3a GP + Geriatrics + Miscellaneous

Question 1

Can you summarise pressure ulcer staging?

Answer 1

Note: commonly on bony prominences = heels, sacrum, shoulders, occiput

Grading
- Grade 1 = erythematous skin/colour change, temperature change, firm/soft
- Grade 2 = partial-thickness skin loss affecting epidermis +/- dermis
- Grade 3 = full-thickness skin loss affecting epidermis + dermis but not through fascia // can have tunnelling and undermining
- Grade 4 = ulcer extends through the epidermis, dermis, fascia and exposes underlying bone/muscle/tendons // includes tunnelling and undermining

Question 2

What are some risk factors for falls?

Answer 2

Previous fall
Stroke
LD
Dementia
Parkinson’s
Delirium
Fear of falling
Depression
Hypoglycaemia
DM causing neuropathy (including autonomic neuropathy)
Pain
MSK weakness/foot drop
Incontinence
Visual impairment
Sensory neuropathy
Polypharmacy (oxybutynin, diuretics, antihypertensive, alpha/beta-blockers, digoxin, sedatives)
Postural hypotension
Vertigo/problems with vestibular system/DCML

Question 3

How would you manage someone who has fallen?

Answer 3

Who to investigate
- Anyone > 65y
- Anyone with risk factors

Investigations
- Timed up and go test
- Turn 180 degrees test

Who to refer for assessment?
- Poor results on TUGT or turn 180 degrees
- Anyone > 65y with recurrent falls in last 12 months
- Anyone with fall requiring medical attention

Multi factorial assessment
- Medication review
- Vision assessment
- Cardiovascular, neurological, gait/MSK and balance assessment
- Home hazards review
- Assess fear of falling and perceived impairment
- Assess osteoporosis risk
- Assess incontinence
- Assess previous falls

Management
- Manage underlying causes
- Medication review
- Strength and balance training

Question 4

What is osteoporosis and how would you treat osteoporosis?

Answer 4

BMD less than - 2.5 standard deviation from T-score
Common fractures
- Vertebral wedge (anterior + more stable, no neurological compromise) or burst fracture
- Colle’s (distal radial - dinner fork deformity)
- NOF (external rotation and shortening)

Investigations
- FRAX/QFracture
- DEXA
- ALP (normal)
- Calcium (normal)
- Phosphate (normal)
- FBC, U&E, LFT, CRP, TFT

Who do you treat?
- All indicated by FRAX
- All > 75 F with fragility fracture without DEXA
- All with fragility fracture + DEXA < -2.5

Management
- Bisphosphonates (alendronate/risedronate/zolendronate) + calcium and vitamin D supplements
- Others: teriparatide/denosumab, HRT, strontium ranelate, raloxifene

Question 5

How would you manage constipation in adults? What are some causes of constipation?

Answer 5

Constipation: < 3 spontaneous bowel movements a week

Impaction = spontaneous evacuation unlikely

Management
- 1st line = bulking laxatives (ispaghula husk)
- 2nd line = osmotic laxatives (macrogol or lactulose)
- 3rd line = stimulant laxatives (bisacodyl or senna or sodium picosulfate)
- 4th = suppository or enema

Causes
- Opioids
- Rectocele
- Hypothyroidism
- IBD and IBS
- Bowel obstruction
- Malignancy
- Dehydration
- Hypercalcaemia
- Autonomic neuropathy, MS, PD, spinal injury

Question 6

What are the different types of urinary incontinence? Can you tell me about the different risk factors and management for each?

Answer 6

Stress

Urge

Question 7

Can you tell me a bit about GORD in adults?

Question 8

What is IBS and how do we manage it?

Question 9

What is hypertension? Can you tell me about some causes, classification and management?

Question 10

What is heart failure? What are some causes?

Question 11

How would heart failure present? Can we give any medications?

Question 12

Can you summarise osteoarthritis for me?

Question 13

What is gout? What are the investigations and management?

Question 14

Can you tell me about pseudogout?

Question 15

Can you summarise rheumatoid arthritis and its presentation?

Question 16

Can you tell me about how to investigate and manage rheumatoid arthritis?

Question 17

Can you tell me about Crohn’s disease?

Question 18

Can you tell me about ulcerative colitis?

Question 19

What are some common complications of IBD?

Question 20

What genetic syndromes are associated with IBD?

Answer 20

Turner’s
Trisomy 21

Question 21

What is aortic stenosis?

Question 22

What is mitral regurgitation?

Question 23

What is peripheral arterial disease?

Question 24

What is aortic regurgitation?

Question 25

What is mitral stenosis?

Question 26

Can you summarise hyperthyroidism?

Question 27

Can you summarise hypothyroidism? What are some complications in pregnancy?

Question 28

What are the ‘cut-off’ levels for diagnosing diabetes?

Question 29

What is type 2 diabetes and how do we manage this condition?

Question 30

What scoring system can you use to determine the risk of developing pressure ulcers? How would you manage pressure ulcers?

Answer 30

Waterlow Braden Norton Management - Refer if grade 3 or 4 pressure ulcer or extensive ulcers - Manage underlying risk factors and encourage mobilisation (or turn regularly) - Ulcer itself: analgesia + clean + dress +/- debride Antibiotics - Do not routinely offer topical antibiotics (even if wound swab +) - Only give systemic antibiotics if systemically unwell + positive swab culture

Question 31

What are some risk factors for developing pressure ulcers?

Answer 31

Previous pressure ulcer Immobility - Surgery or traumatic injury - Spinal injury - Cognitive impairment/dementia/LD Affecting skin - DM - Cushing’s/steroid medication - Incontinence - Peripheral arterial disease - Oedema Nutritional - Malnutrition - Malignancy - CKD/HF/liver disease

Question 32

Who would you assess osteoporosis risk in? When would you order a DEXA scan?

Answer 32

Risk assessment - 65+ (F) or 75+ (M) - Those with risk factors (recurrent falls, high dose steroids) DEXA - FRAX with intermediate result - 50+ with fragility fracture - < 40 but major osteoporotic or repeated fragility fractures

Question 33

What are some risk factors for developing osteoporosis?

Answer 33

Steroids Hyperparathyroidism/hyperthyroidism/hypercalciuria Alcohol and smoking Testosterone deficiency/Turner’s Thin Erosive bone disease (RAS/SLE/JIA/myeloma) Renal/liver failure (vitamin D) Early menopause Diet/malabsorption (IBD, coeliac)/DM

Question 34

Can you summarise fibromyalgia for me?

Question 35

What is chronic kidney disease (staging separate)? How would you investigate and manage?

Question 36

What is acute kidney injury? How would you manage?

Question 37

Can you tell me about the management for COPD?

Question 38

What is bronchiectasis?

Question 39

What are the commonest types of lung cancer? How would someone with lung cancer present? When would you refer?

Question 40

How would you manage stable angina?

Question 41

How would you manage unstable angina or NSTEMI?

Question 42

How would you manage a STEMI?

Question 43

Can you tell me about atrial fibrillation?

Question 44

How would diverticular disease and diverticulitis present? How would you investigate and manage?

Question 45

What can you tell me about cholecystitis?

Question 46

How would pyelonephritis present?

Question 47

What can you tell me about appendicitis?

Answer 47

Refer to paediatric notes for presentation Only difference = can give piperacillin-tazobactam (tazocin) AND CT is investigation of choice Paediatrics prefers USS as no radiation meaning it is safer

Question 48

Can you summarise renal stones and renal colic for me?

Question 49

How would you stratify the severity of DKA?

Question 50

How would symptomatic gallstones present?