AKT Flashcards
1
Q
1. Atrial Fibrillation: Risk Factors Key modifiable risk factors: CATHODE * C- Cholesterol * A- Alcohol *T- Tobacco * H- Hypertension / hyperthyroidism * 0- Obesity or overweight *D-Diabetes * E- Exercise Other risk factors: * Coronary heart disease * L diastolic dysfunction * Valvular heart disease * Heart failure @medica
A
2. Coronary Heart Disease Risks Key modifiable risk factors: TOP CHD * T-Tobacco * O- Obesity or overweight * P- Physical inactivity * C- Cholesterol * H - Hypertension * D- Diabetes Non - modifiable risk factors: AGE * A - Age (increases with age) * G- Genetics (FH of CHD) * E- Ethnicity (South Asian / Afro- Caribbean have higher risk)
2
Q
- Diabetes Diagnosis: WHO criteria
* Random glucose
11.1+ mmol/L
* Fasting glucose
7.0+ mmol/L
* HbA1c
48+ mmol/mol
* OGTT (2 hrs)
11.1+ mmol/L
*1 abnormal reading needed with
classical diabetic symptoms
* Polyuria
* Polydipsia
* Nocturia
* Weight loss
*2 abnormal readings on different days
for asymptomatic patients - if in
doubt, confirm using OGTT
A
- Gestational Diabetes Screening
* Screen only patients at high risk
* BMI 30 kg/m? or more
* Previous macrosomic infant (4.5kg+)
* Previous gestational diabetes
* FH of diabetes (1st degree relative)
* Family origin of & diabetes prevalence
* South Asian, Caribbean, Middle Eastern
* Test of choice: OGTT
* 2 hour reading of 7.8+ mmol/L diagnostic
* Usually done at 24-28 weeks
* If previous gestational diabetes, screen
with early self-monitoring or OGTT
after booking + repeat OGTT at 24-28
weeks
3
Q
- Assessing Blood Pressure
* Check pulse - if irregular, measure BP
manually
* If 1st reading is 140/90+, repeat reading
* If 2nd reading substantially different, repeat
* Record lower of 2nd and 3rd reading
* Clinic BP <140/90 = normotensive
* 140/90+: ABPM / HBPM to confirm
diagnosis
* 180+ systolic OR 120+ diastolic: consider
treatment while awaiting ABPM / HBPM
* 180/120+ with papilloedema / retinal
haemorrhage - admit / refer urgently to
hospital for assessment
A
A+ C+ D + consider further diuretic
Step 4
or alpha-blocker or beta-blocker
Consider seeking expert advice
* A = ACE inhibitor / ARB if ACE not suitable
* C= Calcium channel blocker
* D = Thiazide like diuretic
* At each step, optimise current drug(s) before
moving to next step
* Patients of African or Caribbean heritage that
need an A class drug should be offered an ARB,
rather than an ACE inhibitor
4
Q
- Non-specific low back pain
* Offer all patients self-management advice
* 1st line drug: NSAID e.g. ibuprofen /
naproxen
* Lowest effective dose for shortest time possible
* Offer gastroprotective treatment while on NSAID
* If NSAID unsuitable / ineffective, offer
codeine +/- paracetamol (not paracetamol
alone)
* If patient has muscle spasm, consider
diazepam 2mg TDS for up to 5 days
* Advise follow up in 3-4 weeks if not
improving or if worsening symptoms
* Advise to report any red flag signs /
symptoms
A
- Cauda equina syndrome
* Compression of the cauda equina
below L2
* New onset low back pain / sciatica
with
* Bilateral neurological deficit in legs
* New onset urinary retention /
incontinence
* New onset faecal incontinence
* Saddle anaesthesia or paraesthesia
* Unexpected laxity of anal sphincter
* Neurological emergency
* Arrange urgent admission for assessment
5
Q
- Notifiable diseases
* Statutory duty to notify
“proper officer” (e.g.
public health team) of suspected cases of
certain diseases / organisms
* Remember key vaccinations as a clue:
* Acute meningitis / encephalitis (MenB / MenC)
* Diphtheria, tetanus, pertussis, polio (DTaP/IPV)
* Measles, mumps, rubella (MMR)
* Tuberculosis (BCG)
Some other key infectious diseases / organisms:
* Food poisoning / infectious bloody diarrhoea
* Invasive group A streptococcal disease
* Yellow fever / enteric fever
* Whooping cough, rabies, cholera, anthrax
* Covid-19, SARS-COV-2
* Severe acute respiratory syndrome (SARS)
A
- Live attenuated vaccines
* Should not routinely be given to patients who are
clinically immunosuppressed
* Rotavirus vaccine
* MMR vaccine
* Nasal flu vaccine
* Shingles vaccine
* Chickenpox vaccine
* BCG vaccine against TB
* Yellow fever vaccine
* Oral typhoid vaccine
* Where an immunosuppressed patient needs a live
attenuated vaccine, this should be with specialist
oversight
6
Q
- Antibiotics in sore throat: FeverPAIN
* Use the FeverPAIN score to aid decision
making
* FeverPAIN more accurate than CENTOR
* High score indicates possible bacterial
infection
* Score 1 for each of the following:
* Fever in the last 24 hours
* Purulence
* Attend rapidly (3 days or less from onset)
* Inflamed tonsils
* No cough or coryza
* Score 0-1: No antibiotics
* Score 2-3: Consider delayed script
* Score 4-5: Consider antibiotics
* 1st line: Penicillin V for 10 days
* If allergic: clarithromycin / erythromycin for
5 days
A
- Pre-eclampsia: risk factors
* Age 40+
* BMI 35 kg/m? or more at first visit
* Multiple pregnancy
* First pregnancy
* Pregnancy interval >10 years
* FH of pre-eclampsia
* Hypertension in past pregnancy
* Chronic kidney disease
* Thrombophilia
* SLE / Antiphospholipid syndrome
* Diabetes
7
Q
- Stable Angina: Assessment
* Features of stable anginal pain:
* Constricting discomfort in the front of
chest, neck, shoulders, jaw or arms
* Precipitated by physical exertion
* Relieved by rest or GTN within 5 mins
* 3 features = typical angina pain, offer
diagnostic testing
* 2 features = atypical angina pain, offer
diagnostic testing
* 1 or 0 features = non anginal pain,
consider gastro or musculoskeletal
causes
A
- Stable Angina: Diagnostic Testing
* Patients with typical or atypical
angina pain - offer diagnostic testing
with coronary angiography
* Patients with non-anginal pain need a
resting 12-lead ECG - refer for
diagnostic testing only if ST changes
or Q waves present
* Patients with confirmed CAD - offer
noninvasive functional testing
* Test for exacerbating conditions such
as anemia in all suspected angina
patients
8
Q
- Parkinson’s disease: key features
* Bradykinesia - slowness in initiation of
movement
* Hypokinesia - poverty of movement
* Reduced facial expression / blinking
* Difficulty with fine movement
* Slow, shuffling, festinating gait
* Other typical features include:
* Lead pipe or cogwheel rigidity
* Resting tremor - improves on moving
* Postural instability - assess using the “pull test”
A
* Refer anyone with suspected Parkinson's to a specialist UNTREATED for confirmation * Either neurologist or elderly care physician * Refer within 6 weeks for early / mild disease * Refer within 2 weeks for late / complex disease * If patient is taking a drug known to cause parkinsonism: * Reduce or stop the drug if appropriate / possible * Do NOT delay specialist referral to assess response medica
9
Q
- Mild acne: management
* Provide reassurance about natural
course of condition without trivialising it
* Give advice on self-care
* Do not wash more than twice daily
* Use mild soap or cleanser with warm
water
* Do not scrub vigorously or use exfoliating
agents
Avoid picking acne - it can worsen the
condition
* Topical treatment 1st line
* Benzoyl peroxide
* Topical retinoid +/- benzoyl peroxide
* Topical antibiotic + benzoyl peroxide
* Azelaic acid 20%
* Follow up after 6-8 weeks or sooner if
deterioration significant
A
18.Oral antibiotics in acne
* For moderate acne with high risk of
scarring / pigment change or where
difficult to reach (e.g. back)
* For severe acne while awaiting specialist
assessment
* Oral tetracycline, oxytetracycline,
doxycycline or lymecycline all 1st line
* Erythromycin if tetracyclines not
tolerated or contraindicated (e.g.
pregnancy)
* Do not prescribe oral antibiotic alone
combine with topical retinoid/benzoyl
peroxide
* Do not combine oral + topical antibiotics
* Consider combined oral contraceptive if
contraception also required
@medica
10
Q
- Acute migraine: management
* Adults: Combination treatment 1st line:
* Oral triptan + NSAID
* Oral triptan + paracetamol
* If monotherapy requested, offer either:
* Triptan
* NSAID
* Aspirin 900mg
* Paracetamol
* Consider adding an anti-emetic even in
the absence of nausea or vomiting
* Do NOT use ergots or opioids
* 12-17 year olds: 1st line is paracetamol
or NSAID
* Add nasal triptan if monotherapy ineffective
@medica
A
- Prostate cancer: referral
* Consider PSA and digital rectal
examination to assess for prostate
cancer in men with:
* Lower urinary tract symptoms e.8.
nocturia, frequency, hesitancy, urgency or
retention
* Erectile dysfunction
* Visible haematuria
* Refer within 2 weeks if prostate feels
malignant on digital rectal examination
* Refer within 2 weeks if PSA levels above
the age-specific reference range
* Age 50-69: >=3.0 ng/ml
* Age 70+:
>=5.0 ng/ml
@medica
11
Q
- Vitamin D deficiency: who to test
* Symptoms of osteomalacia:
* Bone pain / discomfort in lower back,
pelvis, and lower extremities
* Impaired physical function
* Muscle aches and weakness
* Symmetric lower back pain
*
Chronic widespread pain
* Other clinical reason for testing:
* Prior to specific treatments which will
affect Vitamin D levels
* Bone disease that may improve with
vitamin D treatment - e.g. osteomalacia,
osteoporosis, or Paget’s disease
* Following a fall
* Patient has features of hypocalcaemia
(rare), including muscle cramps,
carpopedal spasm, numbness,
paraesthesia tetanv or seizures
A
- Vitamin D deficiency treatment
* Based on serum 25-hydroxyvitamin D levels
* Level <25 mol/L= deficiency - treat
* Level 25-50 mol/L= insufficiency - treat if:
* Has fragility fracture / osteoporosis / high fracture
risk
*
On treatment with antiresorptive drug
*
Has symptoms suggestive of deficiency
Has raised parathyroid hormone levels
*
cholestyramine
*
Has a malabsorption disorder (e.g. Crohn’s
disease) or a condition known to cause deficiency
(e.g. CKD)
* Level above 50 mol/L is adequate - advise
on measures to prevent deficiency
12
Q
- Osteoporosis risk assessment
* All women aged 65+, all men aged 75+
* Women aged 50-64, men aged 50-74 with:
* A previous osteoporotic fragility fracture
*
Current or frequent recent oral steroid use
*
History of falls
*
*
LOW BMI (<18.5kg/m2)
Smoker
*
Alcohol intake more than 14 units per week
* A secondary cause of osteoporosis
* People younger than 50 with:
* A previous fragility fracture
*
Current or frequent use of oral steroids
Untreated premature menopause
* People younger than 40 with:
* Current or recent high dose oral steroids
(equivalent to 7.5mg prednisolone for 3
months+)
* Previous fragility fracture of spine, hip,
forearm, or proximal humerus
* History of multiple fragility fractures
@medica
A
- Drugs that increase risk of fractures
* Consider assessing fracture risk in patients
taking these medications:
* Selective serotonin reuptake inhibitors
* Antiepileptic medication - particularly
enzyme-inducing drugs, such as
carbamazepine
* Aromatase inhibitors, such as exemastane
* Gonadotropin-releasing hormone agonists,
such as goserelin
* Proton pump inhibitors
* Thiazolidinediones, such as pioglitazone
* Oral steroids, especially with long term use
medica
13
Q
- Neuropathic pain: management
* For trigeminal neuralgia - offer
carbamazepine
* For any other neuropathic pain offer
either:
* Gabapentin
* Pregabalin
* Duloxetine
* Amitriptyline
* Do NOT prescribe more than 1 drug for
neuropathic pain at the same time
* For localised neuropathic pain or where
oral not tolerated - offer topical
capsaicin
* Refer to pain service if pain is severe or if
treatment fails
A
- Diagnosing IBS in Primary Care
* Assess for IBS if 6 month+ history of
Abdominal pain, Bloating or Change in
bowel habit
* Red flags: Signs or symptoms of cancer or
markers for inflammatory bowel disease
* pipsness,it a bodominaleaj wralievediby
bowel frequency /stool form + 2 of the
following 4:
* Altered stool passage (straining, urgency,
incomplete evacuation)
*
Abdominal bloating, distension, tension or
hardness
Exacerbated by eating
Passage of mucus
* Tests in primary care to exclude other
causes:
* FBC, ESR /plasma viscosity, CRP and antibody
testing for coeliac disease (EMA or TTG).
@medica
14
Q
- Reactive arthritis - Reiter’s syndrome
* Reactive arthritis following either:
* Gastroenteritis (enteric form)
* Sexual activity (genital form)
* Classic triad of symptoms
* Conjunctivitis
* Urethritis
* Arthritis (seronegative)
* Remember: “can’t see, can’t pee, can’t
bend the knee!”
* Treatment separate for each problem
* Conjunctivitis - chloramphenicol
* Urethritis - tetracycline if chlamydial
source likely
* Arthritis - rest, NSAID / steroids if severe
A
- Jarisch-Herxheimer reaction
* Can happen with any antibiotic
treatment
* Occurs in ~15% of patients with
Lyme disease treated with
antibiotics
* Occurs within 24 hours of treatment
* Caused by release of toxins following
death of bacteria
* Causes worsening of fever, chills,
muscle pains, and headache.
* Additional features can include
tachycardia, hyperventilation,
vasodilation with flushing, and mild
hypotension
medica
15
Q
- eGFR - creatinine
* The standard method of assessing
estimated glomerular filtration rate
* Need 4 metrics to calculate:
* Creatinine
* Age
* Sex
* Ethnicity
* NICE recommends use of CKD-EPI
equation for calculation
* Calculation inaccurate in patients
with abnormal muscle mass or skin
surface area
* Avoid meat for 12 hours before
testing
A
- Bell’s Palsy
* Unilateral, idiopathic, acute facial
nerve paralysis
* Maximum facial weakness usually
develops within 2 days
* Earache, discomfort or facial pain may
precede the palsy
* Most people make a full recovery
within 9-12 months - protecting the
affected eye is important
* If onset was <72 hours ago then
consider prednisolone
* Refer if there are doubts, if the
condition is recurrent or if it is bilateral
16
Q
- Whooping cough management
* Arrange admission if:
* 6 months old or younger and acutely
unwell
* Significant breathing problems
* Significant complications e.g. seizures
or pneumonia
* If admission not needed, prescribe
antibiotics if onset of cough within 21
days:
* Clarithromycin if aged <1 month
* Azithromycin or Clarithromycin if
1m+
* Erythromycin for pregnant women at
36 weeks+ gestation
* Complete form for notifiable disease
A
- Impetigo
* Typical features - golden coloured, crusting
lesions
* Non bullous infection
* Localized + low risk - hydrogen peroxide 1%
cream or topical fusidic acid - (5 days)
==
Widespread + low risk - topical OR oral
antibiotic
* Severe infection + high risk - oral flucioxacillin
(7 days)
-=
Clarithrorycin or erythromycin if penicillin
allerzy
* Treat underlying cause if applicable (eg,
Eczema, scabies, head lice)
¿ Bullous infection - oral antibiotics as above
• Advise time off school
# Until lesions crusted over or 43 hours from
start of antibiotics
17
Q
- Lipid therapy ~ primary prevention
* Offer medication to patients 84 years or
younger with 10 year CVD risk of 10%+
* Use ORISK2 to assess CVD risk
* Offer medication without need for
formal risk assessment to patients with:
* Type 1 diabetes
* Chronic kidney disease
* Familial hypercholesterolaeria
* Consider offering medication to patients
85 years+ after considering risks and
benefits based on individual
circumstances
* 1= line medication is atorvastatin 20mg
unless contraindicated (e.g. in
pregnancy)
A
- Lipid therapy - CVD prevention
* For primary and secondary prevention:
* Address other modifiable risk factors e.g.
smoking, obesity
* Identify and manage secondary causes of
dyslipidaemia e.g. hypothyroidism
* Arrange follow up to monitor treatment
and adverse outcomes
* Baseline bloods before medication:
* Non-fasting lipid profile
* Liver function tests (transaminases)
* Renal function (including eGFR)
* HBA1C
* 1st line treatment: atorvastatin
* 20mg daily for primary prevention
* 80 mg daily for secondary prevention
medica
18
Q
- CHA,DS,VASc score
* For assessing stroke risk in patients with AF
* C - Congestive heart failure
1
* H - Hypertension
1
* A, - Age 75+
2
* D - Diabetes
1
* S, - Stroke / TIA / thromboembolism
2
* V- Vascular disease (MI, PAD etc.)
1
* A- Age 65-74
1
* Sc - Sex category - female
1
* Score 1+ for males, 2+ for females: consider
anticoagulant treatment to reduce stroke risk
* Use ORBIT bleeding risk scoring tool to assess
risk of bleeding when considering
anticoagulants
A
- For assessing bleeding risk for patients
with AF - more accurate than HAS-BLED
Criterion Score
Males: haemoglobin <130 g/L or 2
haematocrit<40%
Females: haemoglobin <120 g/L 2
or hematocrit <36%
Personal history of bleeding e.g. 2
Gl / intracranial bleeding,
hemorrhagic stroke
Age > 74 years. 1
eGFR < 60 mL/min/1.73m2. 1
On antiplatelets. 1 - ORBIT score:
- 0-2: Low risk
*3:
Medium risk - 4-7: High risk
19
Q
- Chronic Plaque Psoriasis: Management
* Offer topical emollients to reduce scale
* Offer topical potent steroid + Vitamin D
preparation
* Steroid and vitamin D preparation
should be applied at different times of
day
* Advise on risks of topical steroids
* Refer for second and third-line
treatments (e.g. phototherapy or
systemic therapy) at the same time as
offering topical treatments where
topical is unlikely to control psoriasis:
* Extensive disease (>10% body surface
affected)
* A score of moderate or worse on static
PGA
* Psoriasis unlikely to respond (e.g. nail
involvement)
A
J. Hirsutism: Reterral guidelines * Refer urgently (2WW) to rule out androgen-secreting tumors in patients with: * Sudden onset or rapid progression of hair growth * Severe hirsutism * Signs of virilization * Pelvic or abdominal mass * Refer to endocrinology if features of Cushing' syndrome: * Weight gain (moon face) * Weight gain in the neck, upper back, torso * Stretch marks (new onset) * Easy bruising * Proximal muscle weakness * Refer if initial investigations abnormal: * Serum total testosterone >4 nmol/L * Refer urgently (2WW) if testosterone >6 nmol/L * Elevated 17-hvdroxvorogesterone levels
20
Q
39. Genetic conditions - modes of inheritance Autosomal dominant * Marfan syndrome, achondroplasia, neurofibromatosis, Huntington's disease Autosomal recessive * Albinism, cystic fibrosis, phenylketonuria, sickle cell anemia, Tay Sachs disease X linked dominant * Alport syndrome, Rett syndrome, Vitamin D resistant rickets, Fragile X X linked recessive * MD, haemophilia, G6PD deficiency, Hunter syndrome, colour blindness Polygenic / multifactorial * Neural tube defects, pyloric stenosis @medica
A
40. Chromosomal genetic disorders Error in number: * Down syndrome Trisomy 21 * Edwards syndrome Trisomy 18 * Patau syndrome Trisomy 13 * Turner syndrome 45X0 (× missing) * Klinefelter syndrome 47XXY (Extra X) Deletions: * Cri-du-chat syndrome * Missing short arm on chromosome 5 * Prader-Willi syndrome * Deletion on chromosome 15
21
Q
Test Positive result
Fractional exhaled nitric 40 ppb (Age oxide (FeNO) 17+)
35 ppb (Age
5-16)
Spirometry: FEV./FVC. Ratio <70% ratio. or be below the lower limit of normal Bronchodilator FEV1: 12%+ improved + reversibility (BDR) test Volume: 200ml+ increase Peak flow variability 20%+ variability
A
- Frozen shoulder
* Shoulder pain / stiffness on elevation and
external rotation
* Incidence higher in diabetic patients
* Usually self-limiting but can take months to
years to resolve
* Consider the following in management:
* Regular analgesia - paracetamol +/- NSAID /
codeine
* Physiotherapy for 6 weeks+
* Joint injection (glenohumeral) with steroids
* Refer to secondary care:
* If no response after 3 months
* If symptoms or impact on patient is severe
* If there is diagnostic uncertainty
* If steroid injection cannot be done in primary
care
22
Q
43. Infertility - early referral criteria FemaleMale Age 36+ Previous genitalpathology Amenorrhoea or oligomenorrhoea Previous urogenital surgery Previous abdominal or pelvic surgery Varicocele Previous pelvic inflammatory disease Significant systemic illness Abnormal pelvic examination Abnormal genital examination Previous sexually transmitted infection Known reason for infertility (e.g. prior treatment for cancer)
A
- Infertility - Investigations (females)
* Regular unprotected sex for 1 year, test
earlier if identified as less likely to conceive
* Screen for chlamydia
* Confirm ovulation with serum progesterone
on 7 days prior to 1st day of period (e.g. day
21 of 28 day cycle)
* Offer additional testing if:
* Prolonged cycles - repeat serum
progesterone weekly after initial sample
(adjust sample day e.g. day 28 of a 35 day
cycle) until next cycle
Irregular cycles - measure gonadotrophins
(follicle-stimulating and luteinizing hormones)
* Symptoms of thyroid disease - measure TFTs
* Ovulatory disorder, galactorrhoea or
suspected pituitary tumour - measure
prolactin
