Semester B

Question 1

Agnes is an 84-year-old lady who presents with dyspnoea worsening over the last few days. She has come via ambulance from a nursing home and has severe dementia as well as a past history of ischaemic stroke, emphysema, atrial fibrillation and ischaemic heart disease. No history is available from the patient as she is non-verbal following her stroke two years ago. She is afebrile and has a productive sounding cough.

Which of the following is the most likely cause of her dyspnoea?
A. Pulmonary embolism
B. Exacerbation of her emphysema
C. Foreign body inhalation
D. Acute coronary syndrome

Answer 1

B. Exacerbation of her emphysema

Exacerbation of her emphysema is correct, as the others are all acute causes of shortness of breath/dyspnoea whereas her presentation is of a sub-acute nature.

Question 2

Sally is a 35-year-old lady who has presented with mild dyspnoea and left-sided pleuritic chest pain since returning from London three days ago. She has a small pulmonary embolus reported on CT pulmonary angiogram. She is otherwise well with no other significant medical history.

Which of the following is the most appropriate management of her pulmonary embolus?
A. Immediate thrombolysis
B. Commence anticoagulation with warfarin as the sole agent
C. Enoxaparin at a dose of 40 mg once daily
D. Rivaroxaban 15 mg orally twice daily

Answer 2

D. Rivaroxaban 15 mg orally twice daily

Thrombolysis is only for massive life threatening pulmonary embolus which this is not.

Warfarin should be commenced in conjunction with heparin cover in some form until adequate INR is achieved.

Enoxaparin at 40 mg daily is a preventative and not therapeutic dose.

The Australian Therapeutic Guidelines recommends treating proximal DVT and PE with apixaban or rivaroxaban in preference to warfarin if oral anticoagulation is suitable (oral anticoagulants are not first-line therapy for VTE during pregnancy or for cancer-associated VTE). It is unlikely that Sally has significant renal impairment at 35 years old, so a NOAC would be the first choice. The Australian Therapeutic Guidelines recommends commencing rivaroxaban at 15 mg orally twice daily for 21 days, then decrease to 20 mg once daily.

Question 3

Leo is an 88-year-old man with known ischaemic cardiomyopathy and chronic heart failure.

He is on perindopril 10 mg daily, bisoprolol 5 mg daily, rosuvastatin 20 mg daily, aspirin 100 mg daily and rivaroxaban 2.5 mg BD.

He presents with a two week history of progressive exertional breathlessness and puffy ankles, although the viral respiratory infection he had two weeks ago has fully resolved. He is still managing his activities of daily living adequately.

Examination reveals 3 kg weight gain, blood pressure 140/90 mmHg, pulse rate 105 bpm regular, JVP 3 cm raised, bilateral basal lung crepitations and pitting oedema to his mid shins bilaterally.

What is the most helpful medication change for Leo right now?
A. Up-titrate his bisoprolol to 10 mg daily and review in two weeks
B. Add frusemide 20 mg mane and review in a few days
C. Change the perindopril to ivabradine because of his tachycardia
D. Add irbesartan 75 mg daily

Answer 3

B. Add frusemide 20 mg mane and review in a few days

Rationale
Up-titrating his bisoprolol would probably help, but it should be in smaller increments e.g. 1.25 or 2.5 mg steps, and will not address his current fluid overload as immediately
He is fluid over-loaded so a diuretic is indicated as an add-on medication to give him prompt symptom relief
Ivabradine is an add-on to an ACEI, mineralocorticoid receptor agonist or beta blocker at maximal doses, in HFrEF with persistent tachycardia. Leo is not at maximal betablocker, and his tachycardia may be transient
Angiotensin receptor antagonists replace ACEIs. This combination is reno-toxic and increases adverse cardiac outcomes.

Question 4

Nigel is a 25 year old who you recently diagnosed with pericarditis, and he is seeing you today for follow up in the general practice, 10 days after his ED visit, after missing his planned review a few days before due to work. At the time of the ED visit, he was commenced on colchicine, 500 microg BD and ibuprofen 600 mg TDS, the latter of which he is due to down-titrate in four days. He states he’s still uncomfortable and unable to lie down properly, and it doesn’t seem like anything has gotten better.

What is the next most appropriate step?
A. Consideration of admission/specialist referral
B. Continue ibuprofen at 600 mg TDS for another two weeks
C. Switch from ibuprofen to aspirin
D. Commence prednisolone, 1 mg/kg/day

Answer 4

A. Consideration of admission/specialist referral

Nigel has pericarditis that hasn’t responded to 7 days of treatment, which is concerning and he should then be reassessed with consideration of both the diagnosis and specialist input. While glucocorticoids may be used in these situations, they present their own risks as well as frequent reoccurrence of pericarditis when ceased, specialist input is desirable. There would be little evidence for longer higher-dose NSAID or switching from one NSAID to another in this situation.

Question 5

Maria is a 35-year-old woman from the Northern Territory. She presents with a moist productive cough that has been present for over six weeks. You have excluded influenza with nasal swabs. She has been on two courses of oral antibiotics. The cough is intermittent and not associated with exercise. She is not on any regular medications and does not have asthma. She has never smoked.

What is the next best step in her management?
A. Reassurance that the cough will improve over time
B. Consider chest X-ray
C. Start her on another course of antibiotics
D. Spirometry

Answer 5

B. Consider chest X-ray

Maria has a chronic cough that is not improving, so it would be wise to investigate for a cause. Chest X-ray would be the most likely next step followed by further investigations depending on progress. Chest X-ray can help look for some causes of chronic cough including pneumonia, chronic obstructive pulmonary disease, pulmonary fibrosis, tuberculosis, bronchiectasis, lung cancer and aspiration pneumonia. Maria is not a known smoker and not asthmatic, so spirometry is also an option to consider following a chest X-ray, if symptoms persist.

Question 6

Morrison is a 55-year-old Aboriginal man who has been diagnosed with bronchiectasis. He has had six acute exacerbations in the last 12 months treated with antibiotics, including two hospital admissions for intravenous antibiotics. His last sputum microscopy culture sensitivities (MCS) result grew Pseudomonas aeruginosa. He is on a regular bronchodilator. He has no haemoptysis. He has gained 3 kg in the last year.

What feature in his presentation would prompt you to refer Morrison to a respiratory physician?
A. Frequent use of a bronchodilator
B. Pseudomonas aeruginosa isolated in sputum
C. Six courses of antibiotics in the last 12 months
D. Weight gain in the past 12 months

Answer 6

C. Six courses of antibiotics in the last 12 months

A frequent need for antibiotics, such as more than 3 to 4 courses of antibiotics within 12 months, is an indication for seeking a respiratory physician as suggested by therapeutic guidelines.

Regular use of a bronchodilator would not be an indication unless it was associated with a rapid progression of symptoms and increased use.

Pseudomonas aeruginosa would not be considered an unusual organism to isolate in the sputum and therefore would not warrant referral of its own accord, unless it was resistant.

Weight gain is a positive feature of the clinical history in this case; an inability to maintain weight would indicate a clinical deterioration of bronchiectasis that may require referral to a specialist.

The following are suggested indications for seeking respiratory physician opinion:
Rapid progression of disease or symptoms
Disease requiring hospitalisation
Severe respiratory symptoms or lack of response to current treatment
Frequent need for antibiotics, such as more than 3 to 4 courses of antibiotics within 12 months
Resistant or unusual organisms isolated in sputum
Haemoptysis
Clinical deterioration indicated by
Inability to maintain weight
Declining lung function.

Question 7

52-year-old Winston presents with acute severe unremitting “burning” jaw pain for 60 minutes, unaffected by position, jaw, neck or arm movement, and associated with sweating and nausea. He has no chest pain and his ECG is normal. His oxygen saturations are 98 % on room air and blood pressure 127/82 mmHg.

What is the next most appropriate step in his management?
A. Administer oxygen via Hudson mask
B. Treatment with an antacid
C. Treatment with sublingual glyceryl trinitrate (GTN)
D. Perform a chest X-ray

Answer 7

C. Treatment with sublingual glyceryl trinitrate (GTN)

The routine use of supplemental oxygen is no longer recommended in the patient with acute myocardial ischaemia. Oxygen therapy is indicated for patients with hypoxia (oxygen saturation <93 %) and those with evidence of shock to correct tissue hypoxia. This presentation has features strongly indicative of acute myocardial infarction or unstable angina despite the absence of chest pain. The acute onset, the unremitting nature, the duration, the absence of local factors to influence pain and the systemic upset all strongly suggest an ischaemic myocardial origin. Therefore, the next most appropriate step of those listed is treatment with sublingual GTN. This should happen before a chest X-ray is conducted. Treatment with an antacid is inappropriate as the presentation should be treated as possible cardiac chest pain.

Question 8

Jillian is 68-year-old lady who is brought in to the emergency department via ambulance with acute shortness of breath. She has a blood pressure of 80/40 mmHg, respiratory rate 40 breaths/minute, oxygen saturations 90 % on room air and an irregularly irregular heart rate of 130 bpm.

Which of these is the next most appropriate step in her management?
A. Administering intravenous metoprolol 1-2mg
B. Immediate electrical cardioversion
C. Ensuring a patent airway
D. Commencing non-invasive ventilation

Answer 8

C. Ensuring a patent airway

The stem is suggestive of an unstable patient with atrial fibrillation. Electrical cardioversion is the recommended treatment, however, resuscitation always begins by ensuring a patent airway. Intravenous or oral metoprolol are recommended as first line therapy for rate control of atrial fibrillation of more than 48 hours duration in stable patients; this patient is clearly unstable. Non-invasive ventilation may be appropriate but ensuring a patent airway is a higher priority.

Question 9

25-year-old Lara is brought in to the emergency department with acute shortness of breath and wheeze. She cannot speak and appears frightened with an audible stridor and increased work of breathing. Her respiratory rate is 42 breaths/minute. She has a significant bilateral expiratory wheeze on lung auscultation. Her blood pressure is 70/40 mmHg. High flow oxygen is being applied by the nurse.

The next most appropriate step in her management is:
A. Nebulised salbutamol 5 mg
B. Administer intramuscular adrenaline 0.5 mg
C. Nebulised adrenaline 5 mg
D. Intravenous normal saline bolus 20 mL/kg

Answer 9

B. Administer intramuscular adrenaline 0.5 mg

Lara has the three clinical features of life-threatening anaphylaxis:

Laryngeal oedema (manifested as stridor and respiratory distress)
Bronchospasm (expiratory wheeze)
Hypotension.
Anaphylaxis is a severe hypersensitivity reaction characterised by cardiovascular collapse and respiratory compromise. Most patients will have an associated rash, but some will not.

The management of anaphylaxis begins with a high index of suspicion and requires a rapid assessment and decision-making process, often with a minimal amount of information.

Immediate intervention is essential to prevent deterioration and death. After assessing the airway and applying high-flow oxygen, the immediate management of anaphylaxis is the administration of adrenaline IM.

Nebulised adrenaline can be used as an adjunct for symptomatic treatment of stridor or bronchospasm.

Salbutamol is not the correct choice as it is not part of the management of anaphylaxis.

Intravenous normal saline can be used after the administration of IM adrenaline for severe hypotension in anaphylaxis.

Question 10

Kevin is a 65-year-old male with known chronic obstructive pulmonary disease who presents with an acute worsening of his chronic shortness of breath. His chronic cough is unchanged. He has a respiratory rate of 30 breaths/minute and an oxygen saturation of 85 % on room air. His venous blood gas reveals a pCO2 of 62 mmHg. His chest X-ray is normal.

The most appropriate management is:
A. Non-invasive ventilation with bilevel positive airway pressure (BiPAP)
B. Continuous positive pressure ventilation
C. Commence oral amoxicillin and doxycycline
D. Administer intravenous hydrocortisone 100 mg

Answer 10

A. Non-invasive ventilation with bilevel positive airway pressure (BiPAP)

The use of non-invasive ventilation in COPD results in more rapid clinical improvement with decreased hospital stay and is associated with lower mortality, decreased complications and lower rate of intubation.

BiPAP is preferred to CPAP in COPD as the additional inspiratory pressure improves ventilation and aids in removing the pCO2, correcting hypercapnia.

It is currently recommended that antibiotic therapy should not be used unless the patient has clinical signs of infection with increased purulent sputum or volume of sputum in associated with increased dyspnoea.

Steroids should be administered orally where possible.

Question 11

Brian is a 29-year-old Aboriginal male who has a past history of IV drug use but no significant medical conditions. He has however, recently been released from the local prison where he served two years. He is now in a new relationship and would like to be screened for hepatitis B.

In order to be eligible for the Medicare rebate for all of HBsAg, anti-HBs and anti-HBc, which of the following would be appropriate to write on the pathology request form?
A. Nothing needs to be written
B. “Significant risk factors for chronic hepatitis B”
C. “Patient/partner concern”
D. It doesn’t matter what is written as these items are not Medicare rebatable

Answer 11

B. “Significant risk factors for chronic hepatitis B”

These pathology tests are Medicare-rebatable but there must be appropriate clinical justification documented on the pathology request form. Patient and/or partner concern is not sufficient in itself. Brian has several risk factors for hepatitis B including being from a priority population for screening and previous IVDU.

Question 12

Clive is a 53 year old man who attends your clinic with his wife, Tania. He’s been feeling more tired than usual, and you decide, after further history and examination, to complete some blood tests, including an FBC, U&Es and LFTs. Some key results include:

Analyte Result
Platelets 83 x 109/L (150-400)
AST 76 U/L (<35)
ALT 54 U/L (<40)

You decide, based on the elevated ALT and AST, to screen Clive for hepatitis B and C, when he discloses that he used heroin IV a couple of times in his late teens. On previous examination his liver felt firm with a somewhat nodular edge. The following results return:
Analyte Result
Hepatitis C Ab Positive
Hepatitis C RNA PCR (qualitative) Positive

You discuss the result with Clive. What is your next step?
A. Discuss asking Tania in for testing
B. Commence a 12 week course of sofosbuvir/velpatasvir
C. Complete HCV genotyping
D. Refer to hepatologist/gastroenterologist

Answer 12

D. Refer to hepatologist/gastroenterologist

Clive has signs of cirrhosis, including a firm, nodular liver, and his APRI and FIB-4 scores (2.693 and 6.60, respectively) are strongly suggestive of advanced cirrhosis. Referral to a hepatologist/gastroenterologist for further assessment for his cirrhosis, and to treat his hepatitis C, would be advisable.

Hepatitis C genotyping is an optional step, now, but may be considered in some cases. With cirrhosis, sofosbuvir/velpatasvir may need to be supplemented with ribavirin, usually not suitable for general practitioner care. While not the first consideration, reflex testing of Tania and their children, should Tania also be hepatitis C positive, would be required.

Question 13

Mavis is a 71-year-old retiree who presents to you with a five-day history of constipation. She has had difficulty passing stools which were hard, large and dry. You recommend an adequate fluid intake, a healthy diet, improved toileting posture and regular exercise.

What is the most appropriate first line laxative to prescribe for her?
A. Bisacodyl 5 mg tablets (Dulcolax), two nocte orally
B. Pear juice, 1 cup daily, orally
C. Psyllium mucilloid (Metamucil), 1 teaspoonful daily, orally
D. Sodium phosphate (Fleet) enema, nocte

Answer 13

C. Psyllium mucilloid (Metamucil), 1 teaspoonful daily, orally

Psyllium, a bulking agent, is a typical starting point. Pear juice, a softener and mild stimulant, might also be an option though caution for Mavis’ other comorbidities, especially diabetes, and the cost may be more than other agents. Bisacodyl and sodium phosphate are both stimulants, and usually third line options.

Question 14

Nigel is a 35-year-old taxi driver with a two-day history of rapidly progressive perianal pain and now has malaise, fever and a very painful lump. Examination reveals a red, hot, tender swelling in the perianal area, involving the local gluteal soft tissue. You diagnose perianal abscess.

What do you recommend for Nigel?
A. Sitz baths and await spontaneous drainage
B. As above and oral antibiotics
C. Incision and drainage under local anaesthetic in your rooms
D. Admit for incision and drainage under general anaesthetic

Answer 14

D. Admit for incision and drainage under general anaesthetic

Deep extension of the abscess is to be avoided, so delay in definitive treatment is not recommended
Oral antibiotics are not effective for abscesses. Drainage is recommended
The precise focus of the deep infection is not readily evident from the surface
Exploration under anaesthetic is the best way to drain the deeper aspects of the abscess and prevent fistulae.

Question 15

Joshua is a 35-year-old butcher who presents to you with constipation for the past week. He reports passing two stools over the past week, both type 1 stools, painful defecation with blood on the toilet paper. No abnormalities are notable on physical examination.

Which aspect of his history is included in the Rome III diagnostic criteria for functional constipation?
A. Irregular motions
B. Fewer than three defecations per week
C. Blood on toilet paper
D. Painful defecation

Answer 15

B. Fewer than three defecations per week

The Rome III criteria for functional constipation must include two or more of the following:

Straining during at least 25 % of defecations
Lumpy or hard stools in at least 25 % of defecations
Sensation of incomplete evacuation for at least 25 % of defecations
Sensation of anorectal obstruction/blockage for at least 25 % of defecations
Manual maneuvers to facilitate at least 25 % of defecations, e.g. digital evacuation, support of the pelvic floor
Fewer than three defecations per week
There are insufficient criteria for irritable bowel syndrome.

Question 16

Julie is a 62-year-old teacher who has recently presented with chronic constipation despite increasing fibre and fluid intake as well as daily exercise. In the past 6 months she was commenced on medication for hypertension, type 2 diabetes and osteoarthritis.

Which of the following medications is most likely to be contributing to her chronic constipation?
A. Prazosin
B. Metformin
C. Verapamil
D. Paracetamol

Answer 16

C. Verapamil

Examples of drugs that commonly cause constipation from eTG:
Opioids
Drugs with anticholinergic effects, e.g. oxybutynin, trihexyphenidyl [benzhexol], tricyclic antidepressants, clozapine, olanzapine, risperidone, quetiapine
5-HT3–receptor antagonists, e.g. ondansetron
Aluminium- and calcium-containing antacids
Oral calcium supplements
Oral iron supplements
Verapamil
Glucagon-like peptide-1 (GLP-1) analogues, e.g. liraglutide, semaglutide.

Question 17

Greg, a 45-year-old man who is otherwise usually well and not on any regular medication, presents with gastroenteritis. He ate fried rice from a market stall yesterday evening. The illness began with 4-5 episodes of vomiting overnight and progressed to profuse watery diarrhoea and abdominal cramps this morning. There is no blood in the stool, and he does not have a fever.

The most likely pathogen is:
A. Norovirus
B. Bacillus cereus
C. Staphylococcus aureus
D. Salmonella spp. (non-typhoidal)

Answer 17

B. Bacillus cereus

Greg’s symptoms are consistent with a toxin-mediated infectious gastroenteritis i.e. a short incubation period beginning with vomiting and progressing to profuse watery diarrhoea and abdominal cramps. Bacillus cereus is a common pathogen causing food poisoning from eating contaminated fried rice.

Question 18

Juliette, a 32-year-old scientist, presents with a one-week history of abdominal pain (mild to moderate intensity) and diarrhoea, passing three to four blood containing small volume motions per day. On further questioning, she has been having episodes of abdominal pain and diarrhoea for about two months. Over this time, she has also been feeling generally unwell with fatigue, joint pains, a decreased appetite and has had one to two kilograms weight loss. She has no significant past history, does not take any regular medications and has not travelled overseas recently.

Juliette does not look toxic, observations are within normal ranges, and she has mild generalised abdominal tenderness without guarding. The rest of her abdominal examination, including PR, is normal.

Initial investigations including FBC, ESR, CRP, stool microscopy and faecal calprotectin all point towards a diagnosis of inflammatory bowel disease.

You arrange for her to have urgent gastroenterology review and endoscopy.

Once the diagnosis is confirmed, the most appropriate initial management (in consultation with her specialist) is likely to be:
A. Dietary advice, including referral to a dietitian
B. Treatment with a 5-aminosalicylate preparation both orally and rectally
C. Supportive treatment, including fluids, analgesia, loperamide, peppermint oil, prebiotic
D. High dose oral steroids

Answer 18

D. High dose oral steroids

History, examination and initial investigations all point to a likely diagnosis of Crohn’s disease in this case. Clinically, this is a moderately severe presentation due to the number of stools passed per day, the intensity of her abdominal pain, the presence of one extra-intestinal manifestation (joint pains) and mild weight loss, without signs of systemic toxicity or anaemia. GESA recommends using oral prednisone 40 mg daily (and tapering off over 6-8 weeks once achieving a clinical response) for induction therapy for mild to moderate Crohn’s disease, once diagnosis is confirmed, with consultation with gastroenterology for follow up.

Question 19

You are working in a rural emergency department. Your next patient, Erica, a 54-year-old presents with severe abdominal pain on a background of a multi-day alcohol binge. The pain is sharp/stabbing in her left upper quadrant radiating around to her back. The pain is exacerbated when she tries to eat or drink anything. On examination she is very tender in the left upper quadrant but there are no signs of peritonism.

Which of the following test results would suggest an increased mortality rate?
A. Blood glucose >8 mmol/L at admission
B. Fall in her haematocrit by >10 % at 48 hours
C. Serum lipase >50000 U/L at any time
D. Presence of gallstones on ultrasound

Answer 19

B. Fall in her haematocrit by >10 % at 48 hours

Based on the Ranson criteria a fall of her haematocrit of >10 % at 48 hours is associated with an increased mortality when it is combined with other test results. The Ranson criteria are as follows:

At admission:
Age in years > 55 years
WBC count > 16 x 109/L
Blood glucose > 11.11 mmol/L
Serum AST > 250 U/L
Serum LDH > 350 U/L.

Within 48 hours:
Serum calcium <2.0 mmol/L
Hematocrit fall >10 %
Oxygen (hypoxemia, PaO2 < 60 mmHg)
Urea increased by ≥1.8 mmol/L after IV fluid hydration
Sequestration of fluids > 6 L.
A score of 3 or more is associated with an elevated mortality risk:

Score 0 to 2 : 2 % mortality
Score 3 to 4 : 15 % mortality
Score 5 to 6 : 40 % mortality
Score 7 to 8 : 100 % mortality.

Question 20

Steven, 60 years old, a long-term patient with a long history of heavy alcohol use and several admissions for acute pancreatitis, presents numerous times with a constant dull ache in his abdomen, more so in the LUQ. The pain is always present with intermittent sharp flares. Extensive investigations and his history suggest chronic pancreatitis.

Which of the following tests would be best to show if he has pancreatic enzyme deficiency?
A. Serum lipase
B. Serum amylase
C. Blood glucose
D. Faecal elastase

Answer 20

D. Faecal elastase

Elastase is an enzyme that is secreted by the pancreas and is excreted in the feces. When pancreatic insufficiency is present the amount of elastase in the stool will be decreased.

Question 21

Jane is an 18-year-old female with fatigue, who suffers from occasional loose stools. She often experiences abdominal bloating, and has lost five kilograms in the past year. Her initial results come back as follows:

Haemoglobin 108 (115-160g/L)
Haematocrit 0.337 (0.350-0.450L/L)
WBC 7.4 (4.0-11.0 x 109/L)
Platelets 347 (150-400 x 109/L)
MCV 74 (78-100fL)
RBC 3.4 (3.8-5.8 x1012/L)
MCH 23.7 (27-32pg)
MCHC 320 (310-370g/L)
RDW 17.3 (11.5-15)
Reticulocytes low
Serum iron 70 (80-200ug/dL)
Serum TIBC 400 (80-200ug/dL)
Serum ferritin 5 (12-250ug/dL)
B12 500 (138-652pmol/L)
TSH 2.61 (0.32-4.00mIU/L)

COMMENT
Slight hypochromasia, slight microcytosis

The next most important investigation is:
A. Duodenal biopsy
B. Serum folate levels
C. Total IgA level
D. Faecal occult haemoglobin

Answer 21

A. Duodenal biopsy

Jane has the classic tetrad of diarrhoea, weight loss, iron deficiency and abdominal bloating indicating coeliac disease.

Her blood test results are consistent with an iron deficiency anaemia, which is likely to be caused by coeliac disease in this case.

The key investigation for coeliac disease is endoscopy and duodenal biopsy to demonstrate villous atrophy.

Serum folate levels are likely to be low, but are not as important as a duodenal biopsy in this case.

Total IgA levels should be requested when requesting IgA antibodies as part of the work-up for coeliac disease, including specific coeliac antibodies, as a reduced total IgA level could give falsely low antibody results.

However, with a strong clinical suspicion of coeliac disease as in this case, performing duodenal biopsy is still the most important investigation and would likely be performed even if serum IgA antibodies were not elevated.

Question 22

Oliana is a 22-year-old Pacific Islander whose primary complaint is fatigue. Her full blood count demonstrates a haemoglobin of 105 g/L, MCV of 75 fL (normal range 78-100) and MCH of 25 pg (normal range 27-32) with a low serum ferritin.

The next most important step is to:
A. Start oral iron supplements
B. Start parenteral iron
C. Perform haemoglobin electrophoresis
D. Encourage diet rich in iron

Answer 22

C. Perform haemoglobin electrophoresis

Oliana is from an ethic background with an increased carrier frequency of haemoglobinopathy, and requires haemoglobin electrophoresis to exclude thalassaemia. Thalassaemia may co-exist with iron deficiency. If the initial haemoglobin electrophoresis is normal, the current Australian guidlelines recommending treating the iron deficiency and then re-testing.

Question 23

Juliette is on chemotherapy after hemicolectomy for colon cancer. She is losing weight from anorexia, nausea and vomiting despite prophylactic ondansetron and rescue metoclopramide 10 mg tds.

The next best step in her management would be to:
A. Arrange a dietitian to assess her and recommend meal replacements e.g ensure and supplements
B. Discuss her problems with the medical oncologist
C. Reduce the chemotherapy dose by a third and assess her progress
D. Add dexamethasone 4 mg mane for it’s antiemetic benefits

Answer 23

B. Discuss her problems with the medical oncologist

There are many possible causes for her weight loss, so simply adding meal replacement drinks without a diagnosis is unwise. Some supplements can exacerbate diarrhoea in certain situations, which could exacerbate her weight loss problem.

Likewise, dexamethasone can have antiemetic benefits in chemotherapy, but treatment without understanding the cause of her symptoms is not best practice.

It may be that Juliette needs her chemotherapy dose adjusted, but this is a decision to be made by or with her oncologist. Thus discussion with her oncologist is the best option.

Question 24

Jennifer is a 55-year-old who has noticed a marked reduction of colostomy output and some abdominal distension over the past few days.

What is the next most appropriate step in her management?
A. Assess for stoma stenosis or bowel obstruction
B. Prescribe aperients and an increased fluid intake
C. Recommend a higher fibre intake and arrange dietitian referral
D. Order a stoma flush out

Answer 24

A. Assess for stoma stenosis or bowel obstruction

Jennifer has new symptoms so she needs assessment for the underlying cause. It may be that she simply needs to manage constipation with an improved intake of fibre or fluids, the help of aperients or even a stoma flush out, but if she has a post surgical stenosis or tumour-related obstruction, constipation treatments would be unhelpful.

Question 25

Harold is a 78-year-old man with metastatic prostate cancer, continuous slow rectal bleeding from radiation proctitis and haematuria. He has stopped active treatment for his cancer and is now being palliated. His anaemia has been treated with weekly blood transfusions but the symptomatic benefits from each transfusion are no longer sustained, with Harold experiencing significant fatigue, dyspnoea and tachycardia between transfusions. The next appropriate step in management would be to: A. Increase the frequency of blood transfusions B. Prescribe tranexamic acid C. Encourage Harold to continue with current management D. Discuss stopping transfusions with Harold

Answer 25

D. Discuss stopping transfusions with Harold Anaemia in the palliative care setting is commonly multifactorial, as was likely in this case. The burdens and benefits of repeated transfusion for chronic haematological disorders should be discussed with the patient when the symptom-free interval between transfusions shortens (e.g. from monthly to fortnightly or weekly), or if the improvement seen on each occasion decreases or becomes nonexistent. For a patient on long-term treatment with blood products, it can be very confronting when symptomatic benefits diminish or are not sustained. At some point, the patient may need ‘permission’ to stop repeated transfusions (rather than encouragement to continue) and to accept the supportive care that will provide symptom relief during their continuing decline. Tranexamic acid may offer some benefit in the setting of slow continuing blood loss in the palliative patient, but care must be taken in a patient with haematuria as intravesical clots may develop. Stopping the blood transfusions and providing symptom relief is a better management option in this case.

Question 26

Ali is a 57-year-old male who presents with a unilateral enlarged non-tender cervical lymph node that has been present for 5 weeks. The most important investigation would be: A. Full blood count B. Serological testing for B. henselae and T. gondii C. Lymph node biopsy D. HIV serology

Answer 26

C. Lymph node biopsy Ali’s history contains features concerning for a malignancy. Age >50 years increases the chances of a malignancy being the cause of lymphadenopathy. The lymphadenopathy’s lack of tenderness, supraclavicular location and chronicity are all indications for lymph node biopsy as per the Cancer Council’s clinical guidelines. The Australian Therapeutic Guidelines suggests performing fine-needle aspiration of a lymph node, then proceeding to lymph node biopsy if the diagnosis remains in doubt, which would be performed by an otolaryngologist.

Question 27

35-year-old Alison comes to see you six weeks after being diagnosed with Epstein-Barr Virus (EBV). She is having ongoing problems with fatigue and hasn’t yet been able to return to work full-time. She has had no other constitutional symptoms and examination is unremarkable. Her full blood count shows: Hb 136 (115 – 165g/L) Total WCC 9.6 (4.0 – 11.0x 109/L) Neutrophils 3.8 (2.0 – 7.5x 109/L) Lymphocytes 4.8 (1.5 – 4.0x 109/L) Monocytes 0.8 (0.2 – 0.8x 109/L) Eosinophils 0.05 (0.04 – 0.4x 109/L) Basophils 0.07 (0.05 – 0.1x 109/L) Platelet count 310 (150 - 400 x 109/L) The next most appropriate step in management is: A. Order flow cytometry B. Refer her to haematology C. Arrange to repeat her full blood count in 6 weeks D. Tell the patient you think she has leukaemia

Answer 27

C. Arrange to repeat her full blood count in 6 weeks Alison likely has an ongoing reactive lymphocytosis post EBV infection. It is reasonable to monitor a lymphocytosis less than 5.0 x 109/L, without constitutional symptoms, lymphadenopathy or hepatosplenomegaly, or in the context of recent acute illness, with repeat testing within three months.

Question 28

Andrew, 50 years old, is a long term patient of yours who was diagnosed with motor neurone disease four years ago. He is increasingly affected by the condition, and is now only able to mobilise with assistance and a wheelchair. At a regular review with his wife, May, in attendance, he states, "I want to start planning for my death. I have the advance health directive, my will is in order, even have a funeral plan. But I wanted to discuss that assisted dying thing." You have a conscientious objection to VAD for personal reasons, but know one of the senior GPs in your practice does offer VAD. What is the next most appropriate step? A. Explain to Andrew you have a conscientious objection to VAD B. Refer Andrew to the other doctor in your practice for VAD C. Explain to Andrew you can no longer care for him D. Divert the consultation to another topic

Answer 28

A. Explain to Andrew you have a conscientious objection to VAD Your obligation is to state you hold a conscientious objection to VAD. This is then followed by onward referral to a practitioner you reasonably believe offers VAD. In many cases, conscientious objection need not affect your ongoing relationship with a patient, or continued care of them, though the patient may choose another practitioner for ongoing care in some cases. Ignoring the query is inappropriate, as is providing false information. Some practitioners who hold a conscientious objection may be open to discuss VAD, but may be unwilling to provide it, or varying degrees of practice. Some accredited VAD practitioners are open to assess people, and prescribe a self-administered substance, but are not willing to administered the substance to the patient themselves, and may delegate that aspect to another practitioner. VAD is rarely an all-or-nothing proposition.

Question 29

Jennifer, aged 25 years, G2P1, is 36 weeks pregnant. She has a routine full blood count which shows the following results: Hb 111 105 - 160 g/L Mean corpuscular volume 82 80 - 100 fL White cell count 8.9 5 - 15 x 109/L Platelet count 88 150 - 450 x 109/L Jennifer has had an uncomplicated pregnancy and a history of a previously normal vaginal delivery two years ago. At this visit her blood pressure is 120/80 mmHg and her urine dipstick is negative for protein or glucose. Fundal height is 35 cm and the fetal heart rate is 155 beats/minute. She feels well and baby is moving. What is the most likely diagnosis? A. Gestational thrombocytopenia B. Immune thrombocytopenic purpura C. Congenital thrombocytopenia D. HELLP Syndrome (Haemolysis, elevated liver enzymes, low platelet)

Answer 29

A. Gestational thrombocytopenia Thrombocytopenia is second to anaemia as the most common hematologic abnormality encountered during pregnancy. The prevalence of a platelet count <150 x 109/L in the third trimester of pregnancy is 6.6 to 11.6 %. A platelet count of <100 x 109/L, the definition for thrombocytopenia. In this case she is well with no significant prior medical history and she doesn’t have any other features of pre-eclampsia or HELLP.

Question 30

Gloria is an 81-year-old female with metastatic gastric carcinoma. She has developed post-prandial nausea and vomiting that is increasing in frequency and intensity. She is currently prescribed dexamethasone 4 mg mane, metoclopramide 10 mg PO TDS and liquid morphine 1 mg PO QID. What is the most likely cause of her symptoms? A. Pharmacotherapy side effect B. Bowel obstruction C. Generalised inflammation D. Cerebral metastases

Answer 30

B. Bowel obstruction Gloria’s symptoms are most consistent with a bowel obstruction as her nausea and vomiting is post-prandial.

Question 31

Sarah, a 23-year-old lady, sees you today with an exacerbation of her major depressive disorder. Her K10 is 40/50. She has been having suicidal ideations most days but none today. She states she was trialled on citalopram a couple of years ago but discontinued after a few months because it wasn’t working. You decide to prescribe a medication for Sarah today. Which of the following options would be the most appropriate medication for Sarah? A. Citalopram B. Sertraline C. Paroxetine D. Amitriptyline

Answer 31

B. Sertraline Sarah didn’t respond to citalopram previously so a different first line SSRI, e.g. sertraline, or mirtazapine, would be appropriate choices. Amitriptyline is a tricyclic antidepressant (TCA) which carries a higher risk of lethality in overdose compared to the other classes of antidepressants in overdose. Given her recent suicidality, overdose risk is a consideration. TCAs are usually reserved for treatment-resistant depression and are ideally used under the guidance of a psychiatrist; however, they may be used first line for patients who have responded well to them previously. Paroxetine is not recommended in pregnancy (because of its association with cardiac malformations and miscarriage), and Sarah is of childbearing age.

Question 32

Jean is a 60-year-old frail lady who was commenced on sertraline one month ago for major depressive disorder. Jean’s co-morbidities include hypertension and grade 2 renal impairment. Jean sees you today complaining of new nausea and fatigue. What is the most important blood test to check in Jean today? A. Full blood count B. Iron studies C. Urea, electrolytes, creatinine D. Calcium, magnesium, phosphate (CMP)

Answer 32

C. Urea, electrolytes, creatinine Antidepressants, old age, female gender, low body weight, concurrent medications, impaired renal function, comorbidities and hot weather are all risk factors for hyponatraemia.

Question 33

Shirley is a 45-year-old lady whom your colleague saw in GP rooms two days ago. Your colleague started Shirley on citalopram 10 mg daily for major depression and she returns to the practice today to see you feeling flushed, anxious and sweaty. You review Shirley’s over-the-counter and prescribed medication list. Which of the following is most likely contributing to Shirley’s acute symptoms? A. Tramadol B. Glutamine supplement C. Ginkgo biloba D. Oestrogen patch

Answer 33

A. Tramadol Serotonergic toxidrome (also known as serotonin toxicity) develops within hours of Interaction between serotonergic drugs Commencing or increasing the dose of a serotonergic drug Poisoning with a serotonergic drug. Tramadol via its serotonin reuptake inhibition is associated with serotonin toxicity when combined with other serotonergic agents, including selective serotonin reuptake inhibitors (in this case, citalopram). Serotonergic toxidrome can be caused by a single serotonergic drug, particularly in poisoning, but most cases arise from co-ingestion of two or more serotonergic drugs. Treatment of serotonergic toxidrome involves cessation of any implicated drug(s) and supportive care. Symptoms usually resolve within 12 to 24 hours. Sedation with a benzodiazepine may be required. Severe serotonergic syndrome (including symptoms of hyperthermia, clonus and seizures) is life threatening - urgently seek advice from a clinical toxicologist.

Question 34

Jack is a 19-year-old man brought into your emergency department by a friend with significant agitation, sweatiness and clonus after an impulsive overdose on a combination of desvenlafaxine and sertraline tablets he found at home. His vital signs are temperature 38.1 ℃, heart rate 112/minute (regular), blood pressure 130/70 mmHg, respiratory rate 20/minute, oxygen saturations 99 % on room air. Which one of the following initial management options is the MOST appropriate? A. Give Jack 5 mg of oral diazepam B. Give Jack 12 mg of oral cyproheptadin C. Tell Jack’s friend to dispose of any remaining desvenlafaxine and sertraline tablets from the house D. Refer Jack to the nearest community mental health team

Answer 34

A. Give Jack 5 mg of oral diazepam Jack is showing signs of moderate serotonin toxicity. Assuming he is cooperative, oral diazepam 5 to 20 mg is recommended. If there is no improvement with a benzodiazepine, antidotal therapy with cyproheptadine can be tried.

Question 35

Michael is a 22-year-old university student, staying with his parents on the family farm near Stampsville, for study week prior to his university exams. His parents bring him to you because he has insomnia, paranoia, and he rarely leaves his bedroom to eat, wash or socialise. He is dishevelled, disorganised and not studying. He is uncharacteristically agitated and concerned that screen devices are hearing his thoughts and stealing his memories. He has never been like this before. His parents found cannabis in his desk. Your general and mental state examinations confirm psychosis and no other conditions are identified. What management do you recommend? A. Reassure him that stress can induce this and give him a certificate to defer his exams. B. Assess safety for him and his family, and ask his parents to encourage him towards normal diet, sleeping and not isolating himself in his bedroom. C. Evaluate whether admission to hospital is needed. D. Recommend he cease using cannabis

Answer 35

C. Evaluate whether admission to hospital is needed. Stress can trigger the first episode of psychosis but leaving him distressed with untreated psychosis may cause harm, so simply supplying a certificate is inadequate. Assessing safety and rallying parental support and supervision where appropriate is helpful, but his paranoia is unlikely to be relieved by this. Evaluating whether admission to hospital is needed is the most appropriate option listed. Considerations include The risk of harm the patient poses to themselves or others The patient’s level of insight and disorganised thinking, and their competency to make decisions Availability of community mental health resources and family or other social supports. Ideally, a first episode of psychosis should be managed by a specialist - urgently refer patients to a psychiatrist or mental health service because early treatment reduces the period of untreated psychosis and improves outcomes. Cannabis use is a recognised risk for psychosis, but simply ceasing its use does not address the patient's current episode of psychosis.

Question 36

Monica, a 26-year-old, was recently promoted to office manager. She feels isolated, ignored and disrespected at work by an older workmate who was unsuccessful in her promotion application. Monica is doing more of her work out of hours and avoiding staff by staying in her office during business hours. She is losing sleep, tired, nauseated and experiences tension headaches and palpitations when more stressed. Monica requests a script for sleeping tablets. What do you recommend for Monica? A. Take a comprehensive sleep history as a part of further assessment of her overall presentation B. Prescribe temazepam 10 mg nocte when needed C. Prescribe mirtazepine 15 mg nocte regularly D. Prescribe temazepam and complete workers compensation certification for adjustment disorder

Answer 36

A. Take a comprehensive sleep history as a part of further assessment of her overall presentation Fatigue impairs our ability to cope with adversity but temazepam will not resolve her interpersonal difficulties at work. Mirtazepine reduces anxiety and depression and can improve sleep but she does not have anxiety nor depression. Although her distress arises from situations at work, interpersonal difficulties are not necessarily a compensable condition. A complete sleep history will help you help Monica manage her adjustment disorder symptoms and allow provision of sleep advice more likely to be useful in the long term, and focus on developing strategies which will be more effective in her interactions with staff at work, perhaps via work with a psychologist or counsellor.

Question 37

John is a 23-year-old male who was diagnosed with schizophrenia five years ago. He has been brought into the clinic by his aunty because she is concerned about his weight gain. On examination you note he has gynaecomastia and galactorrhoea. Which medication is most likely to be responsible for John’s symptoms? A. Clozapine B. Quetiapine C. Aripiprazole D. Risperidone

Answer 37

D. Risperidone Many antipsychotics, includign risperidone, can cause dose-dependent hyperprolactinaemia - see Table 8.31 Links to an external site. within eTG to compare them. Consequences include amenorrhoea, sexual dysfunction, galactorrhoea and gynaecomastia. Other causes of hyperprolactinaemia, including prolactinoma and pregnancy should be excluded as causes in patients on antipsychotics presenting with these features. Clozapine and aripiprazole do not elevate serum prolactin concentrations, and quetiapine is far less likely to be responsible for John's symptoms than risperidone.

Question 38

Timothy is a 15-year-old student who has presented to your rural emergency department in handcuffs accompanied by two policemen. They report he was wandering the streets semi-naked, proclaiming he was sent by god, and had become physically abusive towards the policemen when they attempted to assist him. He is very agitated and attempts to kick the emergency department walls and lunge at a staff member. He is not responding to verbal de-escalation and is refusing to take any medication. There are no on-site security guards at your local hospital. Which statement is correct in regards to his management? A. Request police take him to the watch house and return for a comprehensive assessment until he is no longer under the influence of drugs or alcohol B. You must have Timothy’s parents’ consent to commence treatment C. Commence treatment under the Mental Health Act D. Call Timothy’s GP to get additional information before commencing treatment

Answer 38

C. Commence treatment under the Mental Health Act A person who is disturbed and aggressive, with poor insight into their illness, refusing treatment and threatening others can be assessed and treated involuntarily under the Mental Health Act. Wherever possible, the opportunity to consent to treatment should be offered. Children under the age of 16 can be competent to provide informed consent without parental permission or knowledge under certain circumstances ('Gillick' competence). The ideal arrangement is to obtain the consent of both the parent/guardian and the adolescent. Children under the age of 16 should not be sedated without the consent of the parent(s)/guardian and before conferring with a consultant psychiatrist, except in emergency circumstances. In this situation, Timothy is an imminent risk to himself and others. While contacting parents is a reasonable option, it may unnecessarily delay treatment in this emergency situation where there is an immediate risk to staff. He is disturbed, aggressive and has poor insight. If the child/adolescent lacks capacity to provide or withhold consent to treatment, and consent cannot be obtained from a parent/guardian, involuntary treatment under the Mental Health Act (MHA) is possible if the criteria of the Mental Health Act legislation is met. This legislation may vary slightly from state to state in Australia and it’s important you are familiar with the Mental Health Act legislation in your own state/territory. This RANZCP tableLinks to an external site. compares the legislation.

Question 39

Angela is a 22-year-old university student who complained of anxiety and insomnia and requested a thyroid check because she always feels cold. She is thin. Vital signs are temperature 35.4 ℃, heart rate 44/minute (regular), blood pressure 75/42 mmHg. Her body mass index is 11.8 kg/m2. Haemoglobin 112 115-160 g/L TSH 0.9 0.5-4.0 mIU/L Na 125 137-147 mmol/L K+ 2.7 3.5-5.0 mmol/L BSL 3.1 3.0-6.0 mmol/L What do you recommend for Angela? A. Referral to dietitian B. Refer urgently for tele-psychology C. Arrange psychiatric admission D. Arrange medical admission

Answer 39

D. Arrange medical admission Angela likely has an eating disorder. She requires medical admission to prevent refeeding syndrome while safely supervising her intake e.g. starting with 1500 kcal/day of low glycaemic index supplements e.g. Resource Plus, or Nutrison Energy if nasogastric. Excessive simple carbohydrates initially can trigger refeeding syndrome and rebound hypoglycaemia in patients with inadequate glycogen stores. Rationale: Angela’s biometrics and blood results clearly put her in the category requiring admission rather than community based care initially. She is at significant risk of refeeding syndrome so requires medical stabilisation before transfer to a psychiatric ward.

Question 40

Penny is breastfeeding her 6-week-old first child. She is concerned about his crying and night waking. She complains of fatigue, not coping with the house chores and asks about the baby blues. Her partner is a fly-in fly-out worker so she has spent the last two weeks at home alone with the baby. Her family are interstate and she is new to town. Her DASS21 scores are D - 19, A - 12, S - 18. What do you recommend? A. Penny joins a mothers' group, and put her baby in child care for a few sessions per week B. Arrange cognitive behavioural therapy with the local psychologist C. Prescribe fluoxetine because of the severity of her symptoms and lack of supports D. Admit her and the baby to resolve the infant problems and let her catch up on sleep

Answer 40

B. Arrange cognitive behavioural therapy with the local psychologist Fatigue, lack of support and social isolation are risks for post-natal depression, but correcting them alone, either in the community or hospital setting, is not necessarily sufficient treatment. Psychological therapies are the mainstay of post-natal depression treatment, and medications are used if the symptoms are severe or psychology is not possible. An SSRI other than fluoxetine is recommended if an antidepressant is started whilst breastfeeding for a new-onset disorder. Fluoxetine passes into breastmilk to a greater extent than other SSRIs and has a long half-life with the potential to accumulate in the breastfed infant. Fluoxetine has been associated with low weight gain, irritability, difficulty settling and infant gastrointestinal dysfunction. Sertraline has the most safety data in breastfeeding and is recommended first line.

Question 41

You are working in a remote Aboriginal community in Central Australia and arranged to have Melanie, a 12-year-old girl, flown to Alice Springs as she had significant hypertension associated with post streptococcal glomerulonephritis. Your priority in the community is to: A. Ensure that Melanie is on the recall system to follow up blood pressure checks once she returns. B. Arrange a team meeting with all health staff to ensure they are checking all children for streptococcal skin and throat infections. C. Arrange for all her current household contacts under 12 years of age to be reviewed and treated with appropriate antibiotic cover. D. Arrange all household contacts over the past two weeks to be reviewed and treated with appropriate antibiotic cover.

Answer 41

D. Arrange all household contacts over the past two weeks to be reviewed and treated with appropriate antibiotic cover. Every single case of APSGN requires notification, contact identification and contact tracing of "all children and adults staying in the same house(s) as the case in the 2 weeks preceding onset of the index case’s illness." Examination of contacts should include: Assess for skin sores, scabies and oedema Swab sore for MCS if present Treat with IM benzathine benzylpenicillin (Bicillin-LA), without waiting for results of swabs Measure blood pressure Test urine for presence of haematuria (dipstick) Education about signs and symptoms of APSGN to watch for, and prevention of APSGN.

Question 42

Thomas is an 82-year-old retired farmer who has presented to your emergency department acutely unwell with fevers, hypotension, tachycardia and positive for leukocytes on urine dipstick. You suspect he has urosepsis. Point of care testing and comparison with previous results suggest he has acute on chronic renal failure. When initiating antibiotic therapy for Thomas: A. The gentamicin dose does not need to be renally adjusted. B. The first dose of gentamicin should be 4-5 mg/kg. C. In addition to gentamicin it is suggested to add in either amoxycillin or ampicillin 1g IV eight hourly. D.Gentamicin is to be given IV over 20 minutes.

Answer 42

B. The first dose of gentamicin should be 4-5 mg/kg. Thomas has clinical findings consistent with septic shock. For those patients with existing kidney impairment the first dose of gentamicin in septic shock is 4-5 mg/kg. In patients with septic shock and normal kidney function the dose of gentamicin is 7 mg/kg. It is suggested to add amoxycillin or ampicillin to gentamicin at 2 g IV six hourly.

Question 43

Bob, a 45-year-old Aboriginal man with chronic kidney disease, presents with lethargy. He had an iron infusion two months ago and has normal iron studies. What type of anaemia would you most likely find when you perform his full blood count? A. Microcytic hypochromic anaemia B. Normocytic normochromic anaemia C. Macrocytic anaemia D. Haemolytic anaemia

Answer 43

B. Normocytic normochromic anaemia Reduced erythropoetin production due to impaired renal function reduces erythropoiesis in the bone marrow. Some uremic patients will also have iron deficiency due to impaired gastrointestinal absorption of iron and reduced dietary intake and increased losses due to gastritis.

Question 44

Dennis is a 56-year-old male who has CKD Stage 5 and in two weeks he will be going to the regional town to have a fistula formed in preparation for dialysis. Which of the following symptoms is NOT expected in patients with CKD Stage 4 or 5? A. Insomnia B. Restless legs C. Hallucinations D. Anorexia

Answer 44

C. Hallucinations The metabolic disturbances including electrolyte imbalances and uraemia commonly cause all the symptoms except hallucinations. Delirium can occur with severe metabolic disturbances or urosepsis, but hallucinations are not a common symptom in CKD.

Question 45

Jan is 42-year-old woman who has a long history of type 1 diabetes. Examination reveals a blood pressure of 162/92 mmHg and a pulse of 52/minute. Her body mass index is 30 kg/m2. She is on regular insulin injections. Her renal function shows: eGFR 30 >9omL/min/1.73m2 Potassium 4.5 3.2 - 4.5 mmol/L Which of the following medications would be most indicated today? A. Amlodipine B. Frusemide C. Lisinopril D. Atenolol

Answer 45

C. Lisinopril Hypertension is both a cause of CKD and a complication of CKD and can be difficult to control. It should be considered as part of absolute cardiovascular risk. The treatment target for all people with CKD is to maintain blood pressure consistently below 130/80 mmHg. In people with CKD, blood pressure lowering therapy should begin with either an ACEI or ARB. When treatment with an ACE inhibitor or ARB is initiated, the eGFR can initially decrease and potassium levels can rise. If the serum potassium concentration is greater than 6 mmol/L despite dose reduction, diuretic therapy and dietary potassium restriction, then any ACEI, ARB or spironolactone should be stopped.

Question 46

Zack is a 21-year-old man in the Torres Strait, and he has recently been unwell with a sore throat. He is lethargic, has a headache, puffy face and has noticed his urine is darker than normal. His urinalysis is positive for blood and protein. Which of the following features on formal urine testing are most likely to explain his symptoms? A. White cells B. Ketones C. Red cell casts D. Bilirubin

Answer 46

C. Red cell casts In APSGN urine examination often reveals protein and haemoglobin, with red blood cell casts. The presence of red blood cells within the cast is always pathological.

Question 47

Sergei, a 54-year-old male, presents to you in general practice several days after having a ureteric stent inserted by his urologist, complaining of urgency, flank pain during micturition and macroscopic haematuria. He denies any fevers, has a soft and non-tender abdomen on examination and normal vital signs. Which of the following management options is the most appropriate? A. Perform a urine dipstick B. Order a CT-KUB C. Reassure the patient D. Order a midstream urine

Answer 47

C. Reassure the patient The symptoms of urgency, flank pain and haematuria are all common symptoms post stent insertion and patients presenting with these symptoms should receive reassurance. A urine dipstick is not helpful in patients with stents. A midstream urine for culture is not indicated in this patient as he is otherwise well. A CT-KUB would be appropriate if stent misplacement or migration were suspected but this patient has no symptoms to suggest this (i.e. fever or persistent and severe flank pain).

Question 48

Cathy is a 38-year-old long term patient of your practice with newly diagnosed diabetes. During her annual diabetes management plan, you note an eGFR of 85 mL/min/1.73m2 and her first urine albumin:creatinine ratio (ACR) result was 20 mg/mmol. What is the next step in her management? A. Repeat the urine ACR within next three months B. Order a renal ultrasound scan C. Repeat the urine ACR within seven days D. Perform urine microscopy

Answer 48

A. Repeat the urine ACR within next three months Cathy’s results only meet the criteria for stage 2 chronic kidney disease if they are confirmed in a follow-up sample. Kidney Health Australia recommends that if the urine ACR is positive, repeat it within the next three months. If the second uACR is normal, another repeat, preferably on first morning void, is warranted. However, if the eGFR is <60mL/min/1.73m2, repeat within 7 days. Any two uACRs ≥3 mg/mmol in three months would result in proceeding to CKD staging. Cathy’s eGFR is more than 60, so repeating it in a year is recommended. A renal ultrasound and urine microscopy (for dysmorphic red cells, red cells casts or crystals) are always indicated as part of the diagnostic evaluation of CKD, however, the next step in Cathy’s management is to confirm the diagnosis before going on to evaluation.

Question 49

Sally, a 66-year-old female with a background of diabetes and hypertension, comes to see you feeling nauseated and generally unwell. She commenced cephalexin 500 mg QID four days ago for a localised cellulitis. Her regular medications include metformin 2 g daily and perindopril 5 mg daily. Recent routine bloods results include: Hba1c 7.1% ≤7% eGFR 71 >90mL/min/1.73m2 Serum creatinine 76 60-110μmol/L Her observations include blood pressure 140/90mmHg, pulse rate 80/minute, afebrile. The cellulitis is improving, and examination is otherwise unremarkable. Urinalysis shows low specific gravity <1.005 and is otherwise normal. Investigation results today: Full blood count results in range Serum creatinine 150 60-110μmol/L eGFR 32 > 90mL/min/1.73m2 Urine osmolality 295 50-1500mOsm/kg Urine sodium 45 about 20mmol/L N.B. her urine osmolality is low and is close to normal serum osmolality Urine microscopy - granular casts present, otherwise normal. The most likely cause of Sally’s acute kidney injury (AKI) is: A. Sepsis B. Post infective glomerulonephritis (GN) C. Acute tubular necrosis (ATN) secondary to cephalexin D. Bilateral renal artery stenosis (RAS)

Answer 49

C. Acute tubular necrosis (ATN) secondary to cephalexin Sally has risk factors for AKI – age, diabetes, hypertension, on an ACEI Cephalosporins have been associated with ATN The urine chemistry results are diagnostic of ATN (low osmolality, high sodium, granular casts) and are not consistent with GN The clinical presentation does not fit with RAS, the ACEI is not new, and urine chemistry results are consistent with an intra-renal cause She does not have sepsis clinically.

Question 50

Ronald, a 44-year-old Aboriginal man with chronic kidney disease, stage 4, comes to see you for the results of his recent routine blood test results. He is feeling generally well. His current medications include: Lantus (glargine insulin) 36 units daily Ramipril 10 mg daily Atorvastatin 40 mg daily Cholecalciferol 1000 IU daily Calcium carbonate 1200 mg TDS Darbepoetin alfa 150 microg subcut monthly Results show: eGFR 28 >90mL/min/1.73 m2 Creatinine 230 60 - 110μmol/L Potassium 4.3 3.5 – 5.0mmol/L Sodium 137 135 – 145 mmol/L Corrected calcium 1.8 2.2 - 2.6mmol/L Phosphate 1.8 0.8 – 1.5mmol/L Bicarbonate 13 25 - 33mmol/L Parathyroid hormone 25 1.5 – 7.6pmol/L Vitamin D 52 >50nmol/L Hba1c 7.4% ≤7% What is the most appropriate initial change to make to Ronald’s management? A. Commence sodium bicarbonate B. Commence calcitriol C. Increase calcium carbonate D. Commence dialysis

Answer 50

B. Commence calcitriol Although Ronald has acidosis with a low bicarbonate, the hypocalcaemia and hyperphosphataemia should be corrected first. He is on the maximum dose of calcium carbonate so calcitriol should now be commenced, with careful monitoring of serum calcium and PTH. Sodium bicarbonate can be commenced if acidosis persists after correcting hypocalcaemia.