Semester A

Question 1

Matilda is a 75-year-old lady who has been taking temazepam 10mg nocte for the past four months. She has a craving for it in the evenings and ‘can’t sleep without it’. Matilda has found that it’s not working as well as it used to and wants a higher dose. You recognise that weaning off temazepam is indicated.

What is the most appropriate advice to give her about stopping temazepam?

A. No dose tapering is required
B. Consider a written contract to wean with slow reduction in 2-3 week stages, ideally to cease
C. Switch to suvorexant or melatonin
D. Slowly taper dose over 2-4 months

Answer 1

B. Consider a written contract to wean with slow reduction in 2-3 week stages, ideally to cease

Matilda meets two of the criteria for a substance use disorder (SUD). Her craving for the medicine is a sign of impaired control, and the diminished effect with continued use of the temazepam at the same dose is a sign of tolerance, one of the pharmacological criteria for SUD.

Gradual dose reduction of the prescribed benzodiazepine is recommended for patients with SUD, so as to minimise or avoid withdrawal symptoms.

Sudden cessation of benzodiazepines in patients on high doses may result in seizures. Because she has been using the temazepam for between 8 weeks to 6 months, it is recommended that her dose is tapered slowly over 2-3 weeks, or more, with advice regarding sleep hygiene. A written plan may be ideal.

Question 2

Desley is an 82-year-old lady living in the community who was recently discharged from hospital after a fall from her toilet, where she was unable to get up from the floor for over an hour. This resulted in a forearm fracture.

For Desley, which of these options would best help prevent future falls?

A. Checking Vitamin D, and supplementing if required
B. Wearing hip protector pads
C. Continuing psychotropic medications
D. Replacing multifocal spectacles with single focus spectacles

Answer 2

A. Checking Vitamin D, and supplementing if required

All of the strategies listed are useful for falls prevention or to minimise the damage for falls, but vitamin D supplementation is relevant in this case as Desley has a history suggestive of osteoporosis as well as high falls risk. Vitamin D in individuals with low levels may made no difference to the risk of falling, but reduces rate of falling.

Hip protectors show a moderate reduction in injuries for RACF residents, if they wear them. Reducing use of multifocal lens reduces falls risk, where psychotropics may increase it.

Question 3

You performed a GPCOG assessment on 72-year-old Patrick after his wife raised concerns about his memory. While he could recall the date, his score indicates cognitive impairment and you explain that you want to do further tests. Patrick is a non-smoker who has been happily married for 50 years.

First-line investigations for memory loss in Patrick would include:
A. Thyroid function
B. Chest X-ray
C. Serology for syphilis and HIV
D. Electroencephalogram

Answer 3

A. Thyroid function

Thyroid function is routinely recommended as an investigation for memory loss to exclude hypothyroidism or thyrotoxicosis. A chest X-ray is considered if lung cancer causing cerebral metastases is likely, but Patrick is a non-smoker so this would not be a first-line investigation for him. Serology for syphilis and HIV is only performed in those with histories suggesting they are at risk. An EEG is not a routine investigation in people with dementia, but should be considered if a diagnosis of delirium or Creutzfeldt-Jakob disease is suspected, or in the assessment of associated seizure disorder in those with dementia.

Question 4

Albert is an 89-year-old man from a local nursing home who was admitted directly to the general medical ward of your rural hospital because of confusion. At night, he wanders into other patients’ rooms, and on one occasion when a nurse tried to take him back to bed, he became very angry and tried to hit the nurse. This is not his usual behaviour.

Initial management of Albert would include:
A. Oral olanzapine nocte
B. A review of Albert’s medications
C. Oral melatonin nocte
D. Use of physical restraints

Answer 4

B. A review of Albert’s medications

The first priority is to screen for and treat delirium. This would include a review of Albert’s medications.

Prescribing an anti-psychotic is not first-line management – a cause for the confusion should be sought. Olanzapine is particularly associated with confusion because of its anticholinergic activity and is therefore not recommended as a first-line anti psychotic. Benzodiazepine prescription carries many risks in this setting including increasing the risk of falls.

Sleep hygiene is the preferred treatment for insomnia. If sleep hygiene is not effective, a benzodiazepine with a short half-life such as temazepam may be considered in the short term only. The use of physical restraints should be viewed as a temporary solution and only as a last resort. The risks associated with the person being unrestrained must outweigh the risks associated with restraint.

Question 5

You are discussing behavioural management for Dottie’s aggression secondary to dementia with her daughter. She asks about medication. What would be the first line for management of behavioural problems in dementia?

A. Benzodiazepines, e.g. oxazepam
B. Antidepressant medication, e.g. an SSRI
C. Antipsychotic medication, such as risperidone
D. A person-centred, multidisciplinary management plan

Answer 5

D. A person-centred, multidisciplinary management plan

Person-centred multidisciplinary planning to reduce distress, manage routine and provide activities are the primary core of managing behaviours in dementia. Medications, where considered, should be selected appropriately and for limited time periods, noting each is associated with other risks, such as further cognitive impairment and increased falls risk.

Question 6

Donald is an 87-year-old patient of your practice who has developed disabling Alzheimer’s dementia. He is currently taking:
Metoprolol 50mg bd
Atorvastatin 40mg od
Pantoprazole 20mg od
Temazepam 10mg nocte
Fluoxetine 20mg od

You decide to re-evaluate the role of his medicines and discuss the benefits of deprescribing with Donald and his carer.

The most appropriate focus of deprescribing at this appointment would be to:

A. Cease metoprolol, atorvastatin and pantoprazole at once
B. Discuss a plan to wean him off temazepam before stopping other drugs
C. Discontinue the fluoxetine and prioritise other drugs later
D. Discontinue the pantoprazole and monitor for recurrence of illness

Answer 6

B. Discuss a plan to wean him off temazepam before stopping other drugs

The general approach to deprescribing of ‘stop slow, go low’ includes stopping or reducing the dose of one drug at a time. This helps to identify which drug might have been causing harm or, if withdrawal symptoms occur, to provide a guide for which drug to consider recommencing.

When there is more than one medicine to deprescribe, GPs should first prioritise the medicine with the highest risk of harm and the lowest anticipated benefit from continued use, which in this case is the benzodiazepine temazepam.

Discontinuing the fluoxetine (SSRI) will potentially result in an antidepressant discontinuation syndrome. It should be weaned rather than abruptly ceased.

Stopping proton pump inhibitors is associated with hypersecretion of acid and aggravation of gastrointestinal symptoms. This might be avoided by switching to second daily or PRN dosing before ceasing completely. Don’t use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or ceasing. - Choosing wisely

Question 7

Russell is a 78-year-old retired truck driver with a history of bowel cancer, post-chemotherapy peripheral neuropathy, insomnia, Parkinsons disease, hypertension and osteoarthritis. In the last two months, he has had several falls when standing up from a seated position. His seated BP in clinic today is 114/55 mmHg.

His current medications are:
Levodopa/benserazide 125/25 mg, one tablet PO three times a day
Pramipexole 750 microgram MR, one tablet PO nocte
Ramipril 5mg, one tablet PO twice a day
Paracetamol 665 mg ER, two tablets PO twice a day

What is the management step that will best reduce his risk of falls?
A. Cease the ramipril
B. Add fludrocortisone 0.1 mg daily, increasing to 0.2 mg daily if needed
C. Advise Russell to avoid extreme heat, alcohol, large meals, straining and standing up rapidly
D. Advise Russel to wear compression stockings

Answer 7

A. Cease the ramipril

It is likely that Russell has orthostatic hypotension secondary to Parkinson’s disease. As an anti-hypertensive, ramipril is likely to be making this worse and ceasing it may improve his symptoms and reduce his risk of falls. The history in the stem does not include cardiovascular risk factors such as previous myocardial infarction or stroke that make continuing an anti-hypertensive more favourable. Fludrocortisone could be added in as specific treatment for orthostatic hypertension if ceasing the ramipril alone didn’t significantly improve Russell’s symptoms. The other options both contain good advice for a patient suffering with orthostatic hypotension, but are unlikely to be as effective as stopping the anti-hypertensive.
The Guileline for the diagnosis of management of hypertension in adults states: Clinical judgement should be used to assess the benefit of treatment against the risk of adverse effects in all older patients with lower grades of hypertension.

Question 8

Margaret is an active 72-year-old retired accountant. She is an ex-smoker (35 pack year) and drinks four standard alcoholic beverages daily. She completed radiotherapy for breast cancer over 12 months ago. While discussing recommended vaccinations with her, she notes besides COVID-19 vaccination and annual ‘flu shots she hasn’t really kept up since dealing with the cancer. Her vaccination record shows she had a Boostrix 4 years ago (“My first great-grandchild!” she volunteers).

What other vaccinations need to be considered for Margaret?
A. Pneumococcal
B. Herpes zoster
C. RSV
D. All of the above

Answer 8

D. All of the above

There is a place for all of the above in people over 70. Shingrix, the new zoster vaccine, is also available, Margaret may have been unable to have Zostervax depending on timing of radiotherapy for her breast cancer. Of the above, only RSV is not subsidised.

Question 9

Jack is an 82-year-old retired Council officer. He has a history of hypertension and type 2 diabetes well-controlled by lifestyle and dietary measures. He takes perindopril 5 mg daily. While completing a 75 year old health check, he notes that he has experienced unintentional recent weight loss, about 5 kg in the last six months, without other symptoms he can recall.

What is the best initial focus for Jack regarding his weight loss?
A. Request tumour markers
B. Consider malnutrition screening
C. Prescribe appetite stimulants
D. Chest x-ray

Answer 9

B. Consider malnutrition screening

Malnutrition is common in older people, especially as a cause of unintentional weight loss. Investigation should be multifactorial. While screening for cancer may be a component of the investigation of weight loss, scatter-gun ordering of tumour markers is rarely suited to identification of malignancy. A chest x-ray is unlikely to reveal a diagnostic reason for weight loss alone. Appetite stimulants, if used, are not associated with a reduction in mortality from weight loss in older people.

Question 10

Melva is a 97-year-old nursing home resident who has Alzheimer’s disease, spinal stenosis, constipation, urinary incontinence and a history of frequent urinary tract infections.

The home’s nurse phones you at your morning clinic stating that Melva has had another fall and she has appropriately managed the resultant skin tear on Melva’s forearm. The nurse informs you that Melva’s urine is smelly and her blood pressure is 113/62 mmHg, her pulse is 94 beats per minute and regular and that her temperature is 36.6⁰ Celsius. The nurse cannot collect a urine sample because of Melva’s incontinence. Nurse asks you for a phone order for antibiotics for presumed urinary tract infection, given that you cannot attend the nursing home for at least another seven hours.

What is the most appropriate advice for you to give the nurse at this stage?
A. Facilitate an increased oral fluid intake and monitor her vital signs
B. Commence chair restraints to prevent further falls
C. Start trimethoprim 300 mg daily
D. Perform an in – out bladder catheter to collect a urine sample for microscopy, culture and sensitivity studies

Answer 10

A. Facilitate an increased oral fluid intake and monitor her vital signs

Dehydration is a common problem in nursing home patients who are unable to access drinks for themselves when needed, or where carer to resident ratios compromise full assistance provision. Dehydration increases the incidence of hypotension, tachycardia, constipation, falls, delirium and urinary tract infections. Melva demonstrates many of these signs. Addressing this problem is a safe and appropriate initial measure.

There is no proof she has a urinary tract infection. Smelly urine can indicate dehydration and is not necessarily consistent with infection. Avoiding invasive procedures and unnecessary antibiotics in geriatrics has merit. It may be that with better hydration a urine sample can be collected and trimethoprim commenced if it’s indication is confirmed.

There are numerous falls risk reduction strategies suitable for nursing home residents such as Melva. Physical and pharmacological restraints are not first line options.

Question 11

Scottie is a 13-year-old boy who presents with his mother to your practice. Scottie has attended multiple times over the past few months with minor ailments. His mother is frustrated that Scottie keeps complaining of minor ailments and the time it is taking to bring him in to see you so often. You want to explore the situation further by engaging with Scottie.

The next most appropriate step in the consultation would be to:
A. Take a history from Scottie using the HEEADSSS psychosocial assessment
B. Explain confidentiality to Scottie and his mother
C. Ask Scottie’s mother to leave
D. Explore Scottie’s mothers concerns further

Answer 11

B. Explain confidentiality to Scottie and his mother

This question is based on ACRRM’s Youth Friendly Consultation SkillsLinks to an external site. course. Confidentiality should be explained to both Scottie and his mother whilst she is still in the room using a form of words that the adolescent will be able to understand. Confidentiality is a legal right of minors. Taking a history using the HEEADSSS assessment tool should be done without the adolescent’s parent in the room. Seeing Scottie is his own is very important in order to be able to engage with him.

A suggested script would be ‘I’m going to talk to you both for a few minutes and then, as is my normal practice once young people are in high school, I would like to talk to Scottie on his own for a while’. Getting some more information from Scottie’s mother may be highly relevant, but building a rapport and engaging with Scottie is the first priority.

Question 12

A two-year-old girl is brought into your hospital emergency department with a fever and being generally unwell for 24 hours. When examining the child, she suddenly starts to convulse in a generalised tonic-clonic nature.

The next most appropriate step is to give midazolam:
A. As soon as possible after commencement of the seizure
B. Either buccally or intramuscularly (IM) at the same dose
C. After 5 minutes of observation
D. Withhold midazolam as it should not be given under three years of age

Answer 12

C. After 5 minutes of observation

Pharmacological management of child convulsions is generally not given until 5 minutes of seizure activity have elapsed. When giving midazolam via the buccal route the dose is 0.3 mg/kg (maximum 10mg) compared to 0.15 mg/kg when given IM or IV and 0.2 to 0.5 mg/kg IN (maximum 10mg).

Question 13

A 10-day-old child is brought in to your general practice by his mother with a six-hour history of drowsiness and poor feeding.

With respect to signs of sepsis in children:
A. The child will always have a fever
B. Poor feeding can be a sign of sepsis in the neonate
C. In patients with early-onset neonatal sepsis, Streptococcus agalactiae, Staphylococcus aureus, Haemophilus influenzae, and Listeria monocytogenes are the most frequent organisms encountered.
D. Between 5 % to 10 % of people carry the meningococcal bacteria in their nose or throat without showing any signs of illness

Answer 13

B. Poor feeding can be a sign of sepsis in the neonate

Children, especially younger children, often don’t produce a fever at all and may, in fact, be hypothermic when septic. Staphylococcus is not one of the four most common organisms in this age group, with the fourth being E Coli.

Source: Medscape. (2018). Paediatric sepsis.

10-20% of people carry the meningococcal organism in their nose asymptomatically.

Question 14

You consult with Timothy, a 5 year-old Aboriginal boy from a remote community in the Northern Territory who has the following skin complaint:

Ear lobe impetigo

After taking a skin swab for culture and susceptibility testing, the next most appropriate management option is to:
A. Treat with topical mupirocin 2 % ointment or cream
B. Administer a single dose of benzathine benzylpenicillin IM
C. Prescribe oral cefalexin in addition to topical mupirocin
D. Treat with permethrin 5 % cream

Answer 14

B. Administer a single dose of benzathine benzylpenicillin IM

This patient is from an area where impetigo is endemic. As per Australian Therapeutic Guidelines, first-line treatment options are benzathine benzylpenicillin IM, or trimethoprim and sulfamethoxazole PO. An IM injection of benzathine benzylpenicillin treats group A streptococcal infection and reduces the chance of serious complications including acute post-streptococcal glomerulonephritis and acute rheumatic fever. Treating impetigo with mupirocin is recommended for patients in nonendemic settings; the same applies to cefalexin. Treating with permethrin may be appropriate if the skin sores are suspected to have occurred secondary to scabies but administering IM benzathine benzylpenicillin would still be the next most appropriate step.

Question 15

Five-year-old Jerry has been brought in to your clinic with abdominal pain. The pain is intermittent, and he has had some soiling of his underwear. On examination you feel a firm non-tender mass in the left lower quadrant.

The next most appropriate step is to:
A. Order an abdominal X-ray
B. Do a rectal examination and consider manual disimpaction
C. Start a movicol disimpaction programme
D. Give him a rectal enema

Answer 15

C. Start a movicol disimpaction programme

This child has constipation with overflow faecal incontinence. He has a clear history of constipation and has a palpable mass on examination. Rectal examination, manual disimpaction or rectal enemas should be avoided in children. There is no role for abdominal X-ray in constipation. It would be best to trial disimpaction using oral agents for constipation such as movicol. A suggested regime is starting with 1 sachet on day 1, 2 sachets on day 2 and 3, 3 sachets in day 4 and 5, up to 4 sachets on day 6 and 7 as tolerated and titrate according to clinical response.

Question 16

Danielle is a 15-year-old girl who presents to you with her mother, with a history of headaches for the past three months. The headaches occur every fortnight or so at the end of day, and she sometimes leaves school early. The pain is diffuse and not worsened by physical activity.

The next most appropriate step is to:
A. Organise an MRI brain at the nearest regional centre
B. Ask Danielle to start a headache diary
C. Commence Danielle on triptan medication
D. Consult with Danielle alone for a HEADSSS assessment

Answer 16

D. Consult with Danielle alone for a HEADSSS assessment

Danielle’s headache has features of a tension-type headache. An MRI brain is not indicated with the history given as there are no red flags. A headache diary is a good way to identify triggers, but the correct answer is to consult with Danielle alone. This is because she may reveal stressors at school or home which are contributing to her headaches, and therefore significantly alter your management. Triptans are indicated for the management of migraine.

Question 17

You are concerned that 18-month-old Monti, an Aboriginal infant that you have been seeing at your clinic in a community in the remote part of Australia, has growth faltering and may be experiencing neglect.

Concerning his management, which of the following options are most likely to prevent neglect and improve health outcomes for this child?
A. Micronutrient zinc supplementation
B. Educating Monti’s mother on nutrition
C. Implement the Triple P parenting program
D. Arranging regular home visits

Answer 17

D. Arranging regular home visits

Note that it is difficult to distinguish between neglect and material poverty. Nutrition education coupled with growth monitoring can improve a mother’s knowledge of good diets, but may not translate into improved health outcomes for a child. The potential for an impact on growth appears to be greater with interventions that combine nutritional information with provision of complementary food.

In the context of Aboriginal and Torres Strait Islander health, home visits to relay nutritional information are recommended. There is some evidence to suggest that home visiting helps prevent neglect, particularly first episode neglect, and particularly when used as part of a preventive multicomponent package including parent education and possibly enhanced paediatric care. Written information such as leaflets are not very effective.

There is a lack of consistent evidence whether providing multiple micronutrients to children in the first two years of life improves growth. Zinc supplementation is recommended by some Australian experts in cases of FTT to reduce infections, especially respiratory infections or chronic diarrhoea when given to children in the first year of life.

A Cochrane review showed insufficient evidence to support parenting programs as an intervention in child abuse, including neglect. The Triple P parenting program is a well known multilevel program aimed at helping caregivers find solutions to parenting and child-rearing problems. If it is being considered for Aboriginal and Torres Strait Islander families, it is recommended that child health professionals consult with their local community regarding the cultural appropriateness and acceptability of Triple P before implementing the program, and that the program be facilitated in partnership with Aboriginal and Torres Strait Islander child health workers.

Question 18

You are working in a remote Aboriginal community and you are asked by the child health nurse to see a 6-month-old Aboriginal boy who is found to have a haemoglobin of 90 g/L on point of care testing during a routine health check. The child is currently otherwise well and is afebrile. He was breastfed until 4 months of age. His weight, length and head circumference are all tracking along the 15th percentile on WHO growth charts. You take a dietary history, provide dietary advice to the child’s mother and prescribe albendazole 200 mg daily for 3 days.

The next most appropriate step in management is:
A. Order a formal FBC
B. Order iron studies
C. Commence oral iron treatment
D. Commence parenteral iron treatment

Answer 18

C. Commence oral iron treatment

Iron deficiency anaemia (IDA) is very common in Aboriginal and Torres Strait Islander children. A prevalence of greater than 5 % is considered by the World Health Organization (WHO) to be of public health significance; the data that are available indicates rates of IDA in Aboriginal and Torres Strait Islander children in remote Australia are significantly higher.

Contributors to IDA in Aboriginal and Torres Strait Islander children are multifactorial and may include low birthweight, prematurity and maternal anaemia, twin birth, poor quality and late introduction of weaning foods, high rates of infection and tropical enteropathy syndrome associated with failure to thrive (FTT), and cow’s milk in the first year. Moderate to severe infestations with hookworm, via intestinal blood loss, can also contribute to IDA.

In Aboriginal and Torres Strait Islander children, anaemia is most commonly diagnosed by capillary haemoglobin (Hb) and further investigation is not usually required. Screening can be done with Hb and/or FBC on venous blood, and this is the most reliable method of testing, but this may not be acceptable to all carers of young children. If there is good training and quality control, point-of-care testing of capillary Hb is easy to use, is sensitive enough for screening and can correlate well with laboratory testing.

In Aboriginal and Torres Strait Islander children, anaemia is often caused by iron deficiency, and intercurrent rates of infection are high, making iron indices an unreliable indication of current iron stores. A common diagnostic approach in high prevalence areas is to measure the Hb response to iron therapy without measuring iron indices. If Hb does not improve, adherence should be confirmed and further investigation is warranted. The prevalence of haemoglobinopathies as a cause for microcytic anaemia is low, but should still be considered as a possible cause, particularly in those in whom treatment for IDA fails to show an improvement in Hb.

More formal investigation and discussion with a paediatrician may be needed if a child’s Hb is <80 g/L, if the child is under 6 months of age, if the child is unwell or if there are any other concerns.

Hb limits to define anaemia should differ according to age, gender and physiological status (e.g. pregnancy), and for babies whether they are breast or bottle fed. The Kimberley Aboriginal Medical Services and the Central Australian Rural Practitioners Association define anaemia in children aged 6–12 months as being Hb <105 g/L, children 1-4 years as Hb <110 g/L, and children 5-7 years as Hb <115 g/L.

There is evidence that intermittent iron supplementation regimes comprising weekly, twice a week and three-week blocks of daily dosing improve Hb, although such approaches tend not to be as effective as daily dosing.

The Kimberley Protocols and the CARPA Standard Treatment Manual recommend oral iron to be given daily at home or twice a week supervised in the clinic (which is preferred as it is more effective, equivalent to parenteral iron).

Iron treatment, particularly parenteral iron, should not be commenced if the child has a fever >38 °C or is acutely unwell.

Hb should be repeated after 4-6 weeks of oral iron treatment. If Hb is not improving, parenteral treatment may need to be commenced. If Hb is improving after 4-6 weeks of oral iron treatment, continue treatment for 3 months. Children with a history of IDA are at risk of recurrence, so regular Hb monitoring at recommended intervals should continue after successful treatment.

Refer to local guidelines for iron doses and treatment regimens.

Question 19

Jarred is a neonate who was delivered after a normal pregnancy, by ventouse delivery at 37 weeks 3 days gestation due to fetal distress. Apgars were 7 and 9. Birth weight: 2.81 kg. He was discharged home, breast fed, on day 4 with physiological jaundice.

His mother brings him to your clinic when he is 16 days old, concerned that he has not regained his birth weight. He sleeps through the night and his jaundice has receded to just apparent on his face and upper trunk now. His bare weight is 2.75 kg.

You weigh him pre and post breastfeeding and watch his feeding. His attachment, positioning and suction are excellent. He fell asleep 10 minutes into the feed. His weight gain was 12 g after the feed.

What is the most effective strategy to improve Jarred’s weight gain?
A. Admit to hospital for phototherapy and nasogastric feeds through the night
B. Wake Jared for feeds every 3 to 4 hours and defer play and cuddles until after feeds
C. Recommend Jared’s mother express breast milk after each feed to increase her supply
D. Prescribe domperidone 10 mg three times daily to his mother to increase supply

Answer 19

B. Wake Jared for feeds every 3 to 4 hours and defer play and cuddles until after feeds

Jarred’s jaundice is receding so he does not need admission to hospital for phototherapy. However, it is common for jaundice to make babies sleepier and for dehydration to exacerbate or prolong jaundice. By waking Jarred for feeds more often, instead of him cueing feeds, his hydration, alertness and jaundice will all improve. This will enable him to feed more effectively and without prematurely stopping to sleep again.

More frequent feeds are often enough to increase milk supply. If this is insufficient, then expressing breast milk and maternal domperidone can help boost supply, as well as optimising maternal rest, nutrition, hydration and psychosocial support.

Question 20

Zeke is a 10-month-old boy brought to your emergency department at 7 pm with 2 days of fever, cough and runny nose. He is now breathing harder, had a disturbed sleep last night and is breastfeeding very little this afternoon. His last wet nappy was over six hours ago.

Examination reveals an alert infant snuggling his mother, with copious clear bubbly rhinorrhoea, a loose cough, increased work of breathing, inter- and sub-costal recession, no stridor, pulse 135 bpm, temperature 37.6 °C, capillary refill 2-3 seconds and bilateral diffuse scattered wheezes, crepitations and transmitted upper airway sounds. Heart sounds are normal. The rest of his examination is normal.

Your best course of treatment is to:
A. Reassure his parents it is simply a viral infection and send him home for symptomatic treatment
B. Start intravenous ampicillin and intravenous fluids after a septic work up
C. Administer nebulised salbutamol and observe in the emergency department
D. Admit for nasal prong oxygen and nasogastric expressed breast milk feeds

Answer 20

D. Admit for nasal prong oxygen and nasogastric expressed breast milk feeds

Zeke has bronchiolitis, with no focal signs suggesting pneumonia, so he does not require a septic workup nor antibiotics. Having had an unsettled previous night and poor fluid intake and output today there is concern about his further deterioration tonight. Thus, admitting him for supportive care is indicated. Salbutamol is unlikely to help whereas hydration support and oxygen will.

Question 21

Wendy is a 58-year-old receptionist who takes perindopril 10 mg daily and indapamide slow release 1.5 mg daily for her hypertension, and naproxen slow release 1000 mg daily for cervical spine osteoarthritis.

Her blood pressure readings in the surgery over the past two months have been consistently around 160/95 mmHg.

Her body mass index is 29. She has a normal fasting blood sugar, fasting lipid profile and renal function.

Which one of the following would be the most appropriate next step in Wendy’s management?
A. Refer for a renal angiogram
B. Substitute paracetamol or tapentadol for naproxen
C. Add a low dose calcium channel blocker
D. Arrange 24-hr ambulatory blood pressure monitoring

Answer 21

B. Substitute paracetamol or tapentadol for naproxen

Combination of medications constitutes a renal “triple whammy” and NSAIDs increase risk of cardiovascular events, e.g. MI and stroke, and should therefore be avoided in patients with an increased cardiovascular risk.

Question 22

Darryl is a 45-year-old Aboriginal non-smoker who has hypertension (persistently more than 160/100 mmHg) and is not diabetic. You calculate his absolute cardiovascular disease risk to be 9%. You discuss lifestyle modifications.

What is the next most appropriate step?
A. Recheck cholesterol in 12 monthss’ time
B. Request exercise stress test
C. Start anti-hypertensive therapy
D. Recommend fish oil

Answer 22

C. Start anti-hypertensive therapy

Absolute CVD risk for this patient is 9%, which is low, but his BP is persistently >160/100 and therefore should be treated pharmacologically whilst lifestyle advice is continued. Note that Aboriginal and Torres Strait Island peoples have a high prevalence of risk factors for heart, stroke and vascular disease. People of Aboriginal and Torres Strait Islander background may experience more rapid disease progression than the reference population.

Question 23

Bill is a 55-year-old truck driver with hypertension. On his last three visits to your practice, his blood pressure has been more than 170/90 mmHg despite treatment with anti-hypertensives.

Your next step is to:
A. Advise Bill he can no longer hold a commercial licence
B. Issue Bill with a conditional commercial license
C. Refer Bill to a cardiologist
D. Advise Bill he can keep driving commercially

Answer 23

C. Refer Bill to a cardiologist

According to the Australian Fitness to Drive Guidelines (p.56), a person is not fit to hold an unconditional commercial licence if the person has a blood pressure consistently greater than 170 systolic or greater than 100 diastolic (treated or untreated).

However, Bill may still be eligible to drive commercially with a conditional licence, so it would be incorrect to tell Bill that he had to stop truck driving.

A conditional licence may be considered by the driver licensing authority subject to annual review, taking into account the nature of the driving task and information provided by the treating specialist as to whether the following criteria are met:

the person is treated with antihypertensive therapy and effective control of hypertension is achieved over a four-week follow-up period; and
there are no side effects from the medication that will impair safe driving; and
there is no evidence of damage to target organs relevant to driving.
As a GP, you cannot grant the initial conditional commercial licence; this must be based on information provided by a specialist. Ongoing fitness to drive for commercial vehicle drivers may be assessed by the treating general practitioner provided this is mutually agreed by the specialist, the general practitioner and the driver licensing authority.

While Bill may be able to keep driving commercially, you would have to explain to Bill that you need to refer him in order for an assessment of his fitness to drive to be made. It would be inappropriate to ignore his blood pressure readings.

Question 24

Dennis is a 47-year-old who presents for his cholesterol test results after a check-up. He is taking an SSRI for depression. You note a waist circumference of 110cm and a body mass index of 40, a blood pressure of 135/70 mmHg, blood glucose of 6.0mmol/L and lipid studies as tabled below. You calculate his absolute CVD risk to be 7% and discuss lifestyle modifications.

Triglycerides 1.9 (Reference <4mmol/L)
HDL-C 0.8 (Reference >1.0mmol/L)

The next most appropriate step is to:
A. Perform a medication review
B. Commence metformin
C. Recommend bariatric surgery
D. Arrange review in 2 years

Answer 24

A. Perform a medication review

Dennis meets the criteria for metabolic syndrome. The mainstays of treatment are lifestyle interventions to address central obesity and insulin resistance. The next step is to consider medications and other conditions that may contribute to the risk of central obesity and insulin resistance. Long term use of anti-depressants, including selective serotonin reuptake inhibitors, has been associated with increased risk of the metabolic syndrome.

The role of metformin in treating the metabolic syndrome is still controversial and is not approved for this purpose in Australia (except in the treatment of polycystic ovarian symdrome). Bariatric surgery may need to be considered for Dennis in the long-term. Although Dennis fits in the ‘low-risk’ CVD risk category, it would be better to see him sooner than in two years’ time to assist with his weight loss interventions given his body mass index and metabolic syndrome.

Question 25

Olivia is a 45-year-old female with type 2 diabetes who has central adiposity and hypertension. She takes ramipril 5 mg daily. Raised aspartate transaminase and gamma glutamyl transferase at twice the upper limit of normal is found on her 45-year-old health assessment bloods. Other liver function tests are normal. What is the next most appropriate step in her management? A. Inquire about excess alcohol consumption B. Request abdominal ultrasound C. Commence a statin D. Request viral hepatitis serology

Answer 25

A. Inquire about excess alcohol consumption Excess alcohol consumption should be excluded as a potential cause for the raised LFTs before other investigations and management are carried out.

Question 26

Darren is a 32-year-old patient with epilepsy and severe depression. He consults with you as he wants to quit smoking. He smokes within 30 minutes of waking and has more than ten cigarettes per day. Which of the following is the most appropriate therapy for Darren to commence? A. Nicotine replacement therapy B. Varenicline C. Bupropion sustained release D. Non-pharmacological support

Answer 26

A. Nicotine replacement therapy Darren has evidence of nicotine dependence, and therefore should be offered pharmacotherapy, so non-pharamacological support is incorrect. Varenicline is not suitable due to the presence of psychiatric disease (depression). Bupropion is contraindicated due to history of seizures. Therefore only nicotine replacement therapy is correct.

Question 27

Elle is a 68-year-old female with a history of osteoporotic fractures and renal failure. Her last bone density scan three years ago showed a T-score of -3.0. Her recent renal function is consistent with stage 4 chronic kidney disease. She has taken alendronate for three years and since commencement, has had no fractures. Regarding her alendronate therapy, which of the following is the most correct action and reasoning? A. Continue due to high risk of further minimal trauma fractures B. Repeat the bone density scan to guide further therapy C. Cease due to 3 year duration of therapy without fractures Correct! D. Cease due to renal impairment

Answer 27

D. Cease due to renal impairment Alendronate is contraindicated in eGFR <35. Oral bisphosophates should be reviewed after 5 years but not necessarily stopped at this time. A repeat bone density scan is not necessary to determine fracture risk.

Question 28

Bob is a 58-year-old male smoker who has severe chronic obstructive pulmonary disease, congestive cardiac failure and gastro-oesophageal reflux disease. His regular oral medications are frusemide and pantoprazole. He takes oral prednisolone prn for exacerbations. He takes inhaled tiotropium (Spiriva) daily. He presents with a fractured distal radius after tripping on a floor-mat at home. Which of the following statements about Bob’s risk of osteoporosis is most correct? A. He is at low risk of osteoporosis because he is a male in his 50’s B. He is at high risk for osteoporosis due to multiple risk factors C. A bone density scan will help determine his risk of osteoporosis D. His radial fracture alone is diagnostic of osteoporosis

Answer 28

B. He is at high risk for osteoporosis due to multiple risk factors There are multiple risk factors (steroid use, smoker, several other medications) that may predispose to osteoporosis in the setting of a minimal trauma fracture. Men comprise ¼ of people with osteoporosis, though usually at an older age. A bone density scan is part of the workup, to be used in conjunction with fracture risk calculators. A fracture of the radius on its own is not diagnostic of osteoporosis

Question 29

Darryl is a 56-year-old male taxi driver who has mild congestive cardiac failure, type 2 diabetes, normal renal function, and a body mass index of 38. He takes metformin slow release 2 g daily and his blood glucose readings have been between 8-18 mmol/L and his latest glycosylated haemoglobin result is 64 mmol/mol (8%). What is the most appropriate additional therapy? A. Insulin B. Sitagliptin C. Gliclazide D. Rosiglitazone

Answer 29

B. Sitagliptin Sitagliptin is the best option. As Darryl holds a commercial driver’s license, hypoglycaemia should be avoided, therefore insulin and gliclazide are less suitable in this case, although he may go on to have insulin if his diabetes worsens. Gliclazide can also cause weight gain which is undesirable in this patient. Rosiglitazone can rarely cause heart failure and is therefore relatively contra-indicated in this patient.

Question 30

Jonathon is a 52-year-old gardener who has a history of essential hypertension, gout, obesity (BMI 30) and current smoking. He has been on perindopril 10mg OD and his BP remains high at 150/100. You recently commenced Amlodipine 5mg OD. He has presented to you with mild oedema of lower legs. What would you do? A. Reduce the dose of his amlodipine B. Encourage him to continue on current dose of amlodipine C. Commence Hydrochlorothiazide D. Change amlodipine to metoprolol

Answer 30

D. Change amlodipine to metoprolol The amlodipine may be responsible for the peripheral oedema. Dihydropyridines commonly cause peripheral oedema due to redistribution of extracellular fluid (rather than fluid retention); this does not respond to treatment with diuretics, which may put the patient at risk of volume depletion. Hydrochlorothiazide may aggravate gout.

Question 31

Thomas is a previously well 19-year-old male mechanic who presents with a two month history of lumbar back pain. He is a keen sportsman and is an opening bowler at the local cricket team. His pain is continuous but aggravated by activity. Which one of the following is the most consistent with this presentation? A. Disc prolapse B. Fractured pars interarticularis C. Ankylosing spondylitis D. Facet joint dysfunction

Answer 31

C. Ankylosing spondylitis This condition is the most common cause of low back pain in adolescent athletes. Cricket fast bowling is a unique asymmetrical action which loads the trunk through rotation, extension and side flexion at the delivery stride. This action which is repeated time after time can lead to the development of stress fractures in adult and adolescent populations. The pars bone is a small bone that connects the facet joints. During sports, due to the repetition of these activities, pressure is exerted on the facet joints and this stress is transmitted to the pars bone. Most pars stress fractures occur at the lowest part of the lumbar spine. These stress fractures may not visible on X-rays of the spine until they have been present for many months. The stress fracture can be diagnosed with an MRI, CT or bone scan.

Question 32

Jim is a 64-year-old farmer who has recently been fencing and has presented with right shoulder pain. He denies any history of trauma. During the examination you notice he has difficultly taking his shirt off. By performing abduction of the shoulder against resistance it helps localise pain to which of the following rotator cuff muscles? A. Supraspinatus B. Infraspinatus C. Teres minor D. Subscapularis

Answer 32

A. Supraspinatus Abduction against resistance tests the supraspinatus.

Question 33

Cindy is a 45-year-old lady who works in the primary school tuckshop. She has presented with a 3-month history of right foot pain that is worse in the morning and improves over the day but has a constant dull ache. She has a normal physical examination apart from tenderness over the plantar fascia attachment on the medial process of the calcaneal tuberosity. Which of the following interventions is initially indicated to help her relieve her symptoms? A. Steroid injection B. Short leg walking cast C. Arch supports D. Surgical release

Answer 33

C. Arch supports The history and examination are consistent with plantar fasciitis. Arch supports, NSAIDs and stretching exercises are the initial interventions to help relieve symptoms. Steroid injections can be used to relieve symptoms but may be harmful by causing rupture if given in the plantar tendon greater than 3 or 4 times.

Question 34

On your weekly rounds at the local nursing home, staff tell you that June, a 79-year-old resident, has increased pain in her left shoulder on movement. There has been no record of trauma. June has type 2 DM, coronary artery disease and mild dementia. She had a mastectomy for breast cancer 11 years ago. On examination there is no obvious deformity or localised tenderness. There is restricted ROM with passive and active movement. Shoulder XR showing joint-space narrowing, osteophytes, subchondral sclerosis, cysts, and eburnation or advanced articular cartilage loss After consideration of the image below what is the most likely cause of June’s pain? A. Osteoarthritis of the glenohumeral joint B. Fracture of the surgical neck of humerus C. Bony metastasis D. Osteoporosis

Answer 34

A. Osteoarthritis of the glenohumeral joint Radiographic evidence of degenerative joint disease may include joint-space narrowing, osteophytes, subchondral sclerosis, cysts, and eburnation or advanced articular cartilage loss.

Question 35

A 55-year-old secretary presents with ongoing pain and numbness in her hand. These symptoms are worse at night and she must shake her hand to regain feeling in it. Which of the following physical examination signs will be present? A. Hypothenar atrophy B. Weakness of finger abduction C. Inability to maintain wrist extension against resistance D. Weakness of thumb abduction

Answer 35

D. Weakness of thumb abduction Median nerve injury causes weakness of thumb abduction along with thenar atrophy. Tinel's and Phalen's signs will also be positive with carpal tunnel syndrome.

Question 36

A 32-year-old Indigenous male presents with acute onset of pain and swelling in his left ankle. On physical examination the ankle is warm, swollen and erythematous. Evaluation of the synovial fluid reveals only leucocytosis with a low glucose. Which is the most likely diagnosis? A. Gout B. Pseudogout C. Acute rheumatic fever D. Septic arthritis

Answer 36

D. Septic arthritis Leucocytosis and low synovial glucose is indicative of septic arthritis. Gout and pseudogout have been excluded by the lack of crystals on synovial fluid analysis. Rheumatic fever commonly involves multiple joints.

Question 37

Joshua is a 7-year-old boy who presents with a limp for several weeks. Findings on physical examination are normal except for limitation of internal rotation and abduction. The most likely diagnosis is: A. Congenital hip dislocation B. Perthes' disease C. Septic arthritis D. Slipped femoral capital epiphysis

Answer 37

B. Perthes' disease Perthes' disease typically occurs in children who are between 2-12 years of age (majority are 4-8 years of age). Avascular necrosis of the capital femoral epiphysis. It is more likely in boys.

Question 38

Sarah is a 12-year-old girl who presents with a painful left hip whilst playing netball. On examination she is afebrile, weight is above 90th centile, she has an atalgic gait, her hip has a reduced range of motion especially internal rotation. The most likely diagnosis is: A. Septic hip B. Muscle strain C. SUFE D. Perthes'

Answer 38

C. SUFE SUFE tends to occur in late childhood/early adolescence with weight often above the 90th centile. They present with pain in the hip or knee and associated limp. It is characterised by displacement of the upper femoral epiphysis from the metaphysis. The hip can appear externally rotated and shortened with decreased hip movement especially internal rotation. May be bilateral. Requires urgent admission for surgery.

Question 39

A 14-year-old boy who fell with an outstretched hand while skate boarding and complains of pain along his entire arm. There is point tenderness and swelling over the midshaft of the radius. There is significant pain with limited flexion of the elbow joint. An X-ray will most likely show which of the following fractures?- A. Galeazzi’s B. Scaphoid C. Colle’s D. Smith’s

Answer 39

A. Galeazzi’s Galeazzi's fracture/dislocation involves a fracture of the mid or distal radial shaft with distal radioulnar joint dislocation.

Question 40

A 65 -year-old male presents with back pain two days after he was shovelling when cementing his driveway. He complains of pain in his low back that radiates into his buttocks, posterior thigh and calf, and the bottom of his foot. There is associated numbness of his lateral and plantar surface of his foot. Which of the following disc herniations is most likely to be affected? A. L3-L4 B. L4-L5 C. L5-S1 D. S1-S2

Answer 40

C. L5-S1 The S1 nerve root impingement is most likely to occur from the herniation of the L5-S1 disc space. The S1 disc affects Achilles' reflex, the gastrocnemius and soleus muscles, and the abductor hallucis and gluteus maximus muscles.

Question 41

Amanda is a 24-year-old lady who has been trying to conceive for 18 months. She has an irregular menstrual cycle with 3 periods a year. She has a body mass index of 28. Her sister has polycystic ovary syndrome and she is concerned she may have polycystic ovary syndrome. To meet the criteria for polycystic ovary syndrome she must have: A. Irregular cycle for at least 12 months and a family history B. Two out of three features: oligo/anovulation, obesity and infertility C. Two out of three features: oligo/anovulation, hyperandrogenism, polycystic ovaries D. Features consistent with polycystic ovaries on ultrasound

Answer 41

C. Two out of three features: oligo/anovulation, hyperandrogenism, polycystic ovaries Diagnosis of polycystic ovary syndrome is as per the Rotterdam Criteria. Ultrasound scan is not recommended in diagnoses less than 8 years post menarche. Adult patients with irregular menstrual cycles and hyperandrogenism do not need an ovarian ultrasound for PCOS diagnosis.

Question 42

A 75-year-old lady presents with recurrent cystitis and atrophic vaginitis. She has a post void volume of < 30 mL on bladder ultrasound scan. She also has very mild stress incontinence. The best management is: A. Vaginal ring pessary B. Oral oestrogen C. Intravaginal oestrogen D. Prophylactic antibiotic

Answer 42

C. Intravaginal oestrogen Oestrogen deficiency results in generalised urogenital atrophy. Postmenopausal women are more likely to experience urinary tract infections as well as symptoms such as dyspareunia, pruritis, pain, urgency, frequency, dysuria and urinary incontinence. In postmenopausal women, vaginal oestrogen (cream, pessary or tablet) has been shown to reduce the risk of recurrent urinary tract infections. The vaginal oestrogen works by improving the flow in the pelvis and improving the skin of the vagina as well as the lining of the urethra and bladder wall.

Question 43

Mary is a 51-year-old female who presents to your clinic complaining of hot flushes and vaginal dryness. Her last period was four months ago. Her only medical history is mild hypertension, controlled on 5 mg of perindopril. Her mother has had a deep vein thrombosis (DVT). She is happy to have either patches or tablets, and has no skin allergies. Her blood pressure today is 125/80 and she has a body mass index of 35. You perform a cardiovascular, breast and pelvic exam, and apart from some vaginal atrophy, your examination is unremarkable. Regarding hormone replacement therapy (HRT) or menopausal hormonal therapy (MHT), which of the following is the most appropriate preparation? A. Sequential (or cyclical) estrogen and progesterone tablets B. Sequential (or cyclical) estrogen and progesterone patch C. Continuous estrogen and progesterone tablets D. Continuous estrogen and progesterone patch

Answer 43

B. Sequential (or cyclical) estrogen and progesterone patch Both oestrogen and progesterone are required as Mary still has a uterus, to protect the endometrium from hyperplasia due to unopposed oestrogen. Combined menopausal hormone therapy may be given as “cyclical”, where the oestrogen is given daily and the progestogen is given for 10 - 14 days of the month, or “continuous” where both oestrogen and progestogen are given daily. “Cyclical” produces withdrawal vaginal bleeds whereas “continuous” should not. As a general rule, cyclical hormone therapy is used for a woman who is pre-menopausal or in the menopausal transition (<12 months since her LMP) and is having some irregular spontaneous menses. As Mary’s last period was only 4 months ago, she is still considered peri-menopausal. Early introduction of continuous MHT close to the menopausal transition may lead to irregular, unscheduled breakthrough bleeding. Breakthrough bleeding may occur in the first six months of any MHT regimen but any unscheduled bleeding after that should be investigated. Patches provide patients with a smaller dose to reach efficacy than oral preparations, as first pass metabolism is avoided. Mary has a family history of DVT and some cardiovascular risk factors, therefore a patch is generally preferred, although in some tropical places, it may not stay on!

Question 44

You are working as one of the doctors at a small rural hospital with the nearest maternity service an hour away. Leanne presents to your hospital, 36 weeks pregnant, having noticed a gush of clear fluid from her vagina 15 minutes ago, with ongoing trickling of fluid down her leg. She tells you she has had not any issues antenatally. She is not having contractions. You use a fetal monitor to auscultate the fetal heart rate which is 105 beats per minute. Leanne’s pulse rate is 65. You press the emergency buzzer, and whilst you are waiting for help to arrive, what is the NEXT thing you would do? A. Do a vaginal examination B. Do a bedside ultrasound C. Put two large bore intravenous cannulas in and start some intravenous fluids D. Do a fetal fibronectin test

Answer 44

C. Put two large bore intravenous cannulas in and start some intravenous fluids Leanne has likely ruptured her membranes. A normal fetal heart rate is between 110 – 160 beats per minute, so the current fetal heart rate is low. This potentially represents fetal distress, and fetal distress shortly after either spontaneous or artificial rupture of membranes is cord prolapse until proven otherwise. To diagnose this, you need to do a vaginal exam to see if you can feel any cord. If this is the case, you need to instigate emergency management for a cord prolapse and aim to organise an urgent transfer for an urgent emergency caesearean section.

Question 45

You are working at a rural GP clinic. Sonia is a 48-year-old female with symptoms of urinary frequency and nocturia for the last two years. She describes when she pulls into the driveway, suddenly needing to go to the toilet, and at times, having urinary leakage. She works out at the gym three times a week and is able to run and jump without any problems. You send off a mid-stream urine for microscopy, culture and sensitivity, and refer her to the gynaecology outreach clinic, which visits once a month. Whilst waiting for the gynaecologist to see her, appropriate initial management options include all of the following EXCEPT: A. Advise her to cut down on caffeine B. Advise her to perform pelvic floor exercises C. Start her on an anti-muscarinic medication D. Advise her to do some bladder re-training

Answer 45

C. Start her on an anti-muscarinic medication Sonia likely has urge incontinence rather than stress incontinence. Although officially, urodynamic studies are needed for a formal diagnosis - as at times, the symptoms and urodynamic diagnosis may not be congruent - given the wait time to see a gynaecologist, it would be reasonable to instigate treatment for an overactive bladder. Start her on an anti-muscarinic medication, advise her to do some bladder re-training and cut down on caffeine. Pelvic floor exercises are conservative treatment for stress incontinence not urge incontinence, so likely will not help her symptoms.

Question 46

Margaret is a 55-year-old who woman presents with continuous vaginal spotting. She ceased having periods three years ago. Her body mass index is 35. She had a cervical screen test done 12 months ago, which was normal. In regards to post-menopausal bleeding, which of the following statements is correct? A. The most common cause of post-menopausal bleeding is vaginal atrophy, so she should be reassured and prescribed vaginal estrogen. B. The most common cause of post-menopausal bleeding is endometrial cancer, so she needs an urgent referral to a gynaecologist for hysteroscopy and endometrial biopsy. C. She does not need a repeat cervical screen test, as she had one 12 months ago. D. It is important to ask whether or not she is taking hormone replacement therapy (also known as menopausal hormonal therapy).

Answer 46

D. It is important to ask whether or not she is taking hormone replacement therapy (also known as menopausal hormonal therapy). First part of answer (a) is correct, but she should at least have an ultrasound to look at the endometrial thickness and possibly still go on to have endometrial sampling, as she has a high body mass index, a risk factor for endometrial cancer. She may need an urgent referral to the gynaecologist but the most common cause of post-menopausal bleeding is not endometrial cancer. Although cervical cancer is a rare cause of post-menopausal bleeding (~ 1 %), she should still have a cervical test done again, for co-testing (liquid based cytology and HPV). HRT can cause vaginal bleeding, so depending on how long she has been on HRT, she may not need further investigation.

Question 47

Regarding the categories of prescribing medications in pregnancy, which of the following statements is correct? A. Nicotine replacement therapy is a category D medication and is contraindicated in pregnancy as a medication to aid cessation of smoking. B. Although nicotine replacement therapy is a category D medication, it is safer than smoking cigarettes, and therefore should be considered to aid cessation of smoking in pregnancy. C. Medications in category C are more harmful to the fetus than in the B categories, and therefore should be avoided in pregnancy. D. The pregnancy categorisation of medications takes into account the different routes of administration of a particular drug.

Answer 47

B. Although nicotine replacement therapy is a category D medication, it is safer than smoking cigarettes, and therefore should be considered to aid cessation of smoking in pregnancy. The safety of medications in pregnancy categories utilises an alphabetical approach, however, it can be misleading in terms of hierarchy of safety. For example, medications under category B do not imply greater safety than those under category C, and category D medications are not all absolute contraindications in pregnancy (e.g. anti-convulsants). It also does not take into account different safety data with different routes of administration of a particular medication. Although nicotine replacement therapy is a category D medication, it is considered safer than smoking cigarettes and therefore is not a contraindication in pregnancy to aid cessation of smoking.

Question 48

Melanie is a 25-year-old G1P0 who is pregnant, confirmed by a positive urinary β-human chorionic gonadotrophin (βhCG). She tells you she is seven weeks pregnant based on her last normal menstrual period. She presents to your small rural hospital with light vaginal bleeding and mild abdominal cramping pain, relieved with paracetamol. She is otherwise well, with normal vital signs. Her serum βhCG level is 7800 mIU/L. A formal transvaginal ultrasound is organised, which shows a gestational sac with a mean sac diameter of 28 mm, with no fetal pole seen. There is no free fluid and no adnexal masses seen. What is the most likely diagnosis and subsequent management advice for Melanie? A. A missed miscarriage – she should now be counselled about expectant, medical or surgical options for management. B. A viable intrauterine pregnancy – she should have a repeat ultrasound in one week. C. An ectopic pregnancy - she needs transfer to the regional hospital with a gynaecological unit. D. It is too early to determine if this is a viable pregnancy. She needs serial B-HCGs and a repeat ultrasound in a week.

Answer 48

A. A missed miscarriage – she should now be counselled about expectant, medical or surgical options for management. A transvaginal ultrasound can detect an intrauterine pregnancy once a patient’s B-HCG is over 1500. The clinical picture and ultrasound finding of no free fluid or adnexal masses points away from the pregnancy being an ectopic pregnancy. With an experienced operator, a true gestational sac seen reflects an intrauterine pregnancy and a miscarriage can confidently be diagnosed without needing repeat ultrasounds on the following criteria: When no live fetus is visible in a gestation sac and the mean sac diameter (MSD) cut off >25mm OR When there is a visible fetus with a crown rump length cut off >7mm but no fetal heart movements can be demonstrated. The area of the fetal heart should be observed for a prolonged period of at least thirty (30) seconds to ensure that there is no cardiac activity.

Question 49

You are the senior medical officer at a small rural hospital, with the nearest maternity service two hours away by road. Ella is G5P4, 38 weeks pregnant. She has had a precipitous labour and has birthed her baby and placenta in the car park 5 minutes ago. There has been 100 mL of estimated blood loss. The baby is well. Ella is feeling a bit stunned but happily talking to you. As she gets up onto a hospital bed, she mentions feeling a gush of fluid from her vagina. You have a look and estimate about 200 mL of acute vaginal blood loss. Currently, there is just you and the triage/general nurse present in the emergency room. You ask the nurse to call the emergency buzzer and to go to the medication room to bring some medications for a potential post-partum haemorrhage. Whilst you are waiting for more help to arrive, what is the first initial step that you single-handedly could do to manage this bleeding? A. Open the drawers of the intravenous trolley, in order to insert a large bore intravenous cannula. B. Put a blood pressure cuff on Ella’s arm, to check her blood pressure. C. Rub the fundus of the uterus, to check the tone and to provide uterine massage. D. Check the placenta to see if it’s complete.

Answer 49

C. Rub the fundus of the uterus, to check the tone and to provide uterine massage. Having limited staff members initially after a birth is common, and whilst seeking help, there can be uncertainty about what might be the most useful initial steps to take. Decisions need to be made about prioritising steps in initiating general resuscitation (ABCD approach) vs diagnosing and managing the causes of post-partum haemorrhage (PPH). The most common cause of PPH is atony, especially in a precipitous labour. Rubbing the fundus of the uterus gives you instant feedback about whether or not the tone is the cause of the PPH, and at the same time, you are giving treatment via mechanical compression, whilst waiting for someone to bring the drugs. If you checked the uterus and the tone was excellent, then you might proceed to check the placenta to look for retained tissue as the cause of the PPH, but you generally wouldn’t do this as the first step. A) is not correct. Whilst general resuscitation is part of the management of PPH, she has not lost enough blood and is not unwell enough to compromise her circulation. If you are the only person there at the moment, then putting an IVC in will take time and is currently not required. B) is not correct, again for the same reason as A). Blood pressure is a late sign of haemodynamic shock from PPH, so it should not be relied on to reassure you of the woman’s risk of becoming compromised haemodynamically.

Question 50

Regarding pre-eclampsia in pregnancy: A. Low dose aspirin should be given to at-risk patients to reduce the risk of developing pre-eclampsia. B. Hypertension diagnosed anytime during pregnancy is pre-eclampsia until proven otherwise. C. Anti-hypertensives given for pre-eclampsia in pregnancy will help to reduce the risk of having eclampsia. D. An emergency caesarean section is the safest option for delivery in severe pre-eclampsia.

Answer 50

A. Low dose aspirin should be given to at-risk patients to reduce the risk of developing pre-eclampsia. Low dose aspirin has been shown to reduce the likelihood of developing pre-eclampsia in at-risk women, if given before 20 weeks. It is usually started at 12 weeks and continued until 36 weeks gestation. Pre-eclampsia is diagnosed if there is new onset of hypertension arising after 20 weeks of gestation, accompanied by one or more of organ/system abnormalities. If there is hypertension before 20 weeks of gestation, this is likely undiagnosed essential or chronic hypertension, white coat hypertension or less commonly, secondary hypertension. Anti-hypertensives reduce the risk of a hypertensive haemorrhagic stroke in pre-eclampsia but does not reduce the risk of having an eclamptic fit from pre-eclampsia. There is no evidence to guide the safest mode of delivery in severe pre-eclampsia. Factors worsening maternal morbidity include low platelets, HELLP syndrome, renal failure and propensity for acute pulmonary oedema. The risks of delay of birth with an induction of labour need to be weighed against the risks of undergoing surgery and an anaesthetic.