Family Medicine/General Practice MEQ 2006

QUESTION 1

1. A 34yo female journalist presents to you, her GP complaining of generalised severe frontal headache for past 6mo. Her only past hx of significance is sprained R ankle 2 years ago for which she took codeine for 4mo. Her ankle recovered fully. Today, apart from headache, she tells you her greatest fear is she feels she must have done "permanent damage to her nervous system" due to taking codeine tablets. She is very guilty about this and is not sleeping well in recent weeks. Your complete physical exam, including CNS entirely normal. a) name 5 key pieces of info you need to collect from patient's hx that might help in reaching clear definition of clinical problem here? (10 marks) 1. symptom: radiation, quality, frequency, duration 2. aggravating and relieving factors 3. nausea and vomiting, photophobia, aura, pulsating 4. diurnal variation, URTI, sinusitis or rhinitis hx 5. cyclical, a/w rhinorrhoea, lacrimation and red eyes b) what 4 approaches to management might you consider in helping this patient to recover? (2 marks) 1. Careful patient education 2. Investigation TRO serious disorders e.g. neoplasia, pitfalls e.g. cervical spondylosis, and masquerades e.g. depression 3. Counselling and relevant advice 4. Medication c) if you decide meds might help her, name 4 classes of drugs available to treat her. (2 marks) 1. NSAIDs 2. Opiates 3. Ergots 4. Anxiolytics d) choose 1 med and name three SEs a/w it. (3 marks) Naproxen 1. Heartburn 2. Peptic ulcer 3. Nausea

e) if you were to decide 1 non-pharma line of tx for this patient in the community, briefly describe how you would explain it to her. (3 marks) Advise stress reduction, relaxation therapy and yoga or meditation classes. Learn to relax your mind and body. During an attack, relax by lying down in a hot bath and practise meditation. Don't bottle things up, stop feeling guilty, approve of yourself, express yourself and your anger. 2. Mr John M aged 46 works long hours as taxi driver in Penang. He attends with low back pain. He rarely consults with you or any doctors in the practice. He is a smoker of 5 cigarettes daily and is obviously overwt. He would like some "strong tablets" for his pain as he needs to go back to work quickly. a) suggest 6 tasks you need to achieve in this consultation, briefly explain each task according to Calgary Cambridge model. (6 marks) 1. Initiate session a. Rapport b. Identify overt and occult reasons for consultation c. Screening questions and negotiate agenda 2. Gathering info a. Explore the symptom(s) b. Open and closed questions c. Red flags d. Pick up cues, signposting, no jargons 3. Physical exam a. Signs to support patient's history b. Red flags 4. Explanation and planning a. Shared decision making b. Correct amount and type of info 5. Closing session a. Clarify, allow patient to ask questions, summarise b. Safety nets 6. Management a. Arrange for relevant investigations b. Medications to relieve symptoms b) suggest 4 reasons why men consult less frequently than women during time of adolescence to late middle age. (4 marks) 1. in a male-dominated society, they are the breadwinners and thus less convenience to go to doctors during office hours 2. men generally less willing to admit weakness and under societal

pressure to always appear strong as providers of families 3. women generally more likely to express vulnerability and seek help 4. more preventive health measures available for women e.g. breast ultrasound/mammogram and Pap smear, thus they're more likely to have routine medical checkups c) what "red flag symptoms" should you specifically ask about in a patient with low back pain in order to exclude potentially serious cause? (3 marks) History of cancer Temperature > 37.8C Constant pain - day and night Weight loss Symptoms in other systems,. e.g. cough, breast mass Significant trauma Features of spondyloarthropathy, e.g. peripheral arthritis Neurological deficit Drug or alcohol abuse Use of anticoagulants Use of corticosteroids No improvement over 1 month Possible cauda equina syndrome o saddle anaesthesia o recent onset bladder dysfunction o severe or progressive neurological deficit Your initial assessment of this pain is that it is mech/simple backache and john accepts your dx and explanation. On his way out of the door, however, he says "doctor, while I'm here" d) what type of consultation is this? (2 marks) Doorknob syndrome He continues, "I have recently started a new r'ship and I'm having trouble with erections" e) list 5 questions impt to ask him: (5 marks) 1. explore the problem, e.g. onset, previous episodes, lack of libido or arousal, failure to ejaculate etc 2. meds e.g. beta-blockers 3. alcohol intake and recreational drugs e.g. marijuana 4. pressure e.g. from family, r'ship, work etc 5. any diabetes, peripheral vascular disease, neuropathy? Control and compliance?

3. Mrs LG, a housewife aged 54, returns to have her BP checked. 2 weeks ago, during her consultation for a common cold, you found her BP to be 160/100. Her previous BP 2 years ago was 140/90. This time her BP is again 160/100 3a) How would you assess Mrs LG? (6 marks) History - Ask symptoms of hypertension eg headaches or visual disturbances (visual disturbances can be caused by late complications eg retinal exudates, vascular narrowing, haemorrhage or retinopathy - Explore symptoms of underlying cause (phaeochromocytoma, signs of renal disease, radiofemoral delay or weak femoral pulses coarctation, renal bruits, palpable kidneys or Cushings syndrome) - Acquire symptoms of complications (end-organ damage) : chest pain, visual disturbance, frothy urine - Review patients diet, medications, substance use and activities - Family history of hypertension or related illnesses (patients with hypertension can have related heart disease, diabetes, renal disease, TIA/stroke, peripheral vascular disease or hyperlipidaemia) (hypertension strong genetic predisposition) Physical Examination - Measure BP in both arms to rule out coarctation or dissection of aorta - HEENT : Check for jugular venous distension, carotid bruits and pulses, perform a fundoscopic exam for papilloedema, retinal exudates, haemorrhages or retinopathy - Chest : Auscultate for abnormal lung sounds, wheezing, crepitations - Heart : Check for arrhythmias, S3, S4, murmurs or displaced apex beat - Abdomen : Listen for renal bruits and palpate for masses or pain - Neurology : Complete neurological examination for signs and symptoms of stroke/TIA Investigations - Full blood count - Renal profile (electrolyte abnormalities) - Urinalysis (proteinuria) - ECG - CXR to rule out cardiomegaly or pulmonary congestion She learns from her friends that treatment for hypertension has to be lifelong. She tells you that at present she will not consider any drug treatment for her blood pressure 3b) What would you discuss with her? (3 marks) Explain that in her case (sustained pressure of =/>160/100mmHg) medical intervention is of great importance in addition to lifestyle and dietary adjustment. This is to prevent possible complications from untreated hypertension eg LVH, retinopathy, nephropathy

3 months later. She brought her son to see you. Upon request, you checked her blood pressure again it is now 162/102

3c) What is your management for this lady ? (5 marks) Non pharmacological - Reduce concomittant risk factors eg smoking cessation, low fat diet, reduce alcohol and salt intake, encourage exercise, weight reduction if obese - Target blood pressure <140/85mmHg - Self BP monitoring at home, regular follow up Pharmacological - Start patient on ACE-inhibitors eg lisinopril 2.5mg-20mg/24h PO (*ACE-i 1st choice in underlying LVF, diabetics, or proteinuria) 4. A 4 year old boy, Jason presented with a 12-hour histroy of vomiting and abdominal pain 4a) Name 5 common causes of abdominal pain for this age (4 marks) Acute appendicitis Intussusception Volvulus Acute gastroenteritis Urinary tract infection

4b) In deciding the most likely diagnosis is acute appendicitis, outline key features of the history and clinical findings that would point to the need for surgical intervention (3 marks) History - Unresolved fever - Persistent vomiting - Anorexia, diarrhoea Clinical findings - Tachycardia, toxic looking child, febrile - Generalised guarding - Rebound tenderness During the same consultation, Jasons mother complains that he still wets his bed about 3 times a week and has never been dry 4c) What are you going to tell Jasons mother ? (4 marks) The condition is called nocturnal enuresis : refers to the involuntary passage of urine during sleep. Assure her that, although there are many factors that contribute to nocturnal enuresis, most children do not have a disease

process that explains their bedwetting. Most children become dry at night between 3 and 5 years of age. Most pediatricians do not consider bedwetting to be a problem until a child is at least six years of age. With care and perseverance, nocturnal enuresis is a problem that can be successfully treated. Jason might not need pharmacological intervention as yet, because nocturnal enuresis before 6 years old often resolve spontaneously. However possible intervention at this stage include restricting fluid intake after dinner, encourage child to urinate properly before bed, use of enuresis alarm as well as psychotherapy (where appropriate). Jasons mother also complains of Jasons whining and temper tantrums. His mother is very frustrated with him kicking and screaming if he does not get his way. He sometimes destroys things in his fits of rage. 4d) What will you cover with her in your discussion of this problem ? (5 marks) Developmentally, it is expected that young children will have a difficult time controlling their emotions, particularly if tired, hungry or stressed. Toddlers and preschoolers often lack the self-control necessary to express anger and other unpleasant emotions peacefully. When this happens it is important for the child's caregiver to be able to provide him or her with the support to deal with these difficult and uncomfortable feelings. Children learn a lot through their parents' modeling of behaviors and this is the main reason for parents needing to be most in control when their children are feeling out of control. If a father or mother joins the child in an uncontrollable emotional state, the situation will likely worsen because the child will feel less safe and more out of control