Quiz topic 1 - General Practice and Primary Health Care Academic ...

QUIZ TOPIC 1 – THYROID FUNCTION TESTS
A 31 year old man who was previously well presents with a thyroid goitre and palpitations. His GP
ordered thyroid function tests and he has returned for the results, which are as follows:
TSH 0.15 mU/l (ref 0.5-5.0)
Free T4 (thyroxine) 29.2 pmol/l (ref 11.0-21.0)
Free T3 (triiodothyronine) 5.7 pmol/l (ref 3.1-6.0)
1. How would you explain these thyroid function tests to the patient – what could the cause be?
2. Discuss further investigations that might be needed
3. Discuss a brief management plan
Answers for tutors
Question 1
“A low TSH and raised free T4 indicate hyperthyroidism and should lead to consideration of
causation and treatment. The majority of younger patients will have Graves' disease, but older
patients are more likely to have nodular thyroid disease. Transitory hyperthyroidism can be seen
in patients with viral thyroiditis. Most have had a recent upper respiratory tract infection and
present with neck tenderness and pain, which may be referred to the ear.” (Australian Prescriber
Thyroid Function Tests)
Question 2 – further tests
Measure TSH receptor auto-antibodies, consider thyroid ultrasound and/or nuclear scan. If viral
thryoiditis is suspected monitor TFTs periodically to assess spontaneous resolution.
Question 3 - management
Medical – first line treatment- carbimazole
thionamides -- are medications that treat an overactive thyroid (hyperthyroidism) by
blocking the thyroid gland's ability to produce T4 and T3. In addition to treating
hyperthyroidism resulting from Graves' disease, antithyroid drugs may also be used to
treat hyperthyroidism associated with toxic multinodular goitre, or a toxic adenoma ("hot
nodule"). Antithyroid drugs work by making it more difficult for the body to use iodine,
thereby blocking the formation of thyroid hormones in the gland.
“TSH may remain suppressed for weeks or even months after a patient starts anti-thyroid
medications. It is useful to monitor free T4 and free T3 every 6–12 weeks to judge the
adequacy of treatment. A rise in TSH indicates overtreatment. Patients with severe
hyperthyroidism may need more frequent monitoring.” (Australian Prescriber Thyroid
Function Tests) An estimated 25 to 50% of patients go into remission when taking an
antithyroid drug for at least six months to a year. While some 30 to 40 percent of patients
treated with antithyroid drugs remain in remission 10 years after they stop their drug
treatment, an estimated half of the patients who have a remission will also have a
recurrence.
- Beta blockers – can also be used for symptom control in the early stages of treatment
Radioactive iodine (RAI) ablation
Surgical – partial thyroidectomy
Resources
see short article from Australian Prescriber on Thyroid Function Tests, 2011.
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QUIZ TOPIC 2 – BOWEL CANCER SCREENING
A 45 year old woman comes to your general practice to ask you about bowel cancer screening.
1. What questions would you ask her to determine her risk of bowel cancer?
2. She has no personal history and is currently asymptomatic, but based on the answers to her
family history the following genogram is developed. Based on this, what screening, if any, would
you recommend?
3. When is FOBT recommended for the general population?
4. The patient wants you to describe what is involved in having a colonoscopy performed. What
would you advise her? What are the risks?
Answers for tutors
Question 1
a. Personal history -Bowel cancer, colorectal adenomas, inflammatory bowel
disease of 8 years or more
b. Family history -History of multiple large adenomas, other cancers eg
endometrial, ovarian, stomach, small bowel, renal pelvis or ureter, biliary tract,
brain; and age at which family members affected
c. Symptoms -Rectal bleeding, symptoms of anaemia, change in bowel habit,
abdominal pain, weight loss
Question 2
She is at moderately increased risk because she has one first degree relative with bowel cancer
diagnosed before age 55. She has 3-6 times greater than the average risk, however should be
advised that 70-90% of people in this risk bracket will never develop bowel cancer. However she
should be offered the following screening:
• Colonoscopy every 5 years (you would start this at age 50 or 10 years younger than the age
of first diagnosis bowel cancer in the family) – starting now
• Consider offering FOBT in the intervening years.
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Question 3
FOBT recommended at least every 2 years for all people over 50.
Note regarding the Government funded FOBT program:
Currently only those turning 50, 55, or 65 years of age, who hold a Medicare card or DVA
gold card, are currently being invited to take part in the program. Next year it will be
expanded to 60 year olds and to 70 year olds in 2015. It is not until 2017-18 that biennial
screening will be commenced – this will be for 72 year olds only initially. Hence it will not
be for many years all Australians aged between 50 and 74 years will be offered free
screening every two years, consistent with the recommendations of the National Health
and Medical Research Council. This can currently be arranged by patients through
pharmacies and GPs.
Question 4
Before the test clear fluids and a liquid medication are used to empty the bowel. The
doctor uses a long flexible tube instrument called a colonoscope to examine the lining of
the rectum and colon. You will be sedated during this procedure. If any polyps (growths)
are found, the doctor will remove these and send them away to be analysed under a
microscope. You may be given some preliminary results after the procedure and will be
asked to come back and see the doctor or your GP for the final results and the results of
any biopsies taken.
Risks of colonoscopy (from Flinders Medical Centre)
• Incomplete colonoscopy: occurs in 5-20% of cases depending on age and if there
has been previous pelvic/abdominal surgery. Would need to have followup with
virtual endoscopy or barium enema
• Missed lesions: Can occur in 2-8% of cases. This is why important to have FOBT in
intervening years.
• Perforation of colon: This will vary by centre but may be between 1 in 400 and 1 in
800
• Bleeding from bowel: this is more common after polypectomy – In 1 in 100 cases of
polypectomy the bleeding may be sufficient enough to require transfusion.
• Dehydration with acute renal failure – is related to the bowel preparation
Resources
Familial aspects of bowel cancer – Cancer Council
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QUIZ TOPIC 3 – RHEUMATOLOGY
A 66 year old woman comes to your general practice with 6 months of gradually worsening
bilateral shoulder pain and stiffness and has lost 4kg. There is pain and stiffness in both shoulders
and some pain in her hips. The pain is worse in the morning and can be so severe that she finds it
difficult to wash/comb her hair. There is no history of antecedent injury or different activity at the
time of onset. She has trialled NSAIDs with mild benefit.
She has no personal history of prior joint pains and there is no history of rheumatological disease
in the family. She has been on statin therapy for 3 years for hypercholesterolaemia (but no recent
changes to her medication).
General appearance: fatigued BMI 23, no pallor, pink conjunctivae; Vitals: BP 130/80 HR 72 reg
Shoulder: restricted ROM in all movements, restricted to 60 degrees abduction/flexion (bilateral).
Hips: restricted ROM in all movements (bilateral)
Cardio: Normal S1-S2, nil added; Resp: nad; Abdo: nad; Neuro: nad
No visual changes, no scalp tenderness or tenderness over temporal arteries
1. What are the differential diagnoses?
2. What tests would you order?
3. What are some appropriate management options for this patient?
Answers for tutors
Question 1 - differentials
• Polymyalgia Rheumatica (PMR)
• Seronegative arthritis
• Rheumatoid Arthritis
• Other inflammatory arthritis (SLE, Psoriatic arthritis)
• OA
• Malignancy
• Fibromyalgia
• Viral myalgias
Question 2 - tests
• FBE
• E/LFTs
• ESR/CRP
• TFTs
• Rheumatoid factor/anti-CCP
• (second line inflammatory markers could be ordered – if specific conditions are suspected
ANA/ANCA/dsDNA/anti-Ro)
• Consider imaging: if so, of what?
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Investigation findings:
FBE: nad
UEC: nad
LFTs: nad
TFTs: nad
ESR: 95
CRP: 30
Antibody screen: nad
Question 3 – management Polymyalgia Rheumatica
1) Look for temporal arteritis (giant cell arteritis) which occurs in 20% of people with PMR.
2) Corticosteroids (explain weaning dose); requires monitoring and review.
3) Osteoporosis screening with DEXA scan if on steroids >5mg for > 3/12
4) Non-pharmacological (including Smoking, nutrition, alcohol, physical activity -SNAP):
a. Education
b. Active; low impact exercise (e.g. swimming, walking)
c. Well-balanced diet (maintain healthy weight; avoid risk of other health problems)
d. Physiotherapist
e. Rheumatologist
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QUIZ TOPIC 4 – BREAST LUMP
A 37 year old female presents to you with a left breast lump that she has just noticed in the
shower yesterday for the first time. It is not painful. She is very anxious because she is worried
about cancer. She has no past medical history. She has a 3 year old son who she breast fed for 6
months and then went back to work. She has just finished her menstrual period. She is using
condoms for contraception at present although used the combined oral contraceptive pill for
many years prior to conceiving. She smoked for 5 years until she gave up at the age of 23.
Family history: Maternal aunt diagnosed with breast cancer aged 55years and is still alive.
Paternal Grandmother breast cancer aged 70 years and survived until the age of 80 years. No
family history of any other cancer including ovarian, bowel, prostate, pancreas etc.
1. What would you do on examination?
2. What would the differential diagnosis be for a woman with a discrete lump at this age?
3. Would you do any investigations? What is the triple test?
4. Assuming a benign result now, when should she commence mammogram screening?
Answers for tutors
Question 1 - examination
• Expose both breasts – patient to take top and bra off.
• Inspect breasts with arms by sides, arms above head and arms pressing on hips.
• Palpate breasts sitting up and lying down.
• Palpate cervical, supraclavicular and axillary lymph nodes.
On examination you find there is nothing of significance on inspection. On palpation, a 20mm X
20mm smooth, firm, non tender round lump palpable in the left breast in the 3 o’clock position
just 20mm lateral to the nipple. The lump is mobile and not tethered to any surrounding
structures. The right breast is unremarkable. There is no associated cervical, supraclavicular or
axillary lymphadenopathy.
Question 2 – differential diagnoses
• Benign: fibroadenoma, cyst, abscess, fibrocystic change, glandular parenchyma,
phyllodes tumour,
• Malignant: Breast carcinoma, malignant phyllodes tumour,
Most likely diagnosis: Fibroadenoma.
Cyst would be softer and very mobile, abscess would be associated with signs of inflammation
including erythema, warmth and tenderness. Phyllodes tumour presents similar to a fibroadenoma
but usually presents much larger e.g. > 30-40mm in size.
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Question 3 – investigations - the triple test
Any new breast lump should be investigated using the triple test.
The triple test involves:
- History and examination.
- Imaging e.g. with an ultrasound and/or mammogram.
- Non-excisional biopsy: Fine needle aspirate cytology and/or core biopsy.
In 99.6% of breast cancers, the triple test is positive. A positive triple test is defined by any of the 3
components being suspicious. A negative triple test is defined by all 3 components being either
negative or benign. If triple test is positive you need to do a surgical excision/biopsy.
You would now proceed to doing an Ultrasound. If there were any suspicious signs on the
Ultrasound then you would do a mammogram.
Ultrasound shows a hyperechoic lesion with a 25mm diameter.
A core biopsy would be arranged under ultrasound control for this type of lesion – most commonly
a fibroadenoma would be found.
If time permits – could discuss management of a fibroadenoma
You need to take into consideration patient’s age, lump size, symptoms the patient is experiencing
and imaging/biopsy results.
There are essentially 2 options:
• Conservative: if the lump is not bothering the patient and there are no indications
for surgery (see below) you can monitor it with ultrasound every 6-12 months and
refer again to a specialist if there are any changes to the lump.
• Surgical excision: if the lump is bothering the patient or there are suspicious
features. Surgery is recommended if lump > 40mm, age of patient > 40, biopsy
results concering, the lump is bothering the patient e.g. painful, the fibroadenoma
is increasing in size while being monitored.
There is no evidence that fibroadenoma increases the risk of developing breast cancer.
Fibroadenoma cells are just as likely as normal breast tissue cells to develop cancer.
Question 4: - screening
Breastscreening Victoria provides free mammograms to all women over the age of 40 years.
Screening is generally recommended every 2 years for women aged 50 to 69 years.
BRCA 1 and 2 genetic testing – appropriate for women with strong family history in 1 st degree
relatives – refer to genetic counselling service first.
Resource
National Breast Cancer Centre – Investigation of a new breast symptom, 2006
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QUIZ TOPIC 5 – DIABETES
A 55 year old man presents worried he may have diabetes, as he has developed a fungal groin rash over the
last few weeks and is very tired. He has searched the internet and feels that he has several of the diabetes
risk factors.
1. How would you determine his risk of type 2 diabetes? Are there any online tools that you can use to
assist?
2. What tests would you order to determine whether he has diabetes?
After testing you determine he does have type 2 diabetes.
3. What are the key management points in managing type 2 diabetes? Include in your answer issues around
monitoring, drug and non-drug treatments, health promotion etc.
Answers for tutors
Question 1 – risk factors
AUSDRISK is a great tool for this: http://www.ausdrisk.com.au/
• Family history of diabetes
• Obesity – particularly central
• Symptoms – polyuria/polydipsia, fungal infections, tiredness, blurred vision
• Symptoms or history of complications – e.g. retinopathy, nephropathy, neuropathy,
cardiovascular disease
• Examination: BMI & waist circumference, Acanthosis nigrens, evidence of neuropathy
• Urine testing in the clinic - glycosuria or proteinuria – although a formal urine
microalbuminuria test is more accurate
• Random finger prick for blood sugar
Question 2 – diagnostic tests
• Fasting glucose > 5.5
• Proceed to GTT
• HbA1c is now approved for diagnosis of T2 diabetes >=6.5%. Currently not Medicare
rebateable, but likely will be in 2013. If diabetes present, may order HbA1c (if not done
previously)
• Tests for complications - EUC/Urine Microalbumin
Question 3 - management
a. Lifestyle modification is the key first line therapy, involves no side effects, and if
adhered to may reverse diabetes in up to 60-70% cases. Education relating to
carbohydrate intake is key. 150min/wk of moderately strenuous exercise is highly
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advised; healthy dietary changes including moving from highly refined to less processed
low GI foods, adequate intake of vegetables and wholegrains and care with
carbohydrate intake; decrease or cease alcohol consumption; cease smoking; weight
reduction aiming initially for 10% weight reduction.
b. Management involving other allied health professionals such as diabetic educator,
dietician, exercise physiologist will often greatly assist the GP in achieving lifestyle goals
with a willing patient.
c. Education around finger prick BGL monitoring and goals of BGLs should be given
(roughly aiming BGL 4-8 fasting and 6-10 post prandial depending on the person),
although there is little evidence that this is effective at improving control in people who
are not requiring insulin.
d. Annual review at least with the patient’s GP will be important for follow up of HbA1c
and consideration of other risk factors, monitoring BP, weight, lipids, microalbumin,
feet, eyes.
e. Medications that may be considered if along with or if lifestyle therapy is not enough
Metformin is first line, then possibly a sulphonylurea e.g. Glicazide. There are a range of
other medications that may be considered and are probably beyond the scope of this
quiz. Eventually insulin therapy may be needed if inadequate control.
Resource
For more information about the management of T2 diabetes in general practice, see:
http://www.diabetesaustralia.com.au/Documents/DA/What%27s%20New/12.10.02%2
0Diabetes%20Management%20in%20General%20Practice.pdf
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