Approach to RACGP Exam

It is almost exam time again. I am hoping that this website will provide some information on how to tackle the exam, and eventually help myself passing the exam.

The exam has three components:
1. Applied knowledge test (AKT)
2. Key Feature Problems (KFP0
3. OSCE

The followings are information about the fellowship exam and you can access this information from the Fellowship Exams Candidate Handbook

Applied knowledge test (AKT)

• To assess the breadth and application of contextual knowledge required for certification to enter unsupervised general practice.
• It contains 150 clinical questions with 2 questions types:
• Single best answer
• Extended matching questions 
• Multiple choice test conducted online for 4 hours.
• Held twice per year. 
• Must pass the AKR as a per-requisite to undertaking the OSCE. From 1January 2017, candidates must pass the AKT and KFP as a pre-requisite to undertaking the OSCE.

Key Feature Problems (KFP) 

• To assess clinical decision making skills in general practice cases 
• A key feature is a critical step in the resolution of a clinical problem in the context of everyday general practice. A KFT question consists of clinical case scenario followed by questions that focus only on those critical steps
• It contains 26 cases of equal value and 2 questions types 
• Write in questions (short answer questions)
• Completion questions (select responses from a list)
• Each question specifics how many responses candidates should provide. For 'write-in' questions candidates will receive a weighted reduction in score in the overall exam for all extra responses they provide. For 'completion' questions candidate will be penalised for extra responses.
• It is a 3 and 1/2 hr exam.

OSCE

• To assess applied knowledge, clinical reasoning, clinical skills, communication skills and professional attitudes in the context of consultations, patient exams and peer discussions. This is a clinical consulting performance assessment. 
• The OSCE includes 14 clinical cases of either 8 minutes or 19 minutes duration, with rest stations interspersed between the clinical stations. It takes around 4 hours to complete the exam. 
• The 8 minute consultation stations require candidates to focus on one or two aspects of a consultation, these consultation stations are not intended to represent whole consultations.
• The 19 minute consultation stations resemble standard general practice consultations and usually require the candidate to focus on a number of tasks.

Preparation for the exam

• RACGP Curriculum for Australian General Practice (RACGP Curriculum handbook) 
• Frequency and patterns of problems in general practice (BEACH. Here is the link to a decade of Australian general practice activity from 2005 to 2015)
• Pre-exam courses
• Check program (access available as a financial member of the college)
• gplearning (access available as a financial member of the college) 
• AKT and KFP online practice exams (available 1 month before the actual exam) 
• 2014 Thursday evening pre-exam tutorial series on DVD (Can borrow from John Murtagh library if you are a member of the RACGP) 
• Clinical Skills scenarios DVD - cases for GP educators or learners (The DVD can be purchased Here)

Some ideas on study topics using BEACH data:
Most frequently managed problems by categories
Most frequently managed problems from 2005 to 2015
Most frequently managed chronic problems from 2005 to 2015
Most Frequently prescribed medications from 2005 to 2015


Exam tips from various training providers and college:
Sturt Fleurieu exam tips 
Valley to coast GP training exam tips

Exam resources from the college:
Candidate handbook
RACGP Curriculum
Beach data

Approach to drug addiction

It is a common presentation in GP land. It is not as bad in the hospital system but once you step into GP practice. Every 5 patients, there is at least one person who is on opioid or benzo long term. How do we get to this stage ? What happened to our medical practice? The recent check program takes on addiction medicine and explores the complex issue of addiction. Personally, I think the best way to deal with this problem is to not prescribe benzodiazepam or morphine without a plan of stopping them.

Key points:

- In Australia, about sever million prescriptions for benzodiazepines are written each year. (7 million! This number is ridiculous) Of patients aged 65 years or older, 15% were prescribed at least one benzodiazepine. Of these, 45% were prescribed more than once and 15% of these for longer than six months.

- There is little evidence that long-term benzodiazepine use is effective for the management of insomnia, anxiety or depression, and other modalities have better effectiveness and safety.

- The effects of caffeine can be directly weakened by smoking. smokers traditionally drink more than twice as many caffeinated drinks as non-smokers.

Chronic Obstructive Airway disease management: 10 fast facts

COPD

10 Fast facts

1. COPD-X is the mneumonic for COPD management. 
1. C: Case finding and confirm diagnosis 
2. O: Optimising function: pharmacological and non pharmacological 
3. P: Prevention 
4. D: Develop a plan
5. X: management of exacerbation 
2. Screen adults over the age of 35 and smokes. Spirometry remains under utilised in GP. 
3. Definition of COPD : Post bronchodilation FEV1/FVC < 70 %
4. Chest x-ray has no diagnostic value but it helps to exclude other possible diagnosis
5. Stop smoking is the most effective strategy in treating COPD, other non pharmacological interventions should be offered to all other patients. 
6. Pharmacological treatment: please refer to step guided treatment. Bronchodilator should be started on anyone with Mild COPD. 
7. Only use ICS/LABA in mod to severe COPD as it increases the risk of pneumonia. 
8. Make sure patient has Flu Vax and Pneumococcal vaccine 
9. When it is appropriate, discuss advance care plan with them 
10. Prednisolone 50 mg x 5 days is good, any longer than that has no extra benefits 
11. Don't forget non pharmacological intervention: smoking cessation, pulmonary rehabilitation, nutrition, GP management, immunisation and exercise.

References:

- Lung fundation 

- COPD - X 

Approach to the eye

GPs are often asked to check the eyes. It is difficult. First, there are no formal trainings for GPs to deal with eye problems. Second, we don't have the equipments which are often required for a proper eye examination, such as a slit lamp.

This post is to deal with some of the common eye problems and emergencies which could present to GP clinic or appear in the exam. John Murtagh's general practice book has two chapters on this topic, sydney eye hospital published an eye manual on how to deal with common eye emergencies, victoria eye hospital also published 35 golden eye rules to help GPs.

This post may be a little bit long but I am hoping to make this the only post a GP registrar needs to read for the exam and daily practice.

As with most things in medicine, history and examination are the key. In Murtagh, there is a section called questions directed to specific symptoms. It is a bit too simplistic but give some basic structure to what questions need to be covered during history taking.

• Presence of floaters --> normal ageing (esp.>55) with posterior vitreous detachment or may indicate haemorrhages or choroiditis
• Flashing lights --> normal ageing with posterior vitreous detachment or indicates traction on the retina 
• Coloured haloes around lights --> glaucoma, cataract
• Zigzag lines --> migraine
• Vision worse at night or in dim light--> retinitis pigmentosa, hysteria, syphilitic retinitis
• Headache --> temporal arteritis, migraine, benign intracranial hypertension 
• Central scotomata --> macular disease, optic neuritis 
• Pain on moving eye --> retrobulbar neuritis
• Distortion, micropsia, macropsia --> macular degeneration 

Diseases/disorders to exclude or consider 

• DM
• Giant cell arteritis
• Hypopituitarism
• Cerebrovascular ischaemia/carotid artery stenosis
• MS
• Cardiac disease 
• Anaemia 
• Marfan syndrome (subluxated lenses) 
• Malignancy (the commonest cause of eye malignancy is melanoma of the choroid) 

Examination. In ophthalmology, there are three vital signs. Visual acuity, Pupils and Tonometry. I am not sure how many GP clinics have a tonometry (my clinic does not), so I have a very low threshold of referring people to ophthalmologist or optometrist. A proper examination should at least include the following:

• visual acuity 
• pupil reacitons 
• confrontation fields 
• colour vision 
• amsler grid 
• fundus examination with dilated pupil 

Common conditions that result in visual loss:

• Central retinal artery occlusion 
• Central retinal vein thrombosis
• Retinal detachment 
• Vitresous haemorrhage 
• Macula degeneration 
• Temporal arteritis 
• Retinal migraine 
• Posterior vitreous detachment
• Optic neuritis

Management of trauma

• hyphema

Common eye conditions that can cause red and tender eye :

• Conjunctivitis (bacterial, viral or allergic)
• Glaucoma
• Uveitis
• Corneal ulcer
• Herpes simplex keratitis
• Microbial keratitis (e.g. fungal, amoeba and bacterial)
• Herpes oster ophthalmicus
• Penetrating injury
• Endophthalmitis
• Orbital cellulitis 
• Scleritis/Episcleritis
• Blepharitis
• Foreign body 

Red Flags

• Beware of unilateral red eyes
• Irritated eyes are often dry
• Never use steroids if herpes simplex is suspected
• A penetrating eye injury is an emergency
• Consider an intra-ocular foreign body
• Beware of herpes zoster ophthalmic if the nose is involved
• Irregular pupils: think iritis, injury and surgery
• Never pad a discharging eye
• Refer patients with eyelid ulcers
• If there is a corneal abrasion look for a foreign body

References:

John Murtagh 

Sydney eye hospital: eye manual 

Victoria eye hospital: 35 golden eye rules 

Approach to doctors as patients

Why do doctors don't want to be patient or don't have a GP?
- embarrassment, concerns about confidentiality
- the culture of medicine is one of working through illness; an image of invincibility is encouraged and vulnerability is denied.

What are the pitfalls for the doctor treating a doctor patient?
- Treating the doctor - patient more as a colleague than a patient
- Having higher expectations for recovery, compliance and participation in treatment
- Corner may be cut in assessment, examination explanation and follow up as a result of the collegiate relationship

What other differences are there when you are looking after a doctor as patient?
- Ensure that your doctor patient is fit to work and is not putting patients at risk. If you think that he/she is unfit to work, you may have to report them to the relevant authority. This issue has to be handled carefully and reporting them to the relevant authority does not mean that they can't practice. It means that they may need to practice under certain condition.

References:
- http://www.gmc-uk.org/doctorswhoarepatientsjanuary2010.pdf_62126868.pdf

Approach to clinical errors

It has a detrimental effect on the treating doctor. Doctors often experience feeling of being incompetent, lost of confidence and fear. We are all fear of litigations but most patients are not out there to get us. Most of them only want good medical care and find out why the error occurr in the first place. I was told by one of my GP supervisors that it eventually comes down to trust. If the patient trusts you and you develop a good relationship with the patient, they will forgive you most of the time.

The following outlines my approach to clinical errors:
1. Acknowledge the mistake
2. Express regret or apologise that it has happened
3. Open disclosure of the event/incident
4. What can be done now ?

References:
- Check program: challenging clinical situations

Approach to aggressive patients

Dealing with angry/aggressive patients.

Is there any difference between anger and aggression?
- Anger is an emotion
- Aggression is a behaviour

What is your approach to angry patient?
- I adopt the RACGP check program approach, using the acronym LASSIE which stands for:

- L : listen
- A: Acknowledge, agree and apologise. It doesn't mean you need to agree with the other person but simply saying I am sorry that has happened to you may help to diffuse the situation
- S: separate. Bring the person to a quiet area
- S: Sit down. Aggression is more difficult in a sitting position
- I: indicate options. Provide options for patient to choose
- E: Encourage choice. Get the patient to choose what is available. Give him/her the feeling that they are in control

How would you follow up the patient?

- Patients often react very differently to GPs and receptionists but GPs can't function without the help with receptionist and other staff members. It is important that we protect them and discourage bad behaviour
- The issue needs to be brought up with the patient at the next appointment, re-stating the fact that this sort of behaviour is not acceptable and if it happens again, we may terminate the patient and doctor relationship. (From the check program, there is a behaviour contract template for GPs to use)

References:
check program

Approach to Scabies

key points:

1. Usually present with intense itching
2. Caused by Sarcoptes scabiei. The female mite burrows beneath the skin in order to lay eggs. The eggs hatch into tiny mites and spread out over the skin and live for only about 30 days
3. The mite antigen, in its excreta, causes a hypersensitivity rash.
4. Diagnosis is by microscopic examination of skin scrapings or by response to treatment
5. Usually spread through close contacts. Children need to be kept away from school until they complete the course of treatment.
6. According to therapeutic guideline, the treatment of choice is permethrin 5% leave on for at least 8 hours or benzyl benzoate for 24 hrs repeat after 1 week. Usually permethrin is better tolerated and less drying.
7. In kids less than 6 months, the current recommendation from therapeutic guideline is still permethrin 5 % but it also stated that permethrin is currently not licensed to be used for this purpose.
8. Other treatment for children under 6 months: sulphur 10%in white paraffin once daily for 2-3 days or chromatin 10% topically once daily for 2 -3 days
9. In immunocompromised patients, it can become crusted scabies, essentially means huge number of mites in the body known as norwegian scabies. Try to get expert opinion, treat with ivermectin 200 mcg/kg as a single dose plus topical treatment.

References:
John murtagh 5th edition
eTG

Treatment for head lice

Head lice is a common problem is school aged children.
GPs need to have an approach in dealing with this problem. Give clear instruction to parents of how to deal with it. Usually diagnosis is via clinical examination. Visualisation of nits and live lice in the hair is diagnostic.

Key points:

1. It is caused by the louse pediculus humanus capitis.
2. Patients can present with significant itching on the scalp and neck.
3. Wet combing: apply generous amount of hair conditioner and comb with fine toothed comb. The conditioner stunt the lice and stops them from crawling for 20 minutes. The method only has around 40 % successful rate.
4. permethrin 1% topically, leave for a minimum of 10 minutes; repeat treatment in 7 days (there are other treatment options, please see therapeutic guideline). Use the wet combing method the day after treatment to check for live lice. If live lice are found despite treatment, that means the lice are resistant to the product used.
5. In between treatments, use the wet combing method twice to remove all eggs less 1.5 cm from the scalp.
6. Wet combing should be repeated weekly for few weeks to ensure complete clearance.
7. Bed sheets and linens should be washed with hot water 60 degrees.
8. Treat all household members
9. Notify school but can still go to school after treatment
10. Treatment resistant: use a different product or ivermectin 200 mcg/kg as a single dose with fatty food, repeat in 7 days.

References:
- eTG
- John murtagh 5th edition

Approach to complaints

It is a difficult situation but almost unavoidable. We need an approach on how to deal with it at the exam and in real life.

We can essentially divide process of handling complaints into three steps:

First step: acknowledge injured feelings and investigate the complaint
Second step: explore options and consequences
Third step: resolving the issues 

First step: acknowledge injured feelings and investigate the complaint

• usually the clinic has a protocol in place to deal with complaints (e.g. third party involvement)
• It is important to take the complaint seriously and to give patient sufficient time to ventilate his/her concerns. 
• Remain calm
• Thank the patient for coming to discuss the issue, and acknowledge that the situation has caused her worry and concern. Demonstrate active listening by posture and verbal responses, and convey that you have understood by repeating, paraphrasing, clarifying and open ended inquiry.
• Make sure at the end of the consultation that the person receives a clear message that you are taking issue seriously and you will investigate. 

Second step: explore options and consequences

• Gather the facts: review notes, copies of reports etc. 
• If it is necessary, may need to contact MDO
• Arrange a meeting to explore what the patient wants
• provide the patient with the information you gather 
• Keeps patients informed about the investigation progress

Third step: resolving the issues 

• Clarify what will happen next 
• provide summary of what has happened so far
• explain if any changes or improvement will happen
• reach an agreement

References:
1. Check program: challenging consultations
2. Dealing with complaints by Avant

RACGP Exam

After studying and preparing for the exam for nearly 6 months, I have the chance to do an assessment today. It was a complete failure. I obviously neglected the OSCE component of the exam, so I didn't do well in the OSCE. My poor time management only left me around 15 minutes for around 10 questions in the KFP, so I needed to quickly rush through them and I don't I did well either.

After today's formative assessment, I identified some weaknesses in my knowledge:

1. Critical appraisal of journals
2. No structured approach to difficult patients e.g. angry patient, complaints against doctors
3. Poor time management
4. Poor understanding of endocrinology
5. Have not read the exam handbook
6. Does not know how to answer questions in KFP

Still has around 2 months to go. I will try to fill in those gaps before the AKT.

Approach to a travel consultation

Key points:
- Take a good history:
      > Information about the traveller
         - Age
         - Medical history
         - Medications
         - Allergies
         - Vaccination history
         - Previous travel
       > Information about the itinerary and activities
        - Reason for travel
        - Style of travel
        - Duration of stay
        - Exact destinations
        - Season/s
        - Accommodation
        - Exposures
        - Specific activities
        - Budget

- Potential issues for pre-travel consultation:

• Aircraft travel issues (e.g. reduce oxygen pressure, humidity)
• lack of fitness to travel 
• DVT risks
• Motion sickness
• Jetlag
• Altitiude illness
• Heat/cold/sun exposure
• Water safety/accidents/injuries
• Animals bites
• Insect bites
• Carrying medicines
• Accessing medical care
• Drugs and alcohol

Communicable risks - no vaccines

• Traveller's diarrhoea from causes other than enterotoxigenic E.Coli
• Dengue fever
• HIV infection 
• Amoebiasis
• Giardiasis 
• Helminthic infestations 
• Sexually transmitted infections 

Communicable risks - vaccine preventable 

• Traveller's diarrhoea due to enterotoxigenic E. Coli 
• Hepatitis A and B
• Typhoid 
• Yellow fever
• Cholera
• Diptheria/tetanus/pertussis
• Measles/mumps/rubells

Altitude sickness can occur at any altitude above 2100 metres and sometimes less, depending on the rate of ascent and individual susceptibility. Acetazolamide 125mg twice per day for 5 days starting just before flying would be appropriate. Acetazolamide is contraindicated in people with severe sulphur sensitivity, but can be tested in those with a vague history of possible sulphonamide allergy in childhood. Common adverse effects of acetazolamide include premolar tingling, flushing and frequent urination 

3 Rs provide a systematic approach to the consideration of the travel vaccination and help guide the priorities. 

Fitness to fly refers to whether a person is physically and mentally fit enough to undergo a trip  in a pressurised jet aircraft, and usually relates to the problem of sitting confined in a depressurised and lower oxygen environment for several hours. 

Malaria is an infection caused by the protozoa plasmodium, transmitted by the bite of female Anopheles mosquitoes. Foremost in prevention is avoiding exposure to theses mosquitoes. Strategies include:

- minimising exposing to the mosquito between dusk and dawn. Anopheles mosquito is a night feeder 

- wearing protective clothing including long sleeves and trousers, ideally pretreated with permethrin 9 ac common insecticide)

- wearing light coloured clothing - this is associated with reduced risk of mosquito bite

- use of 20% or greater concentration DEET insect repellents on exposed skin 

- sleeping in screened or air-conditioned rooms under mosquito nets

- using 'knockdown sprays' (sprays which create a specific rough surface) on the internal walls of accommodation. 

The decision on whether to prescribe chemoprohphylaxis is made after detailed discussion of the risks and benefits, and the realistic risk of developing malaria. 

Chemoprophylaxis is about 90 % protective in high risk areas if travellers are careful with compliance and bite reduction. (please refer to Most commonly used antimalarials currently available in Australia

"VFR"stands for visiting friends and relatives, it describes citizens and permanent residents who were born overseas (and their children) who live in Australia and are travelling to their country of origin for any purpose. 

Pregnancy and travelling: 

- requires planning 

- best time is second trimester 

- history of pregnancy complications such as pre-eclampsia, diabetes and miscarriage should be a contraindication to travelling. 

- need a letter from obstetrician to outline the progress of pregnancy and other requirement. 

Malaria in pregnancy tends to be more frequent and severe, and the risk of complications such maternal death, abortion and stillbirth are significant. 

Oral cholear vaccine reduces the risk of traveller's diarrhoea, as it has also some activity against the toxin which is implicated in traveller's diarrhoea but will not prevent traveller's''s diarrheoa or replace the need for self treatment. 

Malarial protection in children 

- advice the same as adults

- medications essentially the same (please click here to view the list and dose of the mediations) 

Drugs used for malaria chemoprophylaxis in children

Bacteria are condsidered the predominant cause ( 80-90% overall), with enterotoxigenic E.coli being the most common, followed by campylobacter jejune, shigella, salmonella and other strains of E.coli. Viral causes are thought to account for 5-10 % of cases, including norovirus and rotaviurs. Protozoal causes, such those of the guard genus, are slower to present, but may cause about 10 % of disease in long term travellers. 

The adage, ' cook it, peel it, or forget it' is good for travellers to remember but the evidence suggests most people will faiths within 48 hours. 

Oral cholera vaccine (Dukoral) which includes recombinant cholera B toxin subunit provides some cross protection against enterotoxigenic E. Coli. Two doses of the vaccine provide protection against enterotoxigenic E. Coli at 60-80% and the protective effect lasts for about 3 months. Overall, the risk reduction against traveller's diarrhoea is about 20%.

Traveller's medical kit for traveller's diarrhoea:

- anti nausea medication 

- loperimide (except in bloody diarrhoea) 

- azithromycin 

- oral rehydration sachet 

- Tinidazole may be useful for longer travel where giardia becomes more likely 

There are two golden rules in the management of a febrile returned traveller:

- an unwell febrile returned traveller needs hospital admission under an infectious diseases unit

- always consider malaria as a differential diagnosis in a febrile returned traveller where any possibility of malaria exists

Dengue fever aka "breakbone fever"

- biphasic (saddleback) fever pattern may or may not be found d

- rash is often, but not always present. Rash often becomes confluent, sparing normal islands of normal skin, and blanches under pressure. On resolution, the skin may desquamate. 

- There is often some elevation of liver transaminases and mild hyponatraemia in the acute phase of the illness. 

- often associated with leucopenia, thrombocytopaenia and low platelet counts. 

Archive

Intrauterine device

Intrauterine device

Advantages:

• It is in place for approximately 5 years
• It is inexpensive in the long term. The real cost of the levonorgestrel IUCD to the PBS is $246.41. The PBS covers most of the cost so that the user pays only $ 33.30
• Partners cannot usually feel it 
• It has an antiseptic as well as contraceptive effect
• It can be easily removed on request

Disadvantages

•  It is invasive and requires insertion 
•  It can fall out
•  It may be a conduit to infection (however, this not supported by research)
•  There is an increased risk of ectopic pregnancy
•  There is a risk of uterine perforation at insertion 
•  There is a risk of pregnancy, approximately 1-2 pregnancies per 100 women using it
•  Menorrhagia can occur (although reduced menstrual flow usually occurs with the levonorgestrel IUCD and this is used to treat menorrhagia) 
•  If pregnancy occurs, the IUCD should be removed in the first trimester but that carries a risk of miscarriage, however, leaving removal the second trimester increases the risk of sepsis and premature labour. 

PSA Testing

PSA testing

PSA. 3 letters which give many GPs headaches. Men often come in requesting for PSA. The current stand by the college of GP from the Guidelines for preventive activities in general practice:

"Routine screening for prostate cancer with DRE, PSA or transabdominal ultrasound is not recommended.548-550 DRE has poor ability to detect prostate disease.551 Yet some cancers missed by PSA testing alone are detected by DRE,551 which is why those recommending screening advocate DRE as well as PSA."

"GPs need not raise this issue, but if men ask about prostate screening they need to be fully informed of the potential benefits, risks and uncertainties of prostate cancer testing.556When a patient chooses screening, both PSA and DRE should be performed."

It is a difficult topic to educate people on. Sometimes even doctors struggle to understand the statistics presented.

If the patient has already had PSA done in the past, I will just repeat them when they request for it. If they have never had it done before, I will try my best to explain the implication of having a PSA test. There are many resources out there which you can use to explain PSA test.

PSA decision card

PSA info graphic

My feeling is that this information is used in discourage people from having the test done. I don't think I have met any of my patients who actually understand the implication of the test. They often ask me after a good 10 minutes discussion, so "should I have it done?". But for the exam, we need to have a prepared approach in PSA testing, and make sure you take the college's stance.


References:
1. http://www.racgp.org.au/your-practice/guidelines/redbook/early-detection-of-cancers/prostate-cancer/
2. http://www.cancer.gov/types/prostate/psa-fact-sheet
3. http://www.usanz.org.au/uploads/65337/ufiles/PDF/6_PSA_decision_card_041007.pdf

Stomach cancer

Condition	Stomach cancer
Demographics	M: F 3:1 Risk factors: increase age, blood group A, smoking, atrophic gastritis
Murtagh Triad	Malaise + anorexia + dyspepsia + weight loss = stomach cancer Triple loss of appetite + weight + colour = stomach cancer
History features	Weight loss New symptoms > 40 years old  dyspepsia unresponsive to treatment  anorexia, nausea+/- vomiting  Dysphagia - late sign  Onset of anaemia
Examination	Epigastric mass Hepatomegaly - hard and irregular  Anaemia  Enlarged supraclavicular lymph node
Investigations	Gastroscopy
Management	Surgical excision  Chemotherapy  Usually poor prognosis

Depression

Condition	Depression
Demographics	10% of the population have significant depressive illness  Lifetime risk: 12% for men and 25% for women
Murtagh Triad	No Murtagh Triad but 2 questions particularly helpful : In the past month, have you been bothered by feeling down, depressed or hopeless? In the past month, have you often been bothered by little interest or pleasure in doing things?
History features	Trying to see whether the patient’s symptoms fit into the criteria of depression and also determine the severity.  It is also important to exclude other diagnoses, such as adjustment disorder, bipolar and psychotic depression.  **The most important thing is risk assessment** If you don’t ask this in the exam, you will definitely fail  Major Depression Diagnostic criteria
Examination	Mental state examination: Appearance: varies greatly depend on severity Behaviour: psychomotor retardation or agitation Mood: low  Affect: poor eye contact, tearful  Thought stream: normal to slow  Thought form: usually normal, sometimes blocking Thought content: guilt, worthlessness, hopeless, suicidal ideation Perception: Hallucination congruent with the depressive process Cognition: disordered, intact most of the time but disinterested Attention and concentration: may be poor
Investigations	Mainly to exclude organic causes. Suggested investigations: FBE, UEC, LFT, CRP, ESR, TSH, Vit D, Folate/B12  Objective measurement tool to assess depression: K10, DASS
Management	Non pharmacological treatment: Lifestyle changes (e.g. exercise, eat healthy), CBT (online or face to face) Pharmacological: SSRI (1st line), SNRI (2nd line), TCA (not recommended in elderly people), MAOI (specialist area)

The approach to Infertility

Key points:

• Infertility is a complex topic. GPs can start initial investigation and refer appropriately.
• Definition of infertility: absence of conception after a period of 12 months of normal unprotected sexual intercourse.
• In determining the cause of the sub fertility, three basic fertility parameters should be investigated:
• the right number of sperm have to be placed in the right place at the right time
• the woman must be ovulating 
• the tubes must be patent and the pelvis sufficiently healthy to enable fertilisation and implantation 

• Significant causes of infertility 
• Female factors
• Ovulation factors 
• Hypothalamic/pituitary disorders
• hyperprolactinaemia 
• other endocrine disorders
• ovarian failure (e.g. oocyte ageing)
• stress
• PCOS
• weight-related ovulation disorders
• idiopathic eugonadotropic anovulation 
• Tubal disease:
• PID
• endometriosis 
• previous ectopic pregnancy
• previous tubal ligation 
• previous peritonitis
• Uterine and cervical abnormalities
• congenital 
• acquired
• Endometriosis 
• Male factors
• Reduced sperm production 
• congenital cryptorchidism 
• inflammation (e.g. mumps orchitis)
• antispermatogenic agents
• chemotherapy 
• drugs
• irradiation 
• heat
• Idiopathic
• Klinefelter syndrome (46XXY)
• Sperm autoimmunity
• Hypothalamic pituitary disease
• hypogonadotropic disorder
• Disorders of coitus
• Erectile dysfunction 
• psychosexual ejaculatory failure
• retrograde ejaculation 
• genitourinary surgery 
• autonomic disorders (e.g. diabetes)
• congenital abnormalities
• Ductal obstruction 
• Couple factors
• joint sub fertility
• psychosexual dysfunction 

History to cover:

Female factors

Ovulatory function 

- Are her period regular? Cycles from 28-35 days are considered regular. Irregular cycles may indicate involution, with possible underlying causes including polycystic ovarian syndrome, hyperprolactinaemia, thyroid dysfunction and premature ovarian failure. 

- Is there inter menstrual bleeding?

Tubal function 

- Previous STD?

- Pelvic surgery for treatment of conditions such as ovarian cysts, fibroids or endometriosis

- Ruptured appendix

- IUD use

- Infection after previous termination pregnancy

- Severe dysmenorrhoea, dyspareunia or pelvic pain ? Clinical findings of suggestive of endometriosis include a fixed retrieved uterus, thickening of the uteros aural ligaments, cup-de-sac modularity or pelvic tenderness during examination

Male Factors

- Previous infertility, for example, in a previous relationship 

- Testicular injury, torsion, surgery or infection 

- Undescended testes 

- Varicocele

- Hernia or urinary tract surgery including vasectomy reversal 

- Sexually transmitted disease

- Impotence 

- Ejaculatory problems, for example, no ejaculation or retrograde ejaculation

- History of disease or illness that my affect fertility such as diabetes, cystic fibrosis or testicular involvement in mumps

- Drug therapy that may affect fertility such as chemotherapy and hormonal therapy including ETOH

• Medications that could affect fertility
• ETOH
• Chemotherapy
• Anabolic steroids
• Aminoglycoside abx
• Sulphasalazine
• Cimetidine/ranitidine
• Colchicine
• Spironolactone 
• Antihypertensive agents
• Narcotics
• Phenytoin
• Nitrofurantoin
• Nicotine
• Marijuana

Physical examination 

- Female: breast, abdominal and pelvic examination, pay particular attention of fibroids or ovarian cysts

- Male: if the sperm count is abnormal or there is a history of sexual problems

Investigations:

- Female: Pelvic ultrasound +/- hysterosalpingogram (HSG), ovulation may be confirmed by measurement of the serum progesterone level in the mid-luteal phase. If periods are irregular, 2-3 blood samples should be taken over two-week period. A high level of progesterone indicates the woman is ovulating.

- If not ovulating, measure LF, FSH and prolactin. Rubella immunity may be checked with the same blood sample. 

- High LH: FHS ratio may indicate polycystic ovarian syndrome. Elevated FSH may be a sign of approaching or premature menopause. A high prolactin level may be associated with pituitary micro adenoma. Marginally elevated prolactin may warrant a repeat test.

- Investigation of free androgen index may be of benefit if polycystic ovary syndrome is suspected

- TSH measurement may help. 

- urine specimen should be taken to exclude chlamydia 

Sperm assessment:

- A sperm count sample should be collected in a clean, non sterile jar, kept warm and taken to the pathologist within 1-2 hours 

- Semen analysis is normal if the count is more than 20 million/ml, motility is greater than 50 % and there are adequate normal forms. If the sperm count is abnormal, it should be repeated before conclusions are made. 

Advice to patients:

- Have sex at least every second day around the time of ovulation 

- Stop smmoking 

- Limit ETOH intake

- Avoid unnecessary medications; for example : NSAIDs may interfere with ovulation by blocking oocyte release 

- Eat a healthy diet

- Weight loss may increase chances of conception in obese people 

- Commence preconception folate therapy in the female  partner 

Referral:

- Women under 35 years in whom there is a lack of obvious pathology may be advised to keep trying of up to 12 months. Refer if conception has not occurred after 12 months. 

- Couples where the woman is over 35 years may be advised to persevere for no more than six months if investigations reveal correctable factors that can be managed in general practice, such as lifestyle changes. 

- Early referral is appropriate in women over 35 years with no apparent abnormalities because the influence of age of fertility; and in couples with abnormal results of investigations or whose history reveals risk factors for infertility

References: 

- John Murtagh General Practice 5th edition The subfertile couple 

- http://www.australiandoctor.com.au/clinical/therapy-update/investigating-infertility

- http://www.australiandoctor.com.au/cmspages/getfile.aspx?guid=0fd498f2-572c-4484-ac6f-16da37f733a9

Nail and hair disorder

Hair and nail disorder is something that is not very well covered in medical school. I don't even know where to start. I am hoping to have a simple approach to common hair and nail disorders which come through the door. Below is my attempt to understand hair and nail disorders a little more.

I found that John Murtagh's General practice to be a good point to start esp. the key facts and checkpoints:

• There are two types of hair: terminal hair, which is coarse and well pigmented and vellum hair, which is fine, soft and relatively unpigmented. 
• Alopecia is a generic term for hair loss
• Hair loss (alopecia) generates considerable anxiety and the fear of total hair loss should be addressed with the patient and a realistic prognosis given. 
• Androgenic alopecia is the most common cause of human hair loss, affecting 50% of men by age 40 and up to 50% women by age 60
• In telogen effluvium, the traumatic event has preceded the hair loss by about 2 months (peak loss at 4 months)
• Although severe stress could precipitate alopecia areata, day to day stressors are not considered to be a trigger. Stress seems to be a consequence of alopecia rather than the cause of it 
• Hair loss can be patchy or diffuse where it involves the entire scalp. 
• Patchy loss - alopecia aerate and trichotillomania 
• Generalised loss - telogen effluvium, systemic disease, drugs
• Alopecia areata has a poor prognosis if it begins in childhood, if there are several patches and there is loss of eyebrows or eyelashes. 
• Scarring alopecia can be an indicator of lupus erythematousus or lichen planus

Causes of diffuse hair loss

• Androgenetic alopecia
• Telogen effluvium
• Postpartum telogen effluvium 
• Alopecia areata 
• Drugs - cytotoxic and others
• Hypothyroidism
• Nutritional 
• Iron deficiency 
• Severe dieting
• Zinc deficiency
• Malnutrition 
• Post febrile state
• Anagen effluvium

Reference:

John Murtagh's general practice 5th edition 

Respiratory examination

My study for the day.......Respiratory examination from Clinical examination by Talley and O'Connor

• General inspection 
• Sputum mug contents (blood, pus etc)
• Type of cough
• Rate and depth of respiration, and breathing pattern at rest
• Accessory muscles of respiration 
• Hands
• Clubbing 
• cyanosis 
• Nicotine staining
• Wasting, weakness - finger abduction and adduction (lung cancer involving the brachial plexus)
• Wrist tenderness (hypertrophic pulmonary osteoarthropathy)
• Pulse (tachycardia; pulsus paradoxus)
• Flapping tremor (co2 narcosis)
• Face
• Eyes - Horner's syndrome (apical lung cancer)
• Mouth - central cyanosis 
• Voice - hoarseness (recurrent laryngeal nerve palsy)
• Chest posteriorly
• inspect 
• shape of chest and spine
• Scars
• Palpate
• Cervical lymph nodes 
• Expansion 
• Tactile femitus
• Percuss
• Supraclavicular region 
• Back
• Axillae
• Auscultate 
• Breath sounds
• Adventitious sounds
• Vocal resonance
• Chest anteriorly
• Inspect
• radiotherapy marks
• Other signs as noted above
• Palpate
• supraclavicular nodes
• Expansion 
• Tactile fremitus
• Percuss
• Auscultate
• Assessment of right heart failure 

Paediatric skin rash

It is a very common condition, and it is probably the most difficult to diagnose and manage. Fortunately, most of the time, they are self limiting.

Dr. Adrian Bonsall tried to put an end to this confusion. He developed this algorithm which was published in the Royal Children's Handbook.

This algorithm is quite self explanatory.

Professor Robin Marks also made an attempt in tackling this issue. He covers more than paediatric skin rash. His approach was referenced in John Murtagh's general practice.

He stated that most common dermatological problems fall into one of seven categories. If the rash dose not fall into these 7 categories, the person should be seen by a consultant dermatologist.

• Infections
• Bacterial: impetigo
• Viral 
• Warts
• Herpes simplex, herpex zoster
• Pityriasis rosea
• Exanthemata
• Fungal
• Tinea
• Candidiasis
• Pityriasis versicolor
• Acne
• Psoriasis
• Atopic dermatitis (eczema)
• Urticaria 
• Acute and chronic 
• Papular
• Pediculosis
• Scabies
• Insect bites
• Sun-related skin cancer
• Drug-related eruptions 

Cardiovascular Examination

What would you do when you have only 10 minutes per patient? GPs are often accused for not examining patients and expose patients properly. What would you do if you have 10 minutes per patient?

This 10 minutes include: history, examination, diagnosis, management, educate patient and follow up planning, and also documentation. GPs are supposed to do selective examination. It takes fair a bit of experience in order to do that.

Anyway, the following is the standard approach to a cardiovascular examination. It is what is expected for RACGP exam.

The following notes are from Talley and O'Connor. It is an Australian textbook and it is mainly written for physician trainees. It is a bit too much for a GP but it is what it is needed for the exam. I was once told by a medical registrar, he watched one of Talley and O'Connor's videos every night when he was preparing for the physician exam. That is how he fit his study around his family life and work.

Cardiovascular examination step by step as per Clinical Examination by Talley and O'Connor:

• General inspection (lying at 45 degrees)
• Dyspnoea
• Cyanosis
• Marfan's, Turner's Down syndromes
• Rheumatological disorders e.g. ankylosing spondylitis (aortic regurgitation)
• Acromegaly 
• Hands
• Clubbing 
• Stigmata of endocarditis
• Peripheral cyanosis 
• Pulses
• Rate and rhythm
• radial radial 
• radiofemoral delay (if there is a history of hypertension)
• Measurement of BP 
• estimating BP first by palpating radial pulse 
• Face
• Sclerae - pallor (anaemia), jaundice
• Xanthelasma
• Malar flush (mitral stenosis, pulmonary stenosis)
• Mouth
• Cyanosis 
• Palate (high arched - Marfan's)
• Dentition (risk of endocarditis)
• Neck 
• Jugular venous pressure 
• Central venous pressure height 
• Wave form (especially large V waves)
• Abdominojugular reflux test 
• Carotids - pulse character 
• precordium 
• Inspect
• Scars- whole chest, back 
• Deformity
• Apex beat - position, character
• Abnormal pulsations
• Palpate
• Apex beat 
• Character 
• Thrill or parastenal impulse 
• Auscultate
• Heart sounds
• Murmurs
• Position patient 
• Left lateral position 
• Sitting forward (forced expiratory apnoea)
• NB: palpate for thrills again after positioning
• Dynamic auscultation may be indicated (no GPs will do this)
• Respiratory phases 
• Valsalva
• Exercise (isometric e.g. hand grip)
• Standing 
• Squatting 
• Back (sitting forward)
• Scars, deformity 
• Sacral oedema 
• Pleural effusion (percuss)
• Left ventricular failure (auscultate)
• Abdomen (lying flat - 1 pillow only)
• palpate liver (pulsatile etc), spleen, aorta
• Percuss for ascites (right heart failure)
• Femoral arteries - palpate , auscultate
• Legs 
• Peripheral pulses
• Cyanosis, cold limbs, trophic changes, ulceration (peripheral vascular disease)
• Oedema
• Xanthomata
• Calf tenderness
• Clubbing of toes

Here you go. If you have 10 - 15 minutes to study, consider watching one of the examination videos. I always pick up a few things every time I watch it. 

https://youtu.be/Gi0FzMzyJbA?list=PLD30A9F834AD276C9

Reference:

Clinical examination by Talley and O'Connor 

Fitness to drive assessment

Fitness to drive assessment is always difficult. Patients usually walk in with a smile asking you for a fitness to drive assessment. If you fail them, they become very angry and you and your patient's relationship can turn 360 just in 5 minutes. 

However, we do have the obligation to protect the community against incompetent drivers. There is a check program in 2012 dedicated to fitness to drive.

Should you allow a person with dementia to drive?

The diagnosis of dementia does not equal to a immediate ban to driving. It will depend on the severity of dementia. Most of them will have to give up driving in the near future. For those who are still at the very early stage, careful physical examination and referral to a fitness to drive by an OT is required. 

How about people with mental health illness?

People with mental health illness (especially schizophrenia, bipolar, depression and substance abuse) are at higher risks of involving in car accidents compared to the normal population. People with bipolar may not be suitable to drive a commercial vehicle and requires careful assessment before granting the permission to drive a private vehicle. 

How often do you need to review diabetics in regards to fitness to drive assessment?

Diabetics who are on diet alone treatment may be eligible for an unrestricted licence. 

Diabetics who are on oral hypoglycaemic agents may require 5 yearly review with a notification to DLA. 

Diabetics who are on insulin may require 2 yearly review with a notification to DLA. 

What should you do after a hypoglycaemic event?

The person should not drive for 6 weeks and may require a specialist opinion. 

Why is assessing elderly people for fitness to drive is difficult and how would you tackle those difficulties ?

Multiple medical co-morbidities, aged related changes leading to slow reaction time, poor mobility, hearing impairment and impaired vision. 

In country area, they often rely on their licence to shop and visit friends. Removing their licences may increase their social isolation. As pedestrians, they also have at high risks of getting hit by cars. 

Other management options: taxi card, get family members to drive them and conditional licence to drive within 5km radius. 

Here is the summary key points to help GPs in assessing patients fitness to drive:

References:

1. RACGP Check program 2012 fitness to drive. 

What does it actually feel like being a GP registrar?

The longer you are in medicine, the more you realise that the most important thing is not patient care. Good patient care in Australia is not going to get you anywhere in life.

First of all, medicare is not going to reward you by providing good quality care. They reward you by the number of patients you see and the number of procedures you do.

Secondly, no one cares about the quality of care you provide. They worry about what is actually being written down - aka your CV. You can spend a lot of time doing what is deemed good patient care but at the end of the day, in order to enter training program, you really need a good CV. You can't spend most of your energy and time just looking after patients, the focus needs to be on building your CV and getting to know the bosses. As I observe frequently, doctors who don't put their CVs as priority, they often fall behind.

Enough of my whinge. If you want to be ahead, don't put too much focus on treating patients and shift your focus on your CV and exam.

Approach to deafness and hearing loss

Key points:

- Deafness may be conductive, sensorineural or a combination of both (mixed).

- deafness occurs at all ages but is more common in the elderly. Fifty per cent of people over 80 years have deafness severe enough to be helped by a hearing aid.

- The threshold o normal hearing is from 0 to 20 decibels, about the loudness of a soft whisper.

- One in seven of the adult population suffers from some degree of significant hearing impairment

- One child in every 1000 is born with a significant hearing loss

- Degrees of hearing impairment:
--- mild = loss of 20-40 dB (20 dB is soft-spoken voice)
--- moderate = loss of 40 - 70 dB (40 dB is normal spoken voice)
--- severe = loss of 70-90 dB (shout)
--- profound = loss of over 90 dB

- More women than men have a hearing loss

- People who have worked in a high-noise levels (>85dB) are more than twice as likely to be deaf

- There is a related incidence of tinnitus with deafness

- It is useful to consider the causes of deafness in terms of pathophysiology (conductive or sensorineural hearing loss) and anatomical sites

- Diagnostic strategy model

• Probability diagnosis 
• Impacted cerumen
• Serous otitis media 
• Otitis externa
• Congenital 
• Presbyacusis 
• Serious disorders not to be missed
• Neoplasia
• acoustic neuroma
• temporal lobe tumours (bilateral)
• otic tumours
• Severe infections
• generalised infections (e.g. mumps, measles)
• meningitis
• syphilis
• perforated tympanic membrane
• cholesteatoma
• Perilymphatic fistula 
• Meniere syndrome
• Pitfalls (often missed)
• Foreign body
• Temporal bone fracture
• Otosclerosis
• Barotrauma
• Noise-induced deafness
• Rarities
• paget disease of bone 
• multiple sclerosis 
• osteogenesis imperfecta 

- When to refer 

• sudden deafness
• any child with suspected deafness, including poor speech and learning problems, should be referred to an audiology centre
• Any child with middle-ear pathology and hearing loss should be referred to a specialist
• Unexplained deafness

Reference:

John Murtagh General practice 5th edition 

Dermatoscopy

Key points:

- Skin cancer is common in Australia and GPs need to be competent in assessing skin lesions.

- The use of a dermatosope in clinical practice has been shown to increase diagnostic accuracy and is considered the standard of care in assessing patients with pigmented skin lesions.

- All visible lesions that cannot be confidently diagnosed should be examined with a dermatoscope.

- Dermatoscope is more than a magnifying lens and light source. By eliminating reflection from the skin surface, the dermatoscope allows better visualisation of the patterns formed by pigment and blood vessels - critical features in the diagnosis of skin lesions. (Try to get one if you don't have one already)

- There are many different methods in analysing a pigmented lesions. (CASH, the ABCD method of dermatoscopy, the 7-point checklist, the Menzies method, the 3 point checklist, the revised pattern analysis and a short modification of revised pattern analysis called 'chaos and clues'.

- The method I learned is called Chaos and Clues.

- First, we need to learn how to describe pigmented structures, which are objectively defined using the following geometric terms:

• Line: a two dimensional continuous object with length greatly exceeding with 
• Pseudopod: a line with a bulbous end
• Circle: a curved line equidistant from a central point
• Clod: any well circumscribed, solid object larger than a dot; clods may take any shape
• Dot: an object too small to have a discernible shape 
• Lines are further classified into 5 types: reticular, branched, parallel, radial and curved, as these have diagnostic significance

- Blood vessels can be described the same way:

- Colour has great diagnostic significance in dermatoscopy. The main pigments are melanin and haemoglobin, and the colours produced are shown :

- The chaos and clues algorithm:

• The first step is to dermatoscopically assess the pigmented lesion for 'chaos', defined as asymmetry of structure or colour'. Chaos is assessed by pattern not shape. As perfect symmetry is biologically rare, some deviation from geometrical symmetry must be expected. It is helpful to imagine a piece of carpet that can be cut in any shape but which maintains uniform pattern.  It would be regarded as having no chaos regardless of how irregular the shape was and regardless of the presence of a little dust on one part. 
• If chaos are identified, look for clues. 
• As for all the algorithms, there are always exceptions: beware of dermatoscopic grey on head or neck, pigmented nodular lesions, parallel ridge pattern (palms or soles)

- As with many things in life, they don't come easily. It takes a lot of time to practice, practice and practice. If in doubt, do a biopsy. (Spoke to a surgeon in the past, he told me that he has never regretted taken out a normal appendix but he always regret on the ones which he didn't. Biopsy rarely results in major harms but melanoma kills.)

Reference:

1. Dermatoscopy in routine practice 'Chaos and Clues'. Australian Family Physician. 2012. 

Gout

Key points:

1. Gout is the most common inflammatory arthritis with a prevalence of about 2% in Australasia.
2. Key steps in the development of gout are 1)chronic hyperuricemia 2) monosodium rate monohydrate 3)interaction between the crystals and the inflammatory system, which is primarily responsible for the clinical features. 
3. Definition of hyperuricemia: serum rate level > 0.42
4. Hyperuricemia is caused by medications and genetic predisposition
5. Only 20% of patients with hyperuricemia develop gout 
6. Definite diagnosis can only be achieved via synovial fluid analysis. This needs to be done before recommending hypouricemic drug therapy.
7. Management of acute gout:
   
   8. There is an increase risk of gout when the patient is started on rate lowering therapy. Patients can be started on low dose colchicine 0.5 mg daily or daily NSAID or 5mg prednisolone. Usually prophylaxis is required for around 3-6 months.
   
   
   9. Serum rate target is less than 0.36 mmol/L, however for patients with a large rate crystal load (as reflected by the presence of tophi) erosions or chronic joint deformity due to gout, the target is a serum rate of less than 0.3 mol/L
   
   
   10. Diet and lifestyle modification alone usually is inadequate to lower serum urate level.
   
   
   11. Allopurinal hypersensitivity syndrome occurs with greater frequency in the setting of renal insufficiency, advanced age, HLA B58:01 positivity and higher initial doses but can occur in their absence. The syndrome usually occurs in the first 12 weeks of exposure, and thus the development of rash during this period should prompt immediate cessation of allopurinol, assessment of liver and renal function, and for the possibility of hypersensitivity. 
   
   
   12.Probenecid is another agent which can be used as rate lowering agent. But the patient needs to have renal function > 30-40ml/min. Because of the marked increase in urinary uric acid in the early phase of treatment, good hydration and urinary alkalisation are appropriate. 
   
   
   
   
   
   
   

Osteoporosis

Key points:

- Osteoporosis is under-recognised and under-treated, even in people who present with a minimal trauma fracture.

- A minimal trauma fracture is sufficient for a presumptive diagnosis of osteoporosis medicines can start prior to obtaining BMD results with dual energy x-ray absorptiometry (DXA).

- Guidelines recommend risk factor assessment and that modifiable risk factors be addressed in all postmenopausal women aged >45 years and men aged > 50 years.

- A full diagnostic investigation is indicated for:

• women> 50 YEARS and men> 60 years with other clinical risk factors 
• Patients > 45 years with a minimal trauma fracture or suspected vertebral fracture 
• patients who have causes of secondary osteoporosis (medical conditions or medicines such as long-term, high-dose corticosteroids)
• adults aged over 70 years 

- Clinical risk factors (CRFs), use the mneumonic of shattered 

Previous minimal trauma fracture, family history 

• S: steroid use (oral corticosteroid use > 5mg/day)
• H: hyperthyroidism, hyper parathyroidism and hypercalciuria 
• A: Alcohol and tobacco use 
• T: Thin (BMI < 22)
• T: Testosteron decrease (e.g. anti androgen ca, prostate Rx)
• E: Early menopause 
• R: renal or liver failure 
• E: Erosive/inflammatory bone disease (e.g. myeloma or rheumatoid arthritis)
• D: Dietary Calcium decrease/malabsorption , DM1 

- The strongest risk factor is age > 70. Peak bone mass is achieved by age 30. Bone loss occurs steadily from the age of about 40, with accelerated loss in perimenopausal period (4-6%) before slowing again after the age of 70 (1-2% per year).

- Basic investigations: DEXA, Ca, PO, ALP, FBE, UEC, LFT, myeloma screen if indicated

• Hip bone mineral density best predictor for hip fracture
• Lumbar spine bone mineral density best for monitoring treatment effect
• 
  

- Management:

• lifestyle measures
• quit smoking and reduce ETOH consumption 
• Weight bearing exercise may increase bone mineral density 
• Balance exercises such as tai chi reduce risk of falls 
• Calcium and vitamin D supplements 
• recommended dietary intake of calcium is between 1000 and 1300 mg per day, depending on age and sex
• Most Australians do not reach the recommended dietary intake so daily supplements of 500-600 mg of calcium are sometimes needed
• Safety of calcium is still a controversial topic as there is evidence that it may increase risks of MI
• Home based fall prevention program, with visual assessment and a home visit
• Medications 
• Bisphosphonates and Denosumab
• Criteria: minimal trauma fracture or age > 70 with T score <=-2.5
• Bisphosphonates: well tolerated, some significant side effects: oesophageal cancer? (not proven), osteonecrosis of the jaw (see dentist prior to commence treatment) and do not use with the other antiresorptive or anabolic agents
•  Denosumab: use with caution in patients with severely impaired kidney function as denosumab may exacerbate hypocalcaemia 
• Raloxifene 
• postmenopausal woman with a minimal trauma fracture and risk of vertebral fractures predominatly
• reduces vertebral fracture but not non vertebral fractures in postmenopausal women
• Reduces risk of breast cancer so suitable for women at high breast cancer risk
• Associated with increased risk of DVT or pulmonary embolism in meta-analyses
• Strontium ranelate
• Criteria: unable to tolerate other medications or contraindicated to other medications
• assess patient risk of developing CVD before treatment due to safety concerns in patients with history of CVD, embolism or stroke 
• Teriparatide 
• Reduces vertebral and non - vertebral fractures in postmenopausal women 
• limited evidence in men
• must be initiated by a consultant physician
• Vitamin D deficiency
• 600 IU per day for people under 70
• 800 IU per day of people over 70 
• 1000-2000 IU per day may be required for sun avoiders or those at high risk of deficiency
• Monitor treatment response and review therapy to encourage adherence
• BMD measurements 2 years after the commencement of therapy or 1-2 years after therapy changes significantly