02. AKT Insights: Format and MCQs Flashcards
(198 cards)
1
Q
Differential for recurrent tight-squeezing headaches?
A
- Medication overuse headache
- Tension type headache
- Migraine without aura
- Chronic bilateral rhinosinusitis
- Venous sinus thrombosis
- Intracranial hypertension OR hydrocephalus
2
Q
Describe a tension-type headache
A
- Lasts from 30 minutes to 7 days
- Usually bilateral
- Feels like pressure or tightness in head
3
Q
Characteristic of increased cerebrospinal fluid pressure headache?
A
- Typically worse in the morning and when laying down
- Improved by upright posture
- Aggravated by cough, straining and Valsalva manouvre
- May be associated with transient visual obscuration, pulsatile tinnitus and papilloedema
- Exclude a space-occupying lesion, venous sinus thrombosis or obstruction and use of drugs e.g. tetracyclines and Vitamin A analogues (e.g. isotretinoin, acitretin)
- Consider idiopathic intracranial hypertension
4
Q
Risk factors for medication overuse headache?
A
- Medication overuse can cause a rebound headache as the dose wears off
- Opioid analgesics (including codeine), triptans and ergots (i.e. ergotamine, dihydroergotamine) are more potent than non-opioid analgesics in inducing medication overuse headache
5
Q
Management of medication overuse headache?
A
Cease offending medication
Bridging therapy:
* First-line: Naproxen MR 750mg daily PO for 5 days in first week, then 3-4 days per week for 2 weeks then stop OR
* Second-line: Prednisone 50mg daily PO for 3 days, then decrease gradually over 7-10 days, then stop\
Preventative therapy:
* Amitriptyline 10mg nocte PO - if effective, continue for 6 months and then trial withdrawing from therapy
6
Q
Management of pityriasis versicolour?
A
Options:
* Econazole (Pevaryl) 1% nocte TOP for 3 nights
* Ketoconazole (Nizoral) 2% shampoo daily TOP for 5 days
* Selenium sulfide (Selsun) 2.5% shampoo daily TOP for 7-10 days
7
Q
What is pityriasis versicolour?
A
Common yeast skin infection
Causes flaky discoloured patches on the chest and back, arms
Pale patches may be more common in darker skin (pityriasis versicolour alba)
Risk factors: hot, humid climates; sweaty
Diagnosed clinically and on wood lamp (black light) exam -> yellow-green fluorescence
8
Q
What factors would you assess for to estimate severity in a respiratory presentation/croup for a child?
A
- Decreased level of consciousness
- Stridor at rest
- Tachypnoea
- Moderate use of accessory muscles of respiration
9
Q
What are the indicators of severe croup?
A
- Increased agitation/drowsiness
- Persistent stridor at rest
- Marked increase or decrease in respiratory rate
- Marked chest wall retraction
10
Q
Management of mild croup?
A
- Prednisolone 15mg STAT PO
- Advise to attend Emergency Department if he develops stridor ar rest/increased work of breathing
11
Q
Management of severe croup?
A
Pharmacological:
* Adrenaline 0.1% 5mL via nebuliser as a single dose (adrenaline 1:1000 solution 0.5mL/kg, max 5mL (5mg))
* Dexamethasone 9mg STAT PO/IM
Non-pharmacological:
* Arrange urgent hospital transfer via ambulance
* Allow patient to sit in a comfortable position
* Minimise handling
* Keep patient with parent/carer to reduce stress
* Update parent on management plan
12
Q
Management steps for dealing with a patient who is upset? (e.g. context of croup)
A
- Empathetically listen to concerns
- Explain the nature of the illness and how severity can change
- Discuss the case with medical defence organisation
- Offer to discuss the complaint with the practice manager
- Apologise for the unexpected outcome
- Carefully document the complaint and the discussion in the patient file
13
Q
What are the management options for a suspected squamous cell carcinoma?
A
- Excisional biopsy with 3-5mm margins
- Curettage with cautery OR electrodessication with 1-2mm margin with curative intent
- Punch biopsy to establish diagnosis OR incision biopsy to establish diagnosis
14
Q
Which one goes faster: Squamous cell carcinoma or basal cell carcinoma?
A
Squamous cell carcinoma grows rapidly faster
15
Q
When is postoperative adjuvant radiotherapy recommended after excision of squamous cell carcinoma (ie high risk of metastasis)?
A
- Margins are positive (ie. incomplete excision)
- Histopathology shows poor differentiation or other high risk histological subtypes, or perineural or lymphovascular invasion
- Depth of tumour invasion is greater than 4mm
- Tumour is more than two centimetres in diameter
- The SCC is recurrent
- The SCC is in a high risk site (e.g. head and neck, especially lip and ear, genitalia)
16
Q
What risks would you discuss in the consenting process for a skin lesion biopsy?
A
- Risk of bleeding
- Risk of infection
- Risk of prolonged healing time or wound breakdown
- Risk of postprocedural pain
- Risk of scarring
- Risk of requiring repeat procedure if inadequate margins
- Risk of recurrence of the lesion
- Risk of damage to surrounding structures of biopsy site / skin numbness / nerve damage / reaction to anaesthetic
17
Q
When should oral antihyperglycaemic medications, except SGLT2i and injectable GLP1 RAs, be withheld for a procedure?
A
On the morning of procedure
18
Q
When should SGLT2i be withheld for a surgery?
A
3 days prior to surgery
19
Q
When should SGLT2i be withheld for a larger procedure e.g. endoscopy/colonoscopy?
A
2 days prior
20
Q
When should SGLT2i be withheld for a day procedure e.g. gastroscopy?
A
Morning of the procedure
21
Q
When should apixaban/anticoagulant be withheld for a surgery?
A
48-72 hours prior
22
Q
Do DOACs need to be withheld for procedures with minimal risk of bleeding (eg minor dental extractions, skin excisions of less than one cm, cataract procedures)?
A
No, interruption of DOAC therapy is usually not needed
23
Q
Which procedures count is high bleeding risk when assessing the need to withhold DOAC therapy?
A
- Any surgery or procedure with neuraxial anaesthesia (spinal or epidural)
- Neurosurgery (intracranial or spinal)
- Cardiac surgery (eg CABG, heart valve replacement)
- Major vascular surgery (eg aortic aneurysm repair, a auto femoral bypass)
- Major orthopaedic surgery (eg hip/knee joint replacement surgery)
- Lung section
- Urological surgery
- Extensive cancer surgery
- Intestinal anastamosis surgery
- Reconstructive plastic surgery
24
Q
Management options for palmoplantar hyperhidrosis?
A
First line:
* Aluminium dichlorohydrate 20% OR aluminium chloride 15% antiperspirant
* Iontophoresis - introduction of ionised substances through intact skin by the application of direct current
Second line:
* Oxybutynin - use for generalised hyperhidrosis, can be used if vocal treatments fail
* Propantheline - use for generalised hyperhidrosis, can be used if vocal treatments fail
* Glycopyrrolate - usually via dermatologist, can be topical or in iontophoresis
* Botulinum toxin injection - expensive and painful
* Surgical sympathectomy - last resort, high risk of recurrence an compensatory sweating in previously unaffected areas
25
Secondary causes of hyperhydrosis (e.g. Sweating occurs at night during sleep, or is not consistent with primary hyperhidrosis)?
* Fever
* Chronic infection eg endocarditis
* Endocrinopathy eg hyperthyroidism, diabetes, pheochromocytoma
* Certain neurological conditions eg parkinson's disease
* Drugs Eg antidepressants
* Malignancy eg lymphomas
* Raynaud phenomenon
* Trauma Eg after surgery (Frey syndrome), spinal cord injury
Note: in practise, only hyperthyroidism routinely needs to be excluded, because the other triggers usually present with specific symptoms
26
Management options for generalised hyperhidrosis?
* Oxybutynin 2.5-5mg daily PO initially OR
* Propantheline 15-30mg BD PO initially
27
What are the clinical differences between urticaria and erythema multiforme?
Urticaria:
* Nontarget lesions (central pallor)
* Itchy
* Migratory
28
What questions should you ask when evaluating the possible cause of a rash such as urticaria?
* Previous episodes of the rash
* Timing of rash in relation to food intake or recent introduction of new foods
* Recent coryza or rhinorrhea or cough or fever
* Contact with animals or plants
* Recently changed soap or laundry detergent
* Recent insect bite or sting
* Relationship of rash to exercise
* Associated abdominal pain or diarrhoea or breathing difficulty - anaphylaxis
29
How long does chronic urticarial last for?
Chronic urticaria occurs most days for more than six weeks
30
What are the causes of urticaria?
* Idiopathic
* Infection: viral
* Allergy: food, medication, insect sting, exercise
* Contact and irritant dermatitis eg plants, animals, latex
* Physical triggers Eg pressure, heat, cold, exercise
* Systemic diseases eg autoimmune, connective tissue and lymphoproliferative disorders
31
First line pharmacological management options for urticaria?
* Cetirizine PO - non-sedating antihistamines are first line
* Fexofenadine PO
* Loratadine PO
* Desloratadine PO
32
Management options for acute urticaria?
* Most cases only last for a few days or weeks and resolve without any treatment
* Remove identifiable triggers
* Avoid aggravating factors eg excessive heat or spicy foods
* Avoid NSAIDs as they often make symptoms worse
* Cool compress
* Antihistamines to alleviate itching: cetirizine (non-sedating), loratidine
* In severe cases not responding to antihistamines: single dose oral prednisone
* Leukotriene antagonist: montelukast (short term trial)
* Histamine H2-receptor antagonists (consider trial while awaiting specialist appointment and consideration for omalizumab and other treatments): famotidine, nizatidine
* Doxepin (adults only)
33
Describe urticaria
* Characterised by transient erythematous lesions that vary in size and often oedematous
* Superficial swellings tend to be itchy, while deeper swellings can be painful
* Episodes of urticaria involve individual lesions coming and going
* Consider anaphylaxis if urticaria is associated with respiratory, gastrointestinal or cardiovascular symptoms
* If individual lesions persist for more than 24 hours, and are not itchy, consider urticarial vasculitis, erythema multiforme and erythema nodosa
34
Differential diagnosis for mild cognitive impairment / forgetfulness?
* Dementia
* Delirium secondary to urinary tract infection or pneumonia
* Major depression
* Alcohol intoxication or withdrawal
* Cerebrovascular accident
* Subdural hematoma
* Brain cancer
* Normal pressure hydrocephalus
* Vitamin b12 deficiency
* Hypothyroidism or hyperthyroidism
* Hyponatremia
35
Pharmacological management options for mild alzheimer's dementia?
* Donepezil PO
* Galantamine PO
* Rivastigmine TOP
36
What are some side effects of acetylcholinesterase inhibitors used for alzheimer's dementia?
* GI - nausea, vomiting, anorexia
* Weight loss
* Vivid dreams
* Urinary incontinence
* Tremor
* Cramps
* Bradycardia
* Dizziness
* Drowsiness
37
What investigations are required to exclude reversible causes of dementia?
* Full blood count - to exclude anaemia infection
* Electrolytes, urea, creatinine and calcium - to exclude various metabolic disturbances and organ failure
* Liver biochemistry
* Blood glucose concentration - to exclude hyperglycemia or hypoglycemia
* Thyroid function tests - to exclude hypothyroidism or hyperthyroidism
* Vitamin b12 and folate concentrations - To exclude deficiency
* If at risk of STI: serology syphilis and human immunodeficiency virus
* Cerebral imaging - To exclude other neurological pathologies eg cerebral space occupying lesions, normal pressure hydrocephalus, and determine dementia subtyping
38
Non pharmacological long term considerations for dementia management?
* Refer to My Aged Care for an assessment
* Recommend appointing an Enduring Power of Attorney / Enduring guardian
* Advise patient they are legally required to inform the Driver Licencing Authority of their diagnosis of dementia
* Recommend organising a webster pack or home medicines review
* Refer to National Dementia Helpline / Dementia Australia website for advice about support / services
* Encourage to maintain social activities
* Encouraged to exercise for 30 minutes on most days
* Recommend regular routine or schedule
* Recommend the use of timers or alarms or calendar - memory aids
39
What screening questions would you ask when suspecting a high risk of falls in a patient?
* Have you had two or more falls in the last 12 months?
* Are you presenting following a fall?
* Are you having difficulty with balance?
* Are you having difficulty with walking?
Note: if any are positive, complete a multifactorial risk assessment including obtaining relevant medical history, completing a physical examination, and performing cognitive and functional assessments
40
How is severity of obstruction on spirometry reading graded?
By Z score which is the number of standard deviation from the median.
* Mild: -1.65 to -2.5
* Moderate: -2.51 to -4.0
* Severe: < -4.1
41
What is the definition of a positive bronchodilator response in adults and adolescents 12 years or older?
Post bronchodilator FEV1 (and/or FVC) increased by at least 10% of predicted value.
42
In a patient with asthma or COPD, aside from titrating inhaled medications, how would you address poor response to Pharmacotherapy?
* Check inhaler technique
* Assess adherence to their inhalers
* Recommend smoking cessation
* Suggest using a spacer with inhalers to improve delivery of medications
* Create a written asthma action plan
* Explore the possibility of occupational triggers such as dust
* Assess for comorbidities such as gastroesophageal reflux disease
43
What comorbidities may worsen asthma control or contribute to the risk of exacerbations?
* Obesity
* Gastroesophageal reflux
* Rhinitis and rhinosinusitis
* Inducible laryngeal obstruction
* Anxiety and depression
44
What are some indications for referral to a respiratory physician for a patient with asthma?
* Following a life threatening asthma exacerbation requiring admission to hospital
* For suspected occupational asthma
* Frequent asthma requiring emergency department review or urgent general practitioner visits
* Moderately severe obstructive airways disease OR not responsive to maximal therapy
* Assessment for suitability of home oxygen therapy
* Frequent chest infections
* Not responding to asthma management plan
45
Discussion points required before starting denosumab for osteoporosis?
* Emphasise importance of adhering to six monthly administration - due to increase risk of vertebral fractures if delayed more than four weeks
* Explained the rare risk of osteonecrosis of the jaw after dental surgery OR advised to complete any major dental work prior to starting therapy OR educate patient to advise dentist that they will commence denosumab / explain the rare risk of atypical fracture of the femur
* Educate the denosumab is to be taken lifelong = Can be tapered with help of bisphosphonates
* Explain the need to check calcium OR vitamin d levels OR renal function levels before first dose / Explain treatment may cause hypocalcemia OR ensure adequate calcium intake of 1300 mg per day
* Explain that treatment reduces risk but does not completely prevent fracture OR a change in therapy may be required if fracture occurs with treatment
* Monitoring of bone mineral density response with Dual energy xray absorptiometry in two years
46
In patients at risk of hypocalcemia, what parameters should be measured before each dose
* Vitamin D: aim greater than 50
* Corrected calcium: aim normal range (2.1-2.6)
* Creatinine clearance: aim greater than 3mL/min
47
What are some reasons for why it is important to offer a 16 year old a private consultation without their parent/carer?
* You may not be able to get an accurate history about sensitive issues from the patient in the presence of another person / they may not be comfortable giving information with their parent present
* Patient may feel coerced to agree to form of treatment in the presence of another person
* Seeing the patient alone will promote their access to healthcare
* Seeing the patient alone will help to develop the doctor patient relationship
* Seeing the patient alone will reinforce their developmental need for autonomy
* You may not be able to make an assessment of competency with another person contributing to the consultation
48
What is the definition of heat stroke?
An elevated core body temperature, usually in excess of 40.5°c, with associated central nervous system dysfunction (e.g. altered mental status) in the setting of a large environmental heat load that cannot be dissipated
49
What are the types of heat stroke?
* Non-exertional heat stroke: patients have a chronic medical condition that impairs thermoregulation, prevents removal from a hot environment, or interferes with access to hydration or attempts at cooling
* Exertional heat stroke - generally occurs in young, otherwise healthy individuals who engage in heavy exercise during periods of high ambient temperature in humidity
50
What is heat exhaustion compared to heat stroke?
Heat exhaustion is when core temperature is also elevated but never above 40°c and mental status always remains normal
51
What history questions would you ask for intermenstrual bleeding?
* Length or regularity of menstrual cycle
* Timing or frequency of intermenstrual bleeding - cyclical mid cycle bleeding can occur
* Clotting or volume of intermenstrual bleeding - spotting or heavy
* Post coital bleeding - cervical cancer
* Dyspareunia - pain and bleeding could be secondary to vulval disorders, deep dyspareunia can also be a symptom of endometriosis which can cause intermenstrual or premenstrual spotting
* Abnormal per vaginal discharge / Pelvic pain / Condom use / Past history of chlamydia or gonorrhoea - PID or increased risk of STI
* Possibiility of pregnancy
* Heat OR cold intolerance / Constipation - Thyroid dysfunction
* Easy bruising / bleeding from the gums - Coagulopathy
* Family history of endometrial cancer
52
Differentials for intermenstrual bleeding?
* Cervical or uterine polyp
* Cervical ectropion
* Cervicitis secondary to chlamydia or gonorrhoea or herpes simplex virus / pelvic inflammatory disease secondary to chlamydia or gonorrhoea
* Cervical cancer
* Endometrial cancer / endometrial hyperplasia
* Von willebrand disease
* Leiomyoma or uterine fibroid
* Threatened miscarriage
53
What are some indications for performing the cervical co-test?
* Intermenstrual bleeding
* Post coital bleeding
* Post menopausal bleeding
* Unexplained persistent unusual vagina discharge - especially if offensive or bloodstained as may be associated with cervical cancer
* Follow up of previous high grade changes / follow up post LLETZ procedure / following treatment of adenocarcinoma in situ
* Diethylstilbestrol exposure in utero
54
How often should women exposed to diethylstilbestrol in utero be offered co-test and colposcopic examination of both the cervix and vagina?
Annually indefinitely
55
What strategies can you use to make a patient feel less nervous for a speculum examination?
* Offer a chaperone during the examination
* Allow patient to undress behind the curtain / leave the room while patient is undressing
* Cover their pelvis or genital region with a sheet during the examination
* Run the speculum underwater for lubrication
* Ask if the patient would prefer the door unlocked or locked
* Provide the patient with options on positioning such as lateral decubitis position (good for high BMI)
* Offer for the patient to insert the speculum
56
What do you ask on history for suspected psychosis?
* Auditory or visual or tactile hallucinations
* Recreational drug use
* Ideas of reference or thought broadcasting or thought insertion
* Depressed mood or reduced appetite or anhedonia - psychotic depression
* Panic attacks or anxiety
* Recent major stressful event - PTSD
* Manic or hypomanic episodes / insomnia - BPAD
* Family history of psychosis
* Past history of psychosis
* Weight loss or fever or night sweats - organic pathology
57
What is the time frame for schizophreniform disorder?
Symptoms between 1-6 months
58
What is the time frame for schizophrenia?
At least six months of symptoms needed to be formally diagnosed
59
What is the time frame for substance induced psychotic disorder?
usually <4 week duration
60
What is the time frame for brief psychotic disorder?
Symptoms lasting between one day to one month
61
What are some common side effects of antipsychotics such as risperidone?
* Cardiometabolic effects
* Hyperprolactinemia
* Orthostatic hypotension
* QT interval prolongation
* Anticholinergic effects e.g. dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils
* Extrapyramidal effects e.g. dystonia, akathisia, tardive dyskinesia
* Sedation
62
What monitoring is required for antipsychotics?
* Blood pressure and heart rate - every six months
* Fasting blood glucose an hba1c - every six months
* Fasting lipids - Every six months
* Weight, waist circumference and BMI - every six months
* ECG annually
* Full blood count annually - for leukopenia and agranulocytosis
* Assess for extrapyramidal side effects - every six months
* Prolactin Annually
* Assess for sexual and reproductive problems annually
63
What features on history would support paediatric obstructive sleep apnea?
* Snoring more than or equal to three nights per week
* Restless or agitated sleep
* Increased work of breathing overnight
* Observed apneas or pauses in breathing overnight
* Night sweats
* Daytime sleepiness
* Morning headache
* Hyperactivity or difficulties with behaviour / Problems with learning at school
* Secondary enuresis
* Recurrent tonsillitis
64
What are some common causes of nasal obstruction causing mouth breathing in school age children?
Anterior nasal obtruction
* Rhinitis (allergic or non-allergic)
* Inferior turbinate hypertrophy
* Deviated nasal septum
Middle nasal obstruction
* Nasal polyposis (rare)
Posterior nasal obstruction
* Adenoid hypertrophy
65
What is your approach to assessing nasal obstruction?
Assess OSA risk:
* Snoring
* Restless sleep
* Bed wedding
* Choking or gasping noises
* Irritability
* Poor concentration
Assess severity of nasal obstruction:
* Mouth breathing during day and/or night
* Coughing
* Regular throat clearing
Trauma to the nose
Assess for allergic rhinitis:
* Itching
* Sneezing
* Running or blocked noise
* Itchy red, watery eyes
If present, assess the severity of allergic rhinitis:
* Seasonal/Perennial
* Chronic/Intermittent
* Worse at night or morning
Ask about features of atopy:
* Eczema
* Asthma
* Food allergies
* Family history of atopy
Ask about associated dental issues or speech issues:
* Grinding teeth (Bruxism)
* Orthodontic treatments Eg maxillary expanders, crowded lower teeth, tongue-thrusting
66
What physical exam findings would you search for to find an underlying cause of paediatric obstructive sleep apnea?
* Boggy inferior turbinates / nasal mucosal inflammation
* Tonsillar hypertrophy
* Long or narrow face - Adenoid face is suggestive adenoidal hypertrophy
* Retrognathia OR microngathia
* Obesity
* Deviated nasal septum
67
What are important aspects of clinical examination in a child who mouth breathes?
General examination
* Hyperactivity, restlessness
* Forward slumped posture
* Dry lips
* Receding chin
Nose
* Nasal crease
* Deviated septum
* Pale, buggy inferior turbinates, Degree of anterior nasal obstruction and mucus
Eyes
* Allergic conjunctivitis
* Venous pooling (allergic shiners) - dark, discolored circles under your eyes that may look like black eyes (bruises)
Oral
* High arched palate
* Narrow palate
* Crowded lower teeth
* Tonsillar size
Eyes
* Glue ear or middle ear effusion or retracted eardrum
Chest
* Wheeze
* Poor air entry
* Respiratory distress
68
What are some common causes of obstructive sleep apnea in children?
* Allergic rhinosinusitis
* Adenoid or tonsillar hypertrophy
* Obesity
* Micrognathia OR mandibular hypoplasia - associated with conditions such as Down syndrome and Foetal Alcohol Syndrome
69
List points of discussion for parents who are concerned about the use of both inhaled corticosteroids and intranasal steroids (e.g. for asthma and allergic rhinosinusitis)
* Reassure that concurrent use of inhaled corticosteroids and intranasal corticosteroids are safe
* Discuss that inhaled corticosteroids can also improve allergic rhinitis symptoms
* Discuss that inhaled corticosteroids are important for maintaining asthma control
* Recommend the use of nasal oil to prevent dryness or crusting or the nasal mucosa
* Advise that nose bleeds are a common side effect of intranasal corticosteroids
* Discuss optimal spray technique
70
What are some common side effects of intranasal corticosteroids?
* Nasal stinging
* Itching
* Nosebleed
* Sneezing
* Sore throat
* Dry mouth
* Cough
71
Differentials for intermittent dysuria and burning sensation in the labia?
* Vulvovaginal candidiasis
* Irritant contact dermatitis / allergic contact dermatitis
* Atopic dermatitis
* Vulvodynia OR vestibulodynia
* Atrophic vaginitis
* Lichen sclerosis
* Lichen planus
* Psoriasis
72
Differentials for vulvovaginitis?
* Inadequate arousal
* Vulvovaginal atrophy - related to menopause
* Bacterial vaginosis
* Candidal vulvovaginitis
* Retained foreign body
* Irritation
* Dermatoses - e.g. dermatitis, lichen sclerosis, psoriasis
* Trichonoonas vaginalis
73
Trichomoniasis: cause and symptoms?
Cause: Trichomonas vaginalis
Symptoms:
* Vulval itch
* Inflamed vagina and cervix
* Vagina discharge that maybe yellow green and frothy with inoffensive fishy odour
74
Management options for candidal vulvovaginitis?
* Clotrimazole 1% cream 1 applicatorful intravaginally nocte for 6 nights
* Clotrimazole 2% cream 1 applicatorful intravaginally nocte for 3 nights
* Clotrimazole 10% cream 1 applicatorful intravaginally nocte for 1 night
* Clotrimazole 100mg pessary intravaginally nocte for 6 nights
* Clotrimazole 500mg pessary intravaginally nocte for 1 night
* Fluconazole 150mg PO stat
75
Symptoms and signs of candidal vulvovaginitis?
* Genital or vulval itch or discomfort, sometimes with pain
* Red rash on the vulva
* White curd like vaginal discharge
* Superficial dyspareunia
* External dysua
* Excoriation
* Featuring
* Erythema
* Swelling
76
What is the treatment for Candida glabrata (AKA Nakaseomyces glabrata) vulvovaginitis?
Nystatin 100,000 units/5g vaginal cream 1 applicatorful intravaginally, once daily at bedtime for 14 nights
77
What is the definition of recurrent acute candidal vulvovaginitis?
Four or more acute episodes of candidal vulvovaginitis in a year, with at least two of these episodes confirmed by microscopy or culture
It's thought to be related to host factors:
* Immunocompromised
* Recently used antibiotics
* Used exogenous estrogen (endogenous estrogen can also contribute)
* Diabetes and glycaemic targets are not achieved
78
Treatment of recurrent acute candidal vulvovaginitis, especially if Candida albicans is confirmed?
Fluconazole 150mg PO, on day 1, day 4 and day 7, followed by fluconazole 150mg PO once a week for 6 months
79
Non pharmacological management for candidal vulvovaginitis?
* Wear cotton underwear
* Wash clothing in unperfumed to laundry detergent
* Avoid wearing tight fitting pants
* Avoid using soap or shampoo on the vulva / Wash the vulva with water only
* Wash hands before touching vagina
* C supplying tea tree oil on volvo
80
Possible complications of vulval lichen sclerosis?
* Squamous cell cast member of the vulva
* Anatomical distortion of the vulva resulting in stenosis of the introitus or fusion of the labia minora
81
What is lichen sclerosis?
* Lichen sclerosis is a chronic inflammatory dermatosis commonly affecting the anogenital region
* Characterised by White sclerotic patches that subsequently coalesce, becoming shiny personal white or ivory white colour
82
Clinical manifestations of lichen sclerosis of the vulva?
* Pruritus (often intractable), pain and bleeding from fissuring and erosion
* Dyspareunia near another sexual dysfunction
* Atrophy and distortion of anatomical structures including burying of the clithoris, fusion of loss of labia minora, stenosis of the introitus
* Constipation and painful defecation if perianal skin is involved
83
What autoimmune related diseases are associated with lichen sclerosis?
* Thyroid disease
* Vitiligo
* Alopecia areata
* Pernicious anaemia
84
Treatment of lichen sclerosis of the vulva?
* Potent topical corticosteroids eg betamethasone dipropionate 0.05% ointment Used at least two to three times weekly
* In patients with coexisting menopausal vulval atrophy, topical oestrogen is sometimes used as an adjunct therapy
85
What are some key indicators of poor prognosis in patients with rheumatoid arthritis
* High rheumatoid factor titer / positive anti-CCP antibody
* Raised inflammatory markers (crp or esr )
* Swelling in more than 20 joints
* Impaired function early in disease
* Bony erosions evident on x rays early in disease
* Smoking
86
What are some features suggesting rheumatoid arthritis?
* Early morning stiffness lasting longer than one hour
* Symmetry in areas affected
* Rheumatoid factor positive
* Anti-CCP antibody test positive
* Raised inflammatory markers e.g. CRP or ESR, in absence of infection
* Swelling in five or more joints
* Bilateral compression tenderness of the metatarsophalangeal joints
* Symptoms present for longer than six weeks
* Family history of inflammatory arthritis
* Bony erosions evident on x rays of the risk, hands or feet (uncommon in early disease)
* Presence of rheumatoid nodules
87
In the management of rheumatoid arthritis, what would signify remission?
* Sustained normalisation of ESR or CRP
* Resolution of joint pain OR joint stiffness
* Absence of joint swelling
88
What would you continue to monitor in a patient with rheumatoid arthritis?
* Joint effects: number, tenderness and swelling
* Extra-articular eg nodules and rash
* Cardiovascular disease: blood pressure and other risk factors, and renal function
* Risk of infection (immunomodulators)
* Toxicity: monitoring (eg skin, lungs, GIT, heart, blood and/or urine tests)
* Lifestyle eg smoking, wait, bmi
* Activities of daily living eg function, sleep, mood, fatigue
* Annual foot review
* Medication adherence
* If long-term corticosteroids, review osteoporosis risk, blood pressure, lipids, cataracts
89
What would you discuss before prescribing methotrexate as a continuing script if the patient couldn't get it from their specialist?
* Confirm patients adherence with the dosing regimen - weekly
* Recommend safe alcohol consumption of no more than one standard drink per day - alcohol increases the risk of hepatic toxicity and side effects of methotrexate
* Ensure patient is aware that methotrexate is teratogenic
* Discuss drug interactions with folic acid antagonists eg trimethoprim
* Confirm she is taking folic acid supplement - folic acid reduces the incidence of adverse effects
* Discuss the ongoing requirement for regular monitoring of liver function OR kidney function OR full blood count - risk of hepatotoxicity, nephrotoxicity, leukopenia, thrombocytopenia
* Assess level of joint pain or swelling or symptom severity
* Assess whether vaccinations are up to date
* Discuss safe sun protection strategies - due to risk of photosensitivity
* Advise to seek medical advice about withholding methotrexate in the event that they develop concurrent illness or require surgery
* Assess for diarrhoea OR alopecia - side effects of methotrexate
90
When should live vaccines be given to patients on immunomodulatory drugs?
They should be given at least four weeks before starting Immunomodulatory therapy
91
What is low level immunosuppression defined as:
- Prednisone
- Methotrexate
- Azathioprine
- Prednisone: < 20mg/day
- Methotrexate: <0.4mg/kg/week
- Azathioprine: <3mg/kg/day
92
What is the shingrix vaccination schedule for immunocompromised adults?
2 injections, 1-2 months apart
93
What questions on history would you ask for returned traveller with a fever?
* Patterns of fevers
* History of mosquito bites / compliance with malaria prophylaxis
* Contact with native wildlife
* Any history of sick contacts
* History of intravenous drug use or new tattoos - Blood borne viruses
* History of dysuria or penile discharge or penile ulcer/lesion during trip - STI
* History of unexplained rash during trip
* History of diarrhoea or blood in stool or abdominal pain - gastrointestinal infection
* History of freshwater swimming
* Consumption of unwashed vegetables or salads or street food or untreated water
* Arthralgia or myalgia
* Cough or coryza or conjunctivitis
* History of swollen glands - Lymphadenopathy
* History of retro-orbital headache or breathing abnormally or yellowing of skin - Dengue fever
94
Fever in the recently returned traveller PLUS clinical feature:
- Rashes/skin lesions
* Dengue
* Typhoid
* Rickettsial infection
* Measles
* Leptososis
* Syphilis
* Gonorrhoea
* Brucellosis
* Chikungunya
95
Fever in the recently returned traveller PLUS clinical feature:
* Eschar
* Rickettsial infections
* Borrelia
* Crimean-congo hemorrhagic fever
96
Fever in the recently returned traveller PLUS clinical feature:
* Hepatomegaly
* Malaria
* Typhoid
* Dengue
* Viral hepatitis
* Amoebiasis
* Leptospirosis
97
Fever in the recently returned traveller PLUS clinical feature:
* Splenomegaly
* Malaria
* Typhoid
* Mononucleosis
* Trypanosomiasis
* Brucellosis
* Dengue
* Kala-azar
98
Fever in the recently returned traveller PLUS clinical feature:
* Acute abdomen or GI haemorrhage
Typhoid
99
Fever in the recently returned traveller PLUS clinical feature:
* Cough, coryza, conjunctivitis
* Respiratory viruses
* Measles
100
Fever in the recently returned traveller PLUS clinical feature:
* Jaundice
* Viral hepatitis
* Measles
101
Fever in the recently returned traveller PLUS clinical feature:
* Lymphadenopathy
* Rickettsia
* Toxoplasmosis
* Brucellosis
* HIV
* Mononucleosis
* Visceral leishmaniasis
102
Fever in the recently returned traveller PLUS clinical feature:
* Petechiae
* Meningococcal disease
* Viral haemorrhagic fever
* Rickettsia
103
Fever in the recently returned traveller PLUS clinical feature:
* Haemorrhage
* Dengue
* Meningococcaemia
* Lassa fever
* Marburg or Ebola
* Crimean-Congo virus
* Yellow fever
* Rocky Mountain Spotted Fever
104
Fever in the recently returned traveller PLUS clinical feature:
* Altered conscious state, lethargy, meningism
* Cerebral malaria
* Meningitis
* African trypanosomiasis
105
Fever in the recently returned traveller PLUS clinical feature:
* Fever persisting >2 weeks
* Malaria
* Enteric fever
* EBV
* CMV
* Toxoplasmosis
* Acute HIV
* Acute schistosomiasis
* Brucellosis
* Tuberculosis
* Q fever
106
What clinical features do you look for in a recently returned traveller with fever?
* Rashes/skin lesions
* Eschar
* Hepatomegaly
* Splenomegaly
* Acute abdomen or GI haemorrhage
* Cough, coryza, conjunctivitis
* Jaundice
* Lymphadenopathy
* Petechiae
* Haemorrhage
* Altered conscious state, lethargy, meningism
* Fever persisting more than two weeks
107
Differentials for fever in a recently returned traveller with a rash taking malaria prophylaxis?
* Secondary syphilis
* Measles
* Chikungunya
* Dengue fever
* Zika virus infection
* Acute HIV seroconversion
* Typhoid or enteric fever
* Rubella
* Rickettsial infection
* Doxycycline rash
108
What are some common causes of travel related fever?
Infectious
* Malaria
* Influenza
* Dengue fever
* Rickettsial infection
* Non specific viral syndromes
* Bacterial diarrhoea
Non-infectious
* Pulmonary emboli
* Drug reactions
109
Clinical features of dengue fever?
* Headache
* Retro orbital pain
* Marked muscle and bone pains
* Fever
* Rash
110
Clinical features of chikungunya?
* Acute febrile polyarthralgia and myalgia
* Maculopapular rash
111
Clinical features of zika virus?
* Fever
* Rash
* Headache
* Arthralgia
* Myalgia
* Conjunctivitis
112
Clinical features of rickettsial infection?
* Fever and rash
* Eschar
* Lymphadenopathy
113
Clinical features of Enteric fever?
* Abdominal pain
* Fever
* Chills
* Rose spots: faint salmon-coloured macules on the trunk and abdomen
114
Clinical features of acute human immunodeficiency virus infection?
* Fever
* Lympphadenopathy
* Sore throat
* Rash
* Myalgia/arthralgia
* Headache
115
Clinical features of measles?
* Fever
* Rash
* Cough
* Coryza
* Conjunctivitis
* Pneumonia is a possible complication
116
Clinical features of meningococcal infection?
* Fever
* Nausea
* Vomiting
* Headache
* Confusion
* Myalgia
* Non-blanching purpuric rash
117
Management of secondary syphilis?
* Benzathine penicillin 1.8g (or 2.4million units) IM stat
* Advise my sexual contact for seven days after treatment is administered
* Contact tracing for sexual partners over the past six months
* Notify Public health department
* Avoid sexual contact with partners from last six months until they are tested/treated
* Explain possible transient fever/rigors/arthralgia/reaction with commencing treatment is harmless (+/- Jarisch-Herxheimer reaction)
Note: Presumptively treat all sexual contacts from the last three months of patients with primary or secondary syphilis regardless of serology with Benzathine penicillin 1.8g (or 2.4million units) IM stat
118
Management of late syphilis or syphilis of unknown duration?
* Benzathine penicillin 1.8g (or 2.4million units) IM stat weekly for 3 weeks
* Advise my sexual contact for seven days after treatment is administered
* Contact tracing for sexual partners over the past 12 months
* Notify Public health department
* Avoid sexual contact with partners from last six months until they are tested/treated
* Explain possible transient fever/rigors/arthralgia/reaction with commencing treatment is harmless (+/- Jarisch-Herxheimer reaction)
119
What is the test of cure procedure for syphilis?
Review all patients clinically and with repeat RPR testing at three months, then at six months and (if necessary) at 12 months after completing treatment
120
How does ear barotrauma occur?
On descent from a high altitude (e.g. flying), atmospheric pressure increases. If middle ear pressure cannot increase at the same time (e.g. eustachian tube dysfunction), the tympanic membrane is forced medially and stretched, which can cause bruising or bleeding into the tympanic membrane.
121
Clinical features of ear barotrauma?
* Ear pressure
* Pain
* Hearing loss
* Tinnitus
* Blocked ear
* Vertigo
* Tympanic membrane retraction
* Fluid build up
122
Management of acute sudden onset sensorineural hearing loss?
Prednisone 1mg/kg (max: 60mg) daily PO for 7-14 days
123
Causes of sudden onset sensorineural hearing loss?
* Idiopathic - most cases
* Tumour (vestibular schwannoma, leukaemia, myeloma)
* Vascular (cerebrovascular disease, sickle cell disease)
* Neurological (multiple sclerosis, cerebrovascular accident, migraine)
124
What investigation is required in the workup for sudden onset sensorineural hearing loss?
MRI with gadolinium contrast of the internal acoustic meatus and brain is essential in unilateral or asymmetrical SNHL to exclude a vestibular schwannoma
125
Clinical features of OSA in children?
Nocturnal signs and symptoms:
* Night waking
* Enuresis
* Gasping
* Sweating
* Mouth breathing
Daytime signs and symptoms:
* Mouth breathing
* Hyperactivity
* Poor attention
* Poor school performance
* Daytime somnolence
Peak incidence: 2-7 years old
Adenotonsillar hypertrophy
126
What pharmacotherapy may help reduce symptoms of OSA in children?
Mometasone 50microg in each nostril daily for 4-6 weeks INH
127
Clinical features of hypnic headache/alarm clock headache?
* Age 50+
* Bilateral dull/throbbing headache
* Awakes from sleep
* Occurs only during sleep and causes awakening
* Treatment: caffeine, indomethacin or lithium
128
Differentiate between the location of upper motor neuron and lower motor neuron lesions
* UMN: above the anterior horn cell
* LMN: from the anterior horn cell and below
129
Describe motor neurone disease
* Progressive neuromuscular disorder resulting in muscular limb and bulbar weakness due to death of motor neurones in the brain, brain stem and spinal cord
* The sensory system is not involved, nor the cranial nerves to the eye muscles
130
Cause of motor neurone disease?
* 5-10% inherited
* Remaining are sporadic
131
What are the patterns of motor neurone disease?
1. Amyotrophic lateral sclerosis - combined LMN muscle atrophy AND UMN hyperreflexia, leading to progressive spasticity
2. Progressive muscle atrophy - wasting beginning in the distal muscles; widespread fasciculations
3. Progressive bulbar (LMN) palsy and pseudobulbar palsy (LMN lesions in the brainstem motor nuclei) - results in wasted fibrillating tongue, weakness of chewing and swallow and of facial muscles
132
Most likely diagnosis for intermittent pain on the left side of the face? It is shooting and brief, occurring over the jaw and cheek. Sudden onset with no other symptoms.
Left sided trigeminal neuralgia
133
Pharmacotherapy for trigeminal neuralgia?
* First line: carbamazepine MR 100mg BD PO
* Second line: oxcarbazepine 300mg BD PO
134
What imaging is needed to exclude sinister causes of trigeminal neuralgia?
CT with specific views of the trigeminal nerve and ganglion
135
Clinical features of Meniere's disease?
Classic triad of symptoms: episodic vertigo, tinnitus and hearing loss
Clinical diagnosis based on the following criteria:
* Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours
* Audiometrically documented low- to mid-frequency sensorineural hearing loss in the affected ear
* Fluctuating aural symptoms (reduced or distorted hearing, tinnitus, or fullness) in the affected ear
* Symptoms not better accounted for by another vestibular diagnosis
136
Differential diagnoses for Meniere's disease?
* Vestibular schwannoma
* Multiple sclerosis
* Transient ischaemic attacks
* Vestibular migraine
* Benign paroxysmal positional vertigo
* Cogan's syndrome
137
Management of Meniere's disease?
* Lifestyle modification - salt restriction (no more than 3g/day), limiting caffeine and alcohol consumption (maximum 1 of each beverage daily)
* Vestibular rehabilitation
* Pharmacotherapy: diuretics (HCT)
138
What is a Tympanogram Type A?
Normal
139
What is a Tympanogram Type B?
Advanced otitis media with fluid
140
Which patient populations require antibiotic therapy for otitis media?
* Infants younger than 6 months
* Children younger than 2 years with bilateral infection
* Children who are systemically unwell (e.g. lethargic, pale, very irritable)
* Children with otorrhoea
* Aboriginal and Torres Strait Islander children at high risk
* Children at high risk of complications e.g. immunocompromised
ATSI high risk:
* Living in remote communities
* Less than 2 years and/or who have had their first episode of otitis media before 6 months of age
* Persistent otitis media with effusion
* Current or history of bilateral acute otitis media without perforation
* Current or history of bilateral acute otitis media with perforation
* Current or history of chronic suppurative otitis media
* Family history of chronic suppurative otitis media
* Craniofacial abnormalities
* Cleft palate
* Down syndrome
* Immmunodeficiency
* Cochlear implants
* Developmental delay
* Hearing loss
* Severe visual impairment
141
When is augmentin indicated in the management of otitis media?
* If a child has not responded adequately to amoxicillin therapy by 48-72 hours (may have infection caused by beta-lactamase-producing strain of Haemophilus influenzae or Moraxella catarrhalis)
* If a child has received amoxicillin in the last 30 days
* Has concurrent purulent conjunctivitis
* Has a history of recurrent otitis media unresponsive to amoxicillin
142
If a child has otitis media with chronic otorrhoea, what would you consider adding to oral antibiotic therapy?
Topical ciprofloxacin drops
143
Pharmacotherapy for otitis media in a child with a penicillin allergy?
Cefuroxime 15mg/kg BD PO for 5 days (max 500mg)
144
What is glue ear / persistent otitis media with effusion?
3 months of hearing loss secondary to middle ear effusion
145
When is ENT referral earlier than 3 months recommended in otitis media with effusion?
Speech delay or learning problems in a child
146
What is chronic suppurative otitis media?
Infection of the middle ear with a perforated eardrum and discharge for at least 6 weeks
147
Complications of chronic suppurative otitis media?
* Acute mastoiditis
* Intracranial infection
148
Management of chronic suppurative otitis media?
* Dry aural toilet then antibiotic ear drops
* Ciprofloxacin 0.3% ear drops, 5 drops instilled into the affected ear Q12hourly until the middle ear has been free of discharge for at least 3 days
149
Clinical features of acute epiglottitis?
* Fever
* Soft voice
* Lack of a harsh cough (vs croup where there is)
* Preference to sit quietly
* Soft stridor with a sonorous expiratory component
150
What is the most common cause of acute epiglottitis?
Haemophilus influenzae
151
Differentials for acute epiglottitis?
* Bacterial tracheitis
* Retropharyngeal abscess/Lateral pharyngeal abscess
152
Management of severe croup?
* Adrenaline 0.1% solution 5mL by benuliser, repeated after 30 minutes if no improvement PLUS
* Dexamethasone 0.6mg/kg IM/IV/PO
Note: child needs observation for 4 hours after initial treatment
153
Possible manifestations of a complex partial seizure/focal impaired awareness seizure?
* Slight disturbance of perception and consciousness
* Hallucinations
* Absence attacks or vertigo
* Illusions
154
Describe simple partial seizures (Jacksonian epilepsy)
* There is no loss of consciousness
* Jerking movements begin at the angle of the mouth or in the thumb and index finger and "march" to involve the rest of the body (e.g. thumb -> hand -> limb -> face +/- leg on one side and then on to the contralateral side)
* A tonic-clonic or complex partial seizure may follow
155
Describe absence seizure
* Child ceases activity and stares suddenly
* Child is motionless
* No warning
* Sometimes clonic (jerky) movement of eyelids, face, fingers
* May be lip-smacking or chewing
* Only lasts few seconds
* Child then carries on as though nothing happened
* Usually occurs several times per day
* May lead to generalised seizures in adulthood
Diagnosis: best evoked in the consulting room by hyperventilating
156
Classic EEG finding for absence seizure?
3 Hz wave and spike
157
Describe narcolepsy
Permanent neurological disorder that is characterised by brief spells of irresistible sleep during daytime hours in inappropriate circumstances, even during activity
Onset between adolescence and 30 years of age
158
Clinical features of narcolepsy
* Daytime hypersomnolence - sudden brief sleep attacks (15-20 minutes)
* Cataplexy - sudden decrease or loss of muscle tone in the lower limbs
* Sleep paralysis
* Hypnagogic (terrifying hallucinations)
159
Management of narcolepsy?
* First-line: modafinil 200mg mane PO
* Second-line: armodafinil 150mg mane PO
160
What investigation is more relevant in a patient presenting with symptoms suggestive of restless leg syndrome?
Ferritin level
161
Secondary causes of restless leg syndrome?
* Anaemia
* Iron deficiency
* Uraemia
* Hypothyroidism
* Pregnancy (usually ceases within weeks of delivery)
* Drugs e.g. antihistamines, anti-emetics, antidepressants, lithium)
162
Management of restless leg syndrome?
Non-pharmacological:
* Modest walking before bed
* Calf and hamstring stretches before bed
* Good sleep hygiene
* Keep the legs cooler than the body for sleeping
Pharmacotherapy:
* Mild and infrequent: Levodopa+benserazide
* Severe: pregabalin OR dopamine agonist e.g. pramipexole
163
Clincial features of Parkinson's disease?
* Tremor (at rest)
* Rigidity
* Bradykinesia
* Postural instability
* Gait freezing
164
Clinical features of essential tremor?
* Slight tremor in both hands
* May involve head, chin and tongue
* Interferes with writing (not micrographic)
* May affect speech
* Strong family history (autosomonal dominant)
165
Management of essential tremor?
Most patients do not need treatment
If required, can consider:
* Firstline: Propranolol 10mg BD PO
166
Clinical features of post-concussion syndrome?
* Headache
* Dizziness
* Cognitive impairment
* Psychological symptoms
167
Clinical features of spinal canal stenosis?
* Neurogenic claudication
* Pain exacerbated by walking, standing, and/or maintaining certain postures
* Relived with sitting or lying
* Primary symptoms: discomfort, sensory loss and weakness in the legs
168
Which nerve is most commonly affected by fractures of the mid-shaft of the humerus?
Radial nerve
169
How do you quickly test for radial nerve function?
Wrist extension
170
How do you quickly test for median nerve function?
Active opposition of the thumb and forefinger (pincer grip)
171
How do you quickly test for ulnar nerve function?
Abduction of the fingers (2nd and 5th)
172
Management of scalp seborrhoeic dermatitis?
* Firstline: standard shampoo daily
* Secondline: Antiyeast shampoo twice a week to daily (zinc, selenium sulphide, ketaconazole)
* Thirdline: Add a topical corticosteroid (betamethasone diproprionate 0.05% lotion topically, applied to scalp once daily at night for 7 nights)
* Fourthline: Add a tar preparation (coal tar preparation or LPC+salicyclic acid)
* Fifthline: Replace the antiyeast shampoo with a topical corticosteroid shampoo twice a week (clobetasol shampoo)
173
Management of facial, flexural and scrotal seborrhoeic dermatitis?
* Use low irritant skin cleanser
* Wash hair often with an antiyeast shampoo to reduce yeast burden on the scalp
* Combination topical corticosteroid and antifungal cream
* If combination product has no effect after 2 weeks, apply a topical corticosteroid cream and an antifungal cream separately with different strengths
* If separate creams doesn't work, use a weak tar preparation (e.g. LPC 1-2% in aqueous or sorbolene cream)
174
Management of truncal seborrhoeic dermatitis?
* Use low irritant skin cleanser
* Wash hair often with an antiyeast shampoo to reduce yeast burden on the scalp
* Combination topical corticosteroid and antifungal cream
* If combination product has no effect after 2 weeks, apply a topical corticosteroid cream and an antifungal cream separately with different strengths
* If separate creams doesn't work, use a weak tar preparation (e.g. LPC 3-6% + salicyclic acid 2-6% in aqueous or sorbolene cream)
175
Management of infantile seborrhoeic dermatitis / cradle cap?
* Self-limiting and clears spontaneously in a few weeks
* If wanted, paraffin or baby oil to soften the thickening and then salicyclic on top
NO olive oil - disrupts normal skin
176
Clinical features of cutaneous larva migrans?
* Erythematous serpiginous pruritic eruption
* Usually on hands, legs or feet of a person from a subtropical or tropical area
177
Management of cutaneous larva migrans
* Self limiting
* Ivermectin
178
Clinical features of schistosomiasis?
* First clinical sign is a local skin reaction at the site of penetration
* Within a week, there is a generalised allergic response - fever, malaise, myalgia, abdominal pain and urticaria
* Gastroenteritis-like syndrome and respiratory symptoms can occur
179
Clinical features of pinworm?
* Pruritus ani
* Diarrhoea
* Abdominal pain, mimicking appendicitis
180
Management of pinworm?
Non-pharmacological:
* Hands should be washed thoroughly after toileting and before handling food
* Clip fingernails short (eggs lodge under nails)
* Patient should wear pyjamas (not nightgowns) and shower each morning
* Bed linen, nightwear and underwear changed and washed in very hot water daily for several days
* Vacuum room of affected person daily
* Have a vet check any pets, especially dogs
Pharmacological:
* mebendazole STAT +/- repeat in 2-3 weeks (patient and household contacts)
181
What is phytophotodermatitis?
A pruritic dermatitis that occurs when exposed skin comes in contact with certain plants (e.g. parsley, parsnips, celery) and that area becomes exposed to sunlight
182
Clinical features of complex regional pain syndrome?
* Pain that is not restricted to a specific nerve territory or dermatome and usually has a distal predominance of abnormal sensory, motor, vasomotor, and/or trophic findings
* Mixture of pain, sensory changes, motor impairments, autonomic symptoms and trophic changes of affected limb
* Usually triggered by soft tissue injury
183
What is the first line pharmacotherapy for mood and behavioural disturbance in elderly with dementia, provided that non-pharmacological management has been maximised?
Risperidone 0.25mg BD PO PRN
184
Describe mononeuritis multiplex
Painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy involving isolated damage to at least 2 separate nerve areas
185
Associations/causes of mononeuritis multiplex?
* Diabetes mellitus
* Vasculitis
* Amyloidosis
* Polyarteritis nodosa
* Rheumatoid arthritis
* Systemic lupus erythematosus
* Direct tumour involvement - lymphoma, leukaemia
* Paraneoplastic syndromes
186
What is tardive dyskinesia?
* Involuntary movements of the face, mouth, tongue, trunk and limbs.
* Secondary to long-term antipsychotic drugs
187
Clinical features of neuroleptic malignant syndrome?
* High temperature
* Muscle rigidity
* Altered level of consciousness
Note: usually from antipsychotics
188
Management of extrapyramidal side effects?
Benztropine 1mg IV STAT
189
Management of vestibular neuritis?
Prednisolone 1mg/kg (up to 75mg) daily PO in the morning for 5 days and then taper dose over 15 days and stop
190
Clinical features of vestibular neuritis?
* Acute or subacute onset of severe rotatory vertigo, nausea and postural imbalance without hearing loss
* Can be associated with nausea, vomiting and with nystagmus
* Can last a week
191
Pharmacotherapy for premature ejaculation?
First line options:
* Dapoxetine 30mg PO PRN; 1-3 hours before sexual activity
* Paroxetine 20mg PO PRN; 3-5 hours before sexual activity
192
Clinical features of cat scratch disease?
Delayed onset (1-3 weeks later):
* Fever
* Headache
* Malaise
* Regional lymphadenopathy (may suppurate)
193
Management of cat scratch disease (Bartonella infection)?
* Usually self limiting
* If unresolved lymphadenopathy (>1 month): azithromycin 500mg PO on first day, then 250mg daily for another 4 days
194
Clinical features of carcinoid tumours and carcinoid syndromes?
Classic triad:
* Skin flushing (especially face)
* Diarrhoea (with abdominal cramps)
* Valvular heart disease
Other possible features:
* Wheezing
* Telangiectasia
* Hypotension
* Cyanosis
195
Diagnosis of carcinoid tumours/carcinoid syndrome?
* 24 hour urine 5-hydroxyindoleacetic acid
* Plasma chromogranin A / hepatic ultrasound
196
Predisposing factors for otitis externa?
* Water exposure
* Trauma from cotton buds or fingernails
* Known narrow ear canals
* Past history of exostoses
* Ear canal dermatitis (psoriasis)
197
What is the unsafe area of perforation of the tympanic membrane and why is it unsafe?
* Unsafe area: superior region and the posterosuperior region above the handle of the malleolus
* Can lead to cholesteatoma
198
