Clinical challenge _123KB_ - Instructions for clinical challenge

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					EDUCATION • Clinical challenge

                              Instructions for clinical challenge

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  162    Reprinted from Australian Family Physician Vol. 33, No. 3, March 2004
                                                                                                          Clinical challenge • EDUCATION

Clinical challenge
  Questions for this month’s clinical challenge are based on articles in this issue. The style and scope of questions
  is in keeping with the MCQ of the College Fellowship exam. The quiz is endorsed by the RACGP Quality
  Assurance and Continuing Professional Development Program and has been allocated 4 CPD points per issue.
  Answers to this clinical challenge will be published next month.                                       Jenni Parsons

                                                fracture because of the mechanism of                  Question 1
SINGLE COMPLETION ITEMS                         injury. Choose the correct statement:                 Which of the following clinical features
                                                A. absence of significant localised tender-           is most strongly indicative of redback
                                                    ness in the anatomical snuffbox excludes          spider bite:
DIRECTIONS Each of the questions or
                                                    a scaphoid fracture                               A. pain at the bite site
incomplete statements below is followed
by five suggested answers or completions.       B. scaphoid tenderness can be elicited by             B. localised or regional sweating
Select the most appropriate statement as            pressure on the volar aspect of the ulnar         C. nausea and vomiting
your answer.                                        side of the wrist                                 D. headache
                                                C. the scaphoid is compressed by pushing              E. tender regional lymphadenopathy.
  Case 1 – Samantha Stone                           the thumb and first metacarpal toward
                                                    the radius
                                                                                                      Question 2
  Samantha Stone, 14 years of age, is
  on school camp at a bush retreat. She         D. one test of scaphoid tenderness is suffi-          Over the next few hours, the pain in Will’s
  tripped during a night bush walk and              cient to exclude scaphoid fracture                hand spreads to the entire limb. First aid
  fell onto her outstretched right hand.        E. clinical tests for scaphoid pain are of little     measures for redback spider bite include:
  You are called by the supervising
                                                    value as scaphoid fractures are easily            A. heat packs
  teacher at 9.30 pm and agree to see
  Samantha at the local hospital.                   seen on X-ray.                                    B. paracetamol
                                                                                                      C. pressure immobilisation
                                                Question 4                                            D. opiate analgesics
Question 1
                                                Samantha has scaphoid tenderness. No                  E. diazepam.
Samantha is distressed and complains of         fracture is apparent on X-ray. The best
pain in her wrist and lower forearm.            management plan is to:
                                                                                                      Question 3
Important features in assessment include:       A. send her home with a crepe bandage and             Will develops headache, nausea and vom-
A. Samantha’s hobbies and talents                  tell her to get an X-ray in 10 days                iting. You consider the role of redback
B. drug history                                 B. apply a scaphoid plaster and explain the           antivenom. Choose the correct response:
C. Samantha’s medical history                      need for plaster check next day and re-X-          A. antivenom is only indicated for patients
D. other injuries from the fall                    ray in 10 days                                         with systemic symptoms
E. all of the above.                            C. communicate directly Samantha’s local              B. antivenom is only indicated for patients
                                                   GP regarding follow up                                 with severe life threatening symptoms
Question 2                                      D. apply a scaphoid plaster and ask her to            C. antivenom is indicated for severe local pain
Samantha requires pain relief. Samantha            see you in 6 weeks time                            D. allergic reaction to antivenom occurs in
weighs 50 kg. Options include all except:       E. B and C.                                               10% of cases
A. ice                                                                                                E. allergy to horses is a contraindication to
B. paracetamol 1 g orally                         Case 2 – William Fossick                                administration.
C. temporary splinting                            Will Fossick, aged 59 years, was
D. pethidine 100 mg intramuscularly               ‘spring’ cleaning. He felt a sharp pain             Question 4
E. ibuprofen 500 mg orally.                       on his right hand and noted several                 Will’s headache and systemic symptoms
                                                  black spiders in the box he was
                                                                                                      worsen. You give Will redback antivenom
Question 3                                        sorting. The spider that had bitten him
                                                  had a reddish stripe over its abdomen.              in the ER of the local hospital. Choose the
You consider the possibility of scaphoid                                                              correct statement. Redback antivenom:

                                                                              Reprinted from Australian Family Physician Vol. 33, No. 3, March 2004   163

  A. should not be given intravenously                      Question 3                                        E. circumscribed sclerotic areas in the skull
     because of the risk of collapse                                                                             in early lesions.
  B. should be given IV in severe envenomation              You discuss medication for osteoporosis
  C. initial dose is 1000 units (two vials)                 with Mrs Mustafa and her daughter:
                                                                                                              Question 2
  D. should be repeated if no response within               A. calcium and vitamin D significantly reduce     A radionucleotide bone scan reveals
     15 minutes                                                hip and vertebral fractures                    increased uptake in the femur, pelvis and
  E. is only effective if given within 4 hours of           B. bisphosphonate treatment reduces verte-        skull, and serum alkaline phosphatase is
     the bite.                                                 bral fracture risk                             significantly elevated at 303 U/L. Liver
                                                            C. the evidence for calcitriol in fracture pre-   function tests are otherwise normal. In PD:
                                                               vention is stronger than for                   A. sites of radionuclide uptake correlates
      Case 3 – Naheed Mustafa                                  bisphosphonates                                    poorly with symptoms
      Naheed Mustafa, aged 73 years, lives                  D. oestrogen replacement therapy (ERT)            B. radionucleotide scans are more sensitive
      at home with her daughter and rarely
                                                               does not reduce fracture risk                      than plain X-ray in identifying affected bones
      leaves the house. She has a past
      history of inflammatory bowel disease                 E. there is no evidence for reduction in frac-    C. the degree of elevation of alkaline phos-
      that has required prednisolone inter-                    ture rates with raloxifene.                        phatase is a good predictor of subsequent
      mittently for control.                                                                                      fracture
                                                            Question 4                                        D. 50% of patients will have elevated alka-
                                                            Further investigation reveals a serum 25              line phosphatase
  Question 1                                                OHD (vitamin D) of 11 mmol/L. You                 E. alkaline phosphatase elevation does not
  A veiled Mrs Mustafa comes in for a plaster               suggest:                                              correlate well with the extent of skeletal
  check for a fractured wrist she sustained in              A. vitamin D 3000–5000 IU per day                     involvement.
  a fall at home yesterday. You consider her                B. vitamin D 800–1000 IU per day
  risk factors for osteoporosis, falls and frac-            C. vitamin D 600 IU per day
                                                                                                              Question 3
  ture. Choose the incorrect response:                      D. 5 minutes of sunlight to hands, face and       You discuss PD symptoms and complica-
  A. inflammatory bowel disease is associated                  arms 4 times per week to correct vitamin       tions with Sid. Choose the correct
      with osteoporosis and vitamin D deficiency               D deficiency                                   statement:
  B. vitamin D deficiency is an independent                 E. no treatment is required.                      A. the majority of patients have no symptoms
      predictor of falls                                                                                      B. bony swelling or deformity is the most
  C. having had one fracture, Mrs Mustafa is                                                                     common symptom
                                                               Case 4 – Sid Bender
      at increased risk of further fracture                                                                   C. fracture and arthritis are the most
                                                               Sid Bender, aged 65 years, is a retired
  D. veiled women are at risk of vitamin D                                                                       common complications
                                                               builder. Apart from hearing loss that
      deficiency                                               he attributes to long term noise expo-         D. heart failure and ischaemic heart disease
  E. doses of prednisolone over 2.5 mg per day                 sure at work, he has no significant               are increased in PD patients
      for 3 months are associated with bone loss.              medical problems. Over the past                E. hearing loss and tinnitus occur in the
                                                               couple of years he has been experi-               majority of patients.
  Question 2                                                   encing musculoskeletal pains and
                                                               more recently has had severe pain              Question 4
  As part of your assessment you arrange a                     localised to his right hip and thigh.
  DEXA scan. Her T-score is -2.6 and her                                                                      Sid’s management options include an oral
  Z-score is -2.3:                                                                                            bisphosphonate for 6 months because:
  A. Mrs Mustafa is ineligible for a Medicare               Question 1                                        A. treatment is likely to improve his symptoms
     rebate for her DEXA scan                               On examination Sid has restricted range of        B. treatment will prevent fracture
  B. the T-score reflects osteopenia                        movement in his right hip. X-ray reveals          C. bisphophonates normalise bone turnover
  C. the T-score reflects osteoporosis                      mild to moderate osteoarthritic changes in           in all patients in 3-6 months
  D. a pathological cause of bone loss is                   the right hip and changes consistent with         D. bisphophonates will normalise his bone
     unlikely                                               Paget disease (PD) in the upper femur. X-            scan appearance within 3-6 months
  E. medication for treatment of osteoporosis               ray features of PD include all except:            E. there will be no need for further treat-
     would not be covered by the PBS.                       A. cortical thickening                               ment after 6 months.
                                                            B. bowing of long bones
                                                            C. disruption of normal trabecular pattern
                                                            D. mixed osteolysis and sclerosis

164    Reprinted from Australian Family Physician Vol. 33, No. 3, March 2004