In this episode Dr Dave Maplesden tests Dr Jo Scott-Jones on key “snippets” of the “clinical snippets” from 2021. This is a great opportunity to test how much you actually retained from the podcast in the past year – see if you can beat Dr Jo – and to be honest, that isn’t going to be hard !
Questions ( And Answers – so don’t peek ! ) are in the shownotes below.
Clinical Snippets Quiz – DECEMBER 2021
1. When a patient applies for a licence or an endorsement, and you assess that your patient is medically unfit to drive, you must advise Waka Kotahi (NZTA) of this in writing (regardless of whether your patient submits their application).
TRUE
You must notify Waka Kotahi (NZTA) if you believe that the mental or physical condition of a licence holder means that in the interest of public safety they should not be permitted to drive and are likely to continue to do so. You do not have to prove the patient is driving or will continue to drive.
2. New gambling addiction can be an adverse effect of dopamine agonists such as pramipexole and ropinirole, used in treating Parkinsons disease and restless leg syndrome.
TRUE
Risk is up to seven times greater than the general population. Risk factors for pathological gambling include being young, male, and having psychiatric co-morbidity and is greater with higher doses of the medication. The cause of drug-related gambling disorder isn’t fully understood, but it has been linked to an impaired function in the mesolimbic system, which is involved in risk and reward assessments.
3. Patients with type 2 diabetes taking empagliflozin or dapagliflozin alone or in the metformin combination tablets should be instructed to continue the medication even when unwell.
FALSE
These drugs (SLGT2 inhibitors) carry a risk of diabetic ketoacidosis which can occur with normal or only slightly elevated blood glucose levels, and need to stop with any intercurrent illness or 2 days before an elective surgical procedure. Also small risk of Fournier’s gangrene which may present with perineal pain and redness.
4. Nitrofurantoin is the treatment of choice for uncomplicated urinary tract infections in older patients with mild to moderate renal impairment.
FALSE
Contraindications to nitrofurantoin treatment include eGFR < 60 ml/min/1.73m2 and pregnant women in whom labour and delivery may be imminent. If the drug is being used for UTI prophylaxis, ensure eGFR is >60 and note the risk of pulmonary (fibrosis) and hepatic adverse reactions increases with prolonged use. Monitor lung and liver function regularly in patients taking prophylactic nitrofurantoin and periodically check for signs of peripheral neuropathy.
5. It is acceptable to list ‘frailty of old age’ as the primary cause of death on the MCCD in certain circumstances.
TRUE
This diagnosis refers to a gradual multi-system decline in function over a period of several months or years that is attributable to atrophic degenerative changes of ageing, in the absence of any specific organ system disease. It applies to patients aged 80 years or older whose declining function has been appropriately clinically assessed over a period of time for specific organ system disease before death. The diagnosis ‘frailty of old age’ should not be used as a substitute for a more specific diagnosis (if there is one), and should not be used in part 1a if the deceased suffered from an acute illness (e.g. pneumonia), or trauma prior to death.
6. Exclusively or partially breastfed infants (less than 500ml formula per day) up to 12 months of age and with a naturally dark skin are at high risk of vitamin D deficiency and may benefit from being prescribed Vitamin D supplementation.
TRUE
See the Ministry of Health recommendations for Vitamin D supplementation (Puria vitamin D drops subsidised in NZ – standard dose 400IU (one drop) daily) which include all preterm infants with a body weight less than 2.5 kg and all infants who are exclusively breastfed over winter months in New Zealand.
7. You see a 72-year-old man with chronic mild obstructive lower urinary tract symptoms. Prostate is moderately enlarged but feels benign otherwise on DRE. PSA returns at 140 mcg/L. Appropriate next step in management according to local HealthPathways is to check MSU and repeat PSA in 6 to 8 weeks, if there is no reversible cause found such as UTI.
FALSE
If PSA raised and DRE normal: If PSA greater than 100 micrograms/L, request non-acute urology assessment for prostate biopsy within 4 weeks. No repeat PSA test is required before referral.
Otherwise, repeat test in:
- 12 weeks, following management of any reversible causes. Pay particular attention to an abnormal MSU result – infection can cause significant PSA elevation.
- 6 to 8 weeks, if there is no reversible cause
8. GPs with a conscientious objection to participating in the end-of-life choice process are required under the legislation to refer a patient wanting to consider utilising the Act to a colleague who is prepared to engage in the process (usually by reference to SCENZ).
TRUE
A medical practitioner who does not provide assisted dying services due to a conscientious objection (or belief it is outside their scope of practice) is legally required to:
• inform the person asking about assisted dying of their objection
• tell the person they have the right to ask the SCENZ group for the name and contact details of a ‘replacement’ medical practitioner who is willing to participate in assisted dying.
The End of Life Choice Act legislation has now been in force for over two months and it is important all primary care providers have a working knowledge of the legislation. A foundation training module is available on the Learnonline website and further written information is available on the Ministry of Health website.
9. You diagnose a 14-month old child with mild to moderate bronchiolitis. Appropriate management would be carer education, PRN salbutamol via spacer and a three day course of Redipred at 1mg/kg once daily.
FALSE
There is no evidence for efficacy of the following interventions which are recommended against:
• Beta2 agonists including to those with a personal or family history of atopy
• Ipratropium
• Corticosteroids (systemic or local) including nebulised, oral, intramuscular, or intravenous
• Adrenaline (nebulised, intramuscular, or intravenous) except in peri-arrest or arrest
• Nebulised hypertonic saline
• Antibiotics including azithromycin
• Antivirals including ribavirin
See Midland Region Community HealthPathways for clear guidance on management of bronchiolitis
10. You see an 84-year-old female patient in whom you suspect a UTI diagnosis based on symptoms and positive dipstick. She complains of feeling generally unwell and you check her temperature which is 38.2 C. This is a ‘red flag’ for sepsis.
FALSE
However, she is at risk of sepsis and full assessment in this regard should be considered: red flags include new confusion/deterioration in GCS, systolic BP ≤90mmHg (or ≥40 mmHg below normal), Heart rate ≥130 per minute, Respiratory rate ≥25 per minute, Needs oxygen to keep SpO 2 >92% (>88% in COPD), Non-blanching rash or mottled/ashen/cyanotic, Not passed urine in last 18 hours or more or output less than 0.5 ml/kg/hr if catheterised, Recent chemotherapy (within last 6 weeks). Excellent resources for sepsis screening in primary care are available on the sepsis.org.nz website.
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