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)