1. In a 3 year old child with signs and symptoms suggestive of bacterial meningitis, which of the following is the BEST initial management? a) Erythromycin IV b) Gentamicin IV c) Ceftriaxone IV Correct d) Phenoxymethylpenicillin oral e) Amoxycillin oral If bacterial meningitis is suspected clinically it is vital to immediately administer an appropriate antibiotic prior to urgent transfer to hospital, as meningococcal meningitis may be rapidly fatal. The drug of choice would be benzylpenicillin 60mg/kg up to 3g IV or IM, or ceftriaxone 50mg/kg up to 2g IV in patients hypersensitive to penicillin or when further drug treatment may be delayed. (Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 378-379 ) 2. Which of the following statements regarding undescended testes is CORRECT? a) The testes are undescended at birth in 40% of boys. b) Once the testis is palpable in the scrotum it will remain so. c) Descent is unlikely to occur after 1 year of age. Correct d) Orchidopexy should be delayed until late childhood. e) The undescended testis is at reduced risk of malignancy. Testes which are undescended at birth may well descend into the scrotum during the first two weeks of life, however descent is unlikely to take place after the age of one year. 2% of boys born at full-term, and 20% of premature males, have undescended testes. A testis which was palpable in the scrotum in infancy may ascend and become impalpable due to failure of the spermatic cord to elongate at the same rate as body growth. Orchidopexy is best performed by 12-18 months of age as spermatogenesis in the undescended testis is impaired after the age of two years. The undescended testis is at 5-10 times greater risk of developing malignancy (seminoma). (Murtagh, J. (1997), General Practice, Third Edition McGraw-Hill, Sydney, Chap 102, p 1076-7 ) (Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 251-252 ) A 34 year old woman presents with an acutely painful swollen knee. Synovial fluid aspirate shows the following: · · · · WCC 4100/uL (NR < 2000/uL), 80% polymorphonuclear lymphocytes red blood cells ++ no crystals no organisms cultured -What is your interpretation of these results? a) Inflammation is more likely Correct b) Gonococcal arthritis c) Viral arthritis d) Tuberculous arthritis e) Traumatic tap Normal synovial fluid contains less than 2000 white blood cells per microlitre. Inflammation causes counts of 3000 or higher. Inflammation can also cause red blood cells to migrate into the joint fluid. Viral arthritis - usually symmetrical polyarthritis, predominantly lymphocytic effusion TB arthritis - chronic presentation with WCC >10,000/uL, 50% PMNLs, culture positive in 50% Gonococcal arthritis - WCC >10-20,000/uL (Ma, D.T.S., Carroll, G.J, Monoarthropathy Could this be infection?, Australian Family Physician, vol 27 (1/2) p 29-31 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=95832 ) Concerning prostate cancer, which ONE of the following is INCORRECT? a) The majority of carcinomas arise in the peripheral zone of the gland b) The prostate specific antigen (PSA) is elevated in all prostate cancers greater than 1.5 cm c) If metastasis occurs, pelvic lymph nodes are involved early Incorrect. The correct answer is (b). d) Radionuclide bone scan is a sensitive but not specific method of detecting bony metastases e) Prostate cancers usually appear as hypoechoic nodules on transrectal ultrasound A normal PSA occurs in up to 20% of cancers, including tumours greater than 1.5 cm. Prostate cancer is the second most common cause of cancer deaths in men in Australia. The majority of prostate cancers- usually adenocarcinomas- arise in the peripheral zone of the gland, and metastasise early to pelvic lymph nodes. Bony metastases are also common. Bone scan is unreliable at detecting bony metastases when the prostate specific antigen (PSA) is 8yrs who have had the initial course. It is recommended for children 15-17 yrs of age, parents planning their first pregnancy, adults working with young children or at 50 years of age. Babies under 2 months of age who have been exposed are best vaccinated early. Passive immunisation with pertussis immunoglobulin is not effective in the prevention of pertussis. Isolation is not required for household contacts. (NHMRC (2000). The Australian Immunisation Handbook. Seventh Edition. Australian Government Publishing Service ) (Sturmberg, J. P. (1999), Could it be whooping cough?, Australian Family Physician, vol 28, no 2, February, p129-31 ) (Merck Manual Available: www.merck.com/mrkshared/mmanual/section19/chapter265/265a.jsp ) * Question 20 Aidan, a 3 month old boy, presents with paroxysms of coughing associated with cyanosis, lethargy and poor feeding for several days. On examination, between episodes of coughing, he is afebrile and examination is normal. What is the NEXT step in management? a) Admission to hospital Correct b) Nasopharyngeal aspirate and review in 24 hours c) Immunisation at this visit with DTP and review in 24 hours d) Erythromycin syrup and review in 24 hours e) Trial of salbutamol by mask The clinical picture suggests respiratory infection with Bordetella pertussis. The history of cyanosis associated with the coughing suggests the need for admission to hospital but, in addition, children under 6 months of age usually require admission for pertussis because of the risk of complications. Complications include respiratory arrest, bacterial pneumonia and encephalitis. Salbutamol has not been shown to be helpful in a child of this age and is of no benefit. Immunisation at a later date should be encouraged even if the child has had pertussis. Erythromycin is not curative but may reduce infectivity. (Sturmberg, J. P. (1999), Could it be whooping cough?, Australian Family Physician, vol 28, no 2, February, p129-31 ) (Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, Chap 81, p 909-910 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=70757&searchStr=whooping+cough#searc hTerm ) (Merck Manual Available: www.merck.com/mrkshared/mmanual/section19/chapter265/265a.jsp ) Question 19 Arthur is a 74 year old man who presents reluctantly because his wife feels 'he has not been himself since he came home and is not sleeping properly.' His appetite is poor and he has lost 6 kg in weight since discharge from hospital eight weeks ago following treatment for myocardial infarction. He has lost interest in his hobbies and is not taking his medications. He has been a type 2 diabetic for 12 years. On examination he shows signs of mild cardiac failure. The result of an HbA1C test is 10.5% (target