Australian Family Physician
Australian Family Physician


Volume 42, Issue 5, May 2013

Clinical challenge

Melissa Tan
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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 multiple choice questions of the RACGP Fellowship exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional Development Program and has been allocated 4 Category 2 points per issue. Answers to this clinical challenge are available immediately following successful completion online at www.gplearning.com.au. Clinical challenge quizzes may be completed at any time throughout the 2011–13 triennium, therefore the previous months answers are not published.

Case 1

Patrick Kelly

Patrick, 56 years of age, is a commercial international air pilot who presents with sweating that he describes as excessive. Patrick has no significant medical history.  

Question 1

You take a history of Patrick’s symptoms, and consider a diagnosis of idiopathic focal hyperhidrosis. Which one of the following features is NOT consistent with idiopathic focal hyperhidrosis:

  1. at least one episode of sweating per week
  2. bilateral, symmetrical sweating
  3. excessive visible sweating for at least 6 months
  4. onset of symptoms after the age of 50 years
  5. positive family history of idiopathic focal hyperhidrosis.

Question 2

In light of Patrick’s age and that the symptoms are new onset, you order preliminary investigations. Of the following investigations, which one is NOT likely to be an appropriate first line investigation for Patrick’s hyperhidrosis: 

  1. 17 hydroxyprogesterone
  2. 24 hour urinary catecholamines
  3. fasting glucose
  4. HIV serology
  5. thick and thin blood films.

Question 3

Which of the following is the most common cause of generalised hyperhidrosis:

  1. adverse drug reaction
  2. diabetes mellitus
  3. febrile infective illness
  4. malignancy
  5. neurological disorders.

Question 4

Which one of the following statements is CORRECT regarding treatment options for idiopathic focal hyperhidrosis:

  1. aluminium chloride hexhydrate antiperspirants should be the first line of treatment
  2. botulinum toxin A is subsidised by Medicare for axillary, palmar and plantar hyperhidrosis
  3. iontophoresis is not an effective treatment for hyperhidrosis
  4. oxybutynin can be initially prescribed at 7.5 mg/day and gradually increased to
    15 mg/day
  5. surgical removal of sweat glands is a well tolerated and permanent solution to hyperhidrosis.

Case 2

Jenny Maddren

Jenny, 24 years of age, is a student. Her new boyfriend Jerome, 27 years of age, is a painter. They are both generally well.

Question 5

Jenny appears embarrassed today. Jerome mentioned that she sometimes has a strong body odour. She is keen to seek your advice. Which of the following statements is CORRECT regarding bromhidrosis:

  1. axillary bacterial swabs are useful for guiding topical antibiotic treatment
  2. bromhidrosis may be precipitated by ingestion of garlic or alcohol
  3. regular showering has a minimal effect on bromhidrosis
  4. the removal of axillary hair is commonly practiced but generally unhelpful
  5. triethylaminuria is a rare condition that can be controlled by strict hygiene measures.

Question 6

Jenny returns with Jerome, and is happy to report that your previous advice has been helpful.  Today they want to ask you about some penile lumps that Jerome is concerned about. Which of the following features are LEAST suggestive of normal anatomical penile lump variants:

  1. minimal change over time
  2. small sized lumps
  3. previous HPV vaccination
  4. smooth appearance
  5. symmetrical distribution of lesions.

Question 7

Jerome reports the lumps have been present since adolescence and are more visible on stretching the skin. Which of the following features are most suggestive of Fordyce spots:

  1. cauliflower or cobblestone appearance
  2. dome shaped lumps arranged in neat rows
  3. previous sexual contact with genital warts
  4. purple or deep-red papules over the scrotum
  5. thick chalky discharge upon squeezing the lumps.

Question 8

Which one of the following statements regarding penile lumps is CORRECT:

  1. folliculitis is managed with genital hygiene measures and requires oral antibiotics
  2. herpes simplex virus will typically produce a thick purulent discharge
  3. molluscum contagiosum has a self-limiting course and does not require further treatment
  4. penile warts usually recover spontaneously in immunocompetent hosts within 6 months
  5. subcutaneous penile lumps should raise suspicion of Peyronie disease.

Case 3

Adrian Chen

Adrian Chen, 34 years of age, is a bartender. He is generally well.

Question 9

Adrian has had a lifelong issue with premature ejaculation. He wishes to discuss treatment options with you. Which of the following is considered the first line of treatment for primary premature ejaculation:

  1. ceasing stimulation before ejaculation and recommencing on reduced arousal
  2. double condom usage to decrease penile sensitivity
  3. selective serotonin reuptake inhibitors taken PRN before anticipated intercourse
  4. topical anaesthetic cream to reduce penile sensitivity
  5. using sexual positions that are less stimulating.

Question 10

Which one of the following statements is CORRECT regarding men’s health:

  1. erectile dysfunction is most commonly due to psychosocial issues
  2. reduction in libido occurs in all men in conjunction with the ageing process
  3. SSRIs can cause reduced libido, but can be helpful for premature ejaculation
  4. testicular cancers detected early have a cure rate of approximately 75%
  5. testicular cancer risk factors include developing an inguinal hernia before the age of 25 years.

Question 11

Which one of the following statements is CORRECT regarding male sexual difficulties:

  1. behavioural techniques for premature ejaculation have a short term success rate of 50%
  2. erectile dysfunction affects 15% of males aged 40–49 years
  3. erectile dysfunction affecting older males is commonly due to declining male hormones
  4. loss of libido is most commonly due to underlying poor neurovascular supply
  5. premature ejaculation treatments are successful for up to 50% of affected males.

Question 12

Adrian presents a few weeks later and reports improvement with your suggested treatment. Today he wishes to discuss his excessive sweating. Which one of the following statements is TRUE regarding hyperhidrosis:

  1. areas most commonly affected by focal hyperhidrosis are the hip creases and axilla
  2. focal hyperhidrosis is usually secondary to an underlying systemic disease
  3. hyperhidrosis affects an estimated 10% of the population
  4. males are more likely than females to suffer with hyperhidrosis
  5. primary hyperhidrosis will usually cease during sleeping.

Case 4

Mavis Mitty

Mavis Mitty, 73 years of age, presents complaining of bloating and belching.

Question 13

Mavis asks you to explain intestinal gas to gain a better understanding of her symptoms. Which one of the following statements is CORRECT regarding intestinal gas:

  1. air swallowing is one of the most common causes of excess intestinal gas
  2. approximately 12 L of gas is produced in the intestines per day
  3. bloating is detected on physical examination by the presence of abdominal distension
  4. gases produced in the colon are partially reabsorbed and expired in the breath
  5. the average output of flatus for an average adult is 500 mL/day.

Question 14

Mavis describes belching associated with epigastric discomfort. She is unable to eat a normal sized meal and has intermittent difficulties with swallowing. Endoscopy reveals food residue with delayed gastric emptying. Which one of the following conditions is most consistent with Mavis’ presentation:

  1. gastroparesis
  2. oesophagitis
  3. oesophago-gastric dysmotility
  4. rumination and cyclical vomiting
  5. scleroderma.

Question 15

Which one of the following statements is CORRECT regarding treatment options for bloating: 

  1. amitriptyline at a starting dose of 75 mg may improve bloating symptoms
  2. antispasmodics such as mebeverine are generally not helpful for patients experiencing bloating
  3. coffee and fatty foods may trigger bloating due to increased gut fermentation
  4. high fibre intake may trigger abnormal gut motility leading to exacerbation of bloating
  5. the FODMAP diet involves elimination of foods that can generate colonic gas production.

Question 16

Which one of the following statements is CORRECT regarding flatulence:

  1. colonic bacteria that produce methane gas are primarily responsible for increased odour
  2. females are equally likely to produce odourous flatus as compared to males
  3. flatulence odour is largely dependent upon dietary fibre and resistant starch intake
  4. increased sulphur dietary intake usually results in increased volume of flatulence
  5. preservatives often contain sulphur, which can result in worsening flatulence.

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