2013 Osce Booklet - Complete!!

2013 OSCE Booklet Lia Stepan Fe Menz Lachy Stranks Table of Contents 1

3. HISTORIES

189. 193. 197. 200. 204. 207. 210. 213. 216. 220. 224. 228. 230. 233.

- General Medicine & Geriatrics: 8. MMSE/Cognitive assessment 13. Fall in the elderly 19. Headache 1 21. Headache 2 26. Febrile illness (HIV) 29. Obesity 32. Painful rash 36. Polycythaemia 65. SOB 1 74. SOB 2 - Surgery: 10. Difficult swallowing 40. Prostate disease 46. Peripheral vascular disease 53. Back pain (renal colic) 58. Retinal detachment - Orthopaedics: 4. Joint Pain 61. Scaphoid fracture + exam - Obstetrics & Gynaecology: 81. Abdo pain (ectopic pregnancy) 85. Menopause 93. Pre-term labour 100. Pregnancy dating 104. Salpingitis - Paediatrics: 111. Respiratory (Croup) 114. Febrile seizure 119. Anaphylaxis - Psychiatry: 124. Anxiety 1 129. Dementia vs. Depression 134. Anxiety 2 137. Schizophrenic patient 140. Psychosis 145. PTSD 150. Suicidal ideation 158. Suicide attempt

236. COUNSELLING 237. 238. 240. 243. 246. 250. 255. 258. 261. 265. 266. 266. 267. 270.

SPIKES ACEi commencement Angry patient Breaking bad news (CRC) Childhood obesity Genetic counseling Cardiovascular risk factors Pre-operative counseling Skin lesion (melanoma) Dementia Oesophageal cancer Breast cancer Pap smears & HPV Cervical cancer

271. DATA STATIONS 272. ABG interpretation 274. Acute renal failure 280. Assess foetal growth 284. Assess early child growth 288. Asthma management plan 291. Prescribing – Asthma 294. Prescribing – Statin 298. Prescribing – Diabetes 302. Prescribing – Analgesia 305. Prescribing – Incontinence 307. Blood dipstick 311-18. ECGs 319. Pathology

164. PHYSICAL EXAMS 165. 168. 172. 174. 177. 182. 187.

Diabetic lower limb Groin lump Scrotal exam Hearing assessment Knee exam Parkinson’s exam Peripheral vascular exam Respiratory Resuscitation (BLS, ALS) Rheumatological hand Shoulder 1 (impingement) Shoulder 2 (dislocation) Thyroid/neck Trauma & Primary survey

Acute abdo 1 (cholecystitis) Acute abdo 2 (appendicitis) Driving assessment Breast Cardiovascular Carpal Tunnel Exam Cranial nerve

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HISTORIES

JOINT PAIN Ben Smith is a 68-year-old retired man who lives with his wife. Ben has noticed pain in his left knee for the past day and has come to the ED as he is concerned about this. 3

Description of task:  Take a focused history to formulate differential diagnoses and explain them to the patient  Explain to the patient what investigations are needed

Patient Profile: - Ben Smith - 68 year old - Lives with wife, retired lawyer PC: Pain in left knee for past day HPC: 4

- Knee pain;  Onset earlier this morning about 5 hours ago, gradually worsening  Severity 8/10  Burning deep pain in left knee  Nil radiation  Worse on movement, cannot move leg anymore - Additional;  Knee is red and swollen, feels hot  Associated fever and malaise  Had been to ED 4 days previously for pain in same leg – was found to have Staph aureus cellulitis; was given antibiotics but didn’t take them  Nil injury to the joint  Nil pain in any other joint  Nil family history, PMH, social history DIFFERENTIALS FOR ACUTE ARTHRALGIA: - Septic arthritis - Crystal arthropathy – gout, pseudogout - Osteomyelitis - Trauma – fracture, haemarthrosis, dislocation INVESTIGATIONS & MANAGEMENT: - Urgent joint aspiration for synovial fluid microscopy and culture - Empirical antibiotics – flucloxacillin 2g IV to cover staph - Blood cultures - Bloods – CBE, ESR, CRP - Joint X-ray - Further mgmt dependent on aspirate - Consult with orthopaedics and microbiology

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SEPTIC ARTHRITIS

- Infection of one or more joints by pathogenic inoculation of microbes - 10x more common in people with underlying joint disease or with prosthetic joints Aetiology & Pathophysiology: - Most common organisms are Staph and Strep  Together account for 91% of cases - Other organisms;  Gonorrhoea – consider in sexually active patients  Gram –ve – elderly, immunocompromised  Anaerobes – rare except in penetrating trauma - Risk factors;  Underlying joint disease – OA, RA  Joint prostheses  IVDU  DM, immunosuppression, alcoholism  Previous intra-articular corticosteroid injection  Cutaneous ulcers - Inoculation either by direct inoculation or haematogenous spread - Septic arthritis can destroy a joint in 65 years fall each year  50% of people >80 years fall each year - Long-term care setting;  50% of individuals in care fall each year  60% with Hx of previous fall will fall again - Equal prevalence in men and women - Account for majority of nonfatal injuries in adults >65 years, 5% will result in hospitalization Risk factors: - Past history of a fall - Lower extremity weakness - Increasing age - Cognitive impairment - Balance problems - Psychotropic drug use

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Fear of falling Arthritis History of stroke Orthostatic hypotension Dizziness Anaemia

Aetiology & Pathophysiology: - Usually multifactorial in origin and reflect failure/demise of compensatory mechanisms - Can be broadly divided into intrinsic/medical and environmental causes - Sensory impairment;  Poor vision  Poor hearing  Peripheral neuropathy - Neuropsychiatric;  Vestibular dysfunction  Gait and balance disturbance – Parkinson’s, previous stroke  Cognitive/mood impairment – dementia, depression, delirium  Seizure disorder  Subdural haematoma  CVA or TIA - Cardiovascular;  Syncope – arrhythmias, bradycardia, vasovagal syncope  Orthostatic hypotension  Carotid sinus syndrome  Post-prandial hypotension  Anaemia - Musculoskeletal;  Joint bucking/instability  Mechanical mobility/gait abnormality – previous fracture, arthritis  De-conditioning - Medications;  Benzodiazepines  Antihypertensives  Antidepressants  Diuretics  Antipsychotics  NSAIDs  Sleeping medications  Marijuana 17

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- Others; Polypharmacy – use of 5 or more medications increases risk by 30% Substance abuse Environmental – poor lighting, uneven surfaces, loose rugs, ill-fitting shoes, slippery floors

    Clinical assessment:  - History of most recent fall;  Conscious or unconscious collapse/fall – syncope, amnesia etc.  Was the fall witnessed?  Intrinsic or environmental? o Palpitations, syncope, visual disturbance, neuropathy, weakness etc. o Poor lighting, uneven surface etc.  Were they able to get up after the fall? How long were they on the ground?  Complications – fractures, bruising, bleeding, head injury etc.  - History of previous falls/PMHx  Number of falls (>2 falls within a 12 month period is considered significant)  Previous fragility fractures? If yes, patient must receive bone-strengthening meds  Other complications  PMHx – previous stroke/TIA, CVD, osteoporosis, DM etc.  - Medications;  Polypharmacy (>5 meds) is a risk factor for falls  Significant meds for falls; o Benzodiazepines o Anticholinergics o Psychotropics (antipsychotics, antidepressants, sedatives) o Diuretics o Antihypertensives o Statins  Anticoagulants, antiplatelets – bleeding risk  - Physical exam;  General wellbeing – level of self care, nutritional status, body habitus  CV exam – arrhythmias, postural BP, bradycardia  Gait assessment  Balance assessment; o Timed up and go test;  Time taken to get out of chair, walk at a comfortable speed for 3 metres to a line on the floor, turn, return to chair and sit down  Time taken >15 seconds suggests a high risk of falls o Single leg stance test – observe patient standing on one leg with eyes open on firm surface for 10 seconds; repeat 2 more times  Lower limb strength  Cognitive assessment  Visual acuity and hearing assessment  Assessment of feet and footwear     Investigations: 18

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- May be indicated based on Hx and exam, but no standard diagnostic evaluation exists for a person with a history of or at high risk for falls - Investigations are to rule out potential causes - Serology; CBE – anaemia Biochemistry – elevated urea and creatinine (dehydration) BSL, HbA1c Vitamin D - ECG, echo - Brain CT/MRI - EEG (if seizures suspected) - Spine x-ray, MRI - DEXA scan

               Falls prevention:  - Exercise – gait and balance training, muscle strengthening, flexibility, endurance  - Medication assessment and modification – especially benzos/psychoactive drugs  - Vitamin D supplementation;  High dose cholecalciferol especially if vitamin D low  - OT assessment;  Hazard reduction in the home  Proper footwear  Training and education  Mobility devices  - Vision – glasses, cataract surgery etc.  - Podiatry review  - Indications for referral to Geriatrician/falls clinic;  >2 falls in 12 month period  Unexplained falls with syncope, dizziness or poor recall  Falls as part of downward physical, social or psychological spiral  Falls occurring at low threshold (e.g. with basic ADLs)  Falls with head injury, low trauma fracture on floor >1 hour  Gait disturbance or unsteadiness     Complications:  - Falls often result in injury of some type, usually minor soft tissue injuries (bruises etc.)  41% of falls result in minor injury  6% result in major injury (fractures, head trauma, lacerations etc.)  - Fractures – NOF, pelvis, upper limb (fall on outstretched hand)  - Head injury  - Bleeding, bruising, lacerations  - Downward physical/social spiral, reduced QOL  - Loss of independence/ability to perform ADLs  - Rhabdomyolosis, acute renal failure – if immobile on floor for prolonged period  - Hospitalisation (5% of falls result in hospitalization) 19

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- Death

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  HEADACHE 1

 Mary Smith is a 55 year old lady who has been experiencing newonset headaches for the last 5-6 weeks.  Please:  Take a history from Mrs Smith (4 minutes)  Ask the examiner for relevant results of the physical examination that you would perform (1 min)  Discuss differential diagnoses and further investigations (1 min)                                     

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HISTORY Profile o 55 years old o Accountant o Lives at home with her husband and teenaged children PC o 5-6 weeks of headache Headache o Non localised o Worse in the morning, worse on lying down o Non responsive to analgesia o Hasn’t noticed coughing making it worse o Never had this before o Has not been unwell recently Last week or so has had some double vision and been unable to look with her left eye to the left side Nil seizures noticed, husband has been telling her that she has had short moments of unresponsiveness Weird feelings of déjà vu lately Slightly less propensity for concentration Otherwise well No hx cancer No melanomas previously diagnosed, gets skin checked regularly No recent trauma

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Physical Findings Papilloedema 6th nerve palsy Right sided homonymous hemianopia Upbeat nystagmus

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Diagnosis with differentials Space occupying lesion – GBM o Other tumour (30% are metastatic from breast, lung, melanoma) o Idiopathic intracranial hypertension o Trauma

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Investigations CT head

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  HEADACHE 2

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 Charles / Charlotte Young (Fe)Male, age 30‐50, presents with a history of headaches over the past month.  Tasks for the station:  1. Please take a history from this patient in relation to the presentation. (4 minutes)  2. Tell the examiner what you consider is the relevant examination and ask for the results of that clinical examination. (1 minute)  3. Inform the examiner of your likely diagnosis or diagnoses and what would be the important investigations if any required. (1 minute)                                    

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     Patient profile:  Charles Young  45 year old man  Works as lawyer  PC: Headache for the past few weeks  HPC:  - Headache;  Present for the past month  Worst at the back of head but hard to localise, not feeling pain anywhere else  Worse when lying down, coughing, leaning forward  Worse in the mornings when getting out of bed  Never experienced anything like this before, never had migraines Visual changes – blurred vision a couple of times in R eye in the past week – ‘blacking/blurring’ of vision Sometimes feels nauseous when waking up in the morning, has vomited twice in the past couple of days on waking No dizziness No weakness Slightly more tired than usual, but is doing long hours at work No migraine features – no photophobia, no phonophobia, no aura etc. No tinnitus No obvious trigger – has not bumped head, no caffeine, drugs etc.  PMH: Nil significant Asthma as child No operations Not on any medications, occasional Panadol for headache but with little effect No history of malignancy Nil allergies  SMOKING/ALCOHOL: Smokes half a pack/day, has been smoking since age 12 Drinks socially on weekends  FAM/SOCIAL: Nil significant family history Happily married, 3 children, all well   DIFFERENTIALS: Raised ICP of any cause  Brain tumour  Intracranial haemorrhage Migraine unlikely Other headache causes unlikely – tension, cluster   EXAMINATION: Vitals – pulse rate and rhythm, BP Clinical features of raised ICP;  Papillodoema – bilateral

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 Fluctuating conscious level  Cushing’s triad – HT, abnormal breathing, bradycardia Visual function testing – peripheral vision, ocular movements (may have palsy of abducens nerve) Full neurological examination – any features of UMNL   INVESTIGATIONS: Bloods – CBE, biochemistry CT/MRI head If SOL identified, further investigation and referral required   

 HEADACHE HISTORY

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 Introduction History of presenting complaint; Headache; o Location of pain o Onset of pain, duration o Character o Radiation o Chronicity o Severity o Aggravating/relieving factors inc. time of day o Ever had anything like this before? Associated symptoms; o Aura, flashing lights o Nausea, vomiting o Photo/phonophobia o Lacrimation, rhinorrhoea (cluster headache) o Neck stiffness o Weakness, paraesthesia o Fever Possible causative factors; o Head injury o Lack of sleep o Stress, exertion o Refractive errors o Caffeine, alcohol Past medical history; History of headaches? Migraines? Medications – OCP Alcohol, smoking, caffeine Family history – cancer, headaches

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- Often have transient unilateral or bilateral visual disturbances – blurring, blackening - Signs; Altered conscious level Papilloedema Abnormal ocular movement, sluggish light reflexes Bradycardia Systemic HT - Causes; Tumours Subdural/extradural haematoma Brain abscess Hydrocephalus Benign intracranial hypertension Aneurysms, AV malformations - Investigations – CT/MRI head

                  Migraine:  - Defined as recurrent headache that occurs with or without aura and lasts 2-48 hours  - Characteristic features;  May have preceding aura – flashing lights etc.  Usually unilateral  Gradual onset (15-30 mins)  Pulsating/throbbing in quality  Moderate-severe intensity  Aggravated by routine physical activity  Commonly associated with nausea, vomiting, photo/phonophobia  - Investigations – clinical diagnosis  - Management;  Identify any precipitating factors and remove them (e.g. dark chocolate, caffeine etc.)  Withdraw OCP if recurrent episodes  Acute attack; o First line = simple analgesia i.e. paracetamol, NSAID (2x aspirin + 1 maxalon +/- 3 panadol) o If these fail, codeine can be used o Others – antiemetics if vomiting, ergotamine  Prophylaxis for recurrent episodes; o Propranolol o TCAs e.g. amitryptilline o Flunarizine (Ca2+ channel blocker)  Relaxation techniques     Tension headache:  - Most common cause of headache  - Characteristic features;  Steady dull ache  Bandlike sensation around head

 Usually bilateral  Episodic  - Can occur chronically     Cluster headache:  - Occur in ‘clusters’ i.e. periodically  - Characteristic features;  Severe headache, typically steading boring sensation often behind one eye  Tearing (lacrimation)  Red eye  Runny nose/nasal congestion (rhinorrhoea)  Horner’s syndrome   Subarachnoid haemorrhage: - Medical emergency  - Due to rupture of intracranial Berry aneurysm  - Characteristic features;  Severe, acute headache – ‘thunderclap’, worst pain ever felt  Meningism  Decreased consciousness/LOC  Focal neurological deficits  Features of raised ICP +/- herniation     Temporal arteritis:  - Unilateral throbbing headache  - May have associated visual disturbances and jaw claudication  - Tender to palpation over temporal artery  - Associated with polymyalgia rheumatic  - Requires temporal artery biopsy for diagnosis with subsequent corticosteroid treatment 

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Station Name: HISTORY 1 minute reading time 6 minute question time

Instruction to Students You have 6 minutes at this station. You will be warned at 5 minutes. If you finish early, you will be asked some questions for bonus marks. Description of task: You are the student in a local GP practice and have been asked to see Miss Carmen Sandiago, a 22 year old woman. She has had a fever, and been feeling unwell. Take a history from this woman with a view towards a diagnosis

  OBESITY    An obese patient (BMI 35) is concerned about their weight and its effect on their health.  Please take a history focussed on the following two aspects of their obesity:  1) factors leading to their obesity (4 minutes) AND  2) obesity-related complications (2 minutes)  This is a history station. DO NOT give management advice.

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Patient profile: Barry Chubb 42 years old Works in IT, lives alone PC: concerned about his weight and what it might be doing to my health HPC: - Has always been ‘big’ since he was a teenager, but is now at his heaviest (BMI 35) - Has just gradually been putting on weight up to this point - Previous attempts at weight loss; Tried a few diets he saw advertised on TV and bought an AbSwing Pro – none of these worked Wasn’t exercising on the diet and would still snack on junk food, became frustrated with lack of results so gave up Has never tried drug therapy Has never had gastric stapling - Reasons for gaining weight; Does not exercise – sits behind desk for work, watches a couple of hours of TV per night Diet – lots of meat, some vegetables, gets McDonalds for dinner a couple of times per week because he can’t be bothered cooking, lots of soft drink, icecream Drinks socially on weekends - Family history; Mother was obese and had high blood pressure – died from MI when she was 63 Father has DM Brothers and sisters all on the bigger side - Obesity related complications; Occasionally gets reflux – uses antacid, not a major problem Has some back pain and knee pain – was told he probably has osteoarthritis Can walk 500m before getting puffed Has never been told he has diabetes, but sugars were ‘borderline’ on his last test Hypertensive – 150/100 High cholesterol His weight does get him down – feels socially isolated and constantly judged, has no hope of finding a partner when he is this big – ‘I eat becomes I’m unhappy, but I’m unhappy because I eat’ Has never had chest pain, SOB

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  PAINFUL RASH 

 You have 6 minutes at this station  Description of task:  The patient had a painful rash which has cleared up 6 weeks ago. She still has pain.   - Take a focussed history (4 minutes)  - In the last 2 minutes describe to the examiner the patient’s symptoms, give the most likely diagnosis and its natural history and suggest a management plan for this patient.  - You will receive a warning when 4 minutes have passed.                                

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Profile Joan Colins 72 years old Widowed

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PC Painful area over chest

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HxPc Had a rash over current area of pain about 6 weeks ago o Very painful – burning, stinging o Red, bumpy, weepy o Lasted for about a week o Located unilaterally over chest o Went away by itself o Pain started a few days before the rash and is still there now o Skin where rash was is currently more sensitive than usual

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Nil cardiac symptoms Nil SOB

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MHx No allergies Had chickenpox when she was a child Hypertension – metoprolol Osteoporosis – vitamin D and calcium Has been taking panadol for pain but no relief Otherwise well

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FHx Grandchild has just caught the chicken pox o Sees him regularly Father died of MI at 60 Mother died naturally No hx other diseases

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SHx Smoker o 10/day for 20 years Non-drinker No illicit drugs

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MARKING SCHEME Introduction Empathy

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Lives alone Received pension

Nil recent trauma Otherwise well

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History o Pain history – finds out onset and relationship to rash o Excludes cardiac/resp/traumatic causes o Asks about history of chicken pox HERPES ZOSTER This is a sporadic disease that results from reactivation of latent VZV in the dorsal root ganglion. It can occur at all ages, but has the highest incidence in individuals in their sixth decade of life and beyond. Presentation Characterised by a unilateral vesicular eruption within a dermatome Often there is severe pain Dermatomes T3-L2 are most commonly involved Distribution: o 50% thoracic o 10-20% trigeminal o 10-20% cervical o Disseminated in HIV The factors leading to reactivation are unknown. In children the disease can be relatively benign, but in adults it can be debilitating. The pain is called zoster-associated pain: Disease onset is marked by pain within a dermatome o This may precede rash by 24-72 hours An erythematous maculopapular rash evolves rapidly into vesicular lesions (and bullae, pustules In the normal host, these lesions tend to continue to form for 3-5 days and the disease generally resolves within 7-10 days, however it may take as long as 2-4 weeks for the skin to return to normal.

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If located over the trigeminal nerve distribution, this is called ‘Ramsay Hunt Syndrome’ Taste lost at anterior 2/3 of tongue EAC pain Ipsilateral facial palsy

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Patients with herpes zoster can transmit infection to seronegative individuals  chickenpox Risk Factors Immunosuppression Old age Occasionally associated with haematological malignancy

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Complications The most debilitating outcomes are: Acute neuritis Postherpetic neuralgia

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Postherpetic neuralgia is uncommon in a young population, but at least 50% of patients aged >50 report at least some pain for months after resolution of the cutaneous disease. This pain must have been present for AT LEAST 3 MONTHS. Changes in sensation of the dermatome (hyper or hypoalgesia) are common. Differentials Consider other causes of chest pain if there is no rash Rash: o Contact dermatitis o Localised bacterial infection

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Management

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Gabapentin 300-600mg PO TDS for post herpetic neuralgia, or TCA, or anticonvulsants If active rash: o Compress with normal saline or betadine solution o NSAIDs, amytriptiline o If over 50 years with severe acute pain or ophthalmic involvment, or immunocompromised, vancyclovir Non pharmacological o Acupuncture o Relaxation techniques o Heat/cold packs o TENS Outcome In the majority of cases, there is gradual resolution of the pain over around 5 years. Some patients may have this for life Manage with TCAs or gabapentin

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  POLYCYTHAEMIA 

 Description of the task:   A 65-year-old man has presented to the GP to receive his results from the blood test that you performed a week ago due to his 3 month history of shortness of breath and cough. The CBE results are shown below.  1. Take an appropriate history to determine the cause of this problem 2. Tell the examiner your differentials and what investigations are required to distinguish them 3. Tell the examiner how you would manage this patient    Hb: 196 (135-175)  RBCs: 9.0 1012/L (4.5-6)  PCV: 0.49 L/L (0.4-0.5)

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MCV: WBCs: Platelets: Haematocrit:

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Patient profile: John Smith 65 year old man Retired carpenter PC: Told to return for blood test results that were taken as he has been SOB and coughing HPC: Has been feeling increasingly SOB over the past few months which is getting worse Used to be able to walk for 20+ mins without feeling SOB, now struggling to walk 5 minutes on the flat Persistent cough for few months to year o Worse in mornings o Usually clear, occasionally discoloured (brown/green) o No blood Frequently gets chest infections – 1-2 a year, requiring antibiotics Not feeling unwell at the moment, has not lost weight, a little tired

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90 fL (80-98) 8.6 (4-11) 260 (150-400) Increased

This blood profile indicates polycythaemia.

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Currently smoking; o Pack a day o Started age 17 PMH: Generally well, rarely sees doctors Has never been told about lung problems Surgical – cholecystectomy at age 50 Meds – friend suggested Ventolin but hasn’t been helping Nil allergies Smokes Drinks alcohol on weekends Nil illicit drugs SOC: Retired carpenter Lives with wife – well FAM: Father died of lung cancer at age 65 – heavy smoker Mother died of stroke age 80 Diagnosis: Likely COPD causing secondary polycythaemia (due to chronic hypoxia)

   Polycythaemia     

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 - A haematological abnormality characterized by increased number of circulating RBCs (erythrocytosis) – i.e. increased RBC mass Also commonly associated with thrombocytosis and leukocytosis - Classification; Relative (raised RBCs as a result of reduced plasma volume, normal RBC mass) Absolute (raised RBC mass) o Primary – polycythaemia rubra vera o Secondary – caused by hypoxia or inappropriate increase in EPO - CBE findings; Raised RBCs Raised Hb Raised haematocrit Raised PCV May also have elevated WCC and platelets (depending on cause)

          Relative polycythaemia:  - An apparent rise in circulating RBCs secondary to a decrease in plasma volume  - RBC mass is normal, however Hb, haematocrit and RBC count are elevated  - Typically an acute change secondary to;  Dehydration – diuretics, reduced fluid intake, alcohol  Stress  Burns  - A less common, chronic form exists – Gaisbock’s disease, associated with;

 Male gender more common  Hypertension (which produces reduced plasma vol)  Obesity  High alcohol and tobacco intake     Absolute polycythaemia:  - The overproduction of RBCs with either a primary or secondary cause;  Primary – myeloproliferative disorder caused by an acquired or inherited mutation  abnormality with RBC precursors (Polycythaemia rubra vera)  Secondary – as a result of chronic hypoxia or increased EPO   Polycythaemia rubra vera: - Myeloproliferative disorder characterized by neoplastic proliferation of cells derived from the pluripotent marrow stem cell  - Results in;  Erythrocytosis  Leucocytosis  Thrombocytosis  - >90% of cases are related to a mutation in JAK2 (JAK2 V617F)  - Associated with thrombotic complications as a result of blood hyperviscosity  - Clinical features;  May be asymptomatic and detected on routine CBE  Alternatively may present with vague S+S related to hyperviscosity; o Headaches o Dizziness o Tinnitus o Visual disturbance o Itch after hot bath/shower o Erythromelalgia – sudden, severe burning pain in hands and feet  Signs; o Facial plethora o Splenomegaly (60%) o Gout (increased urate due to increased RBC turnover) o Arterial or venous thrombosis  - Investigations;  CBE as above  Marrow aspirate – hypercellularity with erythroid hyperplasia  Reduced serum EPO  - Treatment;  Young patients – venesection  Old patients – hydroxycarbamide  - Complications;  Thrombosis – venous or arterial  Transition to; o Myelofibrosis (30%) o Acute leukaemia (5%)    Secondary polycythaemia: - Increased RBC production as a result of;

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Chronic hypoxia (increased O2 carrying capacity required  erythrocytosis) Increased EPO production - Chronic hypoxia; COPD Cyanotic congenital heart disease High altitudes Heavy smoking - Increased EPO production; (AKA tumour polycythaemia) Renal carcinoma Hepatocellular carcinoma Phaeochromocytoma haemangioblastoma - May also be secondary to EPO doping in athletes

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    PROSTATE DISEASE 

  Mr McClean is a 68 year old man who has been having trouble with his ‘waterworks’ and has been having some back pain.  Instructions for students:  Take a history and give most likely differentials (4 minutes)  List further investigations and justify why you are ordering them  Answer the examiners questions (2 minutes)

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EXAMINER QUESTIONS Four minutes has passed o List differentials and what is the most likely Which investigations would you like to do and why? What are your management options if this patient was shown to have prostate cancer? How would you manage this patient? HISTORY Profile

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Don McClean  She is well 68 years old  Pensioner Lives at home with wife PC Trouble with waterworks and back pain HxPc Difficulty passing urine for the last year or so Takes 20 minutes for him to be able to pass urine o Stopping/starting stream o Passes small volumes o Feels as though the void was incomplete o Dribbling Has the sudden urge to empty his bladder Happens nearly all the time Gradual onset, getting worse Has to get up to use the bathroom during the night (3-4 times) Nothing seems to make it better or worse, but has tried running the tap and using warm water to ‘get things going’ No blood in urine  No loin pain No offensive smell of urine  No discharge No pain  No change in bowels No overflow incontinence  Still able to get an erection No fever Back pain o Started a few weeks ago o Constant pain o Lower back o Nothing makes it better o 7/10 o Worse at night – difficulty o No radiation to legs sleeping

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Has never had his prostate checked MHx Nil allergies UTIs o A few over the last few years Kidney stones o Once, 10 years ago Otherwise well No medications Doesn’t like going to the dr FHx Grandfather died of prostate cancer at 75 No other Hx SHx Non smoker Drinks 1 beer/night 2 children – both well DIFFERENTIALS Prostate cancer o Most likely BPH Prostatitis o No blood, no pain, less likely Renal colic UTI/pyelonephritis Urethral stricture/tumour INVESTIGATIONS PSA Ultrasound o Size, shape of prostate PR o Smooth – BPH o Rough, stony hard – malignancy Trans-rectal biopsy Vertebral XRAY/bone scan o Mets Cystoscopy Urinalysis and culture o Rule out UTI Renal function If suspecting calculi o Abdo XRAY

  MANAGEMENT AND TREATMENT    Radical Prostatectomy:

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The patient most likely to benefit from radical prostatectomy is one with a relatively long life expectancy (>10 years)  Who have a low PSA  Moderately differentiated tumour    Interstitial Radiotherapy:  Patient group most likely to benefit are those with high life expectancy and low volume, low grade disease    No Initial Treatment:  Those who have a preference for no intervention, long life expectancy, low volume disease, moderately differentiated disease    TURP:  A vasectoscope is inserted through the urethra and sections of the prostate are removed in order to increase the opening of the urethra  Complications can include: o Incontinence  Permanent dilation of the urethra  Effects on external sphincter o Infection o Bleeding o Retrograde ejaculation     BRACHYTHERAPY  In patients with METASTATIC DISEASE, the aim of treatment is to control symptoms and to retard the disease progression. Most cancers are androgendependent, at least initially, and hormonal manipulation is the mainstay of treatment of advanced disease. Local radiotherapy is frequently effective for treating painful metastases.     HORMONAL THERAPY  There are three main treatment options:  REMOVAL OF BOTH TESTES BY SUBCAPSULAR ORCHIDECTOMY o Quick and simple procedure that removes around 95% of the testosterone synthesised (the rest is from the adrenals), producing an immediate fall in plasma testosterone  MONTHLY INJECTIONS OF DEPOT LHRH AGONISTS o Need to be administered at intervals ranging from 4-12 weeks o Therapy causes initial stimulation of LH from the pituitary, which turns up testosterone secretion for up to 2 weeks, which is followed by inhibition of LH release by competitively blocking the receptors o Many patients experience a ‘flare’ in symptoms in the first 2 weeks, aggravating bone pain or spinal compression o For this reason, the first dose is usually covered by anti-androgen therapy  ANTI-ANDROGEN DRUGS SUCH AS CYPROTERONE ACETATE OR FLUTAMIDE o These block the binding of dihydrotestoerone to its receptor at a cellular level     5-ALPHA-REDUCTASE INHIBITORS  Examples Include:  Dutasteride  Finasteride  Mode of Action

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They inhibit 5-alpha-reductase, which is the enzyme that converts testosterone into dihydrotestosterone, which is an androgen that stimulates prostatic growth  decreased prostatic enlargement Indications BPH Contraindications Adverse Effects Common o Impotence, decreased libido, ejaculation disorder Uncommon o Breast tenderness or enlargement Rare o Allergic reaction ALPHA-ADRENDERGIC BLOCKERS Examples: Alfusozin Mode of Action These block alpha1 receptors  smooth muscle relaxation in the bladder neck and prostate  decreased resistance to urinary flow  symptom relief in BPH/obstruction Indications Symptom relief in BPH Contraindications Hepatic impairment Adverse Effects This is a new drug so adverse events are relatively unknown

          GNRH ANALOGUES  Examples Include:  Goserelin  Leuopolide  Mode of Action  Stimulates production of testosterone in a continuous manner (non-pulsatile)  increased LH production  feedback to pituitary gland  down-regulation of GnRH receptor  down regulation of testosterone production  eventual cessation of hypothalamus-pituitatry-gonad axis  Indications  Prostate cancer (specifically Goserelin)  Endometriosis  Uterine fibroids  Breast cancer  Contraindications  Pregnancy  Breastfeeding  Unexplained vaginal bleeding  Polycystic ovarian disease  Pituitary Adenoma  Adverse Effects  Common

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o Transient changes in BP, hot flushes, sweats, sexual dysfunction, reduced libido Uncommon o Bronchospasm, rash Rare o Depression, hypersensitivity reactions ANDROGEN-AGONIST Examples Bicalutamide Mode of Action Competitively inhibits the binding of androgens (eg, testosterone) to androgenreceptors Indications Metastatic prostate cancer with GnRH agonist o This prevents the initial surge of testosterone from the GnRH agonist  prostatic growth prior to receptor downregulation Prevention of GnRH-agonist associated initial tumour flare Locally advanced prostate cancer Contraindications Consider dose reduction in hepatic impairment Adverse Effects Common o Dizziness, dyspnoea, constipation, dry skin, rash, weakness Rare o Thrombocytopaenia, CVS disorders (angina, heart failure, arrhythmias, ECG changes), pneumonitis, pulmonary fibrosis MANAGEMENT OF THIS PATIENT Await results and gleason score, staging, PSA Low risk: o T1 or T2a o Gleason score 50%  - Ankle brachial index (ABI);  Ratio of BP in lower limbs compared to BP in upper limbs i.e. ABI = systolic BP of dorsalis pedis (or posterior tibial)/systolic BP of brachial artery  Assessed via Doppler US  Results; o 0.9-1.2 = normal o 0.5-0.9 = moderate arterial disease  intermittent claudication o 1.2 = abnormal/artificially elevated result due to arterial calcification in PVD causing artificial patency of vessels  - Toe pressure test;  Performed if ABI normal but patient is clinically abnormal, or if ABI >1.2  If toe pressure is 2L/day o Alpha blockers increase the spontaneous passage in distal ureteral stones, or in stones >5mm o IV Abx for UTI Interventional

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o If the obstruction endangers the patient (eg, sepsis, renal failure, large stone >5mm)  Ureteric stent (1.5-2.5cm stone)  Percutaneous nephrostomy  Extracorporeal shockwave lithotripsy (35 years)  Previous ectopic pregnancy  Pelvic inflammatory disease  Tubal surgery  IVF  Smoking  - 50% of cases thought to be due to damage to fallopian tube cilia following PID  - Other possible mechanisms;  Conception late in cycle  Intrinsic abnormality of ferilised ovum  Transmigration of fertilized ovum to contralateral tube  - 85% of ectopic pregnancies occur in the ampulla or isthmus of the fallopian tube  - Heterotopic pregnancy refers to an ectopic pregnancy plus an intrauterine pregnancy occurring simultaneously (i.e. twins but one is ectopic)  Uncommon in general population (1 in 4000), but very common in IVF pregnancies (1 in 100)  - Uncommon locations; (associated with increased morbidity)  Abdomen  Ovary  Cervical  C-section scar     Clinical features:  - RIF pain + vaginal bleeding + positive pregnancy test = ectopic pregnancy until proven otherwise

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- Typical presentation is of acute abdominal pain (usually RLQ/RIF) in a woman with recent amenorrhoea or confirmed pregnancy with positive home test Woman may not know she is pregnant May have referred shoulder tip pain - Other common features; Vaginal bleeding Tachycardia, orthostatic hypotension Cervical motion tenderness

          Investigations:  - Serial beta-HCG – range is usually outside that expected for intra-uterine pregnancy or spontaneous miscarriage but is almost always positive  - Transvaginal ultrasound;  Only definitive if foetal cardiac activity is detected  Specific finding on transvaginal US is a tubal ring  May have non-specific findings; o Free fluid in pouch of douglas o Empty uterus o Non-cystic mass in adnexa or pouch of douglas  - Laparoscopy is both diagnostic and therapeutic     Management:  - Mainstay is surgery (laparoscopic);  Salpingectomy – removal of whole fallopian tube  Salpingotomy – removal of embryo only, less favourable as there is a risk of retention of some of the invasive trophoblast cells  - Medical mgmt. – methotrexate (67% success rate); reserved for haemodynamically stable patients who meet strict criteria     Complications:  - Death  - Retention of trophoblast cells  - Infertility  - Recurrence     Prognosis:  - Accounts for 6-9% of maternal deaths during pregnancy (1st trimester)  - 40-60% will be able to become pregnant again following surgery  - Recurrence relatively common 

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      MENOPAUSE

  90 second reading time   Mary Smith aged 50 years has had no periods for 18 months and is severely troubled by hot flushes. Mary takes over the counter Remifemin (a phytoestrogen) and evening primrose oil but no prescription medicines. She has had a recent general and pelvic examination with no abnormalities detected and her recent cervical smear and mammogram were normal. Her BMI is in the normal range.  Task  Please: 1. take an appropriate additional history from Mary (4 minutes) 2. then advise her of your diagnosis and plan of management (1 minute) 3. answer any questions she may have (1 minute).  Please note that the person acting as the patient may not have all of the described physical characteristics            

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HISTORY Profile Mary Smith 50 years old Interior decorator Lives at home with husband and two teenaged children

 PC o Troubling hot flashes  HxPC o Hot flashes for past year or so o Feels like she is suffocating o Needs to leave what she is doing and go and stand outside/by an open window o Very disruptive to her work and life o Feeling a bit more tired than normal o Skin a bit more dry o Not sleeping well o Having trouble concentrating o Dyspareunia o LMP 18 months ago o Whilst she was in her 20s and 30s, always had a regular 28 day cycle o Became slightly irregular in her mid 40s o No bleeding now o Was on the pill before/between pregnancies o Does not use contraception now o Pregnancies all normal o Easily fell pregnant

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Medical History Appendicectomy at 11 No personal or family history of CVS or thrombotic disease No history of breast or gynae malignancy Aunt had breast cancer at 65 Primrose oil and Black Cohosh Nothing else

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Social History Non smoker Drinks a few glasses of wine each night Doesn’t get much exercise

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ADDITIONAL HISTORY Menopause symptoms o o o o o o

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Hot flushes mood swings formication joint aches and pains vaginal dryness GU symptoms including urinary frequency

Menstrual history o LMP o Previous cycle  Length  Regularity o Recent irregularity (over last few years) o Recent abnormal vaginal bleeding Previous pregnancies (?) Contraceptive history o OCP use o Current contraception

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weight gain diminished libido hair loss dry skin memory errors

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 Should be offered until 1 year post LMP Last DEXA Last PAP smear and Mammogram Social history o Smoking o Alcohol o Exercise o Calcium tablets o Weight Medical History (incl family history of these) o Vascular disease o Thromboembolic disorders o Recent abnormal vaginal bleeding o History of breast or gynae carcinoma HRT contraindications o History of stroke, DVT, clotting disorder, MI o Hypertension and BP control (needs to be under control before HRT initiation) o Any vaginal bleeding o Breast/gynae cancers

 APPROPRIATE PLAN o Lifestyle modification o Diet o Exercise o Cut down on alcohol o Introduce calcium tablets o Tests o DEXA o Vitamin D and calcium levels o BGL o HRT and mirena insertion o Oestrogen and progesterone o Replacing oestrogen should reduce symptoms   

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QUESTIONS: Is HRT Safe? Will I get any side effects? o Yes, it is generally safe. We give progesterone to prevent endometrial cancer, which is one of the larger risks o Side effects:  Breast tenderness  Nausea  Fluid retention  Headache  Irregular bleeding in first 6 months Will these symptoms ever go away? o In the majority of women, these symptoms stop within 4-5 years (60%) o 20% have ongoing symptoms into their 60s and 70s I haven’t found the evening primrose very effective but are there any other complementary therapies that I can try?

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o There is no evidence to support that complementary medications are effective. If you wish to take them, I’d like you to discuss it with me prior to commencement so that we can be sure that they won’t interact with your HRT medication I’ve heard about bio-identical hormones, could they help me? o No. We advise against the use of bioidentical hormones for a number of reasons:  There is no evidence to say that they are safe, of an appropriate quality or are useful  We cannot monitor the levels of hormones that you are receiving  They carry an increased risk of development of endometrial cancer  You can get progesterone creams that claim to counteract this risk, however the evidence shows that they do not protect the endometrium at all

   MENOPAUSE           

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Menopause is the final menstrual period but it is a retrospective clinical diagnosis: LMP >12 months ago The average age for a woman to be in menopause is 51 years, with a median age of 45-55 years. There are factors, however, that can promote early menopause: Smoking Hysterectomy/oophorectomy Family history of early menopause Chemotherapy Perimenopause is the 4-5 years immediately prior to menopause and bleeding patterns/symptoms can fluctuate widely during this phase. Menopause occurs as the result of germ cell depletion, and in some women this can occur prematurely. In these situations, HRT is recommended until the age of natural menopause: Early Menopause o Age 50 years – up to 1 year post LMP o 10 years after menopause, as the damage caused by oestrogen depletion is already done, and putting the body into a hypercoaguable state after this increases risk of vascular events) Indications: Woman’s choice Muscle aches/joint pains Urogenital/vaginal dryness Loss of libido Mood symptoms – irritability, sleep disturbance

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Contraindications >60 years, or >10 years post LMP Risk of DVT or stroke Poorly controlled BP Abnormal vaginal bleeding (investigate this before beginning) Avoid after breast or gynae cancers

 TREATMENT OPTIONS 1. Oestrogen only Menopausal symptoms are oestrogen deficiency symptoms. As such oestrogen is the main hormone to be replaced. Otherwise known as unopposed oestrogen therapy, this is normally given to women who do not have a uterus, as progesterone is only given to control uterine bleeding and to prevent uterine cancer. Oestrogen replacement therapy only will increase likelihood of endometrial hyperplasia and endometrial cancer. 2. Oestrogen and progestogen (cyclical) Apart from oestrogen, a cyclical progestogen is added for women who are near menopausal and still menstruating. This is so as to give a more predictable menstrual cycle than they would get on the next option. 3. Oestrogen and progestogen (combined continuous)  A daily dose of oestrogen and progestogen is given as a continuous regimen. This is preferred in older women (say 2-4 years post menopause) as there is a good chance (80% after three months) of no vaginal bleeding with this regimen. Progestorone is important as endometrial hyperplasia and cancer can occur after as little as six month of oestrogen only therapy [1]. Another option for combined treatment would be insertion of an intra-uterine device containing progestogen (eg a Mirena device) combined with oral oestrogen.  Initiating HRT o Combined continuous oestrogen and progesterone (need to give continuous progesterone when >12 months since LMP) o Daily continuous oestrogen in all HRT o Start at a low dose o Can give oral/patch/gel/vaginal. This generally depends on patient preference o Transdermal is preferable if there are risks for DVT (smoking, obesity, FHx) o To give progesterone o Mirena insertion to protect the endometrium and prevent carcinoma formation  o o o o o o

Side Effects Breast tenderness Nausea Fluid retention Headache Irregular bleeding in first 6 months Weight gain is not a side effect, generally something that just occurs at menopause

 Precautions/Risks o DVT o Small increased risk with oral HRT o Transdermal probably safer o Stroke o Small increased risk with oral HRT o Gall bladder disease o Heart disease

o No increased risk in healthy women ages 50-59 years o Breast cancer o 0.1% increased risk compared to normal population in combined HRT o Oestrogen only gives no increased risk (in 7 years)  o o o

Follow Up Yearly review and trial lower dose every few years No maximum time Patient decision

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OTHER TREATMENT OPTIONS Tibolone (a selective tissue androgen estrogenic activity regulator) is as effective in alleviating menopausal symptoms and preventing bone loss, has a greater positive effect on sexual dysfunction and is associated with less vaginal bleeding. There also may be a role for drugs such as escitalopram (a selective serotonin reuptake inhibitor) in the alleviation of the frequency and severity of hot flashes o Good evidence for venlafaxine and desvenlafaxine o Also Clonidine, gabapentin  o o o o o 

No evidence for alternative therapies: Phytoestrogens Promensil Remifemin (Black Cohosh) Evening primrose oil Chinese herbal medicines (in rare cases, can cause liver failure)

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  PRE-TERM LABOUR

  Alexis Perry, a 28 year old woman comes into the ED in a country hospital with her husband and 2 year old son. She is 31+2 weeks pregnant and complains of intermittent abdominal pain. This hospital is 4 hours away from the city by car. Perform the following tasks:  1. Take an appropriate history from this lady 2. Request for examination findings appropriate to her situation 3. Tell the examiner how you would manage this lady                   

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History Profile Alexis Perry 28 years old Bar tender G2P1

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PC Intermittent abdominal pain

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HxPC Pain started this morning o Pain started about 2 hours after she felt a gush of fluid whilst lying in bed o Wet the bed

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o Pains occurring every 15 minutes or so o Getting more frequent o Cramping pains o Doesn’t hurt to touch her abdomen

Fluid o Clear o No mucus o No blood o No offensive discharge No fever Not otherwise unwell No urinary symptoms Pregnancy has otherwise been uneventful, good fetal movements Has been attending appropriate antenatal care

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Previous pregnancy o Delivered at 37 weeks  LSCS  Fetal distress  Child now well, 2 years old

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MHx No significant medical history

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FHx Nil significant

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SHx Non smoker Nil alcohol intake during pregnancy Nil illicit drugs o Cocaine, marijuana

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Physical Exam Obs stable, afebrile Uterine contractions palpable on abdominal exam o 1 in 10 Speculum o Pooling in vagina o 1cm cervical dilation o Digital exam not appropriate Laboratory testing o Ferning on slide o GBS negative o WCC and CRP normal CTG o Normal fetal activity o Confirms uterine contraction

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Diagnosis Pre term labour with Premature Preterm Rupture of Membranes

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Management Antibiotic prophylaxis o No evidence of chorioamnionitis:  Benzylpenicillin for 48 hours or until delivery, whichever is shorter  OR erythromycin orally o Chorioamnionitis  Amoxicillin + gentamicin + metronidazole Tocolysis o Nifedipine  Appropriate if PTL occurring before 34 weeks  Corticosteroids (IM betamethasone) for fetal lung maturation if birth is likely to occur between 23-35 weeks

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o If birth does not occur, re-administer IM betamethasone weekly until birth occurs Expectant management until 34 weeks if GBS positive o Daily assessment of woman o Clinical observations twice daily  Obs, assessment of uterine activity Active management if: o In established labour o Signs of chorioamnionitis are present o APH is present o Signs of fetal compromise  Consider caesarean section if birth is not imminent Transfer to tertiary centre via ambulance (?)

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Definition of Preterm Birth Birth between 20-37 weeks gestation If birth occurs before 20 weeks, it is still classified as a miscarriage

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Risk Factors Previous TOP Lower SES Smoking Previous PTL Inter-pregnancy interval Congenital anomalies Chorioamnionitis PRE-PROM Abruption Fetal Demise Placenta Previa Poor nutritional status

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7 important risk factors are: Abruptio placenta UTI BMI 2 hours

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Approach to Pre Term Labour HISTORY Contractions/abdominal pain o How long ago did they start o Frequency and time between contractions o How long do the contractions last for o What do they feel like o Tenderness to touch of abdomen

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Uterine anomalies Advanced maternal age Age 5 Previous low birth weight

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Has there been any PV fluid loss o Colour o Smell o Amount o How long ago PV loss of mucus and/or blood o Smell o Colour o Frequency Ask about current fetal movements o >10 per hour Risk Factors o UTI symptoms  Dysuria  Polyuria  Frequency  Urgency o Chorioamnionitis  Fever  Offensive discharge o Placental abruption  Bleeding o Pre term/early rupture of membranes  Rupture of membranes occurring anywhere from > 1 hour to 2 weeks before onset of contractions  Considered PPROM if occurring one hour after membrane rupture Management PPROM without PTL Assessment (as above) Antibiotic prophylaxis o No evidence of chorioamnionitis:  Benzylpenicillin for 48 hours or until delivery, whichever is shorter  OR erythromycin orally o Chorioamnionitis  Amoxicillin + gentamicin + metronidazole No need for tocolytics if contractions are not present Corticosteroids (IM betamethasone) for fetal lung maturation if birth is likely to occur between 23-35 weeks o If birth does not occur, re-administer IM betamethasone weekly until birth occurs Expectant management until 34 weeks if GBS positive o Daily assessment of woman o Clinical observations twice daily  Obs, assessment of uterine activity Active management if: o In established labour o Signs of chorioamnionitis are present

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o APH is present o Signs of fetal compromise  Consider caesarean section if birth is not imminent If in a rural centre, transfer to a location with a neonatal HDU (tertiary hospital) for delivery PPROM with PTL Assessment (as above) Antibiotic prophylaxis o No evidence of chorioamnionitis:  Benzylpenicillin for 48 hours or until delivery, whichever is shorter  OR erythromycin orally o Chorioamnionitis  Amoxicillin + gentamicin + metronidazole Tocolysis o Nifedipine  Appropriate if PTL occurring before 34 weeks  Other, less favourable options include salbutamol, NSAIDS (only before 30 weeks gestation)  Generally delays birth by around 48 hours Corticosteroids (IM betamethasone) for fetal lung maturation if birth is likely to occur between 23-35 weeks o If birth does not occur, re-administer IM betamethasone weekly until birth occurs Expectant management until 34 weeks if GBS positive o Daily assessment of woman o Clinical observations twice daily  Obs, assessment of uterine activity Active management if: o In established labour o Signs of chorioamnionitis are present o APH is present o Signs of fetal compromise  Consider caesarean section if birth is not imminent If in a rural centre, transfer to a location with a neonatal HDU (tertiary hospital) for delivery DIFFERENTIALS Braxton Hicks contractions o Usually occur no more than once or twice per hour and often just a few times per day o Irregular and do not increase in frequency with increasing intensity o Resolve with ambulation or change in activity

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     PREGNANCY DATING 

 You are a resident medical officer in the antenatal clinic of a teaching hospital.  You are seeing Jane Rush for the first time. She is carrying her pregnancy record that has been completed by her GP. This records Jane’s EDD as 15.05.09. She had a routine mid- trimester ultrasound scan yesterday.  Jane is upset because, yesterday, the ultrasonographer told her that her estimated date of delivery is wrong.   SCAN INFORMATION  Scan dated: 17/12/2008  Clinical Summary: Routine morphology scan – LMP 08.08.08Scan summary: Normal morphology. Measurements are consistent with a gestational age of 16 1⁄2 weeks, which is less than the duration based on the LMP.   Description of task:  Take a history from Jane relevant to her concern and interpret her ultrasound report so that you can then give her your opinion of her expected date of delivery.   You DO NOT need to examine Jane.    NB: A pregnancy dating wheel is required for this station          

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ID: Jane Rush 29 year old Advertising executive, married to husband of 5 years (happy) P1G0 PC: I am very upset and concerned because the due date given following my US doesn’t match the one in my pregnancy record. I don’t know which one is correct! Tasks for the history: - Menstrual history; How long/how many days is your normal cycle? o Patient will tell you cycle is 35 days long Is your cycle regular? – MUST ASK (dating wheel cannot be used if periods are irregular) Do you ever have spotting/bleeding between periods? When was the first day of your LMP? - Contraceptive history; What methods of contraception did you use prior to falling pregnant? Were they used infrequently/sometimes/always? Have you considered contraception following delivery? - Address patient’s anger/concerns; Unfortunately there is some discrepancy between the dates you have been given It is likely this error is due to the assumption that you have a 28 day cycle, which is the cycle length used on the dating wheel. Your 35 day cycle may not have been adjusted for US gave a younger gestational age as she ovulated about a week or more later than the "usual" 14th day, which was not adjusted for on the dating wheel Calculate patient’s new EDD; Use pregnancy wheel but ADJUST FOR 35 DAY CYCLE Pregnancy wheel assumed menstrual cycle is always 28 days long, therefore turn the wheel back 7 days from LMP to adjust for 35 day cycle o I.e. if LMP is 08/08/13, turn wheel back to 01/08 Therefore EDD is 7th May 2014

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Instructions for the patient: - Appear angry/distressed with discrepancy - Inform student you have a regular 35 day cycle Only give details if prompted - If student incorrectly calculates EDD; “My husband was away on business at that time, that can’t be correct…” - “What day did I ovulate then?”

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 Pregnancy Diagnosis & Dating  - Most reliable methods of detection of early pregnancy; Home pregnancy test Transvaginal ultrasound

       Home pregnancy tests:  - Available over the counter, cheap  - Sensitivity to 25 IU/L  - Produces two lines;  Control line – detects free anti-HCG  Diagnostic line – detects HCG-anti-HCG complex  - Very sensitive if properly interpreted, however wrong interpretation occurs 25% of the time when handled by lay-people

    Human chorionic gonadotrophin:  - AKA HCG  - Secreted mainly by syncitiotrophoblasts  - Components;  Alpha subunit  Beta subunit  Protein (carbohydrate)  - Functions;  Maintains corpus luteum  Regulates growth factors and cytokines involved in cell proliferation, growth and differentiation  Clinical use; o Pregnancy testing/confirmation o Pregnancy surveillance o Screening for Down Syndrome o Tumour marker (trophoblast tumours)  - Levels of HCG gradually increase over first weeks of pregnancy and reach a peak at 9-12 weeks (25000 – 288000 IU/L)  Therefore a single level of HCG is not clinically useful, better to observe the trend  - During the first trimester, levels continue to increase by at least 2/3 (66%) every 48 hours (called ‘HCG doubling’)  If this ‘doubling’ is observed, intra-uterine pregnancy is likely  Useful in early pregnancy when HCG levels are low, but not useful when ultrasound findings are clear  - Can be used to guide timing of ultrasound – intrauterine sac should be visible on US when beta-HCG levels are;  1500 IU/L – transvaginal  6000 IU/L – transabdominal      Pregnancy dating:  - Calculated from first day of last menstrual period (LMP)  Adjusted for length of menstrual cycle  - Pregnancy wheels assumes the menstrual cycle is 28 days long, and ovulation (and therefore inception) occurred on day 14  Adjustments must therefore be made if the woman’s cycle is longer or shorter than 28 days  - Dating is most reliably performed by 1st trimester ultrasound with crown-rump length (CRL)  - Discrepancy between LMP and 1st trimester CRL;  If LMP date is certain and discrepancy is less than 1 week, dates will not be changed  Otherwise, CRL is used between 8-13 weeks gestation to date pregnancy   Easy method of dating: take date of LMP, add one week, subtract 3 months and add a year  e.g. if LMP January 3 2013  Add one week – Jan 10

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Minus 3 months – Oct 10 2013

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      SALPINGITIS

 Instructions to student:   Clinical Case:  Mary Smith is a 24 year old nulliparous woman who was discharged from the Gynaecology Unit of a public hospital one week ago following a 3-day admission with acute salpingitis (Chlamydia PCR positive).  She has been treated with appropriate antibiotics and the hospital has made arrangements for follow up in six weeks.  Although Mary’s symptoms are settling she is very upset about her diagnosis and does not want to wait a further 6 weeks for answers to some questions.   Requirements of this station:  You will be required to take an additional history and to answer Mary’s questions        

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HISTORY Profile Mary Smith 24 years old Event management Lives with housemate

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PC Im very upset about being in hospital one week ago with salpingitis and didn’t want to wait for 6 weeks to get my questions answered

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HxPC Around 3 weeks ago started having some lower abdominal pain o Bilateral o Difficult to localise o Getting progressively worse o Pain during sex (never had this before) o Some spotting between periods Also began developing a fever o Chills Came to hospital when starting to get very sick

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o Looked ‘down there’ and told me that they thought I had something that was caused by chlamydia o Didn’t even know she had chlamydia, asymptomatic o Took antibiotics, starting to feel better o Told her not to have sex with her partner for a week and hasn’t done so o No changes in discharge, all was normal Sexual History o Sexually active from age 17 o Sometimes uses condoms, unless she is drunk and forgets o Has had 8 sexual partners  3 in relationships  5 were people she picked up whilst out o All male o Vaginal sex and oral sex o Monogamous relationship for almost a year  Doesn’t use condoms with current partner  Has an implanon  Had it changed last week  Has been using it for a few years  Has used the OCP in the past when she was young but kept forgetting to take it

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MHx Appendix out when 6 years old No medications No allergies Otherwise well

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SHx Binge drinks on weekend – mostly Friday night drinks Non-smoker No illicit drugs

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FHx No significant family history

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QUESTIONS I want to know how I got this. Does this mean that my partner has been unfaithful? o Explain that it is an STI, got it from having sexual contact with another person o Commonly asymptomatic and long-standing o Not an indication of cheating How do I know if I got rid of the infection? o Good cure rates (>95%) if compliant with antibiotics o Can re-test in 3 months – urine test Is the infection going to prevent me from having children? o Normal pregnancy is possible o Risk of infertility – chlamydia is the most commonly associated with infertility o Risk of ectopic pregnancies in future

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How o o o o

can I prevent getting the infection again Get partner tested and treated if necessary Until treated, use condoms with partner Abstain from sex for a week following treatment If you were to get a new partner, use condoms to prevent transmission                 

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     SALPINGI TIS  CHLAMYDI A  Chlamydia is the most common STI worldwide. National Australian prevalence for the young has been estimated at 5.6%. Contributing factors include: High rates of asymptomatic carriage o Up to 80% in females o Up to 50% in males Inconsistent condom use Frequent partner change Risk factors for infection include: Adolescent and young adult age group o Age is the strongest predictive factor Multiple sex partners, or a partner within three months with other partners, or a recent new sex partner Inconsistent use of barrier contraceptives Clinical evidence of mucopurulent cervicitis Cervical ectopy Unmarried History of prior STD

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Low SES or education not beyond high school

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Clinical Manifestations While most infection is asymptomatic, chlamydia can present in a range of ways: Cervicitis o In women, cervical infection is the most common syndrome o 50% of these are asymptomatic o Symptoms include:  Vaginal discharge  Post coital bleeding  Intermenstrual bleeding  Poorly localised lower abdominal pain o Physical examination is often unremarkable, but can including findings of:  Mucopurulent cervical discharge  Cervical friability  Cervical oedema Dysuria-pyuria syndrome due to cervicitis o Women can complain of typical UTI symptoms o Urinalysis shows sterile pyuria  Perihepatitis (Fitzhugh-Curtis Syndrome) o Occasionally there can be the development of perihepatitis, which is an inflammation of the liver capsule and adjacent peritoneal surfaces o It is more commonly seen when there is also PID o Should be suspected in a person with:  RUQ pain or pleuritic pain in the context of a UTI  There are typically no associated liver enzyme abnormalities  Should be treated with NSAIDs  Pelvic Inflammatory Disease o Approximately 30% of women with chlamydia will develop PID if untreated o These women may complain of:  Lower abdominal pain  Vaginal discharge  Dysuria  Constitutional symptoms (eg fever, chills) o PID due to Chlamydia infection tends to have a higher rate of infertility than other causes  Pregnancy complications o Untreated chlamydia in pregnancy can increase risk of premature rupture of membranes and low birth weight o If the mother in untreated, 20-50% of babies will develop conjunctivitis if born vaginally o 10-20% will develop pneumonia  

DIAGNOSIS NAAT o Nucleic acid amplification o Done on first pass urine, or self collected vaginal swab, or endocervical swab

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MANAGEMENT

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Azythromycin 1g state Second line: Doxycyclin 100mg BD for 7 days Avoid sexual activity for 7 days after treatment Test of cure: o Can be performed no earlier than 3 weeks after medication finished o Cure rates are >95% so these are not usually indicated Reinfection o 15-30% reinfection rate in women  Typically associated with resumption of sex with previous partner (not new partner) o Test after 3 months? Discuss contact tracing o Contact trace 6 months with Chlamydia o “it is important that your partner is treated so that you don’t become reinfected” o Explain that chlamydia is often asymptomatic and people don’t even know they have it  Important to mention that it can lay dormant for a number of years so it does not necessarily mean that their partner is cheating on them o Contact tracing can be done by the patient themselves or anonymously by the GP, web pages sending email notification, nurses in certain practices

PID LONG TERM COMPLICATIONS Recurrent PID o Women with a history of PID are at increased risk of disease recurrence Hydrosalpinx o After PID resolves, the fallopian tube can become blocked, filled with sterile fluid and become enlarged o Associated with tubal factor infertility

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o In patients undergoing IVF, hydrosalpinx has a negative effect on implantation, success of pregnancy, early pregnancy loss, rates of pregnancy, preterm birth, live delivery Chronic Pelvic Pain o Menstrual or non-menstrual pain of at least 6 months in duration that occurs below the umbilicus and is severe enough to cause functional disability o As many as 1/3 of women with PID develop pelvic pain o Recurrent PID is the strongest risk factor for pain development Infertility o Both symptomatic and asymptomatic PID can result in permanent injury to the fallopian tubes o Changes to the fallopian tubes include:  Loss of ciliary action  Fibrosis  Occlusion o The prevalence of infertility after acute PID is dependent upon a number of risk factors, but seems to be increased several fold o Chlamydia infection carries the highest rate of infertility  Approximately 1 in 4 women presenting to fertility clinic have a history of chlamydia infection Ectopic Pregnancy o Tubal damage caused by PID leads to an increase in the incidence of ectopic pregnancy o In one Swedish cohort study, ratio of intrauterine pregnancy vs ectopic pregnancy were as follows:  1 episode of PID 1:16  2 episodes of PID 1:6  3 episodes of PID 1:3 Ovarian Cancer o A number of studies have reported a two fold increase in ovarian cancer incidence in a patient with PID history Clinical severity of infection is a poor predictor of long term outcome.

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  PAEDIATRIC RESPIRATORY HISTORY

   28 year old mum has presented to the ED in winter at 10pm, with her 2 year old boy who has experienced 1-2 days of barking cough, fever and noisy breathing. This has been especially worse at night.  1. Take an appropriate history from this concerned parent 2. Request for the findings from the examiner when ready 3. Tell her what is the most likely diagnosis and differentials, and how you will now manage this child           

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HISTORY Profile Max Martin 2 years old PC 2 days of barking cough, fever and noisy breathing. This has been worse at night. Hx PC 1-2 days ago began getting a runny nose o Fever – 38 – settled with paracetamol Gradually worsening o Developed a cough o Worse at night o Barking quality o Improves after shower Breathing noisily o Mostly on breathing in o No wheeze o He was getting quite distressed and upset Not complaining of a sore throat

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She does not think he has inhaled anything – generally does not let him play with things small enough to fit into his mouth Not eating and drinking as much as he would normally No contact with unwell people Goes to daycare 3 times per week when mum works

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MHx Nil allergies Nil previous illnesses Normal pregnancy and childbirth No evidence of asthma or atopy

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FHx Nil significant

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Examination Findings Vital Signs o Fever – 38 degrees Celsius o tachypnoea o Tachycardic o 97% saturation room air General inspection o Mild respiratory distress  Intercostal indrawing  Tracheal tug  No subcostal indrawing o Child appears distressed o Stridor o Barking cough o Does not appear dehydrated o Pharynx erythematous but no tonsillar enlargement. ENT otherwise normal Chest clear to auscultation with transmitted upper airway sounds No further investigations needed – can do an NPA for clerical reasons

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Diagnosis Croup Differentials: o Acute epiglottitis o Peritonsillar abscess o Foreign body aspiration o Whooping cough

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Management Moderate croup (Stridor at rest, recession on breathing) o Admit to hospital o Humidified oxygen o Nebulized dexamethasone o IV fluid rehydration – maintenance fluids o Panadol to lower fever

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The elements of the Westley croup score describe key features of the physical examination [36]. Each element is assigned a score, as illustrated below: Level of consciousness: Normal, including sleep = 0; disoriented = 5 Cyanosis: None = 0; with agitation = 4; at rest = 5 Stridor: None = 0; with agitation = 1; at rest = 2 Air entry: Normal = 0; decreased = 1; markedly decreased = 2 Retractions: None = 0; mild = 1; moderate = 2; severe = 3 Mild croup is defined by a Westley croup score of ≤2. Typically, these children have a barking cough and hoarse cry, but no stridor at rest. Children with mild croup may have stridor when upset or crying (ie, agitated) and either no, or only mild, chest wall/subcostal retractions [1,32]. Moderate croup is defined by a Westley croup score of 3 to 7. Children with moderate croup have stridor at rest, at least mild retractions, and may have other symptoms or signs of respiratory distress, but little or no agitation [1,32]. Severe croup is defined by a Westley croup score of ≥8. Children with severe croup have significant stridor at rest, although stridor may decrease with worsening upper airway obstruction and decreased air entry [1,32]. Retractions are severe (including indrawing of the sternum) and the child may appear anxious, agitated, or fatigued. Prompt recognition and treatment of children with severe croup are paramoun

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  PAEDIATRIC FEBRILE SEIZURE  

 You are in the emergency department. Mrs Williams and her baby Jessica have just been bought in by ambulance. Jessica is 9 months old and has been a normal healthy child.   Jessica had a ‘turn’ this morning at home. Her condition is stable enough for you to take a history. Please take a history from Mrs Williams.  You can then ask the observing examiner for the examination findings. 

 In the last minute explain your diagnosis to Mrs Williams and the management of Jessica over the next 24 hours. This should include demonstrating to Mrs Williams using the doll what to do if Jessica has another ‘turn’   You will receive a warning when 5 minutes have passed.                                       

ID: Mrs Sally Williams with baby Jessica 9 months old Lives at home with husband and son (5 years old) PC: Jessica had a ‘funny turn’ this morning at home and now I’m really worried

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HPC: - Was changing Jessica’s nappy on the changing table this morning (about 2 hours ago) when she had a ‘fit’ Went stiff and then her arms and legs started to jerk/shake Was awake during episode Lasted 1-2 minutes Was fine afterwards, back to normal, did not vomit - Normally healthy, but has been a little unwell for the past few days Runny nose Sneezing Not sleeping well, difficult to settle Feverish – took temperature last night, 38.2 - Has never had a similar episode in the past PMH: - Has otherwise been well – no problems - Normal vaginal delivery at 37 weeks - No complications with pregnancy or delivery - Vaccinations up to date FAM: - Lives with husband and son (age 5) - Remembers her son had something similar, but occurred at day care so she did not witness it

    EXAMINATION:  - Infant looks normal, but is difficult to settle/crying  - Febrile - 38 degrees  - Tachycardic  - Obs otherwise stable  - ENT;  Nasal congestion, rhinorrhea  Red, watery eyes  Red pharynx, no pus  - No stiffness of neck  - Neurological examination normal  - Chest clear     DIAGNOSIS:  - Febrile seizure/convulsion – likely secondary to viral URTI    MANAGEMENT:  - Does not require admission to hospital  - Investigations not necessary – likely secondary to viral URTI  - Monitoring of body temperature  - Methods to reduce body temperature;  Antipyretics esp. ibuprofen  Tepid sponging  Remove unnecessary clothing

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- Antibiotics not required - Anticonvulsants not required unless seizure is prolonged (>5-10 mins) - If another seizure occurs; Protect child from injury – ensure there are no dangers around them, lie flat Do not restrain infant Reduce body temperature – remove clothes (hats, shoes etc.), open window, turn down heating Check ABCs Time episode Coma position following seizure – hold on their side with head tilted back Call for help - Indications for Ix (to rule out meningitis/encephalitis) Hx of vomiting Child 38 degrees) with normal post-ictal exam  Seizure lasts 15 mins), focal or multiple  - Symptomatic febrile seizure;  5% of cases  Age and fever as above  Occurs in a child with a pre-existing neurological abnormality or acute illness     Investigations:  - Not typically needed as it is a clinical diagnosis, although tests may be useful in identifying source of fever  urinalysis, CXR, NPA etc.  - May need to rule out meningitis/encephalitis  LP, blood cultures, viral studies  - Indications for Ix (to rule out meningitis/encephalitis)  Hx of vomiting  Child 5 mins, urgent IV or rectal diazepam should be given  - First simple febrile seizure;  Most causes are viral, therefore ABs not required  Reduce body temperature; o Antipyretics especially ibuprofen o Tepid sponging o Remove clothing  Anticonvulsant not given (unless prolonged) – do not reduce risk of future epilepsy  - Some children with recurrent or prolonged (i.e. complex) febrile seizures may be prescribed prophylactic diazepam or emergency rectal diazepam controversial  - Educate parents and reassure re recurrence, risk of epilepsy in later life, rarity of neuro problems and management of future febrile seizures   Complications: (all uncommon)  - Todd’s paralysis – transient hemiparesis following seizure; requires neuro consult + EEG, MRI  - Non-febrile seizures, epilepsy – 3%     Prognosis:  - 1/3 of children will have recurrent febrile seizures – risk increases to 50% if onset n infancy or there is a FHx  - 3% go on to have epilepsy – in this case it is the manifestation of the same underlying seizure predisposition (i.e. idiopathic epiliepsy)  - Febrile seizures are not associated with increased mortality or intellectual impairment          

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  PAEDIATRIC ANAPHYLAXIS  Description of task:   5-year-old Isobella has been brought into the Emergency Department by SAAS following an anaphylactic reaction that occurred 1.5 hours ago. SAAS was called after Isobella’s mother noticed her daughter develop an unusual rash and was struggling to breathe and talk.   On handover from the Ambulance Officer, you find that Isobella was given 0.01 ml/kg of 1:1000 deep IM adrenaline as well as oxygen at the scene, and is now currently stable.   Isobella is currently sitting in a cubicle with her mother, Shirley, and as the intern you have been asked to;   - Take a more detailed history from Shirley  - Explain the diagnosis to Shirley and Isobella  - Outline management plan              

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ID: Shirley Williams, 28-year-old mother of two and housewife Isobella Williams, 5-year-old daughter Live at home with husband and younger child, Harry (2) PC: Called the ambulance after Shirley noticed her daughter was developing a widespread rash and was finding it difficult to breathe and swallow HPC: - Occurred about 1.5 hours ago whilst Isobella was eating her lunch Isobella likes Asian food and was given Pad Thai bought from a shop Thinks it may have had peanuts sprinkled over it, but not sure Has avoided giving nuts to children as she heard lots of kids are allergic - Left room, and when she returned noticed Isobella had developed a rash on her chest and arms Red, bumpy, ‘looked like hives’ Worsened over 2-3 minutes - After 5 minutes, noticed Isobella was finding it increasingly difficult to talk and breathe Tongue and face looked swollen Making high-pitched noise when she was breathing in Gradually got worse until Isobella was clearly distressed Coughing - SAAS subsequently called - Remained conscious throughout - Has never had a previous episode PMH: - Previously generally well - No known allergies to any drugs, foods or insects - Some reflux as an infant, some mild ‘asthma’ symptoms – very infrequent - Normal vaginal delivery, at term - Vaccinations given as per schedule - Meeting all milestones, normal growth

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FAM: - Family members all well - Shirley had asthma as a child

DIAGNOSIS: - Anaphylactic reaction – most likely due to allergy to (pea)nuts - Explanation; Isobella has had a severe, acute allergic reaction, most likely to peanuts that were in the Pad Thai she was eating Affects multiple body systems, that is why she had the skin rash and respiratory problems This is obviously a severe condition, and the risk is that this can happen again if Isobella is exposed to peanuts again Thus management plan needs to be formulated! - “But Isobella has never eaten peanuts before. How can she be allergic to something she has never been exposed to? So you are correct that allergies occur in people only after they have had an initial exposure to the allergen (a process called sensitization), but in the case of childhood food allergies, it is assumed that sensitization occurs during early exposure to food proteins in breast milk or by allergen skin contact

MANAGEMENT: - Emergency/Acute mgmt. – already performed by SAAS, patient now stable Remove trigger Administer adrenaline via deep IM injection o 0.01 ml/kg of 1:1000 adrenaline (max dose 0.5 ml) 3. Establish airway if required and administer high flow oxygen (100%) o Mechanical ventilation may be required in case of airway obstruction 4. Assess circulation – if hypotensive, administer; o IV adrenaline dose 0.1 ml/kg of 1:10000 (max dose 3ml) o IV fluids – normal saline 10-20ml/kg as bolus 5. Repeat doses of adrenaline can be administered every 5 minutes until clinical improvement occurs  - Other therapies to consider;  Nebulized salbutamol – recommended if patient is in respiratory distress or is wheezing  Antihistamines – for symptomatic relief of pruritis, second generation preferred  Corticosteroids – used mainly for bronchospasm, not commonly used   - The child should be observed for at least 4 hours, and should be admitted under the following circumstances;  Greater than one dose of adrenaline required  A fluid bolus is required  Inadequate response to treatment  The child lives a long distance from medical services   - Anaphylaxis action plan;  AVOID ALLERGEN

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Outlines steps that should be taken if Isobella has a similar episode in the future Will likely require an adrenaline auto-injector (AAI) e.g. Epipen, Anapen, as Isobella is at ongoing risk if re-exposed to peanuts http://www.allergy.org.au/health-professionals/anaphylaxis-resources/asciaaction-plan-for-anaphylaxis Prescription of AAI is via PBS but requires an authority prescription Dosage of AAI; o Weight 350 mg/kg) transaminase levels may be >1000 IU/L o - ABG – may show metabolic acidosis o - Biochemistry – may show elevated urea and creatinine o - Coags – coagulopathy o - Urine drug screen – to determine if other substances have been taken o o Management: o - Check paracetamol level after 4 hours since ingestion If a patient presents within 4 hours of ingestion, the level is drawn when 4 hours have elapsed since the possible overdose Once obtained, the level should be plotted on the relevant nomogram against the time since ingestion o - If patient presents 6weeks later) o Gall bladder appears edematous and inflamed with petechial haemorrhages, purulent exudates and fibrous adhesions. There will be gall stones present Empyema of the gall bladder o The gall bladder is filled with pus o Sometimes, part of it becomes necrotic  perforation  subphrenic abscess  generalized peritonitis o This is rare due to the rich blood supply from the hepatic bed and cystic artery o Required urgent surgery o

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o o o o o o MARKING SCHEME

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o o o ACUTE ABDO EXAM 2 o

o Instructions to student: o You are an intern working on a surgical unit. This patient has presented with a 24-hour history of colicky abdominal pain, which has now shifted to the right iliac fossa and become constant. He is nauseated and has not eaten anything for 24 hours. He has vomited once this morning. He is in good health and does not take any medications. His only medical history of note is a fractured tibia five years ago (a motor bike crash), which was complicated by a DVT. o Task  Perform an appropriate physical examination  Give the patient your diagnosis  Counsel the patient on your plan of management o Please note: you are NOT required to obtain additional history o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o

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o o o o o o EXAM FINDINGS General Inspection o Lying still on bed clutching abdomen o Looks distressed o Dry mucous membranes o Coated tongue o Lower limbs not erythematous, swollen or tender to palpation Vital Signs o Tachycardic o Tachypnoeic o Febrile – 38.0 degrees Celsius o SaPO2 99% RA o BP 130/90, no postural drop o Urine output poor Abdomen o Inspection  No abnormalities  No scars o Palpation – do not start by palpating the RIF. Keep looking at the patient  No rigidity  Guarding to palpation over RIF  No palpable mass  Positive McBurney’s sign  McBurney’s point located at the lateral third of the distance between the ASIS and the umbilicus  Positive Rovsing’s sign  Crossed tenderness  Negative psoas sign  Pain on passive hip flexion when the patient lies on his side with extended knees, OR active hip flexion  Negative obturator sign  Pain on hip flexion and internal rotation  Negative murphy’s sign (probably no need to do this)  rebound tenderness over RIF – percussion tenderness is a better choice o Percussion  Percussion tenderness o Auscultation  Reduced bowel sounds o DIAGNOSIS Acute appendicitis o Dx (although probably not applicable in this case)  

Ectopic pregnancy UTI

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Mesenteric adenitis Cholecystitis

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Diverticulitis

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Crohn’s

  MANAGEMENT In this case, Im not sure if you would just go straight to theatre given the diagnosis is so clear cut (ie, no USS). If the diagnosis was less clear cut: Investigations o CBE  Neutrophilia and leucocytosis o CRP  Elevated o (pregnancy test) o Abdominal Ultrasound – reliable for diagnosis confirmation but not exclusion  Presence of an aperistaltic, non-compressible, blind ended, sausage shaped structure arising from the base of the caecum  Distinct appendiceal wall layers  An outer diameter greater than 6mm  A target appearance  Faecolith  Periappendiceal fluid collection  Echogenic, prominent pericaecal fat o Other option of CT scan  Only if diagnosis is uncertain following USS Surgical Management o Prompt appendicectomy o Antibiotics  If there is no rupture:  Metronidazole 500mg/8hr and Cefuroxime or cefazolin  In penicillin and cephalosporin allergy: o Clindamycin plus one of ciprofloxacin, gentamicin, levofloxacin  Start 1 hour pre op to minimise wound infection  Rupture  Ceftriaxone plus metronidazole     

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 ASSESSING FITNESS TO DRIVE  STEM  CLINICAL SCENARIO  Mr Talbot has come to you to determine whether he is fit to continue to drive his car. He is in his 70s, an ex farmer, and lives on an outlying property with his spouse.   He had a small non-dominant occipito-parietal stroke two months ago. His family note that he is still bumping in to things around the house. He walked unaided into the consulting room and has no obvious weakness.   He was told he would have to wait 6 weeks after the stroke before he could drive. The following additional information is available: BP 120/70mmHg sitting visual acuity 6/6 with his glasses on Mr Talbot has a mini-mental score of 25/30.   TASK  Examine Mr Talbot’s vision, and advise Mr Talbot regarding his suitability to resume driving his car. (Fundoscopy will not be required)                          

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       ANSWER Visual fields o No vision on left side on either eye Ocular movements o Normal Diagnosis o Left sided homonymous hemianopia o Caused by his stroke Cannot drive   MARKING SCHEME 

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 BREAST EXAM   Instructions to student:  This woman presents with a painless swelling in her right breast, which she first noticed about three weeks ago. She is post-menopausal and has never had any previous breast problems. She is otherwise in good health.  Task 1. Undertake a formal breast examination 2. Provide the patient with a plan of immediate management based on the findings                            

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              EXAM Inspection (sitting) o Asymmetry o Scars o Lumps o Peau d’orange o Nipple changes – crusting, bleeding, oozing, inversion Inspection (sitting with hands on hips and pushing inwards) o Skin tethering Palpation (lying) o Note: patient to place arm behind head on side you are examining o Repeat inspection o All quadrants of each breast o Nipple – attempt to express any fluid o Axillary tail o Lymph nodes including supraclavicular fossa 

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Palpation technique - The vertical strip, or grid, technique

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1. 2. 3. 4. 5.

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The breast is divided into 8 or 9 vertical strips, each approximately one fingers width The examiners 3 middle fingers are held together and slightly bowed to ensure contact with the skin The pads, not tips must be used Using dime sized circles, examine the breasts at each of three different levels of pressure o Light o Medium o Deep  Describing the lump The size of the mass in centimetres and its position The shape of the mass The delimitation, referring to the borders of the mass. Is it well delimited, as with a cyst? Are the edges diffuse, as with a carcinoma? The consistency, describing the hardness of the mass. A carcinoma is often stony The mobility of the lesion. Is the lesion movable in the tissue that surrounds it? Benign tumors and cysts are freely mobile whilst carcinomas are usually fixed to the skin, underlying muscle or chest wall  Findings on Physical Exam Solid, 3cm, non-mobile, painless lump found in right upper outer quadrant No skin tethering No peau d’orange No erythema Lump not visible on general inspection of the breasts Further Management The gold standard of assessment of breast lumps is triple assessment: Clinical examination Breast imaging o Diagnostic mammography Biopsy (where indicated) o FNA initially  

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These are to occur on the same day (in some clinics) and have an accuracy of 99.6% when performed by experienced personnel. MARKING

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Remember: triple assessment for breast lump = clinical exam, imaging (e.g. diagnostic mammogram or ultrasound) and biopsy (e.g. FNA or Tru-Cut/core biopsy)

 CARDIAC EXAM    Instructions to student:  Clinical scenario  You are an intern in the Department of Surgery in a metropolitan hospital. You are conducting a surgical preadmission clinic with a medical student. The student asks you to review a patient who the student feels has an abnormal heart examination. You are informed that the patient is booked for a herniorrhaphy and is otherwise well.   Task  Conduct a cardiovascular examination that focuses on the blood pressure, neck and praecordium, and inform the student of your findings.  Assume the examiner is the medical student .     

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Examination Findings Blood Pressure

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Normal Checks radial pulse first as an estimate Inflate to 30-40 mmHg higher than the radial pulse estimate

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 Neck Carotids palpation and auscultation JVP

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 Praecordium Displaced apex beat o 6 ICS, Anterior axillary line o Pansystolic murmur o Radiation to axilla o Valsalva makes murmur softer  

Diagnosis is Mitral regurgitation

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The Cardiovascular Examination

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Position the patient at 45 degrees  ANSWER General inspection o Respiratory distress o Sweaty or cyanosis o In pain o Obese/wasted BP o Measure with radial pulse first? Neck o Carotids  Auscultate for bruit or radiation  Palpate for volume and character  Aortic stenosis, pericardial effusion - small volume +small upstroke  Aortic regurgitation, anaemia, PDA - collapsing o JVP  Inspection  Should be less than 3cm from sternal angle

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Not palpable, has two flickers (a and v waves), moves on respiration Hepatojugular reflex  Firm abdominal pressure for 10sec  Normal – no increase or small increase for 50; one second degree at any age o Screening  Mammograms every 2 years from age 40  Discuss self-check and modifiable risk factors Category 2 o 1 first degree activation of growth receptors. E7 -> sequesters pRb (promotes cell division) E6 -> activation of p53 causing the cervical cells continue to cycle despite DNA damage. These changes combined with other mutations and damage accumulated over many years results in cervical cancer. Following HPV infection most women are able to clear the infection. However those who are unlucky will go from CIN I – III -> carcinoma over 10-20 years.

Pap smears In Australia organised cervical screening was initiated in 1991 for sexually active women aged between 18-69years with a recommended 2 year interval. (Now two years after sexually active or age 20, whichever occurs last?) Cervical cancer incidence and mortality has dropped dramatically since the introduction of Pap smears. CIN is being replaced by LSIL and HSIL LSIL = low grade squamous intraepithelial lesion Low grade dysplasia CIN I Koilocytosis on Pap smear Typically resolves HSIL = high grade squamous intraepithelial lesion High grade dysplasia

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CIN I and II More likely to progress to cancer

What to do about Pap results Scenario: Results come back unsatisfactory a Explain to patient results were unsatisfactory b Repeat pap smear in 6-12 weeks 2 Result comes back normal a Reassure patient that results was normal b Recommend they come back in 2 years for Pap smear 3 Result comes back as LSIL in patient 3 months. Rescue courses of prednisolone may be used at any time. Occasional short acting beta-2 agonist as required for symptomatic relief. If used more than once daily, or night time symptoms, go to step 2 Add standard-dose inhaled steroid (eg beclamethasone 100-400 micrograms/12 hours) or start at a dose appropriate for disease severity and titrate as required Add a long acting beta-2 agonist (eg salmeterol). If there is benefit but inadequate control, continue and increase the dose of beclamethasone to 400 mcg/12 hours. If there is no effect from the LABA then discontinue. Review diagnosis, consider theophylline or Leukotrine receptor antagonist Consider trials of: a. Beclamethasone 1000mcg/12 hours b. Modified release oral theophylline c. Modified release oral beta-2 agonist

d. Oral leukotriene receptor antagonist e. Oral theophylline 5. Add regular prednisolone (1 dose daily at the lowest possible dose) and refer to asthma clinic     

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o When writing a prescription: Name DOB UR (if applicable) Allergies o On the regular medications section: Inhaled beclomethasone o 50-200 mcg BD (id probably write 50 mcg BD as his symptoms are not too severe) o Inhaled Inhaled salmeterol o DPI 50 micrograms o BD o Inhaled o On PRN section Salbutamol Metred dose inhaler 1-2 inhalations (100-200 micrograms) as required Max 4 times daily o Counselling points Corticosteroids o Rinse mouth out after using o Use every day, even if you are feeling better o Do not use this medication in an acute exacerbation LABA o Salmetrol should not be used in an acute exacerbation, use the salbutamol o Use this every day even when you are feeling better SABA o Use in acute exacerbations o Tell your doctor if using this more than normal o Clean the mouthpiece regularly to prevent blockages o Take 1-2 puffs 5-15 minutes before exercising General o Aim to quite smoking

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o o o o o o o o PRESCRIBING - HYPERLIPIDAEMIA o o Description of task: o o Mr David Smith is a 54-year old man who is presenting to your clinic for follow-up of his recent cholesterol tests. The results are as follows: o o Total cholesterol: 7.8mmol/L (N < 5.5mmol/L) o LDL cholesterol: 6.5mmol/L (N < 4.5mmol/L) o HDL cholesterol: 1.3mmol/L (N >1mmol/L) o Triglyceride: 1.2mmol/L (N 10 years

o Accepted o

Anovulatory infertility due to polycystic ovary syndrome (under specialist supervision):

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with clomiphene (if unresponsive to clomiphene alone) and BMI >30

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as monotherapy, when clomiphene unsuitable (eg not tolerated or lack of access to appropriate monitoring) and BMI 60 mL/minute/1.73m2 who are to receive 100 mL) of ICM should stop metformin on the day of the procedure; restart metformin after at least 48 hours if renal function is normal.

o Renal o

Renal impairment increases risk of lactic acidosis; reduce maximum dose when CrCl is