EDUCATION Clinical challenge

Questions for this month’s clinical challenge are based on articles in this issue. The style and scope of questions is

in keeping with the MCQ of the College Fellowship exam. The quiz is endorsed by the RACGP Quality Assurance and

Continuing Professional Development Program and has been allocated 4 CPD points per issue. Answers to this clinical

challenge will be published next month, and are available immediately following successful completion online at:

www.racgp.org.au/clinicalchallenge.

Jenni Parsons

SINGLE COMPLETION ITEMS

DIRECTIONS

Each of the questions or incomplete statements below is followed by five

suggested answers or completions. Select the most appropriate statement as your answer.

EDUCATION

Clinical challenge

Reprinted from Australian Family Physician

Vol. 35, No. 6, June 2006

433

Case 1 – Renee Baker

Renee, age 22 years, has insulin

dependent diabetes managed with 4 times

per day insulin injections (usually 8 units

of short acting before meals and 20 units

of intermediate acting before bed).

Question 1

Renee calls to request a certificate for work.

She has had severe vomiting overnight.

She has been able to drink some water this

morning without vomiting but doesn’t want to

eat anything yet. Her blood sugar level (BSL)

is 14 mmol/L. She asks what she should do

with her insulin dose. You advise her to

monitor her BSL 2 hourly and:

A. cease her insulin until she is eating nor

mally again

B. reduce her insulin dose by half until she is

eating again

C. reduce insulin by about 25%

D. take her normal insulin dose

E. increase her insulin dose by about 25% as

sugars tend to go up with illness.

Question 2

Renee has no fever and thinks the seafood

she ate last night caused her symptoms. Her

boyfriend ate the same and is also suffering!

She asks you what fluids she should drink.

You advise her:

A. to only drink water as diabetics should not

drink lemonade

B. to drink water if her BSL is >15 and sweet

ened fluids if her BSL drops <15

C. to drink full strength lemonade irrespective

of BSL

D. to avoid drinking at all for a few hours until

she is sure the vomiting has settled

E. she needs hospital admission for IV fluids.

Question 3

You ask Renee to come and see you later

in the day and in the interim to monitor her

ketone levels. If Renee’s urine shows small

ketones or greater:

Question 2

Choose the correct statement regarding

physiological changes that may be affecting

Courtney’s diabetes.

A. insulin resistance increases during adoles

cence

B. there is no evidence that glycaemia is

affected by the menstrual cycle

C. overnight growth hormone secretion

decrease during adolescence making morn-

ing hypoglycaemia more likely

D. insulin resistance decreases during adoles

cence

E. insulin dosage requirement decreases rela

tive to body weight.

Question 3

Courtney is a keen swimmer and does squad

training three times per week. She tells you

that sometimes she gets ‘a hypo’ toward the

end of training. She also asks whether she can

get you to sign a medical form for her to learn

scuba diving. Choose the correct statement:

A. Courtney should be actively encouraged to

go scuba diving as exercise is beneficial in

managing diabetes

B. Courtney should not swim as a ‘hypo’ in the

water is dangerous

C. reducing her insulin dose before her regular

swim may be helpful

D. Courtney is at risk of hypoglycaemia during

the swim but not after the swim finishes

E. exercise when ketotic is recommended to

decrease associated hyperglycaemia.

Question 4

You undertake HEADSS screening with

Courtney and find out that she ‘usually’ uses

condoms but has had unprotected inter-

course ‘a couple of times’ in the context

of high alcohol consumption. She has also

taken ecstasy at a dance party. She is some-

times unsure if she is ‘out of it’ or ‘having a

hypo’. Choose the correct statement:

A. she should reduce her insulin dose

B. she requires a higher insulin dose

C. this is likely to be caused by dehydration

and requires no change in insulin dose

D. she needs immediate hospital admission

E. the presence of urinary ketones is normal

for diabetic patients.

Question 4

When Renee comes to see you later in the day

her condition has deteriorated. She has had

persistent severe vomiting and hasn’t been

able to tolerate oral fluids for 4 hours. She

has moderate ketones and her BSL is 23.1.

The best course of action at this stage is to:

A. arrange transfer to emergency department

or local hospital admission

B. give a maxolon injection and send her home

on usual therapy

C. give a maxolon injection and increase insu

lin dose by 20%

D. give a maxolon injection and decrease insu

lin dose by 20%

E. give sweetened oral fluids and double the

insulin dose.

Case 2 – Courtney Mortensen

Courtney is 15 years of age and has had

insulin dependant diabetes since the age

of 6 years. Until the past 12 months her

metabolic control has been good. She also

has mild episodic asthma.

Question 1

Courtney attends for an URTI and exac-

erbation of asthma. From her records you

note that her most recent HbA1c is 8.5%.

Possible reasons for deteriorating control

may include:

A. erratic meal and exercise patterns and poor

adherence to therapy

B. risk taking behaviour

C. A and B

D. endocrine changes associated with puberty

E. all of the above.

Clinical challenge

EDUCATION

434

Reprinted from Australian Family Physician

Vol. 35, No. 6, June 2006

A. the combined oral contraceptive pill (COCP)

is contraindicated in diabetics

B. Courtney is at lowered risk of pregnancy

because diabetes decreases fertility

C. telling Courtney not to drink alcohol or take

drugs is likely to lead to a change in behav-

iour

D. you advise Courtney to have a meal before

going out and check her sugars during the

night and before bed

E. although Courtney needs contraception you

can’t prescribe the COCP because she is 15

years of age.

Case 3 – Stan Katsoris

Stan, 54 years of age, has recently been

diagnosed with type 2 diabetes. He has

done well in modifying his behaviour.

He has given up smoking, walks for 30

minutes per day and is trying hard to eat

low fat and low glycaemic index foods.

Question 1

At his 6 month review, Stan’s HbA1c is 8.1,

his blood pressure 150/90 mmHg and his BMI

29. You talk to him about commencing met-

formin. You tell him:

A. metformin is commonly associated with

hypoglycaemic episodes

B. metformin improves glycaemia but does not

reduce the risk of macrovascular complica-

tions

C. metformin increases insulin secretion

D. lactic acidosis is a serious but uncommon

side effect

E. the usual starting dose is 1 g twice per day.

Question 2

Stan tolerates metformin well, and contin-

ues with his diet and exercise but his blood

pressure remains around 150/90 mmHg and

his total cholesterol 6.1 with an HDL of 1.2.

Choose the correct statement:

A. an angiotensin converting enzyme (ACE)

inhibitor will reduce blood pressure but not

microvascular complication risk

B. Stan qualifies for statin therapy under PBS

criteria

C. Stan should not be prescribed a statin as he

does not qualify under the PBS

D. if Stan has microalbuniuria then an ACE

inhibitor is contraindicated

E. if Stan has a heart attack he will then quali

fy for a statin under PBS criteria.

Question 2

You discuss GD with Indira. She asks why

she needs to be tested as she wasn’t tested

in either of her previous pregnancies. You

tell her:

A. GD is associated with serious adverse peri

natal effects

B. appropriate treatment of GD decreases

perinatal risks

C. there is clear cut evidence about what

degree of hyperglycaemia on a GTT is

abnormal

D. all of the above

E. A and B are correct.

Question 3

Indira is diagnosed with GD at 26 weeks

gestation. You discuss management with

her. You tell her:

A. carbohydrates should be spread through

out the day and be of low glycaemic index

B. exercise, while beneficial, has no impact on

blood glucose levels

C. the goal for fasting BSL is <6.7 mmol/L and

for 2 hours postprandial is <8.0 mmol/L

D. metformin does not cross the placenta and

is first line therapy

E. insulin is commenced only when dietary

therapy and metformin have failed.

Question 4

What follow up is required for Indira after

her pregnancy?

A. she should have a GTT 2–4 months

postpartum

B. she should be encouraged to follow a

healthy diet, maintain BMI of 20–25 and

exercise regularly

C. she should be aware of and report symp

toms of hyperglycaemia

D. all of the above

E. no follow up required.

Question 3

Five years later Stan is taking metformin and

a sulphonyluria, but his HbA1c has gradually

crept up again and is now 7.9 %. Stan is not

keen on insulin therapy. You decide to main-

tain both his current hypoglycaemic agents

and add in glitazone therapy. Choose the

correct response:

A. pioglitazone is available on PBS authority in

Stan’s situation

B. rosiglitazone is available on PBS authority

in Stan’s situation

C. peripheral oedema and weight gain are

side effects and liver function needs to be

monitored

D. B and C are correct

E. all of the above are correct.

Question 4

In patients such as Stan who go on to

require insulin therapy:

A. all oral hypoglycaemic agents need to be

ceased

B. a typical starting regimen would be 0.1–0.2

units/kg of intermediate acting insulin at

night

C. as there is likely to be insulin resistance

a starting dose of over 1 unit/kg/day is

required

D. glitazones would usually be ceased but

metformin and sulphonylurea continued

E. metformin would usually be ceased and

sulphonylurea continued.

Case 4 – Indira Gupta

Indira Gupta, aged 36 years, attends for

confirmation of third pregnancy at 8

weeks gestation. She has two children,

both born in India before she moved to

Australia, and she tells you they were

both big babies. Her mother has type 2

diabetes.

Question 1

You would screen Indira for gestational

diabetes (GD):

A. with a 50 g glucose challenge test (GCT)

now

B. with a 75 g glucose tolerance test (GTT)

now

C. with a 50 g GCT at 28 weeks

D. with a 75 g GTT at 28 weeks

E. only if she developed glucosuria or abnor

mal fetal growth.

CORRESPONDENCE

email: [email protected]

Clinical challenge

EDUCATION

Reprinted from Australian Family Physician

Vol. 35, No. 6, June 2006

435

Case 1 – Ernest Henry

1. Answer E

While any patient with chest pain needs to

be attended to urgently, a focused history

followed by a targeted examination must still

precede any intervention. The administration

of oxygen, aspirin and glyceryl trinitrate might

become appropriate as this is occurring, as

might some of the actions that were specified

in the question. Only a clinical assessment will

determine what is indicated, however.

2. Answer E

Once again, proper clinical assessment must

precede any special investigations. The pres-

ence of a pleural rub, for example, can greatly

increase the clinical suspicion of a pulmonary

embolus in this case and guide test selection

appropriately.

3. Answer B

Of the options listed, multi-detector CT pul-

monary angiography has the greatest yield.

Ventilation/perfusion studies – not offered as

an option in this question – are comparable. D-

dimer tests have a high rate of false positives

due to low specificity for pulmonary embolus,

and MRI is too expensive and unreliable for

this specific indication. Myocardial perfusion

imaging only demonstrates blood supply to the

myocardium, not the lung.

4. Answer B

One of the discriminators between MDCTPA

and VQ scanning is that the CT based investi-

gation delivers a lower radiation dose, which

may be significant in the pregnant patient.

Case 2 – Ernest Henry continued

1. Answer D

Stable infarction is one cause of a fixed defect

on a stress MPI study along with stress isch-

aemia, hibernating myocardium, or a combi-

nation of all three. Differentiation is made by

comparing the resting study. MPI has a similar

safety profile to exercise ECG, is suitable for

diabetics, and has a low false negative rate. As

it is noninvasive, however, there is no opportu-

nity to dilate coronary stenoses.

2. Answer D

Dipyridamole (or adenosine) can be used to

cause nondemand coronary hyperaemia when

exercise is not possible. Both are contraindi-

cated in asthma or second degree heart block.

Dobutamine is a possible alternative.

3. Answer E

All food, drinks and medications containing

xanthines such as caffeine and theophylline

block the action of dipyridamole in causing

nondemand coronary hyperaemia and thus

they should be avoided for 24 hours before the

investigation.

4. Answer A

As the MPI method relies on comparing rest-

ing myocardium with stressed myocardium,

disorders of myocardial perfusion that restrict

blood flow to all regions equally means that

there is no normally perfused muscle for

comparison. Coronary vasospasm or impaired

vasodilatation are more likely to cause a false

negative resting angiogram with a true positive

MPI.

Case 3 – Ernest Henry continued

1. Answer B

Indications for intervention in abdominal aor-

tic aneurysms include evidence of leakage,

tenderness, complications, or size in excess

of 5.0–5.5 cm. Virtually all aneurysms are due

to atheromatous weakening of the vessel wall

below the renal arteries. Femoral artery ath-

eroma is usual.

2. Answer E

Australian law dictates that Dr Conrad has a

duty to respond to Mr Henry’s preoperative

concerns with information that will help him to

make an informed decision. This must include

information that any reasonable person would

need to know, as well as information specific

to the particular patient. An empathic state-

ment followed by an open ended question is

the best strategy.

3. Answer A

Patients are often discharged 2–3 days fol-

lowing percutaneous aortic stent insertion,

compared with approximately 5–10 days fol-

lowing surgery, depending on comorbidities.

Endoleak is a recognised complication of the

percutaneous method, as is buttock claudica-

tion; angiography is used at various stages of

stent deployment.

4. Answer C

The selection of the correct graft (or manu-

facture of a custom fitted one) is crucial to the

success of this procedure. CT angiography

using a high resolution machine and experi-

enced personnel is vital.

Case 4 – Andrea Christian

1. Answer E

All of the factors listed are likely to be impor-

tant to a woman in Andrea’s situation. Uterine

artery embolisation has the shortest hospital

stay and recovery time, but hysterectomy car-

ries a better guarantee of success.

2. Answer A

Uterine artery embolisation appears to have

similar fertility sparing effects as myomectomy,

but long term data are lacking. Hysterectomy

and endometrial ablation are both sterilising

procedures, as would be clamping the uterine

arteries. It is possible for fertility to be main-

tained after GnRH therapy but this is not freely

available and is not definitive on its own.

3. Answer C

For the purpose of accessing a Medicare

rebate for vertebroplasty, failure of medical

therapy can be defined as minimal or no pain

relief with the administration of prescribed

analgesics, or adequate pain relief with nar-

cotic dosages that produce undesirable side

effects.

4. Answer A

The whole aim of vertebroplasty is rapid relief

of symptoms. Although Mr Gilbert’s malignant

disease may result in a less satisfactory out-

come than if he had an osteoporotic fracture, it

is entirely feasible that he could be returned to

Dr Conrad’s care – with substantially less pain

and more mobility – immediately after the pro-

cedure, depending on local circumstances.

ANSWERS TO MAY CLINICAL CHALLENGE