Download Case 1248: General Practice SAQs - 1 Authors and

Case 1248: General Practice SAQs - 1
Authors and Affiliations
Hannah Pham
School of Medicine
University of Adelaide
Acknowledgements
Dr Josephine Thomas
Dr Eugenie Lim
Dr Jane Conway
Royal Adelaide Hospital
Case Overview
These Short Answer Questions are suitable for those about to undertake their Final Year Examinations.
Learning Objectives
Question 1 : FT
Question Information:
A 24-year-old man has just returned from a trip to Brazil. His main complaint is of night sweats over the
last week. Over the last week, he has also developed a sore throat. He denies weight loss, daytime
fever, loss of appetite, cough, dyspnoea, or abdominal symptoms. On examination his pulse rate is
80/min, blood pressure 130/70mmHg, respiratory rate 20/min, and temperature 38.5C. There is
lymphadenopathy of the anterior chain bilaterally. His left tonsil is covered in exudate. The chest is clear
on auscultation. There is fullness in the left upper quadrant of the abdomen.
Question:
What is the most likely diagnosis? (1 mark) Justify your answer. (1 mark) Include in your justification the
best investigation to confirm this. (1 mark)
Choice 1: null Score : 0
Choice Feedback:
Answer
Epstein Barr Virus or Infectious mononucleosis or Glandular fever (1)
Justification
†¢ EBV is common in young adults which can present, as this man has, with night sweats and a sore
throat. His examination findings are supportive, including lymphadenopathy, tonsillar exudates, and
likely splenomegaly. (1)
Students should state that findings clinically †“ giving examples - are consistent with a
pharyngitis/tonsillitis
†¢ The best test for diagnosis is detection of heterophile antibodies on the Paul-Bunnell test or
Monospot test (1). Heterophile antibodies are produced by the patient in response to the virus. On
exposure to RBCs, they agglutinate.
Question 2 : FT
Question Information:
A 32-year-old man presents to the General Practitioner, seeking some 'strong' analgesia for his lower
back pain that has developed progressively over the past two days. He denies any injury to the back.
He states he has been feeling unwell over the past week and has had fever and chills. He denies chest
pain, dyspnoea, leg weakness, headache, rash, abdominal pain, photophobia, urinary or bowel
symptoms.
He has a past history of intravenous drug use and hepatitis C.
On examination, his pulse rate is 100/min, blood pressure 100/60mmHg, respiratory rate 19/min, and
temperature 38.8C. His chest is clear on auscultation, and heart sounds are dual with no murmurs.
There is erythema noted on his lower back with tenderness on palpation. Neurological examination of
the lower limb is normal. Examination of the hands is normal. There are track marks in his antecubital
fossa.
Bloods are taken for complete blood exam, biochemistry, and cultures.
Question:
What is the most appropriate investigation to diagnose the cause of his back pain? (1 mark) Justify your
answer. (2 marks)
Choice 1: null Score : 0
Choice Feedback:
Answer
MRI spine (1)
†œbone scan†• should be awarded 0.5 marks
Justification
†¢ This patient has a febrile illness of unknown origin. In the context of intravenous drug use and
localised tenderness in the spine, the most suspicious underlying source would be a bacteraemia
resulting in osteomyelitis or epidural abscess. (1)
†¢ The best investigation for exclusion of epidural abscess is an MRI (1), although a bone scan would
be able to provide useful information on the presence of osteomyelitis.
†¢ At least 3 sets of blood cultures would be vital in diagnosis, immediately prior to initiating empirical
IV antibiotic treatment.
Question 3 : FT
Question Information:
A 65-year-old woman presents to her General Practitioner with a three day history of mouth and jaw
pain at the site of a previous dental extraction. This is her first episode and she has been unable to eat.
She denies fever. She has a past history of ischemic heart disease, chronic obstructive pulmonary
disease, and osteoporosis. She received an infusion of zoledronic acid for treatment of osteoporosis
one week ago. Her current medications include aspirin, tiotropium, fluticasone/eformoterol and
perindopril/indapamide.
On examination, her pulse rate is 110/min, blood pressure 100/60mmHg, respiratory rate 19/min, and
temperature 37.6C. A 10mm lesion with the appearance of exposed bone is seen in the left anterior
maxilla. There is no ooze or blood. There is no cervical lymphadenopathy. Her facial movements are
intact.
Question:
What is the likely cause of her mouth and jaw pain? (1 mark) Justify your answer. (1 mark)
Choice 1: null Score : 0
Choice Feedback:
Answer
Osteonecrosis of the jaw (1)
Justification
†¢ She is currently taking a bisphosphonate, which predisposes to this condition. (0.5)
Bisphosphonates bind to osteoclasts and interfere with bone remodelling with an overall effect that
decreases bone turnover and inhibition of the bone†™s reparative ability.
†¢ This diagnosis is supported by her mouth/jaw pain and necrotic lesion in her left anterior maxilla.
(0.5)
Question 4 : FT
Question Information:
A 55-year-old woman with essential hypertension has presented for review of her blood pressure.
Today it is 160/100mmHg, which has not improved since her last review three months ago. She is
currently on ramipril, an ACE inhibitor. She assures you she is compliant with her medication. She is a
non-smoker and has been exercising three times a week since you counselled her on appropriate
lifestyle modifications. Her blood results, including renal function and electrolytes, have been normal in
this time.
Question:
What is the most appropriate next step in management? (1 mark)
Choice 1: null Score : 0
Choice Feedback:
Answer
Add a thiazide diuretic or calcium channel blocker OR Add a thiazide diuretic OR Add a calcium
channel blocker (1)
Notes
†¢ This woman†™s essential hypertension has not responded on monotherapy with an ACE
inhibitor. She has had normal blood tests (no changes in renal function or K+ level in particular), can
tolerate the side effects, and is compliant with the medication.
†¢ The next most appropriate step is to add another agent rather than increase the dose of the ACE
inhibitor.
†¢ Either a thiazide diuretic or calcium channel blocker would be suitable add-on therapy- both are
proven to reduce cardiovascular (CVS) events. Beta-blockers do not have as good evidence for
reducing CVS outcomes and therefore are second line, unless there is a compelling indication such as
heart failure
Synopsis
Recommended learning outcomes from this set of General Practice SAQs include:
1.
Diagnosis of EBV
2.
Causes of back pain
3.
Bisphosphonate side effects
4.
Management of hypertension