Handbook Section 1

Question 1

DxT Acute diarrhoea + colicky abdominal pain ± vomiting

Answer 1

gastroenteritis

Question 2

DxT (Young adult) diarrhoea ± blood and mucus + abdominal cramps

Answer 2

inflammatory bowel disease (UC/Crohn)

Question 3

DxT Pale bulky offensive stools, difficult to flush, weight loss

Answer 3

malabsorption

Question 4

DxT (Young adult) diarrhoea ± blood and mucus + abdominal cramps
DxT As above + constitutional symptoms ± eyes/joints

Answer 4

Crohn disease

Question 5

DxT Fatigue + weight loss + iron deficiency

Answer 5

coeliac disease

Question 6

DxT Failure to thrive (child) + recurrent chest infections

Answer 6

cystic fibrosis

Question 7

DxT Altered bowel habit: diarrhoea ± constipation ± rectal bleeding ± abdominal discomfort

Answer 7

colorectal carcinoma

Question 8

DxT Diarrhoea (fluid/incontinent) + constipation +++ abdominal discomfort + anorexia/nausea

Answer 8

faecal impaction

Question 9

DxT Profuse watery diarrhoea + abdominal cramps and increasing distension (on antibiotics)

Answer 9

pseudomembranous colitis (Girotra’s triad)

Question 10

DxT Variable diarrhoea/constipation + abdominal discomfort + mucus PR + flatulence ++

Answer 10

irritable bowel syndrome

Question 11

Basic Diarrhoea management

Answer 11

In Australia most infective cases are viral. The basic principle therefore is to achieve and maintain adequate hydration until the illness resolves. In adults and children oral rehydration is indicated unless there is evidence of impending circulatory ‘shock’ demanding intravenous
therapy. Oral rehydration solution containing sodium, potassium and glucose should be considered for patients with mild to moderate dehydration. Adults should drink 2 to 3 L of the solution in 24 hours. Normal food intake may start after rehydration.

Question 12

Cause pseudomembranous colitis

Answer 12

This potentially fatal colitis can be caused by the use of any antibiotic, especially clindamycin, lincomycin, ampicillin and the cephalosporins (an exception is vancomycin). It is usually due to an overgrowth of C. difficile, which produces a toxin that causes specific inflammatory lesions, sometimes with a pseudomembrane.

Question 13

Pseudomembranous colitis is diagnosed by

Answer 13

Diagnosed by characteristic lesions on sigmoidoscopy and a tissue culture assay and/or PCR for C. difficile toxin.

Question 14

Pseudomembranous colitis, treated by

Answer 14

Cease antibiotic
Need hygiene measures to prevent spread
Mild to moderate: metronidazole 400 mg (o) tds for 10 days
Severe: vancomycin 125 mg (o) qid for 10 days
(in consultation with specialist). Beware of toxic megacolon.

Question 15

Molluscum Contangiosum, diagnosed by

Answer 15

Molluscum is usually diagnosed by its distinct pink pearly appearance and central punctum. It is very common in
children. The rash lasts weeks to months, or occasionally a couple of years.
Molluscum rarely leaves tiny pit-like scars.

Question 16

Molluscum Contangiosum, spread by

Answer 16

direct contact, sharing towels and bath toys, or through water (e.g. sharing baths or swimming).

Question 17

Molluscum Contangiosum, treated by

Answer 17

The most common approach in children is to leave the rash alone and wait for it to clear. Treatments designed to irritate the lesion can make the rash clear more quickly (see CHAPTER 124 ) but can be distressing to the child and so are not normally done.

Question 18

Molluscum Contangiosum, caused by

Answer 18

Pox virus

Question 19

Acute inflammatory polyradiculoneuropathy (Guillain–Barré syndrome), definition

Answer 19

Guillain–Barré syndrome, which is a rapidly progressive and treatable cause of PN or ascending radiculopathy, is potentially fatal. Early diagnosis of this serious disease by the family doctor is crucial as respiratory paralysis may lead to death. The underlying pathology is segmental demyelination of the peripheral nerves and nerve roots.

Question 20

Acute inflammatory polyradiculoneuropathy (Guillain–Barré syndrome), clinical feature

Answer 20

Weakness in the limbs (usually symmetrical)
Paraesthesia or pain in the limbs (less common)
Both proximal and distal muscles affected, usually starts peripherally
and moves proximally
Reflexes depressed or absent
Within 3–4 weeks the motor neuropathy, which is the main feature, progresses to a maximum disability, possibly with complete quadriparesis and respiratory paralysis.

Question 21

Acute inflammatory polyradiculoneuropathy (Guillain–Barré syndrome), investigation

Answer 21

CSF protein is elevated; cells are usually normal.
Motor nerve conduction studies are abnormal.

Question 22

Acute inflammatory polyradiculoneuropathy (Guillain–Barré syndrome), management

Answer 22

Admit to hospital.
Respiratory function (vital capacity) should be measured regularly (2–4 hours at first).
Tracheostomy and artificial ventilation may be necessary.
Physiotherapy to prevent foot and wrist drop and other general care
Treatment is with plasma exchange or IV immunoglobulin (0.4g/kg/day for 5 days), which may need to be continued monthly.

Question 23

Inguinal hernias, presentation

Answer 23

These usually present in the first 3 to 4 months with an incidence of 1 in 50 males and 1 in 500 females
Inguinal and femoral hernias should be referred urgently as early surgery is advisable to avoid the high risk of bowel incarceration or strangulation and ovarian entrapment and ischaemia in females.

Question 24

Inguinal hernias, when to refer

Answer 24

ASAP, infants and irreducible hernias
Reducible hernias: the ‘6–2’ rule
Birth–6 weeks: surgery within 2 days
6 weeks–6 months: surgery within 2 weeks
Over 6 months: surgery within 2 months

Question 25

Indirect inguinal hernia, definition

Answer 25

a hernia emerging through the deep inguinal ring, originating lateral to the inferior epigastric vessels, following the path of the spermatic cord, and which can traverse the whole length of the inguinal canal and can descend into the scrotum, high risk of strangulation

Question 26

Direct inguinal hernia, definition

Answer 26

Originates medial to the inferior epigastric vessels and protrudes through the posterior wall of the inguinal canal, and is therefore separate from the spermatic cord. It is almost always seen in men and rarely descends into the scrotum. Due to a wider neck, strangulation and obstruction are most unusual.

Question 27

Femoral hernia, definition

Answer 27

Herniates through the femoral ring (also known as the femoral canal), which is the medial component of the femoral sheath. The hernia tends to bulge forward and then upwards as it becomes larger. The neck is lateral to the pubic tubercle. Femoral hernias are often small, usually occur in females and may be unnoticed by the patient. They are particularly liable to produce bowel obstruction or strangulation.

Question 28

Symptoms and signs of hernial obstruction

Answer 28

Colicky abdominal pain Nausea and vomiting Constipation and failure to pass flatus Abdominal distension High-pitched tinkling bowel sounds Local tenderness and swelling of the hernia No expansile cough impulse

Question 29

General hernia treatment

Answer 29

All symptomatic hernias require repair. Those patients who are not symptomatic and who are medically fit should also be offered surgery because most patients usually become symptomatic eventually and a watch-and-wait approach delays rather than prevents surgery. Obstructed and strangulated hernias require urgent surgery. The risk of strangulation is greatest with femoral hernias.

Question 30

Major causes of low back ± leg pain presenting in the author’s general practice (Murtagh)

Answer 30

Vertebral dysfunction (non-specific back pain) (71.8%) Lumbar spondylosis Depression Urinary tract infection Spondylolisthesis Spondyloarthropathies Musculoligamentous strains/tears Malignant disease Arterial occlusive disease

Question 31

Gas gangrene (clostridial myonecrosis), caused by

Answer 31

Several clostridia organisms, for example, Clostridium perfringens, into devitalised tissue, such as exists following severe trauma to a leg.

Question 32

Gas gangrene (clostridial myonecrosis), clinical features of

Answer 32

Sudden onset of pain and swelling in the contaminated wound Brownish serous exudate Gas in the tissue on palpation or X-ray Prostration and systemic toxicity Circulatory failure (‘shock’)

Question 33

Gas gangrene (clostridial myonecrosis), treated by

Answer 33

Surgical centre for debridement (most important) Benzylpenicillin 2.4 g IV, 4 hourly + clindamycin (initial treatment) Hyperbaric oxygen if available

Question 34

Acute appendicitis, clinical features

Answer 34

Acute appendicitis features a characteristic ‘march’ of symptoms: pain → anorexia, nausea → vomiting In children, vomiting occurs in at least 80% and diarrhoea in about 20%. The temperature is usually only slightly elevated but in about 5% of cases it exceeds 39°C.

Question 35

Breast cancer screening, Average risk

Answer 35

Mammography should be performed at least every 2 years on women aged 50–74 years. Women aged 40–49 years may also choose to have a mammogram. Mammography must not be used alone to exclude cancer if a lump is palpable. Such lesions require a complete appraisal since, mammography still has a false-negative rate of at least 10%. Genetic testing should be considered in those at risk.

Question 36

Common causes of breast mass (Murtagh)

Answer 36

Fibrocystic disease (32%) Fibroadenoma (23%) Cancer (22%) Cysts (10%) Breast abscess/periareolar inflammation Lactation cyst (galactocele)

Question 37

Investigation of breast lumps, triple test

Answer 37

1 History and clinical breast examination 2 Imaging—mammography and/or ultrasound ± MRI (more than 40yrs - mammogram, less than 40yrs - ultrasound) 3 Fine-needle aspiration cytology and/or core biopsy

Question 38

Important tell-tale symptoms of breast cancer

Answer 38

Lump Skin dimpling Inverted nipple Bloody nipple discharge Peau d'orange Eczema of nipple (Paget discharge)

Question 39

Types of nipple discharge

Answer 39

Bloodstained: — intraduct papilloma (commonest) — intraduct carcinoma — fibrocystic breasts Green–grey: — fibrocystic breasts — mammary duct ectasia Yellow: — fibrocystic breasts — intraduct carcinoma (serous) — breast abscess (pus) Milky white (galactorrhoea): — lactation cysts — lactation — hyperprolactinaemia — drugs (e.g. antipsychotic, cocaine)

Question 40

Indications for biopsy or excision of breast lump

Answer 40

The cyst fluid is bloodstained. The lump does not disappear completely with aspiration. The swelling recurs within 1 month.

Question 41

Breast cancer treatment

Answer 41

Tumour excision followed by whole breast irradiation was the most preferred local therapy for most women with stage I or II cancer. Total mastectomy and breast-conservation surgery had an equivalent effect on survival. Total mastectomy is preferred for a large tumour, multifocal disease, previous irradiation and extensive tumour on mammography. Recommendations for radiotherapy after mastectomy are: tumours >4 cm, axillary node involvement of >3 nodes, positive or close tumour margins Cytotoxic chemotherapy has an important place, especially in young, healthy women with E receptor negative and have visceral spread. Adjuvant hormonal therapy by the anti-oestrogen agent tamoxifen 20 mg (o) daily if E receptor +ve, which is a specific modulating agent, is widely used and is most suitable in postmenopausal women.

Question 42

Pseudohyponatraemia, causes

Answer 42

• Normal plasma osmolality – hyperlipidaemia – hyperproteinaemia • Increased plasma osmolality – hyperglycaemia – mannitol

Question 43

Hypoosmolar hyponatraemia, causes

Answer 43

• Primary sodium loss (secondary water gain) – integumentary sodium loss: sweating, burns – gastrointestinal loss: vomiting, fistula, obstruction, diarrhoea – renal loss: diuretics, hypoaldosteronism, salt wasting nephropathy, postobstructive diuresis • primary water gain (secondary sodium loss) – primary polydipsia – decreased solute intake (beer potomania) – ADH release due to pain, nausea, drugs – syndrome of inappropriate ADH secretion – glucocorticoid deficiency – hypothyroidism – chronic renal insufficiency • primary sodium gain (exceeded by secondary water gain) – heart failure – hepatic cirrhosis – nephrotic syndrome

Question 44

Female Puberty, landmarks

Answer 44

Stage One – ages 8-11 Ovaries enlarge and hormone production begins. Stage Two – ages 8-14 Breast buds usually develop first. Pubic hair might start, height and weight may increase, curvier body. Stage Three – ages 9-15 Vaginal discharge may start. Stage Four – ages 10-16 Menarche (first menstruation) and ovulation usually starts now. Stage Five – ages 12-19 Full development with regular menses.

Question 45

Puberty stages for boys

Answer 45

Stage One - ages 9-12 Hormone production has begun Stage Two - ages 9-15 Growth spurt begins, body shape changes, muscles and pubic hair begins. The testicles and scrotum get darker and bigger. Stage Three - ages 11-16 Penis grows longer and more frequent erections occur. Voices may start to break. Stage Four - ages 11-17 Penis grows wider and its texture becomes more adult-like. Facial hair also starts to grow. Skin gets oilier. Stage Five - ages 14-18 Full height is reached. Pubic hair and genitals look like an adult. Chest hair is growing and shaving may begin.

Question 46

Low back pain, red flag

Answer 46

Age >50 years or <20 years History of cancer Temperature >37.8°C Constant pain—day and night esp. severe night pain Unexplained weight loss Symptoms in other systems Significant trauma Features of spondyloarthropathy, and cauda equina Neurological deficit Drug or alcohol abuse especially IV drug use Use of anticoagulants Use of corticosteroids No improvement over 1 month

Question 47

Carbon monoxide, clinical effects by blood percentage

Answer 47

< 2.5 % - No significant health effects Physiological background level in the body 2.5 – 5 % - Exacerbation of existing cardiovascular disease 5 – 10 % - Subtle neurobehavioral symptoms 10 – 20 % - lethal with coronary artery disease. Headache (“frontal tightness”), shortness of breath during exertion in healthy adult population. 20 – 30 % throbbing headache, nausea, flushing 30 – 40 % Severe headache, dizziness, nausea, rapid breathing >40 % Collapse, coma, convulsion, death

Question 48

Carbon monoxide, common clinical manifestations

Answer 48

headache, nausea and vomiting, skin flushing, muscle pain, weakness, shortness of breath, dizziness, coordination difficulties, confusion, or chest pain. Symptoms can be mistaken for flu-like illness or food poisoning. Very high levels of carbon monoxide can cause loss of consciousness, seizures and death. Long-term exposure to low levels of carbon monoxide can also lead to impaired thinking and concentration, emotional lability, irritability and impulsiveness.

Question 49

Carbon monoxide, diagnosis

Answer 49

history and examination, in conjunction with an elevated carboxyhaemoglobin level Measure carboxyhaemoglobin levels in any case of suspected carbon monoxide poisoning when the patient is first seen.

Question 50

Exercise a high level of suspicion of carbon monoxide poisoning if:

Answer 50

1. Symptoms are related with the use of a gas/wood heater, or other gas/petroleum fuelled item, in an enclosed space. 2. Symptoms also occur in other occupants 3. Symptoms improve when outside the house. 4. There are concerns about an appliance – faulty or have not been maintained, newly installed

Question 51

Severe anxiety or panic attacks typically cause

Answer 51

lightheadedness with other somatic symptoms include palpitations, sweating, inability to swallow, headache, breathlessness and manifestations of hyperventilation.

Question 52

A panic attack is defined as a

Answer 52

Discrete period of intense fear or discomfort in which four (or more) symptoms which develop abruptly and reach a peak within 10 minutes

Question 53

Panic attack, management

Answer 53

Mainstay: Reassurance, explanation and support Immediate intervention: breathing techniques, Relaxation techniques, Rebreathing into a paper bag is rarely indicated Longterm: Cognitive behaviour therapy (CBT)

Question 54

The most common way people become infected with hepatitis C in Australia is by

Answer 54

sharing injecting equipment such as needles, syringes, spoons and tourniquets.

Question 55

Hepatitis C is spread through

Answer 55

blood-to-blood contact when blood from a person with hepatitis C enters another person's bloodstream.

Question 56

In Australia, hepatitis B in adults is spread most commonly through

Answer 56

unprotected sex and unsterile injecting of illicit drugs.

Question 57

Hepatocellular carcinoma, risk factors

Answer 57

1. chronic liver disease, and cirrhosis (85–90%) 2. Male incidence is three to four times that of females 3. hepatitis B and C virus [HCV] infection 4. alcohol‐related liver disease 5. fatty liver disease 6. Born overseas (50%)

Question 58

Hepatocellular carcinoma, monitored by

Answer 58

Liver ultrasound, the primary tool recommended for HCC surveillance. Serum α‐fetoprotein improves earlier detection of HCC compared with ultrasound alone. Recommend surveillance with a combination of ultrasound and serum α‐fetoprotein levels every 6 months.

Question 59

Pulmonary Embolism should be suspected in

Answer 59

All patients who present with new or worsening dyspnoea, chest pain or hypotension without alternative cause

Question 60

Pulmonary Embolism, investigation

Answer 60

D-dimer - is a degradation product of cross-linked fibrin (high sensitivity but low specificity) Computed tomography pulmonary angiography (CTPA) - preferred as a negative scan excludes PE and it may provide the alternative diagnosis Ventilation/perfusion (V/Q) scan - for patients with renal impairment or pregnant women Lower limb doppler ultrasonography - high positive predictive value but low sensitivity and low negative predictive value

Question 61

Pulmonary Embolism, management

Answer 61

Anticoagulation is indicated in almost all cases of PE. (DOAC - first line, Warfarin - severely obese or renally impaired, LMWH - pregnant, breastfeeding, GIT/GUT cancer) Haematologist or respiratory physician be involved in the decision making. Imaging at the end of the initial 3–6-month treatment period is performed to establish a new baseline for the patient.