar feeds
What are the clinical signs of dehydration?
- Decreased peripheral perfusion (>2 seconds return after compressed for 5 seconds)
- Abnormal skin turgor
- Deep acidotic breathing
List 4 DDx for wheeze in childhood and categorise these as small airway or large airway causes.
- Small airway:
- - Asthma
- - Transient infant wheeze
- - Acute viral bronchiolitis (usually due to RSV)
- - Suppurative lung disease (e.g. CF)
- - GORD and primary pulmonary aspiration
- - Congenital heart disease
- - Chronic neonatal lung disease (in premature babies)
- Large airway:
- - Structural airway diseases
- - Mediastinal mass
- - Foreign body aspiration
List 4 clinical signs/symptoms of asthma?
- Wheeze (esp. expiratory)
- Chest tightness
What are the 4 tests you would order for unexplained fatigue?
- Hb, ESR, glucose, TSH
- (even more cost-effective if you delay Ix for 4 weeks)
List 4 serious causes of fatigue not to be missed
- Cardiovascular disease
Depression is the ..... largest cause of morbidity in Australia.
List 5 side effects of SSRIs.
- Nausea, insomnia, drowsiness, dizziness, agitation (usually resolves in weeks)
- Sexual dysfunction, increased weight
- Hyponatraemia (rare)
What is the major contraindication for TCAs and why?
Cardiovascular disease - anticholinergic and pro-arhythmic effects.
A brief 5 miutes intervention (between 1 to 4 sessions) with the GP can reduce drinking by how much?
List 3 drugs that may be used in alcohol dependence
List 6 secondary causes of insomnia
- Stimulant use/substance withdrawal
- Obstructive sleep apnoea
- Mood disorder
- Acute stressors
- Limb movement disorders
- Chronic end organ failure
List 4 types of drugs that interfere with sleep
- Thyroid hormones
- Antideperssants (SSRIs, SnRIs, NARIs, MAOIs)
What are the 2 most commonly prescribed classes of hypnotics, and list one major side effect of each.
- Short acting benzodiazepines e.g. temazepam - dependence and tolerance develops within 10 days; interferes with REM sleep --> decreased LTM consolidation
- Non-benzodiazepine hypnotics e.g. zolpidem - somnambulism; amnesic effects (potential exploitation)
List 5 symptoms of an acute stress reaction.
- Being "dazed"
- Decreased LOC
- Decreased focus/attention
What is a possible drug that can be used in the treatment of acute stress reactions (albeit somewhat controversial)?
What are the 3 main types of dementia (from most common to least)?
- 1. Alzheimer's Disease (60%)
- 2. Vascular dementia (10-20%)
- 3. Demential with Lewy Bodies (<10%)
What is the Dx for dementia with lewy bodies?
- 2 or more of:
- - fluctuating impairment of cognition
- - visual hallucination
- - parkinsonism
What agents can be used to target cognitive symptoms in dementia and what are the indiciations for their use?
- Cholinersterase inhibitors (e.g. donepezil) - mild to moderate AD only, MMSE 10-24
- NMDA antagonist (e.g. memantine) - moderate to severe AD (but MMSE >10)
What can be used to treat the behavioral symptoms of dementia?
- Carer education
- Antipsychotics (avoid in lewy body dementia!)
- Benzodiazepine (limit to <2 weeks - increased risk of #)
What is the main DDx for a wart on an older patient and what would be your treatment?
Seborrheic keratosis - cryotherapy if patient wants it removed. If not, observe for changes as skin cancer can develop on it.
List 5 risk factors for melanoma.
- Fair skin
- Blue eyes
- >150 moles in childhood
- >5 dysplastic naevi
- Giant congenital melanocytic naevi (>20cm diameter)
- Past Hx of BCC
What are the Clarke's levels?
- 1. Within dermis
- 2. Into papillary dermis
- 3. Reached interface of papillary and reticular dermis
- 4. Into reticular dermis
- 5. Into fat
What is the most common malignancy in Caucasians?
Basal cell carcinomas
What are 2 common features of a nodular BCC?
- Pearly appearance
Baby presents with a scaly scalp extending to ears and neck folds. Probability diagnosis?
Seborrheic dermatitis - can also affect nappy area
What is an important differential for nappy (contact irritant) rash? What signs indicate this alternative diagnosis?
Streptococcal infection of perianal/vulval region - unwell baby (fever, crying), bright red, very tender marginated area
Shingles is due to which causative agent?
What is its hallmark sign?
List 2 complications of shingles.
- Varicella zoster reactivation.
- Unilateral rash (along one dermatome)
- Post-herpetic neuralgic pain (treat with antiviral in 1st 72h to prevent) and blindness (if ophthalmic involvement)
Hand, foot and mouth disease is caused by which agent?
Itchy nodules and scratchmarks on a child's hand are most likely to be ...
How would you manage this case?
- Permethrin cream; treat contacts; wash sheets and clothing in hot water.
A young child has a generalised, erythematous macular rash days around his cheeks days after an URTI. His mother is pregnant. What is it most important to exclude?
Parvovirus - offer serology for parvovirus B19 specific IgG to mother
Jenny, 5yo, has wheals with erythematous margins that come and go over the course of the day. Jenny otherwise appears well. What is the likely diagnosis and appropriate treatment?
Urticarial rash from a virus, antihistamines.
Johnny, 4yo, has a itchy golden crusted rash on his face - what is it likely to be, what is the likely causative agent and how would you treat Johnny?
Impetigo/school sores - Staph aureus - dicloxacillin or flucloxacillin, covering lesion to reduce autoinnoculation and spread to others.
What are 3 possible treatments for common warts (HPV)?
- Salicylic acid
What is the defining feature of molluscum contagiosum?
Central umbilication due to keratotic plug.
Joan, 22, has pink lesions with fine scales all over her torso. It started as just one large patch. What is this likely to be and how would you treat it?
Pityriasis rosea - reassure patient - it resolves in 6 weeks with no sequalae.
A boggy looking ulcer with a sour unpleasant smell is likely to be caused by? How would you treat it?
Fungal ringworm infection - treat with griseofulvin.
Patchy pigmentation change (increased/decreased) on sun-exposed skin is called ... and is caused by ...
How would you treat it?
Pityriasis vesicolor; malassezia furfur (yeast); selenium sulphide shampoo on skin, ketoconazole cream or oral fluconazole.
What is the typical distribution of eczema in (a) adults and (b) infants?
(a) flexural distribution; (b) facial and truncal.
What are the 4 main symptoms of eczema and how would you target it?
- 1. Dryness - soap substitute and bath oil, moisturise and wet bandages
- 2. Heat - avoid overdressing, heating and hot blankets
- 3. Inflammation - topical steroids or calcineurin inhibitors (e.g. pimecrolimus topical)
- 4. Itch/sleeplessness - antihistamines for sedation (e.g. promethazine), CBT, massage, hypnotherapy
What is the pharmacological treatment regime for GORD?
Step down approach - start on PPI for 1-2m, then intermittent PPI/H2 antagonist once symptoms cease, then antacids.
List 3 possible complications of GORD.
- Barrett's oesophagus
- Benign oesophageal stricture
- Polypoid adenocarcinoma
What are 3 local complications from constipation? And how would you treat them?
- Haemorrhoids - topical cream/suppositories
- Anal fissure - topical trinitrate cream, local anaesthetic for toileting
- Perianal haematoma - observe and salt walter bath --> incise and drain.
What is the most common internal cancer in Australia?
What is the most common cancer in Australia?
What is the morbidity and mortality of colorectal cancer?
5% of the population will have it and 50% of sufferers will die from it.
List 3 factors that place a patient at high risk of colorectal carcinoma
- Family cluster of 3 or more
- FHx of FAP or HNPCC
- IBD for mroe than 8y
List 3 factors that place a patient at above average (not high) risk of colorectal carcinoma
- FHx of CRC in 1 relative <55 or 2 relatives of any age
- Past CRC resection
- Adenomatous polyps
List 5 alarm symptoms/signs in a patient with diarrhoea
- Weight loss
- New symptoms >40
- PR bleeding
- FHx of CRC or IBD
- Raised CRP/ESR
Which 2 laboratory findings are hallmarks of hereditary haemochromatosis? What is the diagnostic test?
Increased iron saturation and increased ferritinl PCR for HFE gene
Colonic diverticular disease is associated with whcih 2 factors?
Low fibre diet and constipation.
List 5 symptoms of diverticulitis.
- Left lower abdomen pain
- A little blood and mucus in motions
- Painful defecation
- Looser and more frequent motions
- Patient is older
List 3 examination findings you may find in diverticulitis.
- tender PR,
- left iliac fossa tenderness,
List 5 alarm symptoms in a patient presenting with GORD.
- GIT bleed
- Upper abdominal mass
- Unexplained weight loss
- Persistent vomiting
What is the standard treatment for H. pylori infection?
Triple therapy: PPI, amoxicillin and clarithromycin
What is the diagnostic criteria for irritable bowel syndrome?
- 12 or more total weeks in the last 12m of abdominal pain and discomfort with 2 or more of:
- - relief with defaecation
- - onset associated with change in stool frequence;
- - onset associated with change in stool form
What is the leading cause of death in Australia?
Acute cardiac disease.
List 5 symptoms of acute coronary syndrome
- Radiation to R. arm
- Pain on exertion
- Radiation to L. arm
- Nausea and vomiting
- Worse than previous angina or similar to previous MI
- Chest "pressing" pain
List 5 modifiable risk factors for IHD.
- Obesity, lack of fruit and veg, sedentary lifestyle
What drugs form part of the standard post-MI management plan?
Antiplatelet (aspirin), beta blocker, ACEI, statins
List 5 possible triggers of heart failure.
AF, MI, respiratory infection (esp in elderly), anaemia, hyperthyroidism, renal failure, salt loading, drugs (dihydropyridine CCBs, NSAIDs, steroids, glitazones, TCAs, macrolides, cisapride)
List 5 risk factors for heart failure.
- Older age.
- IHD and MI
- Diabetes mellitus
- Obesity and sedentary lifestyle
- Valvular disease
How would you treat heart failure?
- Diet, exerise, reduce salt and fluids and quit smoking.
- Rx: ACEI, betablocker, spironolactone, loop diuretic (symptomatic only), digoxin
What pharmacological agent do you use in sinus bradycardia?
Atropine to reove PNS brake on SA node.
How would you manage non-sinus bradycardia (i.e. AV block)?
Adrenaline and low dose atropine/pacing
How would you manage supraventricular tachycardia?
- Increase vagal stimulus to SA node with the valsava manouvre or a carotid massage (only in patients <50).
- Failing that --> increasing sharp IV pushes of adenosine (6, 12, 18mg)
How would you manage ventricular tachycardia in a conscious patient?
Amiodarone 150mg IV over 30 minutes OR synchronised cardioversion
A patient has an ectopic ventricular beat - Mx?
Ensure patient is well oxygenated and perfused. Prepare to defibrillate should patient go into VF.
Which two rhythms are shockable in a cardiac arrest?
VF and VT
List 4 contraindications for aspirin use.
- Intracranial haemorrhage
- Active/recurrent peptic ulcer disease.
- Allergy to aspirin
- Bleeding disorder
List 4 side effects of nitrate use
Headeache, postural hypotension, syncope, flushing
How do you differentiate between diastolic dysfunction and systolic function?
Diastolic dysfunction has normal LVEF but a filling defect; LVEF <40% in systolic dysfunction
List 5 risk factors that puts a patient at high risk of chronic heart failure.
- >65y; NY Heart Association class III/IV; Comorbidities
- LVEF <30%; Isolation; Depression, Language barrier; Lower SES; renal dysfunction (eGFR <60)
What agent is the first line treatment for all CHF?
If a patient is symptomatic despite optimal dosing with ACEI and a diuretic, what can you add to their Rx? What is the main side effect of this extra medication?
- Spironolactone (aldosterone antagonist) risk of hyperkalaemia and decreased renal function;
- Digoxin - risk of toxicity
When should you use beta blockers in chronic heart failure?
All patients once they have been stabilised with other medications.
Which drugs have the potential to excacerbate heart failure?
- Non-dihydropyridine CCBs; TCAs; Anti-arrhythmics
- NSAIDs; Thiazolidinediones/Glitazones; Corticosteroids; Cancer drugs; TNF antagonists;Clozapine
The Australian Cardiovascular Risk Calculator takes into account of .... to calculate ....
Gender, age, smoking status, diabetes, BP, total cholesterol:HDL; 5y risk of CV event.
What other factors put you (not taken into account by the calculator) at increased risk of CVD?
Symptomatic/ECG-diagnosed CV (automatically >20% 5y risk of CV event), FHx of CVD, ATSI, >60yo with DM, obesity, socioeconomic disadvantage
What is the diagnostic criteria of grade 3 hypertension?
Systolic >=180 or diastolic >=110 or isolated systolic HTN with widened pulse pressure (syst >=160, diast <=70)
What constitutes mild/grade 1 HTN?
Systolic 140-159; diastolic 90-99 (whichever is the highest).
When must you start patient on antihypertensives immediately?
- 5 year risk of CV event is >15%
- Associated clinical conditions
- End organ disease
- Grade 3 HTN
A patient with A has a BP of B. Is there hypertension meeting the target?
Uncomplicated HTN - 135/85
HTN and diabetes mellitus - 135/85
HTN and hypercholesterolaemia - 128/78
HTN and proteinuria - 128/78
- No - HTN with associated condition/complication < 130/80
- No - HTN with proteinuria target <125/75
What is the recommended waist circumference for men and women?
<94cm M; <80cm for F
Jack, 50yo, was put on enalapril for his HTN 3 months ago. His BP is now 142/92. What should you do?
Add a CCB (e.g. amlodipine) or a low dose thiazide duiretic (e.g. frusemide)
Jack, 50yo, has a history of HTN and gout. He is currently on irbesartan but his BP control is still poor. What additional drug would you recommend?
- Calcium channel blocker (e.g. amlodipine)
- AVOID thiazide diuretic (frusemide) because it reduces uric acid clearance.
Jacque, 50yo, has HTN and AF. He has been on irbesartan for 3 months but his BP is still poorly controlled. What agent should you add?
Non-hydropyridine CCB (e.g. diltiazem) for rate control + BP control.
Debbie, 60, has HTN and type II DM with proteinuria. She has been on enalapril for 3 months but her BP is still 145/95. What can you add?
CCB (e.g. amlodipine) - thiazide diuretics should only be used with caution.
Who should be screened for hyperlipidaemia and how often?
- >=45yo - every 5y
- >=20yo with 1st degree relative of premature CHD (<55yo M/<65yo F) - every 5y
- Established CHD/high risk - yearly
Duncan, a 46 year old male has total cholesterol levels of 8. Mx?
Trial dietary changes for 6 weeks, check fasting lipids afterwards and if TCL still >7.5 or triglycerides >4, start on a statin.
What are the lipid targets for a patient with established heart disease or at high absolute risk of CVD?
- LDL <2.5
- HDL >1
- Total cholesterol <4
- Triglycerides <2
What drug can you add to statins or replace statins with? What is its MoA?
Ezetimide - reduces small intestinal absorption of cholesterol.
What is the most common presenting complaint in GP?
URTI symptoms (e.g. sore throat)
List 4 clinical features of a respiratory infection with group A beta haemolytic streptococcus.
- Fever >38C
- Lack of cough
- Tonsillar exudate
- Anterior cervical lymphadenopathy
Jacqui, 19, presents with a sore throat. She has a temperature of 38.1C, her tonsils exude pus and on palpation she has enlarged anterior cervical nodes. Mx?
Treat as GABHS - penicillin. Do NOT administer amoxicillin in case she has EBV (age group risk).
Antibiotics in URTI should only be given to...
- Bilateral OM in <2yos
- Acute OM with otorrhea
- Acute sore throat/tonsilitis with >3 Centor (GABHS) criteria
- Populations with high rates of complications (remote ATSI communities)
When would you consider prescribing antibiotics for sinusitis? Which one?
- >= 3 of: persistent (>7d) mucopurulent discharge; poor response to decongestants; facial pain, tenderness (esp unilateral) over sinuses, tenderness on percussion of maxillary molar/premolar teeth.
- Amoxyillin or doxycycline
List 4 signs of community acquired pneumonia. What would be your management?
- Fever, productive cough, SOB, chest pain
- Amoxycillin & doxycycline for 7 days
List 3 atypical causative agents for CAP.
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
How do you diagnose acute bronchitis?
Clinically: acute (<14d) cough with one or more other respiratory tract symptom (rhinitis, sore throat, sputum, dyspnoea, wheeze, chest discomfort).
Jay, 22yo, presents with a 5 day Hx of a productive cough (yellow sputum) and rhinitis. What is your management?
Reassure patient this is self-limiting (2-3wks) - paracetamol, fluids and rest.
Jake, 62yo, is a smoker presenting with a 5 day Hx of a productive cough and wheeze. Mx?
Assess for community acquired pneumonia.
Jillian, 50yo, presents with a 4d Hx of cough accompanied by a sore throat and malaise. Her temperature is 38.5C. Next step?
Nose and throat swab for PCR.
What is the most common cause of community acquired pneumonia?
Who is entitled to free annual flu shots and 5 yearly pneumococcal vaccines?
- >65 year olds
- >55 year old ATSIs
- Chronic disease sufferers
Outline the management plan of a severe exacerbation of astham in an adult.
- Continuous nebulised bronchodilator (5mg salbutamol every few minutes)
- 500ug ipratropium stat
- O2 8L/min
- Oral steroid (50mg prednisolone) --> IV hydrocortisone (200mg)
In stable COPD, what would be your first drug of choice?
Intermittent use of SABA or ipratropium
What is the key difference in dosing between inhaled corticosteroids for persistent asthma versus COPD?
- High dose (>500ug fluticasone/beclamethasone) does not provide additional benefits in asthma where as they do in COPD.
- ICS is a first line Tx in persistent asthma whereas it is only introduced in later stages of COPD.
List 3 indicators of COPD severity.
- Symptoms despite SABA use
- Frequent exacerbations (>=2 per year)
- FEV1 <= 50% of predicted
What is SMART asthma Tx and what benefits does it provide to patients? Who should you avoid prescribing SMART to?
Symbicort maintenance and reliever therapy (low dose budesonide and eformoterol dry powder inhaler) - eliminates need for SABA and decreases no. of severe asthma exacerbations. Do NOT give to habitual overusers, <12yos and COPD patients.
Gob, 60, has COPD and his dyspnoea has been worsening despite having been prescribed with an ICS and ipratropium. He gets breathless after walking for a few minuets on a flat. His dyspnoea Medical Research Council scale is .../5? What are your next steps?
4/5; check inhaler technique, smoking, medication use/compliance, conduct spirometry.
List 4 symptoms/signs of an anaphylactic reaction.
- sudden onset severe bronchospasm
- cutaneous flushing, urtacria and angioedema
- airway "tightening" +/- stridor
- nausea and vomiting
- colicky abdominal pain
- oral and pharyngeal pruritis
- progressive respiratory distress
What is the go to drug (and dose) in the treatment of anaphylaxis?
Adrenaline 0.3ml of 1/1000 in adults; 0.01ml/kg of 1/1000 in children SC or IM
Besides adrenaline, what other agents should you administer in anaphylaxis?
- Methylprednisolone IV
- Antihistatime (e.g. promethazine) oral for urticaria
You have just administered an EpiPen dose to an anaphylactic patient, 5 minutes later, they have not improved. What is your next step?
Administer another! 20% of reactions require >1 dose.
List 5 red flag symptoms for back pain.
- sudden onset without precipitating factor
- bladder disturbance
- pain unrelieved by rest
- pain at night
- Hx of cancer
- duration of pain >1m
- weight loss
- Hx of trauma
- older age (>50 with Ca, >70 with compression #)
When should you order a CT for back pain?
- Neurological symptoms are worsening/failing to resolve
True or false: most people with herniated lumbar discs experience low back pain.
False: approximately 1/5 of the asymptomatic population has herniated lumbar discs.
What are 3 clinical features of ankylosing spondylitis?
- pain gets patient out of bed
- pain not relieved by supine position
- pain lasts >3m
- pain at night
- >30 minutes of morning stiffness
True or false: glucosamine does not provide effective pain relief in osteroarthritis.
False: glucosamine provides a 20-25% reduction in pain in mild to moderate osteoarthritis of the knee.
Who should you avoid prescribing NSAIDs or COX-2 inhibitors to?
- Patients with established HF or high risk of HF (>60, on antihypertensives, diabetes, renal failure)
- Patients with aspirin-induced asthma
True or false: weak opioids are much safer in long term use than strong opioids.
False: weak opioids still have the same range of side effects but with a lower efficacy.
What is the severity, quality and location of pain associated with acute angle closure glaucoma?
Severe pain, constant quality, ocular location.
Besides ocular pain, what other symptoms are characteristic of acute angle closure glaucoma?
Red eye, visual loss/blur, coloured ring seen around objects, nausea and vomiting
Abe, 55, presents to you with a severe headache concentrating on the R. side of his forehead and temples. It is a burning, constant ache. What is your next step?
Investigate his ESR levels (>100?) and Dx by temporal artery biopsy. Administer prednisolone.
What do you treat cluster headaches with?
SC sumitriptan, 100% O2 at 7L/minute ia mask, ergotamine, intranasal lignocaine
Derrick, 55, has had a vague frontal headache for the past 2 months, it has been worsening and paracetamol will not relieve the pain. What must you not miss?
Space occupying lesion - especially a lethal midline granuloma.
What agent do you most commonly administer in the acute treatment of stroke?
Tissue plasminogen activator in <3 h once CT shows it is not haemorrhagic.
List 5 signs and symptoms of serotonin syndrome.
Tachycardia, hypertension, hyperthermia, shivering, sweating, pupil dilation, myoclonus, hyperreflexia, agitation, hyperactive bowel sounds, death.
What does the prenatal Down syndrome screen entail? When do you conduct this?
- Nuchal translucency test and blood test (PAPPA and hCG) - 11 weeks to 13 weeks and 6d; or
- Triple test (AFP, hCG and UE3) - 15-20 weeks
What is the diagnostic prenatal test for Down syndrome?
Chorionic villus sampling at 11-14wk and amniocentesis at 15-19wks
List 3 DDx for PV spotting in a woman in her first trimester of a pregnancy.
- Ectopic pregnancy
- Threatened miscarriage
- Cervical cancer
What serology screens are conducted in pregnancy?
Rubella, syphillis, HIV, hep B, hep C
What would you like to do?
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