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)
SOB
Chest tightness
Cough
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
Malignancy
Cardiovascular disease
HIV
Anaemia
Hepatitis
Haemochromatosis
Depression is the ..... largest cause of morbidity in Australia.
2nd
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?
20-30%
List 3 drugs that may be used in alcohol dependence
Acamprosate
Naltrexone
Disulfram
List 6 secondary causes of insomnia
Stimulant use/substance withdrawal
Obstructive sleep apnoea
Anxiety
Mood disorder
Psychosis
Mania
Acute stressors
PTSD
Pain
Limb movement disorders
Thyrotoxicosis
Chronic end organ failure
List 4 types of drugs that interfere with sleep
Beta-blockers
Theophylline
Stimulants
Thyroid hormones
Corticosteroids
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
Agitation/overactivity
Withdrawal
Anxiety
Decreased focus/attention
Disorientation
Depression
Amnesia
What is a possible drug that can be used in the treatment of acute stress reactions (albeit somewhat controversial)?
Propanolol
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.
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
Telangectasia
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?
Coxsackie virus
Itchy nodules and scratchmarks on a child's hand are most likely to be ...
How would you manage this case?
Scabies.
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)?
Cryotherapy
Podophyllotoxin
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
What agent is the first line treatment for all CHF?
ACEI
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
Yes
No - HTN with associated condition/complication < 130/80
Yes
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
Legionella
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?
Streptococcus pneumoniae
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?
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
hypotension
dysrhythmia
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
Post-trauma
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.
