Build and attempt quizzes

A 46-year-old woman presents to your general practice after noticing a small lump in the front of her neck while applying skincare. She feels well and denies heat/cold intolerance, weight change, palpitations, tremor, change in bowel habit, or lethargy.

She has no history of head and neck irradiation, and no family history of thyroid cancer or MEN2. She is a non-smoker. There is no recent upper respiratory infection.

On examination, you palpate a solitary, firm, mobile 1.8 cm nodule in the right thyroid lobe. There is no cervical lymphadenopathy. Her voice is normal. There is no stridor and she denies dysphagia or dyspnoea. Cardiovascular and neurological examinations are unremarkable.

You are planning the most appropriate next step in evaluation in general practice.

Which option is most appropriate?

A 56-year-old Aboriginal man presents to your small rural general practice (nearest hospital with inpatient beds is 180 km away; limited imaging on site). He has had 2 days of worsening shortness of breath, productive cough with yellow-green sputum, and pleuritic right-sided chest pain. His partner drove him in because he “couldn’t catch his breath” overnight.

Background

• Lives on Country with extended family; limited transport and mobile reception at home.
• Smokes ~20 cigarettes/day; drinks 2–3 beers most nights.
• Past history: “chest infections” most winters; no formal COPD diagnosis recorded. Type 2 diabetes (on metformin). Hypertension (on perindopril). No known drug allergies.
• Vaccines: unsure about influenza/pneumococcal; last flu vaccine “a few years ago”.
• Medications today: metformin, perindopril; no regular inhalers.

Focused examination

• Looks unwell, sitting forward, speaking in short phrases, using accessory muscles.
• Vitals: SpO2 88% on room air, RR 30/min, HR 118/min, BP 105/65 mmHg, T 38.7°C.
• Chest: coarse crackles and reduced air entry at right base; no audible wheeze.
• Cardiac: tachycardic, no murmurs. No calf swelling.

Available in clinic

• Oxygen, nebuliser, IV cannulation/fluids, IM/IV antibiotics.
• Point-of-care: capillary glucose, urine dip, ECG; no onsite CXR today (mobile service visits weekly). Limited pathology pickup (results next day).

He says he refuses hospital transfer: “I don’t want to go to the city. Last time I was treated bad and no one explained things.” He asks for “something to take at home”.

Select THREE actions that form an appropriate management plan focused on managing acuity and facilitating safe transfer (or safe management if he refuses).

Case

A 42-year-old Aboriginal man presents to your regional general practice with 2 days of worsening shortness of breath, pleuritic right-sided chest pain and fevers. He has had a productive cough with rust-coloured sputum since yesterday. He says he is “getting puffed just talking”.

Background: Type 2 diabetes, COPD (smokes 20/day), chronic kidney disease stage 3. No regular preventer inhaler use. Lives with extended family. He reports a previous hospital admission where he felt “not listened to”, and he is reluctant to go back to hospital.

Observations: T 38.8°C, HR 118 bpm, BP 98/62 mmHg, RR 32/min, SpO2 86% on room air (rises to 90% on 8 L/min oxygen via simple face mask). He is drowsy but rousable and can answer questions in short phrases.

Examination: Using accessory muscles, central cyanosis, reduced breath sounds and coarse crackles at the right base. No wheeze. Capillary refill 4 seconds. Mild confusion (not oriented to date). No peripheral oedema.

Immediate investigations available in clinic:

• Point-of-care glucose 18 mmol/L
• ECG: sinus tachycardia
• Peak flow not reliable due to breathlessness

You are concerned about severe community-acquired pneumonia with sepsis and impending respiratory failure. When you recommend going to hospital, he says, “No way. I want to go home. Hospitals treat me bad.” His adult sister is in the waiting room.

Question

Which single management plan is most appropriate at this point?

Case

Mr Brown, aged 65 years, presents for a routine review. He reports intermittent palpitations over the past 2 months but no chest pain or syncope. His past history includes hypertension (treated) and no known diabetes, stroke/TIA, heart failure, or vascular disease.

Current medications: perindopril 5 mg daily.

On examination: BP 138/84 mmHg, irregularly irregular pulse 118 bpm, SpO2 98% RA, afebrile. Cardiovascular and respiratory examination is otherwise unremarkable.

ECG in the clinic shows an irregularly irregular narrow-complex tachycardia with absent P waves, consistent with atrial fibrillation. This is presumed to be persistent AF (symptoms for >7 days, not clearly self-terminating).

CHA2DS2-VA factors identified today: age 65–74 years (1), hypertension (1).

Question

According to eTG, which three of the following are major complications associated with atrial fibrillation?

Select 3 options.

A 52-year-old woman presents to your GP clinic with a 5-day history of fever, productive cough (yellow sputum) and shortness of breath on exertion. She has mild pleuritic right-sided chest pain. She has no history of COPD or asthma and is a non-smoker.

On examination, she looks mildly unwell.

• Vitals: T 38.3 °C, HR 102 bpm, BP 118/72 mmHg, RR 22/min, SpO2 94% on room air
• Chest exam: reduced air entry and crackles over the right mid-zone anteriorly; no wheeze

A chest X-ray report describes: air-space opacity in the right mid-zone that obscures the right heart border, with air bronchograms and no pleural effusion.

Which is the most likely radiographic interpretation?

Leonard, a 43-year-old man with no significant past medical history, presents to your clinic. He reports waking up this morning with a sudden, painless weakness on the left side of his face. On examination, he has drooping of the left side of his mouth and is unable to fully close his left eye. He is also unable to wrinkle the left side of his forehead. The remainder of his neurological examination is normal.

What is the most appropriate next step to confirm the most likely diagnosis?

A 62-year-old man presents to your general practice with a 30-minute history of central, crushing chest pain radiating to his jaw. He is a current smoker with a history of type 2 diabetes.

On examination, he appears pale and diaphoretic. His blood pressure is 140/90 mmHg, heart rate is 95 bpm, respiratory rate is 20 breaths/min, and oxygen saturation is 96% on room air. He reports taking one spray of his own glyceryl trinitrate (GTN) 10 minutes ago with minimal relief. You have called an ambulance, which has an estimated arrival time of 15-20 minutes. An in-clinic ECG is not available.

From the options provided, what are the three most important initial actions to take while awaiting the ambulance?

A 32-year-old woman with a moderate intellectual disability is brought to your GP clinic by a support worker from her group home. The support worker reports that over the past 10 days she has become more withdrawn and has had two episodes of shouting at other residents. This is a change from her usual behaviour; she is normally sociable, enjoys music group twice a week, and follows a consistent routine.

Her baseline communication is short phrases and yes/no answers. She uses a picture-based communication book at the group home. Today she is sitting quietly, avoiding eye contact, and repeatedly rubbing her lower abdomen. She appears tense but not agitated. No injuries are visible. The support worker has her current medication list: sodium valproate and sertraline. Past history includes epilepsy and chronic constipation.

The support worker is prepared to answer questions and asks if you can “just talk to me because she won’t understand.” The patient is accompanied, alert, and looks at you when you introduce yourself.

Which is the most appropriate approach to begin history taking in this consultation?