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GP Flashcards

1
Q
A
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2
Q

What does Tinea look like?

A

Annular or arcuate scaly and itchy rash with a definite edge and central clearing as it expands. Tinea pedis occurs on the feet and tinea cruris on the groin

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3
Q

What is the treatment of Tinea?

A

Imidazole topical preparation• Terbinafine (Lamisil)• Bifonazole (Sporanox) • Miconazole (Monistat)• Clotrimazole (Canesten)Lamisil PO required if nails involved (as shown by yellow discolouration). 2° nail infection with candida can occur.

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4
Q

What is the pathogenesis of acne?

A
  1. Increased sebum production
  2. Outflow obstruction

Stasis of sebum leads to infection & subsequent immune reaction:

  • ‘White-head’ (inflammatory) if comedo is closed
  • ‘Black-head’ (non-inflammatory) if comedo is open
  • Cystic acne occurs if the comedo becomes encircled
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5
Q

What are the topial agents used to treat acne?

A
  1. Benzyl peroxide (OTC)
  • Used at night for 15mins, then 30mins, etc. until overnight
  • Bleaching agent (beware of clothing)
  1. Tertinoin / Retinoic acid
  • Vitamin A derivative (not Abx)
  • Excellent for blackheads (non-inflammatory acne)
  • Cream applied to whole face, even when no acne
  • More effective than benzyl but hphotosensitivity & irritation
  1. Erythromycin (Eryacne) and Clindamycin (ClindaTech)
  • Topical Abx
  • Good for whiteheads (inflammatory)
  • Used as cream on whole face
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6
Q

What are the systemic Rx for acne?

A
  1. ABx
  • Tetracycline, Doxycycline, Minocycline, Erythromycin, Trimethoprim
  • Minocycline used when no response to above two agents or poor SE profile
  1. OCP
  • Combined oral contraceptives that are likely to improve acne include those containing cyproterone, desogestrel, drospirenone or gestodene as the progestin.
  • Cyproterone acetate in OCP formulations (2mg)
  • Extra cytoproteroe acetate can be added
    1. Isotretinoin (Roaccutane)
  • Vitamin A derivative
  • Extremely high efficacy typically within 4-6months
  • Last line therapy; also used for cystic cases
  • SE’s: hLipids, photosensitivity, drying of mucous membranes, depression
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7
Q

How is pityriasis rosea commonly described?

A

In young adults. Starts with one “herald patch” (a red, macular patch / plaque) and then spreads 1-20 days later in the T-shirt and shorts region.

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8
Q

What is the prognosis of pityriasis rosea?

A

Pityriasis rosea clears up in about six to twelve weeks.

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9
Q

What is the typical patient and where is the typical distribution of a rash from a fungal infection?

A

In diabetics. In creases (warm, moist areas) eg. under breasts, in groin.

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10
Q

What is the general advice you should give to patients with acne?

A
  • Do not squeeze acne lesions—squeezing can increase depth and severity of inflammation, visibly worsening acne and increasing risk of permanent scars.
  • Use a mild skin-cleansing regimen—blackheads are not due to dirt, so excessive washing is not helpful and may be counterproductive. Use a low-irritant, pH-balanced, soap-free cleanser twice a day.
  • Eat a healthy diet—although diet has not been directly implicated in causing acne, it is reasonable to avoid specific foods that you have linked with flares. Some recent work suggests that dairy products and a high glycaemic index diet may worsen acne in some individuals.
  • Avoid overexposure to the sun—ultraviolet light, either natural sunlight or in solariums, should not be used to treat acne.
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11
Q

What are the three steps of the principles of treatment of acne?

A
  1. Unblock pores with keratolytics such as salicylic acid or retinoids. Retinoids can be topical (adapalene, isotretinoin, tazarotene, tretinoin) or systemic (isotretinoin)
  2. Decrease bacteria in the sebum with systemic antibiotics. These can be topical (benzoyl peroxide, clindamycin, erythromycin) or systemic (tetracyclines, erythromycin)
  3. Decrease sebaceous gland activity with oestrogens, spironolactone, cyproterone acetate or isotretinoin
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12
Q

What are the general management advice for patients with Rosacea?

A
  • Apply cool packs if severe
  • Minimise factors that cause flushing or irritation (see aetiology)
  • Sun protection plus sun avoidance measures are essential
  • Use an emollient soap-free cleanser, combined with a low-irritant sunscreen to reduce irritation
  • Some people may use a green-tinted foundation to mask erythrotelangiectatic features
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13
Q

What topical therapies are used for rosacea?

A

Topical therapy – for mild erythema and inflammatory lesions

  • 2% sulphur in aqueous cream tds OR
  • Metronidazole gel bd OR
  • Azelic acid gel OR
  • Clindamycin 1% solution bd OR
  • Erythomycin 2% gel bd

Topical treatments need to be used for 6 to 12 weeks for maximal response.

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14
Q

What systemic therapies are used for Rosacea?

A

Systemic antibiotics – for more severe cases or when topical therapy unsuccessful

  • Doxycycline 50 to 100mg daily
  • Erythromycin 250 to 500 mg twice daily
  • Minocycline 50 to 100mg daily

An 8-week course is often used and repeated as required.

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15
Q

What is the treatment of psoriasis?

A

General advice

  • encourage brief, safe sun exposure
  • moisturise

Topical Therapy (CC,DD)

  • Corticosteroids (short term)
  • Calcipotriol (a vitamin D derivative)
  • Dithranol

Systemic Therapy (A,B,C)

  • Acitretin (Vitamin A derivative)
  • Biological agents
  • Chemotherapy agents (MTX and cyclosporins)

Phsyical Therapy

  • Phototherapy
  • Intra-lesional corticosteroid injections

Prevention

  • Screen for psoriatic arthritis
  • Increased risk of heart disease
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16
Q

What is the management of conjunctivitis?

A

There are no specific clinical signs to differentiate bacterial and viral conjunctivitis.

  • Limit the spread by avoiding close contact with others
  • Use of separate towels and good ocular hygiene

Many cases resolve spontaneously within 5 days; however, symptoms can last up to 14 days if untreated. A ‘delayed prescription’ approach is appropriate.

  • Mild cases
    • Saline irrigation of the eyelids and conjunctiva
    • Antiseptic drop such as propamidine isethionate 0.1%
    • 1-2 drops 6-8 hourly for 5-7 days
  • More severe cases
    • Chloramphenicol 0.5% eye drops
    • 1-2 hourly for 2 days
    • Decrease to 4 times daily for another 7 days
    • Chloramphenicol 1% eye ointment at night
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17
Q

Patient presents with a painful eye, what is your DDx?

A

Don’t miss/refer today:

  1. Herpes zoster
  2. Iritis
  3. Optic neuritis
  4. Corneal ulcer
  5. Closed angle glaucoma

Common:

  1. Foreign body/corneal abrasion
  2. Entropion/ectropion/Trichiasis
  3. Blepharitis
  4. Dry eye
  5. Stye
  6. Scleritis
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18
Q

What is the management of otitis externa?

A
  • The external ear canal must be kept as dry as possible.
  • Remove discharge or other debris from the ear canal by dry aural toilet, not by syringing with water.
  • Dry aural toilet involves dry mopping the ear with rolled tissue spears or similar, 6-hourly until the external canal is dry.

After cleaning and drying, insert 10-20cm of 4mm Nufold gauze impregnated with a steroid and antibiotic cream

  • For bacterial infection:
    • Dexamethasone 0.05% + framycetin 0.5% + gramicidin 0.005% ear drops
    • 3 drops in affected ear tds, for 3-7 days
  • For fungal infection
    • Triamcinolone acetonide 0.1% + neomycin sulfate 0.25% + gramicidin 0.025% + nystatin
    • 3 drops 3tds for 3-7 days

Systemic antibiotic therapy provides no additional benefit to topical therapy, unless there is fever, spread of inflammation to the pinna, or folliculitis.

Keep the ear dry during, and for 2 weeks after, treatment.

Other measures

  • Analgesia
  • Prevent scratching and entry of water
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19
Q

What is the management of chlamydia?

A

Public health

  • Chlamydia infection (Group C disease) must be notified in writing within five days of diagnosis.
  • Advice to cease sexual activity until treated
  • Contact tracing
  • Sexual partners of individuals with chlamydia should be examined and investigated then treated empirically.

Definitive management

  • Azythromycin 1g as a single dose OR
  • Doxycycline 100mg BD for 7 days

Long term

  • patients should be re-tested 3-4 months after the initiation of antibiotics
  • Abstinence from sexual contact is recommended for at least 7 days during and after completion of antibiotic treatment
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20
Q

What is the managament of gonorrheoa

A

Public health

  • Gonococcal infection (Group C disease) must be notified in writing within five days of diagnosis.
  • Advice to cease sexual activity until treated
  • Contact tracing
  • Sexual partners of individuals with gonorrhoea should be examined and investigated then treated empirically.

Definitive management

  • Ceftriaxone: 250mg IM as a single dose
  • It is recommended that all patients with a suspected or confirmed diagnosis of gonorrhoea be treated for Chlamydia if it has not been excluded. As a practical matter, Chlamydia is treated routinely in patients with gonorrhoea.

Long term

  • Repeat diagnostic method if want to see if infection has cleared.
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21
Q

What is the treatment of syphillus?

A

Public health

  • Syphilis infection (Group C disease) must be notified in writing within five days of diagnosis.
  • Advice to cease sexual activity until treated
  • Contact tracing

Early syphilis (less than 2 years’ duration)

  • benzathine penicillin 1.8 g IM, as a single dose

Late latent syphilis (asymptomatic syphilis of longer than 2 years’ duration, or of unknown duration.)

  • benzathine penicillin 1.8 g IM, once weekly for 3 weeks

Tertiary syphilis (syphilis of longer than 2 years’ duration, or of unknown duration, with cardiovascular, central nervous system or skin and bone involvement.)

  • Expert advice and referral
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22
Q

For how long should one use anti-fungals?

A

For 2 weeks after the fungal infection has been cleared

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23
Q

What is the difference between a papule, a nodule and a pustule?

A

Papule - A palpably raised lesion which is less than 1cm in diameter

Nodule - A palpably raised lesions which is more than 1cm in diameter.

Pustule - Pustules result from accumulation of large numbers of leukocytes in the epidermis or upper dermis

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24
Q

Describe the pathogenesis of acne?

A

Disease primarily affects the pilosebaceous units of the head and neck.

  • Primary lesion is increased formation of keratin within the hair follicle itself.
  • Excess keratin blocks the pore and forms a micro-comedome
  • Bacterial lipases from propionibacterium acnes (G+) convert lipids into fatty acids, which in combination with the excess keratin drive an inflammatory reaction
  • Inflammatory reaction leads to further plugging of the pore - and further inflammatory changes
  • The enlarging pore is called a closed comedone or whitehead
  • This structure can rupture, releasing pro-inflammatory exudate and causing inflammation of surrounding tissue, leading to papules, nodules and pustules.
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25
Q

What is the management of acne?

A
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26
Q

What is the management of eczema?

A
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27
Q

What is this?

What’s the treatment?

A

Infected eczema

Staphylococcus aureus = “impetiginisation”

Soak off crusts

Topical mupirocin or oral fluclox

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28
Q

What is this?

What is the treatment?

A

Herpes simplex virus = “eczema herpeticum”

Admit to hospital

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29
Q

What is this?

What is the teatment?

A

Pompholyx eczema

Pompholyx is a common type of eczema affecting the hands (cheiropompholyx), and sometimes the feet (pedopompholyx).

Same treatment as normal eczema

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30
Q

What is this?

A

Discoid eczema

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31
Q

What is this?

What is the treatment?

A

Asteatotic eczema

Common on legs of older people

Same treatment as normal eczema

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32
Q

What is this?

What is the treatment?

A

Lichen simplex is a localised area of chronic, lichenified eczema/dermatitis.

It is usually somewhat linear or oval in shape, and markedly thickened. It is intensely itchy.

Lichen simplex is often solitary and unilateral, usually affecting the patient’s dominant side.

Potent steroids

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33
Q

What causes erythema multiforme?

A

Infections are probably associated with at least 90% of cases of EM. In order of frequency:

HSV 1
Mycoplasma pneumonia
Other viruses

Medications are an uncommon cause.

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34
Q

Describe the lesions of erythema multiforme

A

Maculopapular skin lesions forming plaques

Few to hundreds of skin lesions erupt within a 24-hour period.
The lesions are first seen on the backs of hands and/or tops of feet, then spread along the limbs towards the trunk.
Mildly itchy or burny
Lesions typically have 3 zones (red rim, clearance zone, and central blister or erosion)

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35
Q

What is the treatment and prognosis of erythema multiforme?

A

For the majority of cases, no treatment is required as the rash settles by itself over several weeks without complications.

Treatment directed to any possible cause may be required such as oral aciclovir (not topical) for HSV or antibiotics (e.g. erythromycin) for Mycoplasma pneumoniae.

Supportive care:

  • oral antihistamines or topical steroids for itch
  • mouthwashes containing local anaesthetic and antiseptic reduce pain and secondary infection in patients with involvement of the oral mucosa

Prognosis

Erythema multiforme usually resolves spontaneously without scarring over 2-3 weeks for the EM minor form, and up to 6 weeks for EM major. However it often recurs.

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36
Q

What is the management of impetigo?

A

In non-remote community settings:

Suspect S. aureus as the pathogen.

For localised skin sores, use:

mupirocin

For multiple skin sores or recurrent infection, use:

di/flucloxacillin 500 mg

In remote community settings in central and northern Australia

Suspect S. pyogenes as the pathogen.

benzathine penicillin

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37
Q

What is the treatment of lichen planus?

A

Treatment is not always required, but if so consider referral for potent and ultrapotent topical steroids.

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38
Q

What is this?

A

Lichen Planus

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39
Q

What is this?

What causes it?

What is the treatment?

A

Pityriasis rosea

We think there may be a viral cause but no-one knows

It will clear up in 6-12 weeks. Dark discolouration of skin may take longer to resolve. It doesn’t normally reccur but it can.

If itchy you can use topical corticosteroid ointment or calamine lotion

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40
Q

What is this?

A

Psoriasis - Guttate subtype

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41
Q

What can aggravate psoriasis?

A

Streptococcal tonsillitis and other infections
Injuries such as cuts, abrasions and sunburn
Obesity
Smoking
Excessive alcohol
Stressful event
Medications such as lithium, beta blockers, antimalarias, NSAIDs
Stopping corticosteroids

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42
Q

What does psoriasis look like?

A

Red, scaly plaques with well-defined edges and symmetrical distribution – usually not itchy.

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43
Q

What is this?

A

Pustular psoriasis

Usually on hands/feet
Often without usual plaque psoriasis
May be painful or “burning”

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44
Q

What are the possible complications of psoriasis you should keep in mind?

A

No good data on the prevalence of psoriatic arthritis in patients with psoriasis, circa 10%

Patients with psoriasis have 2-3x cardiovascular risk of patients without psoriasis!

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45
Q

What is the management of psoriasis?

A
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46
Q

What is this?

A

Rosacea is a common persistent eruption of unknown aetiology. It is characterised by central facial erythema, visible blood vessels and acneiform papules and pustules. It is typically chronic and persistent with a fluctuant course.

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47
Q

What is the management of rosacea?

A

General management

  • Apply cool packs if severe
  • Minimise factors that cause flushing or irritation (see aetiology)
  • Sun protection plus sun avoidance measures are essential
  • Use an emollient soap-free cleanser, combined with a low-irritant sunscreen to reduce irritation
  • Some people may use a green-tinted foundation to mask erythrotelangiectatic features

Topical therapy – for mild erythema and inflammatory lesions

  • 2% sulphur in aqueous cream tds OR
  • Metronidazole gel bd OR
  • Azelic acid gel OR
  • Clindamycin 1% solution bd OR
  • Erythomycin 2% gel bd

Long-term maintenance with topical metronidazole is often used to control rosacea and prolong remissions.

Systemic antibiotics – for more severe cases or when topical therapy unsuccessful

  • Doxycycline 50 to 100mg daily
  • Erythromycin 250 to 500 mg twice daily
  • Minocycline 50 to 100mg daily
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48
Q

What is the typical presentation of scabies?

Where does it typically occur (on the body)?

A

The prominent clinical feature of scabies is itching. It is often severe and usually worse at night. The pruritus is the result of a delayed type-IV hypersensitivity reaction to the mite, mite feces, and mite eggs.

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49
Q

What is the management of scabies?

A

Permethrin 5% cream (adult and child 6 months or older)

Apply topically to dry skin from the neck down, paying particular attention to hands and genitalia. Apply under the nails using a nailbrush. Leave on for a minimum of 8 hours (usually overnight) and reapply to hands if washed. Application time may be increased to 24 hours if there is a history of treatment failure. Repeat treatment in 7 days

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50
Q

What is the prognosis of Bell’s palsy?

A

Resolution in 85% of patients within 4-6 weeks.

Generally good and patients may spontaneously recover even without medication.

Related to severity of lesion and more favourable if some recovery or progress seen within 3 weeks of onset.

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51
Q

What are the 3 main things you want to rule out in Bell’s palsy?

A

Space occupying lesion –> facial twitch or spasm

CVA –> other signs of stroke, not limited to CN VII

Ramsay Hunt Syndrome –> look for vesicles on ear

Otitis Media –> otoscopy

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52
Q

What is the Mx of Bell’s Palsy?

A

Basics

Eye care for patients who have impaired eye closure

Use of short term (10 days) oral corticosteroids (60 mg/ day) within 72 hours after the onset of symptoms.

Antiviral agents if viral etiology is suspected but only in conjunction with corticosteroids.- contentious

Place and person

GP managed

Referral to neurologist in cases of new or worsening symptoms or incomplete recovery after 3 months.

Investigate and confirm diagnosis

Assess and exclude other possible identifiable causes

Non-invasive management

Psychological counselling and physiotherapy

Definitive management

Specialists may do surgical nerve decompression if fails to recover.

Electrical nerve stimulation to promote motor recovery.

Both have limited evidence

Long term

Follow up 1-2 weeks after onset to monitor effect of medications and eye care.

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53
Q

What are common causes of gradual vision loss?

A

Cataracts

Age related macular degeneration

Chronic open angle glaucoma

Diabetic retinopathy

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54
Q

What are common causes of sudden onset vision loss?

A

Branch or central retinal vein occlusion

Branch or central retinal artery occlusion

CVA/TIA

Giant Cell Arteritis

Retinal detachment

Optic neuritis

Migraine

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55
Q

What is the Mx of chalazion/Meibomian cyst?

A

Benign and self limiting

Apply heat and massage twice a day

Avoid antibiotic ointments

Incision and curettage is second line treatment

Prevention by managing any associated blepharitis

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56
Q

What is the Mx of blepharitis?

A

No easy cure

Lid hygiene –> warm compresses for 5-10mins bd

If severe try oral tetracycline for 2-3 months

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57
Q

What is the clinical presentation of infective conjunctivitis?

A

Key features

Gritty red eye
Purulent discharge
Clear cornea

History

Purulent discharge which causes the eyelashes to stick together in the morning
Starts on one eye and spreads to the other (usually)
Hx of contact with a person that has similar symptoms

Examination

Bilateral mucupurulent dischange with uniform engorgement of all of the conjunctivial blood vessels
Non-specific papillary response (larger fleshy swellings on the inside of the eyelid)
Fluorescein staining is negative

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58
Q

What is the Mx of infective conjunctivitis?

A

Limit the spread by avoiding close contact with others
Use of separate towels and good ocular hygiene

Many cases resolve spontaneously within 5 days; however, symptoms can last up to 14 days if untreated. A ‘delayed prescription’ approach is appropriate.

Mild cases

Saline irrigation of the eyelids and conjunctiva
Antiseptic drop such as propamidine isethionate 0.1%

More severe cases

Chloramphenicol 0.5% eye drops

1-2 hourly for 2 days
Decrease to 4 times daily for another 7 days
Chloramphenicol 1% eye ointment at night

Specific organisms

Pseudomonas use topical gentamicin and tobramycinN. gonorrhea use appropriate systemic antibiotics

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59
Q

When a patient complains of “dizziness” what do you think of that they could actually be experiencing?

A
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60
Q

What signs/symptoms differentiate central from peripheral vertigo?

A
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61
Q

What is the Mx of Meniere’s disease

A

Low salt diet + diuretic

Vestibular rehab

Prochlorperazine maleate (stemetil): 5-10 mg orally every 6-8 hours when required

Do not use stemetil long term –> will stop the brain accommodating to a labyrinthine upset

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62
Q

What is the clinical picture of vestibular neuronitis?

A

Severe vertigo that lasts for days

Acute inflammation of the vestibular nerve

Cause unknown

Young or middle aged adults

Incapacitating sustained (non-positional) vertigo

Sudden onset

Very unwell and lie still in bed

Nausea and vomiting

No tinnitus or deafness

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63
Q

What is the Mx of vestibular neuronitis?

A

Reassurance and explanation

Stemetil should be given only in the first few days

After 2-5 days steady resolution usually occurs over a period of 6 to 12 weeks

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64
Q

What are the top 3 DDx for vertigo?

A

BPPV

Meniere’s disease

Vestibular neuronitis

65
Q

What pathogen causes syphillus?

A

Treponema pallidum

66
Q

What is the epidemiology of syphilis?

A

Rare in Australia

High-risk sexual activity and previous STIs increase the risk

67
Q

What are the stages of syphilis?

A

Early syphilis

primary (chancre), secondary (rash or condylomata lata) or latent syphilis (asymptomatic) of less than two years duration exist based on serology results

Late latent syphilis

Latent syphilis has existed for two or more years or of indeterminate duration, in the absence of neurosyphilis and other symptoms and signs of disease

Tertiary syphilis

where cardiovascular involvement and neurosyphilis is present.

68
Q

What are the symptoms of secondary syphilis?

A

Secondary syphilis is caused by haematogenous spread of infection. This leads to a widespread vasculitis.

  • Non-itchy, reddish/brown skin rash + mucous membrane lesions.
  • Systemic symptoms inc fever, pharyngitis, headache and arthralgia
  • condylomata lata (clusters of soft, moist lumps in skin folds of the anogenital area)
69
Q

What is the natural history of syphilis?

A
70
Q

What is this?

A

Condylomata lata, is a cutaneous condition characterized by wart like lesions on the genitals. They are generally symptoms of the secondary phase of syphilis, caused by the spirochete, Treponema pallidum.

71
Q

What is tertiary syphilis?

A

One third of people who have latent syphilis will go on to develop tertiary syphilis - approximately 3 to 15 years after the initial infection. There are three different forms:

gummatous syphilis (15%) - soft tumours on bone/liver/skin
neurosyphilis (6.5%) - dementia/paresis/seizures/apathy
cardiovascular syphilis (10%) - aortic aneurysms
72
Q

What is the management syphilis?

A

Public health

  • Syphilis infection (Group C disease) must be notified in writing within five days of diagnosis.
  • Advice to cease sexual activity until treated

Contact tracing

  • For primary syphilis, Trace sexual contacts for the last 3 months. Such contacts should be treated as for the case, even if their serology is negative.
  • For secondary syphilis, this period should be extended to 6 months
  • For early latent syphilis, to twelve months.
  • For late latent syphilis, any sexual partners and also children of infected women should be evaluated.

Early syphilis (less than 2 years’ duration)

benzathine penicillin 1.8 g IM, as a single dose

Late latent syphilis (asymptomatic syphilis of longer than 2 years’ duration, or of unknown duration.)

benzathine penicillin 1.8 g IM, once weekly for 3 weeks

Tertiary syphilis (syphilis of longer than 2 years’ duration, or of unknown duration, with cardiovascular, central nervous system or skin and bone involvement.)

Expert advice is essential.

benzylpenicillin 1.8 g IV, 4-hourly for 15 days.

73
Q

What is the clinical picture of initial HSV1 infection?

What is the clinical picture of recurrent HSV1 infection?

A

HSV1 – First infection

  • high fever
  • sore throat
  • pharyngeal oedema
  • Generalised muscle pain
  • Rigors
  • Cervical lymphadenopathy
  • Sometimes splenomegaly

Recurrences

  • 6-48 hours of pain/burning/tingling
  • Vesicles then form, crust and heal within 10 days
  • Systemic manifestations rare
74
Q

What is the management of HSV infection?

A

All patients

  • Symptomatic simple analgesia
  • Consider 2% topical lidocaine
  • Pt education
    • Avoid sexual contact when lesions present
    • 100% use of condoms
    • Lifelong infection, could have contracted long ago
    • Lack of serious sequelae for most people

Minor episode (oral)

Aciclovir 5% cream topically, 5 times per day (every 4 hours while awake) for 4 days at the first sign of recurrence

Severe episode

Aciclovir 400 mg orally, 5 times daily for 7 days

Long term suppressive treatment

Aciclovir 400 mg orally, 12-hourly for up to 6 months

Disseminated visceral involvement: pneumonitis, hepatitis, or CNS involvement (meningitis or encephalitis)

Admit to hospital
IV acyclovir

75
Q

What types of HPV cause genital warts and what types cause cervical cancer?

A
76
Q

Apart from HPV infection, what are the other risk factors for cervical cancer?

A

Smoking

Sexual activity (lifetime number of partners)

HIV and immunosuppression

OCP use for >5years

77
Q

A patient presents with urethral discharge after unprotected sex, what are your differentials?

A

Whilst chlamydia is usually asymptomatic, it is much more common than gonorrhea so in a patient with urethral discharge chlamydia is still more common than gonorrheoa!

It could also be HSV

78
Q

What is the clinical picture of gonorrhoea?

A

Infections of the cervix, anus and throat usually cause no symptoms.

Men

  • Urethral discharge 2 – 10 days after unprotected sex
  • Dysuria
  • Men who have sex with men
  • Hx of STD
  • Multiple sexual partners
  • Inconsistent condom use

Women

Most women who are infected with gonorrhoea have no symptoms or vague symptoms that mimic common UTI.

Women with gonnorrhoea are just as at risk of developing serious complications from the infections regardless of the presence or severity of symptoms.

The initial symptoms or signs that women MAY experience, include:

  • Dysuria
  • Vaginal discharge
  • Vaginal bleeding
  • Dyspareunia
79
Q

What are the sexual history systems review questions?

A

The 5 P’s

  1. Partners
    • How many?
    • Male/female/both?
    • Regular or random?
  2. Practices
    • Frottage/oral/vaginal/anal?
    • Drugs used?
  3. Previous STIs
  4. Prevention of STIs
  5. Prevention of Pregnancy
80
Q

What is the management of gonorrheoa?

A

Public health

  • Gonococcal infection (Group C disease) must be notified in writing within five days of diagnosis.
  • Advice to cease sexual activity until treated
  • Contact tracing

Sexual partners of individuals with gonorrhoea should be examined and investigated then treated empirically.

Definitive management

Ceftriaxone: 250mg IM as a single dose

It is recommended that all patients with a suspected or confirmed diagnosis of gonorrhoea be treated for Chlamydia if it has not been excluded. As a practical matter, Chlamydia is treated routinely in patients with gonorrhoea.

Azithromycin: 1 g orally as a single dose

Long term

Repeat diagnostic method if want to see if infection has cleared.

81
Q

What are the complications of untreated chlamydia?

A

PID
Infertility
Epididymitis
Reactive arthritis

82
Q

What is the clinical presentation of chlamydia?

A

Normally asymptomatic but may have Cervical/Urethral discharge

Age 25 years
Multiple sex partner/new sex partner
History or prior STD
Abnormal vaginal bleeding
Dysuria

83
Q

What are the investigations for chlamydia?

A

First pass urine – NAAT (nucleic acid amplification test)

Culture of urethral discharge

Also test for gonorrhea, syphilis, HIV and Hep B

84
Q

What is the management of chlamydia?

A

Public health

  • Chlamydia infection (Group C disease) must be notified in writing within five days of diagnosis.
  • Advice to cease sexual activity until treated

Contact tracing

Sexual partners of individuals with chlamydia should be examined and investigated then treated empirically.

Definitive management

Azythromycin 1g as a single dose OR

Doxycycline 100mg BD for 7 days

Long term

patients should be re-tested 3-4 months after the initiation of antibiotics

85
Q

What is the clinical picture of bacterial vaginosis?

A

50% asymptomatic

White-to-grey discharge adherent to the vaginal mucosa
Dysuria
Vaginal pruritis
Previous episodes
Dyspareunia
Vulvodynia

86
Q

What are the diagnostic criteria for bacterial vaginosis?

A

Amsel criteria

87
Q

What is the management of bacterial vaginosis?

A

Treatment of sexual partners is not required

For symptomatic patients, use:

metronidazole 400 mg orally, 12-hourly for 5 days

OR

metronidazole 0.75% vaginal gel, 1 applicator full intravaginally, at bedtime for 5 nights

88
Q

What are the oestrogenic side effects?

A

Mastalgia

Nausea

Fluid retention

Abdominal bloating

Headaches

Chloasma

89
Q

What are the progestogenic side effects?

A
90
Q

What are some of the downsides/cons of depo-provera?

A

Risk of decreased bone density with prolonged use >5 years

Weight gain up to 2 kg per year

Delay in return to fertility up to 9 month

91
Q

What effect does the implanon have on menses?

A

1/3 amenorrhoea

1/3 intermittent bleeding

1/3 heavy bleeding –> consider removal

92
Q

What effect does the Mirena have on menses?

A

Intermenstrual bleeding first 6 months then at least 90% reduction in blood loss and many have amenorrhoea.

93
Q

What effect does depo-provera have on menses?

A

Amenorrhoea occurs usually by 3rd injection

Small % have heavy bleeding

94
Q

Apart from it’s contraceptive effects, what are the positives (or other uses) of the OCP?

A

Improved acne
Reduced endometriosis and fibroids risk
Reduced menorrhagia, dysmenorrhea, PMT

Reduced ovarian and endometrial cancer risk

95
Q

At what age would you switch a women from the COCP to the POP?

A

35 years if smoker

At menopause if non smoker

96
Q

What are the chances of becoming pregnant if you have unprotected sex? What about if you use the emergency contraceptive pill or the Cu IUD?

A

8 in 100 women who have unprotected sex one time during the fertile part of their cycle will become pregnant.

If these 100 women take ECP about 1 will become pregnant

Only 1 in 1,000 women who have an IUD put in after having unprotected sex will become pregnant.

97
Q

What are the options for emergency contraception and how long after unprotected sex can you use them?

A

You have up to 72 hours after unprotected sex to take the ECP.

You have up to five days after ovulation to have an IUD fitted.

The ECP is most effective at preventing pregnancy (95% effective) if taken within 24 hours of unprotected sex. Within 25 to 48 hours, the effectiveness falls to 85%, and within 49 to 72 hours it is only 58% effective.

98
Q

What are the causes of conductive hearing loss?

A

Foreign body
Earwax
Otitis externa
Otitis media
Cholesteatoma
Perforated membrane
Trauma
Eustachian tube dysfunction
Otosclerosis

99
Q

What are the causes of sensorineural hearing loss?

A

Cochlear –> CN VIII –> Auditory cortex

Presbycusis
Noice induced
Menierres
Acoustic neuroma

Stroke

100
Q

What is the management of sudden sensorineural hearing loss?

A

Do Rinne test
Medical emergency and needs high dose steroids early (Prednisolone 1mg/kg up to 60mg daily)
Refer to specialist
Overall recovery rates are 50-65%
If it recovers, usually within 2-4 weeks
In some patients, the hearing loss is permanent

101
Q

What is this?

A

LUDWIGS ANGINA - MEDICAL EMERGENCY

Mortality = 8%

A serious, potentially life-threatening cellulitis of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheotomy.

102
Q

What is the management of Ludwig’s angina?

A

Basics

  • Secure the airway!
  • Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway.
  • Prevent the development of septic shock and multi-organ failure — give antibiotics early.

Place and person

  • Notify ENT, anaesthetics and ICU.
  • Admit to ICU

Investigate and confirm diagnosis

  • Do not delay treatment whilst waiting for investigations.

Definitive management

  • Antibiotics
    • Metronidazole 500mg IV every 12 hours AND
    • Benzylpenicillin 1.2g IV every 6 hours
  • Steroids:
    • Dexamethasone IV
  • Intensive care
    • 1:1 nursing
    • Continuous RR, ETCO2, invasive BP and ECG monitoring
    • Fluid resuscitation
    • Indwelling catheter

*For patients with non-immediate hypersensitivity to penicillin: Cephazolin 1g IV every 8 hours.

For patients with immediate hypersensitivity to penicillin: clindamycin 450 mg IV every 8 hours

103
Q

What is the definition of otitis externa?

A

Defined as rapid onset diffuse inflammation of the external ear canal, which may also involve the pinna or tympanic membrane. It is a form of cellulitis that involves the skin and subdermis of the external auditory canal with acute inflammation and variable oedema. Acute diffuse otitis externa (swimmer’s ear) often occurs following skin maceration of the external ear canal from water exposure.

Pseudomonas aeruginosa and/or Staphylococcus aureus are commonly isolated from cultures.

104
Q

What is the clinical presentation of otitis externa?

A

RAPID ONSET

Clinical features

  • Itching at first
  • Pain (mild to intense)
  • Fullness in ear canal
  • Scant discharge
  • Hearing loss

Signs

  • Oedema (mild to extensive)
  • Tenderness on moving auricle or jaw
  • Erythema
  • Otorrhoea (offensive if coliform)
  • Pale cream ‘wet blotting paper’ debri – C. albicans
  • Black spores of Aspergillus nigra
105
Q

What is the management of otitis externa?

A

Basics

Simple analgesia

Place and person

N/A

Ix

Culture swab

Management

  • The external ear canal must be kept as dry as possible for >2 weeks after treatment
  • Remove discharge or other debris from the ear canal by dry aural toilet, not by syringing with water.
  • For bacterial infection:
    • Dexamethasone 0.05% + framycetin 0.5% + gramicidin 0.005% ear drops
      • 3 drops in affected ear tds, for 3-7 days
  • For fungal infection
    • Triamcinolone acetonide 0.1% + neomycin sulfate 0.25% + gramicidin 0.025% + nystatin
      • 3 drops 3tds for 3-7 days
  • The tragus should be pumped for 30seconds after instillation by pressing on it repeatedly, within the limitation of any pain.
  • Systemic antibiotic therapy provides no additional benefit to topical therapy, unless there is fever, spread of inflammation to the pinna, or folliculitis.
106
Q

What is the prognosis of acute otitis media?

A

AOM can be either viral or bacterial (or mixed) in origin, but regardless of cause, it is usually self-limiting (60% of children treated with placebo became pain-free in 24 hours, and spontaneous resolution of AOM occurs in approximately 80% of children).

107
Q

What is acute otitis media most often related to?

A

Viral URTI that will self-resolve

108
Q

What is this?

A

Acute otitis media

Perforation of the tympanic membrane with otorrhoea

109
Q

What is the management of acute otitis media?

A

Generally, conservative management with simple analgesia

Adults with otitis media –> conservative management

Indications for Amoxycillin

    • Sick child with fever
  • Vomiting
  • Red-yellow bulging TM
  • Discharge
  • Loss of TM landmarks
  • Persistent fever and pain after 3 days of conservative approach
  • Bilateral AOM
110
Q

What are the differentiating features of safe and unsafe tympanic perforation from chronic otitis media?

A
111
Q

What causes tonsilitis?

A

rhinovirus, coronavirus, adenovirus

112
Q

What are the 3 stages of pertussis?

A

Catarrhal stage (7-14 days)

  • Anorexia
  • Rhinnorrhoea
  • Conjunctivitis/lacrimation
  • Dry cough

Paroxysmal stage (about 4 weeks)

https://www.youtube.com/watch?v=AIVt3e5EVtc

  • Paroxysms of severe coughing with inspiratory ‘whoop’
  • Vomiting (after coughing)
  • Coughing mainly at night
  • Lymphocytosis

Convalescent stage

Chronic cough which may last for weeks

113
Q

What is the management of pertussis?

A

Basics

ABC

Place and person

If younger than 6 months – hospitalization

School exclusion until at least 5 days of antibiotic use

Investigate and confirm diagnosis

Nasopharygeal aspirate

FBE, IgA serology

CXR – to exclude pneumonia

Non-invasive management

Good ventilation

Avoid emotional excitement or distress

Avoid overfeeding during paroxysmal stage

Definitive management

Antibiotics minimize transmission but do not effect course of disease

Azithromycin 500 mg 5 days OR
Trimethorpim and sulfamethoxazole 7 days OR
Clarithromycin 7 days

Prophylaxis

Same treatment as above for household and other close contacts if commenced within 3 weeks of onset of cough in the patient

Prevention

Acellular pertussis is part of the immunization schedule

Initial protection

2, 4 and 6months

Booster (dTpa)

4 years
10-15 years
Parents or household contacts of newborns

114
Q

What is the triad of pyelonephritis?

A

Fever, flank pain, nausea

115
Q

What are risk factors for pyelonephritis?

A
  • Frequent sexual intercourse
  • Urinary tract infections (UTI)
  • Diabetes Mellitus
  • Stress incontinence
  • Foreign body in urinary tract (calculus, catheter)
  • Anatomical/functional urinary abnormality
  • Immunosuppressive states (HIV, transplantation, chemotherapy, corticosteroid use)
  • Pregnancy
  • Hospital acquired infection
  • History of urinary tract infection in childhood
116
Q

What are the Ix for suspected pyelonephritis?

A

Bedside tests

Urine dipstick

–> Pyuria (pus in the urine) is always present in pyelonephritis, bacteriuria, haematuria

Bloods and urine

Urine culture – WBC casts is diagnostic
Blood cultures
FBE – leuckocytosis
ESR/CRP

Imaging -Not needed to confirm diagnosis but may identify cause

Renal ultrasound/CT may aid in diagnosis of hydronephrosis from a stone or obstruction

117
Q

In what setting do staghorn calculi generally form?

A

Staghorn calculi are composed of struvite (magnesium ammonium phosphate) and are usually seen in the setting of infection with urease producing bacteria (e.g. Proteus, Klebsiella, Pseudomonas and Enterobacter). Urease hydrolyses urea to ammonium and increase in the urinary pH.

118
Q

What are the Ix for suspected urolithiasis?

A

Bedside Tests

Urine dipstick test - may be +ve for leukocytes, nitrates, blood

Bloods and urine

Urine Microscopy - may be +ve for WBC, RBC and Bacteria

Serum calcium, phosphate, uric acid, bicarbonate
UEC

Imaging

Plain abdominal xray - approx 80% of stones contain calcium which can be seen on xray

CTKUB
99% of stones are visible using this method
For Monash exams the INITIAL AND GOLD STANDARD Ix for urolithiasis is CTKUB not AXR

U/S

Can show some stones and uteric dilatation
Useful in pregnant women, young women or unstable patients in whom exposure to radiation is undesirable

119
Q

What Ix would you order for someone with recurrent kidney stones?

A

Stone analysis

To determine the chemical composition of the stone
The stone is either extracted from surgery or passed by the patient

Parathyroid levels

As a possible cause of calcium-containing stones
Hyperparathyroidism –> hypercalcaemia à calcium stones

Urine microscopy

Amino acid / cysteine levels

As a possible cause of cysteine stones

24 hour urine monitoring

should be ordered once the patient is stone free
measure volume, pH, creatinine, sodium, calcium, oxalate, uric acid, citrate
Helps in determining underlying metabolic cause or aetiology for nephrolithiasis

120
Q

How big can a kidney stone be for medical management?

What is the medical management

A

D/C home on “push fluids” (drinking a lot orally to try to pass the stone)
Medical expulsive therapy (MET) may also help to pass the stone

Tamsulosin (alpha blocker –> smooth muscle relaxation)
Nifedipine (calcium channel blocker –> smooth muscle relaxation)

121
Q

What are the surgical mx options for kidney stones?

How big does the stone have to be to warrant surgical mx?

A

>6mm

Extracorporeal shock wave lithotripsy (ESWL)
Ureteroscopy
Percutaneous nephrolithotomy (PCNL)

122
Q

What is the Mx of carpal tunnel syndrome?

A

Basics

Education, conservative treatment

Place and person

GP managed, if symptoms persist or worsen refer to orthopaedic/ hand surgeon

Investigate and confirm diagnosis

Nerve conduction study

Non-invasive management

Weight loss (if overweight)
Wrist splinting esp at night
Ultrasound physiotherapy tx
Oral glucocorticoids (short term use only!)
Corticosteroid injections into the carpal tunnel region

Definitive management

Surgical decompression

  • Open
  • Endoscopic

Wide variation in success rates and complications for both

123
Q

Where do symptoms occur in carpal tunnel syndrome?

A
124
Q

What are the indications for surgical management of a fracture?

A

NO CAST

Non-union

Open fracture

Compromise neurovascular

Articular fracture

Salter harris III IV V

Trauma

125
Q

If a patient has an egg allergy what vaccine can’t they receive?

A
126
Q

Which of the common vaccines are live?

A

rotavirus, MMR, varicella

127
Q

Which vaccine has been related to encephalopathy?

A

TDAP - pertussis component

tetanus and diphtheria and bordatella pertussis

128
Q

What are the core features of EBV/infectious mononucleosis?

A

Fever, pharyngitis, lymphadenopathy (94%, usually posterior cervical chain) and fatigue

Sometimes splenomegaly

129
Q

What is the prognosis of EBV?

What complications can occur?

A

Prognosis is typically good for this self-limiting infection. The vast majority of patients recover uneventfully and develop immunity to control the latent infection. Usually, most symptoms will resolve in one to two weeks, although fatigue and malaise may persist for months.

Death can occur rarely from airway obstruction, splenic rupture, neurological complications, haemorrhage (thrombocytopaenia) or secondary infection.

130
Q

What is this?

What is the treatment?

What are the potential complications?

A

Measles

There is no specific treatment of measles except for supportive care, but the disease can be prevented by a live virus vaccine. Immediately notify DoH, isolate for >4 days after rash onset.

Complications of measles occur more often in immunocompromised and poorly nourished individuals and include pneumonia, laryngotracheitis, otitis media, and encephalitis.

131
Q

What is the clinical presentation of measles?

A

Similarly to malaria, the most important clue is travel to measles-endemic area or exposure to individual with measles in an unvaccinated person.

Other key features include:

Fever
Cough
Coryza
Conjunctivitis
Koplik’s spots
Maculopapular rash

132
Q

How can you differentiate between measles and rubella?

A

Measles has Koplick spots

Investigations:

Measles IgM and IgG serology

133
Q

What is mumps?

What is the clinical presentation?

What is the management?

What are the complications?

A

Mumps is an acute, self-limited, viral syndrome. It is spread by respiratory droplets, and, before the advent of the mumps vaccine, it affected school-aged children commonly.

Classically, mumps causes swelling of the parotid glands; the involvement of other salivary glands, meninges, gonads, and pancreas is also common.

Management

  • 5 days of isolation at home
  • Supportive care
  • Mumps (Group B disease) must be notified in writing within five days of diagnosis.
  • School exclusion: exclude for nine days or until swelling goes down, whichever is sooner.

Complications

The more serious complications of mumps, such as meningitis, encephalitis, and orchitis, may occur in the absence of parotitis, which can delay accurate diagnosis of the clinical syndrome.

134
Q

What is the full management of osteoporosis?

A

Basic

Education and reassurance

Place and person

GP managed

Investigate and confirm diagnosis

  • FBE
  • UEC (rule out renal osteodystrophy)
  • LFTs (rule out chronic liver dz)
  • CMP (Hypocalcaemia? Primary hyperparathyroidism (high Ca, low phosphate))
  • Parathyroid hormone levels
  • Vit D levels
  • TSH (hyperthyroidism?)
  • Serum and urine electrophoretogram and immunoelectrophoretogram (multiple myeloma)
  • Anti-TTG and IgA (coeliac)
  • DEXA scan

Non invasive

  • Quit smoking, reduce alcohol
  • Calcium and vitamin D
  • Weight bearing exercise
  • Physio and OT to prevent falls

Definitive

Indications for pharmacotherapy:

  • Minimal trauma fracture
  • >70 yrs and T score -3.0 or lower
  • T score less than -1.5 and prolonged steroids

Options:

  • Bisphosphonates:
    • Aledronate, oral, weekly, up to 10 years
    • Zoledronic acid, IV, yearly for 3 years
  • SERM – Raloxifene
  • Monoclonal antibody – Denosumab
  • Teriparatide (PTH analogue)
  • Strontium ranelate

What do you need to know about bisphosphonates:

  • Significantly reduces the risk of # and complications of OP
  • Do not eat or drink before taking the drug
  • Take once a week, standing up with a full glass of water.
  • Take the tablet whole, do not crush or chew.
  • Remain standing up for 30mins after taking.
  • Do not eat, drink or lie down for 30 mins after taking
  • Risks
    • Oesophageal irritation
    • Upper GI ulcers
    • Musculoskeletal aches and pains
    • Osteonecrosis of the jaw (rare)
    • Atypical femoral stress fractures (rare)
    • Delays bone healing if there is a #
135
Q

When you discover hypertension, what should you do before prescribing an antihypertensive?

A

1) Is the HTN primary or secondary?

ABCDE

  • Apnea, Aldosteronism
  • Bruits / Bad Kidneys
  • Catecholamines, Cushings, Coartation, Calcaemia
  • Drugs
    • Corticosteroids
    • OCP
    • Decongestants (pseudoephedrine)
    • ETOH
    • NSAIDs
    • Oestrogen
    • Psych drugs – MAOi, Lithium, Clonidine
  • Endocrine (hyperthyroidism)

2) How bad is has it been? - assess for end organ damage

  • Heart
    • LVH (ECG, TTE/TOE)
  • Kidneys
    • Albumin:creatnine
    • Protein:creatnine
    • eGFR
  • Eyes
    • Fundoscopy
  • Vascular
    • Auscultate for bruits
    • U/S or angiogram

3) How bad might it be in the future? - assess overall CV risk

136
Q

What are the relative and absolute contraindications to consider before prescribing a hormonal contraceptive?

A

HOMESICK

Headache / Hypertension
Obesity
Medications (some antivirals/ABx)
Embolism / Thrombus / Clotting disorders
Stroke
IHD
Cancer (Breast, Endometrial)
Kids (ie. parity) / Breastfeeding

137
Q

A 60yo patient presents with back pain. You know that non-specific musculoskeletal back pain is the right diagnosis is >85% of cases, but what conditions do you want to rule out and what do you ask on history to do that?

A
  • Could it be cancer?
    • Pain not relived by bed rest
    • Weight loss
    • Age
    • Hx or FHx of prostate, breast of lung ca
  • Could it be cauda equina?
    • Bladder/bowel symptoms
    • Saddle parasthesia
    • Bilateral parasthesia in limbs
  • Could it be spinal stenosis?
    • Pain in legs when walking but relieved by sitting
    • Age >65
    • No pain when seated
  • Could it be AnkSpond
    • Morning stiffness
    • Improves with exercise
    • Onset
    • Slow onset
  • Could it be a fracture?
    • Point tenderness
  • Trauma
    • Age >50
    • Osteoporosis or use of corticosteroids

Signs and symptoms of neurocompressive lower back pain

  • Pins & needles and/numbness
  • Muscle weakness
  • Positive straight leg raise and/or slump test
  • Sharp, lancinating leg pain
  • Leg pain > LBP
  • High irritability and flares of pain and activity limitation
138
Q

What four things do you do to manage non-specific back pain?

A
  • Weight loss + exercise
  • Analgesia
  • Physio referral
  • Monitor
139
Q

What are the Ottowa ankle rules?

A
140
Q

What tests (and results) can be used to diagnose T2DM?

A
  • FBG ≥7.0 mmol/L (on two separate occasions)
  • 2 hour postprandial ≥11.0 mmol/L on OGTT (on two separate occasions)
  • HbA1c ≥6.5% (48 mmol/mol) (on two separate occasions) - ALTHOUGH THIS ISN’T CURRENTLY FINDED BY MEDICARE
141
Q

revise the grading of HT and when to recheck one’s BP

A
142
Q

once you ascertain someone is hypertensive, describe the three steps that need to be considered before presibing anti-hypertensives?

A

What’s caused it?
Determine if their HT is essential or secondary

How bad is has it been?
Assess for end organ damage

How bad might it be in the future?
Assess overall CV risk

143
Q

what are the secondary causes of hypertension?

A

ABCDE

Apnea, Aldosteronism

Bruits / Bad Kidneys

Catecholamines, Cushings, Coartation, Calcaemia

Drugs

Endocrine (hyperthyroidism)

144
Q

What medications can cause hypertension?

A

‘CODE NO’ (+ psych drugs)

Corticosteroids

OCP

Decongestants (pseudoephedrine)

ETOH

NSAIDs

Oestrogen

Psych drugs – MAOi, Lithium, Clonidine

145
Q

How do you assess for end organ damage?

A

Heart
•LVH (ECG, TTE/TOE)

Kidneys
•Albumin:creatnine
•Protein:creatnine
•eGFR

Eyes
•fundoscopy

Vascular
•Auscultate for bruits
•U/S or angiogram

146
Q

What are the risk factors of OP?

A

Epidemiological / Anthrolpological Risk Factors

  • Female
  • Older age
  • Early-onset menopause / menopause
  • Low BMI
  • Immobilisation

Lifestyle Risk Factors

  • ETOH
  • Smoking
  • Low calcium intake
  • Low vitamin D intake
  • Inadequate sun exposure

Medications / Disease Processes Risk Factors

  • Steroids
  • Anti-convulsants
  • HRT (protective)
  • Endocrine disorders:
    *Cushings
    *HyperPTH
    *Hyperthyroidism
  • Other disorders:
    *CKD
    *CLD
    *MM
    *Hysterectomy
147
Q

What is a T score?

What is a Z score?

Which is used for the diagnosis of OP?

What is the other used for?

A

A T score is the number of standard deviations from the BMD of a young healthy adult (30 y.o.)

A Z score is the number of SDs you are from the BMD of someone your age and sex.

A T score is used in the diagonsis of osteopenia / osteoporosis

148
Q

How do you diagnose OP and osteopenia?

A

DEXA scan

T score between -1 and -2.5 = osteopenia

Z score less than -2.5 = OP

149
Q

what might artefactually increased BMD on a DEXA scan?

A

OA

Fracture

Deformity

150
Q

What are the differential diagnoses of pathalogical fractures?

A

‘MR PPP MMM’

Malacia (Adults) / Rickets (Paeds) - vitamin D not mineralizing bone

Porosis / Penia - osteoclastic reabsorption of bony architecture

Pagets - abnormal osteoclasts, intense resorption of bone

Parathyroidism - primary, secondary

Malignant invasion - (think of hexagon: thyroid, breast, lung, kidneys, prostate)

MGUS / MM

Medication - steroids, anti-convulsants

151
Q

What investigations would you order for someone with a pathological fracture?

A

Labratory Tests

  • Serum Vit D
  • CMP
  • UEC
  • LFT
  • PTH
  • TFT
  • Urinary cortisol (if cushings suggestive on history)
  • urine / serum proetin electrophoresis (if MGUS / MM suggestive on history)

Imaging

  • xray of painful site
  • DEXA scan
152
Q

Describe your management of OP (which has been diagnosed on DEXA and without any pathalogical fracture)

A

Basics

Place & Person

Ix and Confirm Diagnosis

FRAX Risk Ax Tool - gives a 10 year probabilty of major osteoporotic fracture

Definitive Management

  • Lifestyle / Non-Pharmacological
    • cessation of ETOH
    • cessation of smoking
    • weight bearing activitiy
    • dietary chanages - calcium and vitmamin D
  • Pharmacologial
    • Bisphosphonates
    • Raloxifene
    • Antibody - denosumab
    • Calcium & Vitamin D
    • Endocrine (HRT, PTH)
    • Strontium ranelate

Referral

  • Physiotherapy - falls and balance classes
  • OT - gait aids
  • repeat DEXA every 2 years?
153
Q

What is the mechanism of action of bisphosphonates?

What routes are they given in?

what are the AE of bisphosphonates?

What should you tell the patient?

A

Bisphosphonates inhibit osteoclastic activity.

They can be given as a weekly tablet or yearly IV (Zoledronic acid).

The AE of bisphosphonates are oesophagitis are:

  • oesophagitis / gastritis
  • osteonecrosis of the jaw (also for denosumab)
  • atypical fractures of the femoral neck

You should tell the patient

  • If taking oral - have the tablet once / week in the morning whilst sitting up, and don’t eat / drink or lie down for at least 30 minutes afterward
  • If taking either oral or IV, visit your dentist prior to commencement and have done any major dental work which needs doing
  • Ensure you are well hydrated prior to IV infusion, you will require some testing (of Ca, Vit D, eGFR)
154
Q

when are bisphosphonates contraindicated? what is second line?

A

poor renal function

if this is the case –> denosumab

155
Q

how is densoumab administered and what is its side effects?

A

6 monthly SC injection

Osteonecrosis of the Jaw

Atypical fractures

156
Q

in whom may raloxifene be used when treating OP?

what is it’s MOA?

what is it’s AE?

A

women, usually younger post-menopausal women with spinal OP, especially in those with a high breast-Ca risk.

it is a SERM.

It has the same AE as other HRT, but it REDUCES the risk of breast cancer. It also can exacerbate vasomotor symptoms. It has been shown to increase spinal BMD but not femoral neck or elsewhere.

157
Q

what is the MOA of teraperatide and who can prescribe it?

A

a PTH analogue

when given in a pulsatile fashion (daily SC injections) it increases BMD

it can only be prescribed by a specialist

it only increases vertebral BMD, not femoral

158
Q

what is the mechanism of action of strontium ranelate?

A

Strontium, which has the atomic symbol Sr and the atomic number 38, belongs to the group II in the periodic table of the elements, just beneath calcium. Because its nucleus is very nearly the same size as that of calcium, the body easily takes up strontium and incorporates it into bones and tooth enamel in the place of calcium

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