10. KFP: Aboriginal and Torres Strait Islander/Rheumatology

Question 1

Potential complications from rheumatoid arthritis?

Answer 1

• Atherosclerosis
• Osteoporosis
• Depression
• Vasculitis
• Peptic ulcer disease
• Lung disease
• Neuropathy
• Atlanto-axial involvement

Question 2

What is the definition of remission in rheumatoid arthritis?

Answer 2

• Symptom relief
• Normalisation of inflammatory markers
• Absence of joint swelling

Question 3

What is typically the drug of choice for conventional synthesis disease-modifying antirheumatic drug for rheumatoid arthritis?

Answer 3

• Methotrexate 10mg weekly on one specified day PLUS
• Folid acid 5 to 10mg weekly (on a different day)

Question 4

What features on history and examiantion would make you suspect rheumatoid arthritis?

Answer 4

History:
- Joint pain and swelling +/- fever
- Morning stiffness > 30 minutes
- Family history RA
- Systemic flu-like features and fatigue

Exam:
- 3 or more tender and swollen joint areas
- Symmetrical joint involvement in hands and/or feet
- Positive squeeze at MCP/MTP

Question 5

Initial therapy for rheumatoid arthritis?

Answer 5

Pharmacological:
- Simple analgesics
- Higher doses of omega-3 fatty acid
- NSAIDs/COX-2 inhibitors
- DMARDs
- Corticosteroids

Non-pharmacological:
- Weight control
- Patient education
- Occupational therapy
- Exercise (dynamic, aerobic, taichi)
- Psychosocial support
- Sleep promotion

Referral to rheumatologist

Question 6

Risk factors for gout?

Answer 6

• Dehydration
• Diet: purine rich substances e.g. meat, seafood, alcohol, fructose-sweetened drinks
• Disorders of high cell turnover e.g. haematological malignancies, severe psoriasis
• Drugs that inhibit renal excretion of uric acid: thiazide diuretics, loop diuretics, cyclosporin
• Comorbidities: hypertension, chronic kidney disease, dyslipidaemia, type 2 diabetes, obesity

Question 7

What options are there for long term urate lowering therapy in the management of gout?

Answer 7

1. Allopurinol
2. Febuxostat
3. Probenecid

Question 8

What are the options for gout flare prophylaxis when initiating or titrating urate lowering therapy and how long are they usually required?

Answer 8

1. Colchicine 500microg daily or BD PO
2. NSAID orally on lower dosing end
3. Prednisone 5mg daily PO

Colchicine can be used in conjunction with either NSAID or prednisone. Do not use NSAID and prednisone. Prednisone should be used in consultation with rheumatologist due to side effects.

Duration: 3 to 6 months

Question 9

What is the hallmark of polymyalgia rheumatica?

Answer 9

• Characterised by bilateral aching and stiffness of the shoulders and hip girdle area caused by low grade synovitis
• Hallmark of the disease: Morning stiffness
• Stiffness tends to improve after a hot shower and with activity
• Occurs almost exclusively in people older than 50 years

Question 10

Suggestive features for the diagnosis of polymyalgia rheumatica?

Answer 10

Features usually present:
- Age >50yo
- Bilateral shoulder aching
- Elevated ESR +/- CRP

Supportive features:
- Absence of RF and anti-CCP
- Morning stiffness lasting longer than 45 minutes
- Hip-girdle discomfort or limited range of motion
- Absence of involvement of joints other than the hip and shoulder

Question 11

Management of polymyalgia rheumatica?

Answer 11

• Prednisone 15mg daily PO for 4 weeks then reduce gradually
• Usually needs 12 months of treatment
• Do not reduce dose if there is active disease

Question 12

Features suggestive of statin-related muscle symptoms?

Answer 12

• Bilateral pain
• Aching or stiffness
• Pain located in large muscle groups
• Onset 4 to 6 weeks after starting or increasing dose of statin
• High dose or high potency statin therapy
• Elevated serum CK that decreases with statin withdrawal

Question 13

ANA staining pattern - what do they mean/what’s the significance?:
- Homogenous
- Speckled

Answer 13

Nonspecific

Question 14

ANA staining pattern - what do they mean/what’s the significance?:
- Centromere
- Nucleolar

Answer 14

Systemic sclerosis

Question 15

Diagnostic criteria for systemic lupus erythematosus?

Answer 15

Four of the eleven criteria are required for classifying a patient as having SLE.

1. Malar rash: malar erythema, flat or raised
2. Discoid rash: erythematous rasied patches with keratotic scaling and follicular plugging
3. Photosensitivity: rash as an unusual reaction to sunlight
4. Oral ulcers: oral or nasopharyngeal ulcers, usually painless
5. Arthritis: nonerosive arthritis involving two or more peripheral joints with tenderness, swelling or effusion
6. Serositis: pleurisy or pericarditis
7. Renal features: proteinuria or cellular casts
8. Neurological and neuropsychiatric features: seizures or psychosis
9. Haematological features: haemolytic anaemia, leucopenia, lymphopenia or thrombocytopenia
10. Presence of anti-double stranded DNA antibody, anti-Smith antibody, or antiphospholipid antibodies
11. Antinuclear antibody positive: ANA positive in the absence of drugs known to cause drug-induced lupus

Question 16

Differentials for non-inflammatory causes of arthralgia and myalgia

Answer 16

• Fibromyalgia
• Benign hypermobility syndrome
• Osteoarthritis
• Hypothyroidism
• Osteomalacia
• Multiple myeloma

Question 17

Differentials for inflammatory causes of arthralgia and myalgia

Answer 17

• Polymyalgia rheumatica
• Giant cell arteritis
• Systemic lupus erythematosus
• Sjogren syndrome
• Polymyositis

Question 18

What is Sjogren’s syndrome?

Answer 18

• Chronic autoimmune disease associated with lymphoid infiltration of the exocrine glands, particularly the salivary and lacrimal glands, leading to secretory gland dysfunction and usually severe sicca symptoms
• In severe cases, dryness can cause salivary gland enlargement and calculus formation, and can affect the trachea causing dry cough and/or hoarse voice

Question 19

Features of Sjogren’s syndrome?

Answer 19

• Can be primary or secondary (when in association with rheumatoid arthritis or another connective tissue disease e.g. SLE or systemic sclerosis)
• Glandular hypofunction
• Fatigue
• Arthralgia
• Nonerosive arthritis
• Raynaud phenomenon

Question 20

Diagnosis of Sjogren’s syndrome?

Answer 20

• Significant and persistent picca symptoms (e.g. severe dry eyes needing ocular lubricants several times a day)
• Associated polyclonal hypergammaglobulinaemia
• Positive antinuclear antibody
• Presence of antibodies to Ro (SS-A) and La (SS-B)

Question 21

Management of common clinical features of inflammatory connective tissue diseases?:
- Sicca symptoms

Answer 21

• Wear sunglasses outdoors to avoid wind-drying effects on the eyes
• Avoid dry and heated air, cigarette smoke, anticholinergic drugs (e.g. TCAs, antiparkinsonian drugs)
• Ensure adequate oral hydration and good dental hygiene to prevent dental caries
• Dry eyes: lubricant drops, gels, ciclosporin drops to improve tear flow
• Dry mouth: hydration, good dental hygiene and regular exams, topical remineralising agents to prevent tooth decay, artificial oral lubricants, products that stimulate saliva e.g. lozenges or gum

Question 22

What’s the diagnosis?
urethritis + conjunctivitis +/- iritis + arthritis?

Answer 22

Reactive arthritis

Question 23

When does reactive arthritis tend to appear?

Answer 23

1-3 weeks after the initial infection

Question 24

What infections can cause reactive arthritis?

Answer 24

• Genitourinary: chlamydia trachomatis
• GI: Salmonella, shigella, yersinia, campylobacter

Question 25

Clinical features of reactive arthritis?

Answer 25

- Inflammatory peripheral arthropathy with an asymmetrical oligoarticular distribution, predominantly affecting the lower limbs - Common: dactylitis, enthesitis - Articular symptoms develop after atleast 1 week after an infective illness Extra-articular features: - Conjunctivitis, anterior uveitis - Genitourinary inflammation: urethritis, prostatitis, balanitis - Keratoderma blennorhagica: pustular hyperkeratotic rash typically affecting the palms and soles of the feet

Question 26

Management of reactive arthritis?

Answer 26

- Treat active infection if present Joint Pain - options: - NSAID OR - Intra-articular corticosteroid injections OR - Prednisone 10-50mg daily PO

Question 27

Who is more likely to be affected by systemic lupus erythematosus?

Answer 27

- F > M - Age: 15 - 45yo (child bearing years)

Question 28

Management of systemic lupus erythematosus?

Answer 28

- Hydroxychloroquine - can reduce risk of flares and improve lipid levels - Moderate or severe: systemic corticosteroids - Belimumab - immunomodulatory drugs can take several months to become effective

Question 29

Clinical features of fibromyaglia?

Answer 29

History: - Chronic widespread musculoskeletal pain (hallmark) - Cognitive clouding - Fatigue - Impaired concentration - Sleep dysfunction - Depression - GI dysfunction and discomfort (irritable bowel) - Urogenital dysfunction and discomfort (irritable bladder) Exam: - Soft-tissue tenderness to pressure is typically diffuse - Tender in the majority of patients: lateral epicondyles, trapezius muscles, anserine bursae - Allodynia

Question 30

Management of fibromyalgia?

Answer 30

Patient education: - Pain is real but not caused by tissue damage - Not a progressive or deforming disease - Fluctuating symptoms - Goal is to manage pain Lifestyle & Non-pharm management: - Regular graded aerobic exercise - graded by duration of time exercising, rather than pain experienced - Cognitive behavioural therapy - Good sleep practices Pharm management: 1. Low dose TCAs: amitriptyline 2. Gabapentinoid 3. Serotonin-noradrenaline reuptake inhibitor Analgesia: paracetamol, NSAIDs

Question 31

Features of streptococcal throat infection?

Answer 31

- Abrupt onset of symptoms - Fever > 38C - Tender cervical lymphadenopathy - Tonsillar exudate - Scarlet fever-type rash: bright, red, bumpy rash - Absence of cough, rhinorrhoea or nasal congestion

Question 32

Clinical features associated with airway obstruction or deep neck infection?

Answer 32

- Muffled voice - Stridor - Trismus: muscle spasms in your temporomandibular joint - Drooling - Unilateral throat pain

Question 33

Conditions associated with airway obstruction or deep neck infection?

Answer 33

- Acute epiglottitis - Peritonsillar abscess (quinsy) and peritonsillar cellulitis - Severe Epstein-Barr virus infection - Severe croup or bacterial tracheitis

Question 34

Antibiotic therapy for streptococcal pharyngitis and tonsillitis?

Answer 34

Phenoxymethylpenicillin 500mg Q12hourly PO for 10 days

Question 35

Why is adhering to Phenoxymethylpenicillin 500mg Q12hourly PO for 10 days important for patients at high risk of acute rheumatic fever?

Answer 35

- To eradicate strep pyogenes from the pharynx and prevent the development of acute rheumatic fever - IM benzathine benzylpenicillin can be used in those who may experience difficulties adhering to the 10 day oral regimen OR if oral therapy is not tolerated OR a single dose is preferred

Question 36

Can children with grommets swim?

Answer 36

Yes, if they wear ear plugs and swimming caps

Question 37

Management of tympanostomy tube otorrhoea?

Answer 37

- Cleaning (dry mopping or syringing with dilute betadine 1:20) - Topical ciprofloxacin 5 drops BD for 7 days - Review weekly for 4 weeks

Question 38

How long should swimming be avoided for after grommet insertion surgery?

Answer 38

One week

Question 39

What is trichiasis and what is its significance?

Answer 39

- Trichiasis is defined as normal lashes growing inward. In trichiasis, the lash follicle is normal, but the direction of lash growth is abnormal. In the presence of inflammation, there may be a misdirection of the follicle with the lash growing inwards towards the cornea - Where trachoma is endemic, trichiasis of any degree indicates trachoma until proven otherwise

Question 40

Management of trachoma?

Answer 40

- Antibiotics: azithromycin 1g STAT PO - Treat contacts - Preventative measures for patient and contacts: face washing

Question 41

When to check for donovanosis?

Answer 41

Anyone with an ano-genital ulcer in remote areas

Question 42

Acute rheumatic fever: major manifestations and minor manifestations?

Answer 42

Major: - Carditis - Mono/Polyarthritis - Sydenham chorea - Erythema marginatum - Subcutaneous nodules Minor: - Fever > 28C - Monoarthralgia - ESR >/= 30 or CRP >/= 30 - Prolonged PR interval on ECG

Question 43

Which areas in Australia are endemic with acute rheumatic fever?

Answer 43

- Far North Queensland and North Queensland - Northern territory - Pilbara and Kimberley regions of Western Australia - Other remote areas

Question 44

Risk factors for chronic kidney disease?

Answer 44

- Smoking - Obesity - Hypertension - Diabetes - Severe socioeconomic disadvantage

Question 45

What is the uric acid level goal when managing gout?

Answer 45

- No tophi: < 0.36mmol/L - Tophi: < 0.30mmol/L

Question 46

Differentials for dyspnoea?

Answer 46

Cardiac: - Increased left sided intracavity filling pressure: HFrEF, HFpEF, left sided valvular dysfunction (aortic or mitral stenosis or regurgitation) - Myocardial ischaemia - Arrhythmia (tachyarrhythmia, bradyarrhythmia, ectopy, AF, atrioventricular dissociation) - Low cardiac output (left sided): pulmonary hypertension, hypovolaemia, cardiac shunt, cardiac compression (pericardial constriction, cardiac tamponade, tension pneumothorax) Respiratory: - Hypoxia: pulmonary parenchymal abnormality (pneumonia, fibrosis, emphysema, pulmonary oedema, alveolar haemorrhage, pleural effusion, pneumothorax), airway obstruction (asthma, bronchitis, upper airway), ventilation perfusion mismatch (pulmonary embolus, pulmonary shunt) - Central respiratory drive abnormality (pharmacologic, metabolic) - Musculoskeletal respiration abnormality: skeletal myopathy, respiratory muscle fatigue, chest wall abnormality (kyphoscoliosis, thoracic skeletal pain, obesity) Peripheral muscle oxygen extraction abnormality or inefficiency: - Poor physical fitness - Myopathy Anxiety: panic attack, chronic anxiety state Anaemia, iron deficiency Hyperventilation: - Acidosis (renal failure, ketoacidosis, shock) - Pharmacological cause - Thyrotoxicosis

Question 47

Drug classes and examples that improve outcomes in HFrEF?

Answer 47

Renin-angiotensin system inhibitors: - ACEi - e.g. perindipril - Angiotensin-receptor neprilysin inhibitor (ARNI) - sacubitril + valsartan [contraindicated in hypotension] - ARBs (only if above not tolerated) Heart failure-specific beta blockers e.g. metoprolol XR, bisoprolol - defer starting if there are clinical signs of congestion Mineralocorticoid receptor antagonists e.g. spironolactone Sodium-glucose co-transporter 2 (SGLT2) inhibitors e.g. empagliflozin

Question 48

How would you classify heart failure?

Answer 48

- Left ventricular ejection fraction 40% or less: HFrEF - Left ventricular ejection fraction 41 - 49%: mild HFrEF - Left ventricular ejection fraction 50% or more: HFpEF

Question 49

What is a possible complication from the combination of a mineralocorticoid receptor antagonist and a renin-angiotensin system inhibitor?

Answer 49

In renal impairment, life-threatening hyperkalaemia

Question 50

Non-pharmacological management strategies for heart failure?

Answer 50

- Develop heart failure action plan - Fluid restriction of 1.5L/day - Daily weight monitoring (watching 2kg increase over 2 days) - Advise no-added-salt diet OR limit salt intake to <2g/day OR refer to dietitian for nutritional assessment - Arrange review in 48-72 hours for assessment of response to treatment - Refer to cardiac rehabilitation OR refer to multidisciplinary heart failure management program

Question 51

Examination findings expected for systemic sclerosis?

Answer 51

- Calcinosis - calcium deposits in the skin - Sclerodactyly - thickening and tightening of digit skin - Telangiectasia - dilation of capillaries - Decreased oral aperture OR perioral skin tightening OR microstomia - Digital ulcers OR pitted scars - Wrist crepitus OR tendon friction rub

Question 52

What is systemic sclerosis, how is it classified and what are its key features?

Answer 52

Systemic sclerosis is an autoimmune inflammatory condition that results in widespread fibrosis and vascular abnormalities It is subdivided according to the distribution of skin involvement - Diffuse cutaneous systemic sclerosis - Limited cutaneous systemic sclerosis (previously CREST syndrome) ---- confined to the fingers, distal portion of the extremities, and the face Limited cutaneous systemic sclerosis (CREST syndrome): - Calcinosis - Raynaud's phenomenon - Oesophageal dysmotility - Sclerodactyly - Telangiectasias Key features: - Skin thickening of the fingers and toes (sclerodactyly) - Specific autoantibodies (anti-Scl70 or anti-centromere) - Abnormal nail fold capillaries - Internal organ fibrosis and/or vascular damage

Question 53

Pulmonary manifestations of systemic sclerosis?

Answer 53

- Interstitial lung disease (common) - Pulmonary hypertension (common - more associated with limited cutaneous systemic sclerosis) - Pulmonary embolism - Pleural effusion - Spontaneous pneumothorax - Airways disease - Aspiration pneumonia - Lung cancer - Drug-induced pneumonitis - Respiratory muscle weakness

Question 54

What should all patients with systemic sclerosis be screened for regularly?

Answer 54

- Interstitial lung disease - High resolution CT chest, pulmonary function tests - Pulmonary arterial hypertension - Transthoracic echocardiogram, ?NT proBNP Annual screening

Question 55

What is watermelon stomach and which autoimmune disease can it be a complication of?

Answer 55

- Watermelon stomach: vascular ectasia (angiodysplasia) in the antrum of the stomach - Systemic sclerosis

Question 56

Questions to ask when assessing patchy hair loss/alopecia areata and differentials?

Answer 56

- Family history of alopecia areata - Cold/heat intolerance OR unintentional weight change (thyroid disorder) - [Past history of vitiligo OR autoimmune disease] or [Arthralgia OR other rashes] (symptoms of possible autoimmune disease) - Past history of dermatitis OR alopecia areata - Localised tingling OR itching in the preceding weeks (trichodynia) - Any new nail changes (pitting or ridging most common in alopecia areata) OR any hair loss noted in other areas (e.g. eyebrows, lashes - alopecia areata) - Excessive OR irresistible urge for hair pulling OR obsessive compulsive disorder (trichotillomania) - Significant stressors OR anxiety (telogen effluvium) - Preceding redness OR scaliness of scalp OR pet dogs or cats - Tinea capitis - Hair grooming behaviour - Traction alopecia - Use of hair chemicals/dye - Painless hair loss

Question 57

What is alopecia areata and who gets affected?

Answer 57

Alopecia areata: autoimmune condition affecting hair follicles causing hair loss and typically presents with discrete bald patches on the scalp but can cause hair loss from all hair-bearing areas on the body Peak incidence occurs in second and third decades and most patients experience onset before the fourth decade Groups at increased risk of alopecia areata: - Other autoimmune conditions such as vitiligo and thyroid disease - A family history of alopecia areata

Question 58

Differential diagnoses for alopecia areata?

Answer 58

- Trichotillomania - Tinea capitis - Telogen effluvium - Androgenetic alopecia - Discoid lupus erythematosus - Secondary syphilis - Lichen planopilaris

Question 59

Clinical features of alopecia areata?

Answer 59

- Discrete oval/round patchy hair loss - Scalp is most affecte but can occur in: beard, eyebrows, eyelashes, other hair-bearing areas - "Exclamation point hairs" at periphery of bald patches: thick distally and thin proximally due to anagen arrest - Trichodynia (localised tingling or itching preceding hair loss) - Nail changes: pitting and ridging

Question 60

What is trichotillomania and its causes?

Answer 60

Trichotillomania is a disorder characterised by an irresistible urge to remove or pull one's own hair. Causes - largely unknown: - Obsessive compulsive disorder - correlation - May be a coping mechanism triggered by stress or anxiety - Commonly associated with other body-focused repetitive behaviours

Question 61

What is tinea capitis and its symptoms?

Answer 61

Tinea capitis is a fungal infection of the scalp, involving both skin and hair. It is contagious and spread through contact with infected persons/animals and contaminated objects (fomites). Symptoms: hair loss, dry scaly areas, redness, itch

Question 62

Management of alopecia areata?

Answer 62

First line: Topical steroid options - needs potent or very potent strength for response: - Betamethasone diproprionate 0.05% (Diprosone OR diprosone OV OR Eleuphrat) topically - Mometasone furoate 0.1% (Elocon OR Novasone) topically - Methylprednisolone aceponate 0.1% (Advantan +/- fatty ointment) Duration: 3-4 months Second line: intralesional corticosteroid injections (e.g. triamcinolone 5mg/mL)

Question 63

What is required for patients considering Q fever vaccination?

Answer 63

- Q fever skin test - Serum Q fever antibody test Rationale: to identify people who have been previously infected with the Q fever organism and not aware of it. These people are likely to have adverse reactions to the vaccine, based on hypersensitivity to the organism Patients previously infected with Q fever should not be vaccinated

Question 64

Questions to ask when working up "tiredness/sleepiness"?

Answer 64

- Does he have trouble falling OR initiating sleep? - Does he have trouble staying OR maintaining sleep? - Does he work night shift? - Any recent international air travel? (Jetlag) - How many hours does he try to sleep at night? - assess for chronic sleep restriction - What time does he usually go to sleep? - assess for delayed sleep phase disorder - Does he have a history of sleep walking OR night terrors OR unusual behaviours? - assess for parasomnia - Does he have restless limbs during sleep? - restless limb syndrome - Does he fall asleep during the daytime OR take naps in the daytime? - assess for disorder of excessive daytime sleepiness - Does he have low mood OR anhedonia OR anxiety? - depression/anxiety - Does he use screens OR have exposure to blue light before bedtime? - assess for poor sleep hygiene - Does he drink coffee after midday? - Duration of the sleep problem and if it was triggered by an event?

Question 65

Physical exam findings you'd search for when assessing sleepiness?

Answer 65

- Hypertension - Waist circumference >/= 100cm OR BMI >/= 35 OR neck circumference > 40cm - Malampati score >/= 3 OR reduced nasal patency OR retrognathia (OSA) - Blunted/restricted affect OR dishevelled appearance OR psychomotor retardation (part of mental state assessment) Less relevant for sleepiness but more for tiredness: - Brittle nails OR dry hair OR delayed reflexes (hypothyroidism) - Subconjunctival pallor OR tachycardia (anaemia)

Question 66

Non-pharmacological management of sleep disturbance?

Answer 66

1. Restrict in bed activity to sleeping or sex only OR reduce bedroom stimuli (ensuring environment is quiet and dark) 2. Optimise light exposure (natural light exposure in the daytime, limit evening blue-light exposure) OR cessation of screen use at least 2 hours before bed 3. Get out of bed if unable to sleep for 20 minutes 4. Progressive muscle relaxation OR other relaxation activity before bed (meditation, visualisation, deep breathing) OR develop a 30 minute wind down routine e.g. warm drink or warm bath 5. Referral to a psychologist for cognitive behavioural therapy for insomnia (CBTi) 6. 30 minutes moderate intensity exercise 5 days a week during daytime OR avoid vigorous exercise within a few hours of bedtime 7. Adopt a regular sleep-wake schedule even when not working (strengthen circadian rhythm) 8. Avoid napping in the daytime OR avoid oversleeping 9. Avoid large meals late in the evening 10. Avoid caffeine in the evening OR minimise or eliminate caffeine, nicotine and alcohol

Question 67

Questions to ask for when assessing for kidney dysfunction (either AKI or CKD)?

Answer 67

- Duration of ibuprofen use if any - Past history of hypertension - Past history of recurrent UTIs/pyelonephritis OR dysuria OR urinary frequency - Past history of autoimmune disease (secondary glomerular disease) - Recent URTI symptoms (sore throat, coryza, cough) - post-infectious glomerulonephritis - Unintentional weight loss OR night sweats OR new character of back pain (multiple myeloma) - Loin to groin pain OR gross haematuria (calculi, obstructive malignancy) - Recent diarrhoea OR nausea OR vomiting OR gastroenteritis - pre-renal cause of AKI but urea is usually elevated too

Question 68

Differentials for subacute kidney injury?

Answer 68

Pre-renal: - Overdiuresis - Decreased oral intake - Diarrhoea - Unreplenished insensible losses Intrinsinc glomerular disease: - Primary (Acute proliferative glomerulonephritis, rapidly progressive glomerulonephritis, membranous glomerulopathy, minimal-change disease, focal segmental glomerulosclerosis, IgA nephropathy, membranoproliferative glomerulonephritis) - Secondary (paraneoplastic, drug-induced, part of systemic rheumatologic disease Intrinsic tubular and interstitial disease: - Interstitial nephritis - Cast nephropathy in multiple myeloma Obstructive nephropathy - substantial eGFR decrease suggests bilateral obstruction: - Prostatic disease - Intra-abdominal cancer - Kidney stones - Acute obstruction causes pain and gradual, severe obstruction may cause kidney dysfunction without obvious symptoms

Question 69

What are the most common causes of end stage kidney disease in Australia?

Answer 69

- Diabetes - Glomerulonephritis - Hypertension - Polycystic kidney disease

Question 70

Which is more sensitive/accurate in detecting haematuria? - Urine dipstick - Urine microscopy

Answer 70

Urine dipstick

Question 71

Risk factors for urological malignancy?

Answer 71

- Male - Age >40 - History of macroscopic haematuria - Smoking - Pelvic irritation - Exposure to occupational chemicals, dyes or cyclophosphamide

Question 72

What is the gold standard for imaging of the urinary tract for the assessment of malignancy?

Answer 72

- CT IVP - In younger patients <50 years or those with significant renal impairment, renal tract ultrasonography is sufficient CT IVP is the modality of choice for older patients, those with risk factors for malignancy, and those with persistent haematuria

Question 73

Non-pharmacological management for chronic kidney disease?

Answer 73

- Refer to nephrologist for further investigation of haematuria with renal impairment OR possible glomerulonephritis - Refer to urologist to exclude urological cause of haematuria (macroscopic) - Aim for weight loss towards BMI < 25 OR waist circumference < 80cm OR referral to dietitian to assist in weight loss towards BMI < 25 (CKD) - Advise to follow Dietary Approaches to Stop Hypertension (DASH) diet OR limit salt intake to <6g a day (hypertension) - Muscle strengthening exercise on at least 2 days a week OR aim for 150-300min/week of physical activity (physical activity) - Aim for BP < 130/80

Question 74

Differentials for haematuria?

Answer 74

Transient: - Exercise induced - Trauma - Sexual intercourse - Pelvic organ prolapse - Vaginal atrophy Malignant: - Urothelial cancer - Prostate cancer - Renal cell carcinoma Infectious/Inflammatory: - Pyelonephritis - Lower urinary tract infection - Radiation cystitis - Foreign body - Urethral caruncle Renal medical disease: - Immunoglubilin A nephropathy - Thin basement membrane disease - Hereditary nephritis Obstructive: - Urolithiasis - Benign prostatic hyperplasia/prostatic regrowth

Question 75

Definition of CKD?

Answer 75

Two options: 1. eGFR <60 for 3 months or more with or without evidence of kidney damage 2. Kidney damage with or without decreased eGFR for 3 months or more as evidenced by the following: - Albuminuria - Haematuria after exclusion of urological causes - Structural abnormalities (e.g. kidney imaging) - Pathological abnormalities e.g. renal biopsy

Question 76

Management of Chronic Kidney Disease?

Answer 76

- Smoking: stop - Nutrition: DASH diet (dietary approaches to stop hypertension) - 4-5 vegetable servings/day, 2 or fewer servings of lean meats, poultry and fish, lots of grains [there's more details]; limit salt <6g salt per day - Alcohol: limit 2 standards per day or less - Physical activity: 150 to 300 minutes of moderate physical activity; do muscle strengthening activities on at least 2 days each week - Obesity: ideal BMI < 25

Question 77

Management options for removal of a benign skin lesion?

Answer 77

1. Shave excisional biopsy of lesion 2. Curettage OR electrocautery of lesion 3. Cryotherapy (only for thinner lesions)

Question 78

Differentials for unilateral nipple pain in the context of breastfeeding?

Answer 78

- Suboptimal fit and hold/poor latch/nipple trauma - Nipple thrush - Strong infant sucking vacuum/infant biting nipple - Inappropriate use of breast pump (assess for inappropriate shield size or high suction) - Nipple bacterial infection - Nipple contact dermatitis OR eczema OR psoriasis - Blocked OR plugged milk duct OR milk blister - Nipple vasospasm - Mastitis

Question 79

Causes of nipple and breast pain in infant feeding?

Answer 79

Most common cause: poor positioning Mechanical: - Poor positioning and attachment - Blocked duct - Nipple variations e.g. flatness, retraction, inversion - Inappropriate use of breast pump - Infant with very strong sucking vacuum - Infant biting nipple - Anatomical variations in infant: e.g. high arched, flattened or bubble palate, disorganised sucking action, tongue-tie (ankyloglossia) Physiological: - Breast engorgement - Nipple vasospasm - Hormonal sensitivity e.g. during new pregnancy, ovulation, menstruation Dermatological: - White spot (blocked nipple pore) - Eczema/dermatitis Infective: - Mastitis - Bacterial infection - Candida infection - Herpes simplex

Question 80

Important elements on history for evaluation of breast pain during breastfeeding?

Answer 80

- Onset of breast pain - Description of clinical setting - Feeding history - Previous yeast infections - Maternal breast surgeries e.g. breast reduction, piercings, implants, inverted nipples - Raynaud syndrome or autoimmune disease (associated with nipple vasoconstriction)

Question 81

Management of nipple thrush?

Answer 81

Baby: - Miconazole 2% gel QID PO for 1 week then daily for 1-2 week (apply to cheeks and tongue with cotton bud or finger) OR - Nystatin liquid QID PO for 7-14 days Mum: - Fluconazole 150mg every 2nd day for 3 doses THEN (nystatin 2 x 500,000 units TDS PO AND miconazole oral gel to nipples QID TOP)

Question 82

Signs and symptoms of thrush in: - Nipple/areola? - Breast? - Baby?

Answer 82

Nipple/areola: - Burning, stinging nipple pain which continues during and after the feed - Nipples are often very tender to touch and even light clothing can cause pain - Nipples appear pink and/or shiny and areola may be reddened, dry or slightly flaky - Consider dermatitis if significant itching and/or rash - Consider nipple vasospasm if exacerbated by cold and/or nipples blanch Breast: - Shooting, stabbing or deep aching breast pain - Breast pain typically occurs after feeding or expressing. The let-down reflex may be more painful than normal - Breasts will appear normal. If inflamed, consider mastitis Baby: - White oral plaques - Assume baby is colonised with thrush if mother has evidence of nipple thrush

Question 83

Questions to consider with an infant vomiting after feeds and green frothy stool?

Answer 83

- Frequency of vomit/vomiting at other times? - Volume of vomit OR projectile nature of vomit? - Blood in vomit OR bile in vomit? - Number of wet nappies per day? - Feeding duration OR feeding frequency OR feeding difficulties? - Malodorous urine OR cloudy urine OR cough? - infective symptoms - Fever - Blood in stool OR frequency of bowel motions? - Presence of rash - Timing of crying OR length/duration of crying - Social supports for mother OR mother's mood OR how mother feels when infant is crying - Loss of weight OR stagnated weight gain - Perianal excoriation OR perianal ulceration

Question 84

Clinical characteristics of normal crying in babies?

Answer 84

- Increases in the early weeks of life and peaks around 6-8 weeks of age and usually improves by 3-4 months of age - At 6-8 weeks of age, a baby cries on average 2-3 hours per 24 hours - Usually worse in late afternoon or evening but may occur at any time - Infant may draw up legs as if in pain, but there is no good evidence that this is due to intestinal problems RED FLAGS: - Sudden onset of irritability and crying - Parental post-natal depression Common non-pathological causes of crying: - Excessive tiredness - Hunger - more likely if there is poor weight gain

Question 85

Average sleep requirements for baby at: - birth? - 2-3 months?

Answer 85

At birth: 16 hours At 2-3 months: 15 hours

Question 86

Differentials for unsettled or crying babies?

Answer 86

- PURPLE crying - Non-IgE cow milk/soy protein allergy - Lactose overload/malabsorption: consider if infant has very frequent breastfeeds and frothy, watery diarrhoea with perianal excoriation - Gastro-oesophageal reflux disease (rare)

Question 87

When should you suspect non-IgE cow milk/soy protein allergy in infants?

Answer 87

- Significant feeding problems that persist day and night - Frequent vomiting - Diarrhoea with blood or mucous - Poor weight gain - Wide-spread eczema

Question 88

Important differentials/causes to consider in an acute history of crying in a baby?

Answer 88

- Raised ICP - Injury e.g. fracture - Incarcerated inguinal hernia - UTI - Hair tourniquet - Corneal abrasion

Question 89

What is PURPLE crying?

Answer 89

P - peak of crying: peaks at 2 months and then decreases over 3-5 months U - unexpected: can come and go without reason R - resists soothing: may not stop no matter what you try P - pain-like face: may look like they're in pain even when not L - longlasting: can last 5 hours a day or more E - evening: may cry more in the late afternoon or evening

Question 90

How do you treat cows milk allergy?

Answer 90

- Remove cows milk and cows milk based products from maternal diet - 0-6 months: extensively hydrolysed formula - 6-12 months: soy formula - Note: lactose free products still contain cows milk protein. Lactose intolerance and cows milk allergy are different - Lactose intolerance: intolerance to the sugar lactose - Cows milk allergy: immune reaction triggered by protein in cows milk

Question 91

Management of lactose overload?

Answer 91

- Block feeding (using one breast within a 4 hour period and then alternate to reduce the speed that the breast makes milk; usually only done for a few days) OR offering one breast at a time until empty: aim to down regulate milk production so infants receive more of the cream based milk at the end of the feed and stay fuller - Referral to lactation consultant - Refer to Australian Breastfeeding Association - Acknowledge impact of child's crying on mother's mental health

Question 92

When to suspect lactose overload?

Answer 92

- Unsettled - Adequate to large weight gains - Usually pass urine more than 10 times per day - Many bowel motions in 24 hours - Faeces may be green and frothy or explosive with perianal excoriation

Question 93

Why does lactose overload occur?

Answer 93

Cream/fat that is usually found at the end of the breastmilk supply slows down the breastmilk transit through the gut to allow lactose to be broken down

Question 94

What questions should be asked when evaluating restricted eating?

Answer 94

- Are animal products OR meat consumed? - higher risk of micronutrient deficiencies if not consuming animal products - Dislike foods with certain textures? - Previous allergic reaction to any foods / history of vomiting OR rash OR abdominal pain OR swelling of his face after meals? - food allergy - Does he have difficulty making friends OR socialising OR maintaining eye contact / does he have difficulty coping with change in routines / does he get easily upset by certain sounds OR from overstimulation - exploring possibility of underlying autism - Does he have constipation OR altered bowel habits OR blood/mucous in stool - gastrointestinal symptoms of possible underlying disorder

Question 95

Which groups of children may have restricted food eating patterns that may place them at risk of micronutrient deficiency? Note: diet highly limited in variety e.g. missing food groups, less than 10 foods/food types regularly consumed, minimal meal to meal variability

Answer 95

- Neurodevelopmental conditions including autism spectrum disorder - Avoidant restrictive food intake disorder (ARFID) - Multiple food allergies - Elective dietary restrictions due to cultural, religious or environmental reasons

Question 96

What are some risk factors for deficiency in Vitamin A (retinol) in children?

Answer 96

- Malabsorption e.g. exocrine pancreatic insufficiency, chronic liver disease, short bowel syndrome, inflammatory bowel disease - Maternal deficiency - Some refugee populations

Question 97

What are some risk factors for deficiency in Vitamin B1 (thiamine) in children?

Answer 97

- White rice-based diets - Malabsorption - Some refugee populations

Question 98

What are some risk factors for deficiency in Vitamin B3 (niacin) in children?

Answer 98

- Corn based diets - Malabsorption

Question 99

What are some risk factors for deficiency in Vitamin B9 (folate) in children?

Answer 99

- Lack of fresh food in diet - Malabsorption - Medications e.g. phenytoin, phenobarbital, methotrexate, long term NSAID use

Question 100

Clinical features of deficiency in Vitamin A (retinol)?

Answer 100

- Xerophthalmia: night blindness, dry conjunctiva, corneal ulceration, blindness - Dry skin and pruritus - Increased susceptibility to infection - Poor growth

Question 101

Clinical features of deficiency in Vitamin B1 (thiamine)?

Answer 101

- Fatigue, irritability, apathy, nausea, abdominal discomfort - Dry beriberi (symmetric peripheral neuropathy) - Wet beriberi (cardiac failure) - Wernicke encephalopathy: confusion, reduced consciousness, ataxia, ophthalmoplegia - Korsakoff syndrome: confusion, amnesia

Question 102

Clinical features of deficiency in Vitamin B3 (niacin)?

Answer 102

- Anorexia, vomiting, abdominal pain - Glossitis, cheilitis - Pellagra: triad of dermatitis, diarrhoea and confusion - Late symptoms include apathy, weakness, headache, confusion, irritability, anxiety, tremor, depression

Question 103

Clinical features of deficiency in Vitamin B9 (folate)?

Answer 103

- Clinical signs of anaemia - Macrocytia anaemia and hyper-segmented neutrophils on full blood count - Glossitis, oral ulcers - Fatigue, slow growth

Question 104

What are some risk factors for deficiency in Vitamin B12 (cobalamin) in children?

Answer 104

- Vegan and vegetarian diet - Some refugee populations - Gastrointestinal disease - Exclusively breastfed infants of mothers with vitamin B12 deficiency

Question 105

What are some risk factors for deficiency in Vitamin C (ascorbic acid) in children?

Answer 105

- Diets without fruit and vegetables

Question 106

What are some risk factors for deficiency in Vitamin D (calciferol) in children?

Answer 106

- Lack of skin exposure to sun - Dark skin - Obesity - Liver/renal failure - Gastrointestinal disease - Exclusively breastfed infants of mothers with vitamin D deficiency

Question 107

What are some risk factors for deficiency in Vitamin E (alpha-tocopherol) in children?

Answer 107

- Malabsorption

Question 108

What are some risk factors for deficiency in Vitamin K (phytomenadione) in children?

Answer 108

- Malabsorption

Question 109

What are some risk factors for deficiency in copper in children?

Answer 109

- Prolonged total parenteral nutrition - Malabsorption

Question 110

What are some risk factors for deficiency in iodine in children?

Answer 110

- Extremely rare unless immigrated from high-risk areas e.g. inland Asia or Africa

Question 111

What are some risk factors for deficiency in iron in children?

Answer 111

- Vegetarian or vegan diet - High milk intake - Gastrointestinal disease - Heavy menstrual loss - Maternal iron deficiency - Prematurity - Low birth weight

Question 112

What are some risk factors for deficiency in selenium in children?

Answer 112

- Prolonged total parenteral nutrition

Question 113

What are some risk factors for deficiency in zinc in children?

Answer 113

- Malabsorption - Total parenteral nutrition - Vegetarian-diet

Question 114

Clinical features of deficiency in Vitamin B12 (cobalamin)?

Answer 114

- Clinical signs of anaemia - Macrocytic anaemia and hyper-segmented neutrophils on full blood count - Irritability, developmental delay, developmental regression, involuntary movements, peripheral neuropathy - Glossitis, oral ulcers - Skin changes e.g. hyperpigmentation, vitiligo

Question 115

Clinical features of deficiency in Vitamin C (ascorbic acid)?

Answer 115

Scurvy - Skeletal fractures and joint pain - Poor wound healing - Fatigue - Weight loss - Gingival inflammation with gum bleeding - Petechiae - Ecchymosis - Purpura - Dry eyes and mouth - Corkscrew hair

Question 116

Clinical features of deficiency in Vitamin D (calciferol)?

Answer 116

- Rickets: lower limb deformities, enlargement of wrists and ankles, protruding abdomen, delayed gross motor development, generalised musculoskeletal pain - Hypocalcaemia: may present with seizures and tetany

Question 117

Clinical features of deficiency in Vitamin E (alpha-tocopherol)?

Answer 117

- Decreased muscle mass - Weakness, unsteady gait

Question 118

Clinical features of deficiency in Vitamin K (phytomenadione)?

Answer 118

- Excessive bleeding/bruising

Question 119

Clinical features of deficiency in copper?

Answer 119

- Anaemia - Peripheral neuropathy

Question 120

Clinical features of deficiency in iodine?

Answer 120

- Goitre - Other signs and symptoms of hypothyroidism

Question 121

Clinical features of deficiency in iron?

Answer 121

- Clinical signs of anaemia: pallor, irritability, anorexia, fatigue - Microcytic anaemia on full blood count - Behavioural disturbance, impaired cognitive function, decreased memory, impaired learning and concentration - Pica (eating non-food items)

Question 122

Clinical features of deficiency in selenium?

Answer 122

- Cardiomyopathy - Myositis - Shortened fingers and toes

Question 123

Clinical features of deficiency in zinc?

Answer 123

- Acrodermatitis enteropathica: periacral, periorificial dermatitis, diarrhoea, alopecia - Depressed mood, apathy, and emotional disturbance in older children

Question 124

First line blood investigations for suspected micronutrient deficiency (even if asymptomatic)?

Answer 124

- FBC - EUC, LFT, CMP - Iron studies - Vitamin A (light sensitive, cover tube with foil) - Thiamine - Folate and Vitamin B12 - Vitamin C - Vitamin D - Zinc

Question 125

Second line investigations for suspected micronutrient deficiency (risk factors or clinical features identified)?

Answer 125

Blood: - Coagulation profile (marker of vitamin K deficiency) - Thyroid function test (marker of iodine deficiency) - Vitamin E - Selenium - Copper Urine: - Vitamin B3

Question 126

Investigations required for children with more than 1 risk factor for vitamin D deficiency but asymptomatic?

Answer 126

- Vitamin D - Calcium - Phosphate - ALP - If low calcium intake, symptoms or multiple risk factors: PTH

Question 127

What education points are required when prescribing oral liquid iron supplements?

Answer 127

- Drink through a straw OR brush teeth after administration (baking soda to remove stains) OR liquid iron may stain teeth - Take with vitamin C OR orange juice to increase absorption OR do not take with milk due to decreased absorption with dairy, calcium, antacids, tea and coffee - Side effects can include nausea, black stools and constipation - Iron supplementation should be taken for 3-6 months

Question 128

What is the recommended dose of iron to treat iron deficiency and iron deficiency anaemia?

Answer 128

3-6mg/kg/day

Question 129

When is oral iron best absorbed?

Answer 129

On an empty stomach either: - 1 hour before food OR - 2 hours after food

Question 130

What are some non-pharmacological management strategies for fussy eating?

Answer 130

- Offer a variety of foods from the core food groups (fruits, vegetables, meats or alternatives, grains and dairy) - Offer the same meal that everyone else is eating - Offer nutritious meals and snacks 5-6 times per day - Allow 20-30 minutes OR adequate time for mealtimes - Provide small portions to avoid overwhelming child - Eat together as a family - Avoid screens OR toys OR distractions at meal times - Praise child during each meal OR use positive reinforcement - Keep meal times relaxed - If child refuses to eat a meal, avoid offering an alternative food - Try different foods often/repeatedly - children may need to be offered a new food more than 10 times before accepting it - Offer new foods alongside accepted foods - Avoid milk OR fruit juice OR soft drinks between meals

Question 131

List examination findings you'd search for when assessing for alcohol-associated fatty liver disease and liver cirrhosis?

Answer 131

- Elevated wasit circumference OR elevated body mass index - Spider naevi/angiomata - dilated superficial blood vessels - Palmar erythema - Dupuytren's contracture - finger contractions caused by thickening of the palmar fascia - Leukonychia OR clubbing (nail changes) - Gynaecomastia - enlarged breast tissue - Hepatomegaly - Splenomegaly - Caput medusae - engorged epigastric vessels - Ascites OR shifting dullness - Pleural effusion - Metabolic flap OR asterixis - Testicular atrophy - Jaundice OR scleral icterus - hyperbilirubinaemia - Confusion - sign of hepatic encephalopathy - Incoordination OR gait disturbance - Muscle twitching OR myoclonus - Slurred speech

Question 132

When interpreting Hepatitis B serology, what does this mean? - HBsAg: negative - Anti-HBc: negative - Anti-HBs: negative

Answer 132

Susceptible (consider vaccination)

Question 133

When interpreting Hepatitis B serology, what does this mean? - HBsAg: negative - Anti-HBc: positive - Anti-HBs: positive

Answer 133

resolved HBV infection

Question 134

When interpreting Hepatitis B serology, what does this mean? - HBsAg: negative - Anti-HBc: negative - Anti-HBs: positive

Answer 134

Vaccinated

Question 135

When interpreting Hepatitis B serology, what does this mean? - HBsAg: positive - Anti-HBc: positive - IgM anti-HBc (high titre): positive - Anti-HBs: negative

Answer 135

acute HBV infection

Question 136

When interpreting Hepatitis B serology, what does this mean? - HBsAg: positive - Anti-HBc: positive - IgM anti-HBc (high titre): negative - Anti-HBs: negative

Answer 136

Chronic HBV infection

Question 137

How would you monitor for hepatocellular carcinoma in patients with Hepatitis B at high risk for development of HCC?

Answer 137

Q6monthly liver ultrasounds and serum alpha-fetoprotein

Question 138

Which Hepatitis B positive patients are at high risk of developing hepatocellular carcinoma?

Answer 138

- Patients with cirrhosis - ATSI > 50 yo - Asian male > 40 yo - Asian female > 50 yo - Sub-Saharan African patients > 20 yo - Patients with a family history of hepatocellular carcinoma in a first degree relative

Question 139

What non-pharmacological management advice would you give for a patient with Hepatitis B?

Answer 139

- Condoms should be used for all types of intercourse - Alcohol cessation - Smoking cessation - Confirm contact tracing of sexual partners has occurred / ensure sexual partners are immunised against Hepatitis B / Ensure household contacts are immunised against hepatitis B

Question 140

Questions on history for the evaluation of acute ear ache in children?

Answer 140

- Fever - Otorrhoea - Nausea OR vomiting - Headache / neck stiffness / altered mental state / photophobia - symptoms of meningitis - Coryzal symptoms / Sore throat - ATSI descent - Recent swimming history - otitis externa - Recent air travel - barotrauma - History of direct ear trauma OR foreign body insertion into ear

Question 141

What is the difference between acute otitis media and otitis media with effusion?

Answer 141

Acute otitis media - acute onset of either: - Bulging of the tympanic membrane AND/OR - Otorrhoea (provided acute diffuse otitis externa is excluded) Acute otitis media: infected effusion Otitis media with effusion: non-infected effusion Signs and symptoms that support AOM instead of OMWE include: - acute onset of pain: tugging, holding or rubbing the ear - fever - irritability - poor feeding - bulging tympanic membrane

Question 142

Management of acute otitis media in average risk children?

Answer 142

- Paracetamol PO OR ibuprofen PO - Review in 48 hours to check if symptoms are improving - Advise that antibiotics are not currently indicated - Review in 3 months time for resolution of middle ear effusion

Question 143

When treating acute otitis media, what are the red flags or groups who should be treated with antibiotics earlier?

Answer 143

- < 6 months old - Children younger than 2 years with bilateral infection - Immunocompromised - ATSI - Systemically unwell (e.g. lethargic, pale, very irritable) - Single hearing ear - Child has a cocklear implant - Possible suppurative complication

Question 144

How would you manage inappropriate request for antibiotics in acute otitis media?

Answer 144

- Reassurance that acute otitis media is a self-limiting condition OR reassurance that severe complications are rare with or without antibiotics - Advise that the symptoms of acute otitis media usually last 2 to 3 days regardless of if antibiotiucs are used - Antibiotics do not improve pain at 24 hours - Antibiotics only shorten the duration of symptoms by about 12 hours total - For every 100 children treated with antibiotics, 7 will experience adverse effects OR adverse effects may include diarrhoea OR rash OR clostridium difficle OR antibiotic resistance - If there is no improvement in 48 hours then antibiotics can be trialled

Question 145

What questions would you ask on evaluation of hearing loss?

Answer 145

- Otorrhoea? - Otalgia? - Vertigo OR dizziness OR dysequilibrium? - Nature of tinnitus - pulsatile or constant, pitch? - Previous exposure to loud noises - Previous head trauma? - Previous ear surgery? - Previous cerumen OR ear wax compaction OR ear syringing? - Past recurrent ear infections? - Family history of hearing disorders? - Facial numbness - acoustic neuroma - Aural fullness - Meniere's disease - Associated headache OR aura - vestibular migraine?

Question 146

What would you look for on examination for a patient with hearing loss - aside from Rinne and Weber testing?

Answer 146

- Otoscopy or pneumatic otoscopy - for impacted cerumen, tympanic membrane perforation, middle ear effusion/infection - Reduced sensation over face trigeminal nerve distribution OR temporalis/masseter muscle wasting OR impaired corneal reflex - CN V examination - Facial asymmetry OR facial droop - CN VII examination - Abnormal head thrust test OR vestibulo-ocular test - CN VIII vestibular component

Question 147

Differentials for sensorineural hearing loss?

Answer 147

- Presbycusis OR age-related sensorineural heairng loss - Noise-induced hearing loss - Hereditary sensorineural hearing loss - Meniere's disease - Acoustic neuroma OR meningioma - Cerebrovascular ischaemia/accident

Question 148

Which diagnostic investigations are always indicated when investigating CKD?

Answer 148

- Renal tract ultrasound - Repeat (within 1 week) serum EUC and albumin - FBC, CRP, ESR - Urine ACR - Fasting lipids and glucose - Urine microscopy (for dysmorphic red cells, red cell casts or crystals)

Question 149

What investigations are required when investigating CKD and signs of systemic disease (e.g. rash, arthritis, features of connective tissue disease, pulmonary symptoms or deteriorating kidney function)?

Answer 149

- Anti-glomerular basement membrane antibody - Anti-neutrophil cytoplasmic antibody - Anti-nuclear antibodies - Extractable nuclear antigens - Complement studies

Question 150

What investigations are required when investigating CKD and risk factors for HBV, HCV, HIV (these conditions are associated with an increased risk of glomerular disease)?

Answer 150

HBV, HCV, HIV serology

Question 151

What investigations are required when investigating CKD and age >40 years and possible myeloma

Answer 151

serum and urine protein electrophoresis

Question 152

Differentials for proteinuria?

Answer 152

- Diabetic nephropathy - Hypertensive nephropathy - Multiple myeloma - Nephrotic syndrome / membranous nephropathy / minimal change disease / focal segmental glomerulosclerosis - Polycystic kidney disease - Amyloidosis - Congestive heart failure

Question 153

What are some factors other than CKD known to increase urine albumin excretion?

Answer 153

- Urinary tract infection - High dietary protein intake - Congestive cardiac failure - Acute febrile illness - Heavy exercise within 24 hours - Menstruation - Genital discharge or infection - Drugs (especially NSAIDs)

Question 154

What questions would you ask on history when evaluating recurrent epistaxis and easy bruising?

Answer 154

- Bleeding from mouth OR gums / bleeding from rectum OR malaena OR haematemesis / Haematuria - History of menorrhagia OR number/frequency of pad/tampon changes a day - Previous post procedural (e.g. dental) bleeding complications OR need for blood transfusions - Family history of bleeding disorders - Over the counter NSAID use OR intranasal spray use OR supplements - Weight loss OR night sweats - haematological malignancy - Alcohol use history - Cold intolerance OR weight gain OR hair thinning - acquired Von Willebrand's disease from hypothyroidism - Cocaine use - Nose-picking OR previous trauma to nose

Question 155

What physical exam findings would you search for when evaluating easy bleeding?

Answer 155

- Petechiae OR purpura OR ecchymoses - Telangiectasias - hereditary haemorrhagic telangiectasia - Oropharyngeal exam for mucocutaneous bleeding - Splenomegaly - Lymphadenopathy - haematological malignancy - Spider naevi OR jaundice OR hepatomegaly OR asterixis - stigmata of liver disease - Palmar crease pallor OR conjunctival pallor

Question 156

Differentials for prolonged prothrombin time (PT) and/or a prolonged activated partial thromboplastin time (aPTT)?

Answer 156

Von Willebrand disease Haemophilia (inherited OR acquired) - Haemophilia A = factor VIII deficiency - Haemophilia B = factor IX deficiency - Haemophilia C = factor XI deficiency (very rare)