1st Session AKT, GP academy-11/11/2015 MCQ question 1/ Mahfuz Martin, a 61 yrs old gentleman came for a check-up. Last week he had his routine blood test done. His HbA1C is 6.7% and he is on Galvumet. His creatinine is 99, eGFR 60 & total serum cholesterol is 4.5 (HDL-1.1, LDL-2.5). Rest of the blood test results are with in normal limits. He is not on any other medication & he feels fine. On examination- BP: 130/80 no postural drop, pulse-74bpm regular, CVS exams-normal, Martin plays golf 4 times a week. Recently one of his mate sustained a heart attack which concerns him. He is asking about his cardiovascular risk. Q) What is the best answer for him? A) He is in a high risk group B) He is in a moderate risk group C) He is in a low risk group D) He has no cardiovascular risk at all.
My answer is A) high risk group. Although his blood test results are all with in normal limit- but because of his age & having DM, his is in a high risk. Guideline: Absolute CVD risk- Page 7 Already known to be at increased risk? Adults with any of the following conditions do not require absolute CVD risk assessment using the Framingham Risk Equation because they are already known to be at clinically determined high risk of CVD: (EBR: Grade D) • Diabetes and age >60 years • Diabetes with microalbuminuria (> 20 mcg/min or urinary albumin:creatinine ratio >2.5 mg/mmol for males, >3.5 mg/ mmol for females) • Moderate or severe chronic kidney disease (persistent proteinuria or estimated glomerular filtration raterate [eGFR] <45 mL/min//1.73 m2) • A previous diagnosis of familial hypercholesterolaemia • Systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg • Serum total cholesterol >7.5 mmol/L
MCQ question 2/Mahfuz Jenny, a 21 yrs old women requesting to have a mammogram done. She said that her aunt (dad’s sister) has breast cancer at the age of 51 year. No other family members from either side of the family has breast cancer or ovarian cancer. She has noticed no lump or other breast symptoms (pain, nipple discharge or skin change). Her periods are regular & normal. Q) What would be the best course of action in response to her mammogram request?
A) Refer her to family cancer clinic for surveillance program B) Organise a mammogram for her C) Organise U/S breast for her D) Reassure her & tell her that she would need mammogram from the age of 50yrs, unless she notice any breast symptoms My answer is 4) reassure her. Reference : Red book, RACG page 66, 8th edition Average or only slightly higher* risk (>95% of women) �� No confirmed family history of breast cancer �� One first-degree relative diagnosed with breast cancer at age 50 years or older �� One second-degree relative diagnosed with breast cancer at any age �� Two second-degree relatives on the same side of the family diagnosed with breast cancer at age 50 years or older �� Two first- or second-degree relatives diagnosed with breast cancer, at age 50 years or older, but on different sides (i.e. on each side) of the family As a group, risk of breast cancer up to age 75 years is between 1:11 and 1:8. Clarify risk at www. nbocc.org.au/fraboc Mammogram Breast awareness (I,A) Every 2 years from age 50–69 years‡ Regular (Practice
MCQ question 3/Mahfuz Elaine, aged 42yrs, asking for advice. She told that three of her immediate family members have developed breast cancer at different ages. Her mum had breast cancer at 55yrs, mums sister has it diagnosed at 48yrs and a cousin from mum’s side has diagnosed it at the age of 39 yrs. She has no breast symptoms. Q) What would be the best course of action? A) Refer her to family cancer clinic for surveillance program B) Organise a mammogram for her C) Organise U/S breast for her
D) Reassure her & tell her that she would need mammogram from the age of 50yrs, unless she notice any breast symptoms My answer is A) refer her to family cancer clinic Reference Red Book- RACGP, page 66
Extended Match style question/ Mahfuz/topic: Heart disease-Chest pain Michael aged 29, complaints of 24hours of severe, steady, crushing & retrosternal chest pain associated with fever. He has been unwell with a flu-like illness for a few days before the pain started. Q) What is the most likely diagnosis for Michael’s chest pain? A. Acute myocardial infarction. C. Bornholm disease E. Costochondritis G. Domestic violence I. Herpes zoster K. Musculoskeletal pain M. Pericarditis O. Pneumothorax Q. Pulmonary Embolism S. Rib metastasis
B. Angina pectoris D. Carcinoma lung F. Dissecting aortic aneurism H. GORD J. Mediastinitis L. Oesophageal spasm N. Pleurisy P. Psychogenic R. Rib fracture
My answer is M. Pericarditis Reference J. Murtagh- 5th ed. Page 409, & AFP Oct 2011-Pericarditis- P-793
AFP: Discussion History and examination findings These symptoms are characteristic of pericarditis, a common condition that is diagnosed in 5% of patients presenting to hospital with chest pain in the absence of myocardial infarction.2 Pericarditis is typically associated with sharp retrosternal pain (present in 98.3% of cases) that may radiate to the neck, shoulder or arms.3 The pain is often worse when the patient is supine and improves when sitting upright or leaning forward. It may be aggravated by deep breathing, swallowing or coughing. Pericardial friction rub is the most important. physical sign of pericarditis (present in 35% of cases).3 It is a high pitched, scratching sound and is heard most frequently at the left lower sternal border during expiration with the patient upright and leaning forward. Other important clinical signs to look for are fever ≥38°C and signs of tamponade (raised JVP, muffled heart sounds, decreased blood pressure). Patients with findings supportive of tamponade should be transferred to hospital urgently. Michael’s ECG and chest X-ray are unremarkable. He had mild leukocytosis and moderately elevated C-reactive protein (CRP).