Community health Flashcards
What is the primary cause of polycythaemia?
Polycythaemia vera - JAK2 gene mutation
What are the secondary causes of polycythaemia?
Obstructive sleep apnoea
COPD
Chronic heart disease
EPO/anabolic steroids
What can cause apparent polycythaemia?
Diuretics
Alcohol
Obesity
What is polycythaemia?
High concentration of red blood cells
Makes blood thicker and less able to travel through blood vessels
What are the causes of macrocytosis?
B12 folate deficiency
Alcohol
Drugs
Haematological disorders
Liver disorder
Smoking
Pregancy
What drugs may cause macrocytosis?
Methotrexate
Azathioprine
What haematological disorders may cause macrocytosis?
Myelodysplastic syndrome
Aplastic anaemia
Myeloma
What are the potential causes of hypocalcaemia?
Decreased PTH
Low Vit D
CKD
Liver disease
Sclerotic (blastic) bone metastases
What are the potential causes of raised GGT?
Alcohol
Obesity
Pancreatic disease
MI
Renal failure
Diabetes
Which 2 liver enzymes may demonstrate cholesystitis?
ALP and GGT
What are the potential causes of raised ALT?
Statins
NSAIDs
Hep B&C
Coeliac disease
Alcohol
Fatty liver disease
Haemochromotosis
Alpha-1 antitrypsin deficiency
What are the causes of low phosphate?
GI - reduced absorption/intake (anorexia)
Alcoholism
DKA
Hyperparathyroidism
Renal disease - increased excretion
What are bisphosphonates?
Analogues of pyrophosphate
Potent inhibitors of osteoclast medicated bone resorption
What are bisphosphonates used for?
Paget’s disease
Hypercalcaemia
Osteolytic bone disease of malignancy
Primary and secondary hyperparathyroidism
Osteoporosis
What must you look out for in someone on bisphosphonates?
Osteonecrosis of the jaw
What BP range is a stage 1 hypertension?
130-139 systolic
80-89 diastolic
What BP range is a stage 2 hypertension?
140 of higher systolic
90 or higher diastolic
What BP range is a stage 3 hypertension?
Higher than 180 systolic
Higher than 110 diastolic
Name 5 risk factors of hypertension
Heart disease/angina
MI
Strokes
HF
PAD
Aortic aneurysms
Kidney disease
Vascular dementia
Aortic valve disease
Vision loss/choroidopathy
Sexual dysfunction
Brain aneurysms
Arrhythmias
Arterial thrombosis
How does hypertension damage blood vessels?
Increased shearing pressure due to increased BP
Therefore damage to arterial walls, then plaque formation and athlerosclerosis
What is choroidopathy?
Build up of fluid in eye due to burst blood vessels
Name 3 methods of lifestyle management for hypertension
Weight loss
Making sure weight not carried around abdomen
Regular exercise
Healthy diet - lots of fruit and veg
Reduce salt intake
Reduce alcohol consumption
Quit smoking
What examination may you do in an initial consultation for someone newly diagnosed with hypertension?
BP
Fundoscopy
Auscultate heart
What further investigations may you do for someone newly diagnosed with hypertension?
Urine albumin:creatinine
HbA1c
Electrolytes
Fundoscopy
ECG
Ambulatory blood pressure (if not already done for diagnosis)
Further tests to identify secondary cause of hypertension if signs
Which 3 further investigations are the most important for someone with a new diagnosis of hypertension?
Urine albumin:creatinine
Fundoscopy
ECG
Why do you need further tests for someone recently diagnosed with hypertension?
Checking for signs of end organ damage
Name 3 secondary causes of hypertension
Renal disease
Conn’s disease
Phaeochromocyotoma
Cushing’s disease
Acromegaly
Hyperthyroidism
Alcohol
Corticosteroids
NSAIDs
Name 2 renal causes of hypertension
Chronic pyelonephritis
Diabetic nephropathy
Glomerulonephritis
PKD
Obstructive uropathy
Renal cell carcinoma
Name 3 types of antihypertensives available
ACEi
ARBs
Diuretics
CCBs
Beta-blockers
Alpha-blockers
Name an ACEi
Ramipril
Name 3 S/E of an ACEi
Bradykinin cough
Hyperkalaemia (ramipril)
Angioedema
What is a benefit of ACEis?
Protective for kidneys
What should you look out for with kidneys in using ACEis?
Some may get damage if atherosclerosis in renal arteries so do U&E 2 weeks after starting
Name 2 S/E of ARBs
Dizziness
Headaches
Fatigue
Name an ARB
Candesartan
Name a loop diuretic
Furosemide
Name 3 S/E of loop diuretics
Hyperuricaemia
Hypomagnesaemia
Hypocalcaemia
Hypokalaemia
Alkalosis
Urinating a lot
Name a thiazide like diuretic
Indapamide
Name 3 S/E of thiazide like diuretics
Hypokalaemia
Alkalosis
Hypercalcaemia
Hyperuricaemia
Hyperglycaemia
Hyperlipidaemia
Name a potassium sparing diuretic
Spironolocatone
Name 2 S/E of spironolactone
Hyperkalaemia
Gynaecomastia
Name a CCB
Amlodipine
What are the S/E of CCBs?
FIGHTED
Fatigue/flushing
Increase in glucose levels and uric acid
GI upset (nausea/constipation), gingival hyperplasia
Headache
Tachycardia, palpitation, angina
Edema (pedal, peripheral, facial) - dose dependent
Dizziness
Name a beta-blocker
Bisoprolol
Why may bisoprolol be preferable in the treatment of hypertension?
Cardio selective - less likely to get some of the S/E
What are the S/E of beta-blockers?
BALD FISH
Bronchoconstriction/bradycardia
Arrythmias
Lethargy
Disturbance in glucose metabolism
Fatigue
Insomnia
Sexual dysfunction
Hypotension
Name an alpha blocker
Doxazocin
What are the S/E of alpha blockers?
Postural hypotension
Nausea
Drowsiness/fatigue
Swollen ankles/legs
What tests might you do for someone with erectile dysfunction?
History - psychological?
External genitalia exam
PSA and prostate
Bloods - testosterone, LH if low testosterone, diabetes, cholesterol, FBC
What combination of 4 drugs is classically given to patients post-MI?
ACEi
Amlodipine/beta-blocker
Aspirin
Statin
Name 5 risk factors for heart failure
Coronary heart disease
MI
Hypertension
Valvular heart disease
Infection
Myocarditis
Heavy alcohol usage
Illegal drug usage
Chemotherapy
Congential heart defects
Arrythmias
Hyperthyroidism
Phaeochromocytoma
NSAIDs
Sleep opnoea
Smoking
Obesity
Family history - cardiomyopathies, hyperlipidaemia
Chronic lung disease
Pregnancy
Anaemia
Sarcoidosis
What are the different types of heart failure?
Left sided heart failure
- Reduced EF
- Preserved EF
RHF
Congestive HF
What is the difference between reduced EF and preserved EF left sided HF?
Reduced - ventricle not contracting properly
Preserved - ventricle not relaxing properly
What is BNP?
Made by heart and tends to be raised in HF
Used to diagnose/rule out HF
What is a normal BNP?
< 400
What is eGFR?
Estimated glomerular filtration rate
What is a healthy eGFR?
90ml/min
What does an eGFR of 60-90 mean?
G2
What does an eGFR of 45-59 mean?
Ga3
What does an eGFR of 30-44 mean?
G3b
What does an eGFR of 15-29 mean?
G4
What does an eGFR of <15 mean?
G5
What is the prognosis of heart failure?
50% die within 5 years
How does a loop diuretic work in heart failure?
Inhibits Na-K-Cl cotransporter in the thick ascending limp of loop of henle
Helps kidneys remove excess water and salt so that your heart has less fluid to pump around the body
What is a loop diuretic used for in heart failure?
Symptomatic relief
Which is the only medication used in preserved EF HF?
Loop diuretic
What is the second line diuretic for HF?
Spironalactone
What are the S/E of loop diuretics?
Needing to wee more often
Electrolyte imbalances
How does an ACEi work?
Prevents the formation of angiotensin II
Angiotensin II causes narrowing of blood vessels therefore raising BP and resistance within arteries
How does an ACEi help in HF?
Reduces pressure so heart doesn’t have to work as hard
How do beta-blockers help in HF?
Slows down HR to prevent heart from overworking
Prevents heart responding to stress hormones therefore preventing the heart from overworking
What monitoring do you need to do for someone with HF?
Annual ECG
BP - BB
HR - BB
U&Es - diuretics
What might you see on a chest x-ray in someone with HF?
Alveolar oedema (bat wings when acute)
Kerley B lines - interstitial oedema
Cardiomegaly - >50% oedema
Dilated upper lobe vessels - pulmonary venous hypertension
Pleural effusion
What bloods should you do for someone with suspected HF?
FBC
U&E
TFT
LFT
Lipid profile
HbA1c
NT-proBNP
What is the gold standard investigation for HF diagnosis?
ECHO
What LVEF suggests HF?
< 50%
What are the symptoms of measles?
CCCK
- Cough
- Coryza
- Conjunctivitis
- Koplik spots
What does the fever pain score assess and ?
The likelihood of an infection being caused by strep and when to prescribe antibiotics
What answers on the fever pain score would suggest strep?
Fever in past 24 hours - yes
Absence of cough or coryza - yes
Symptoms of onset
When is strep less likely?
As you get older. Much more common in children
What is the centor score?
Likelihood of a fever being strep
What answers would suggest that an infection is strep on the centor score?
Exudate or swelling on tonsils - yes
Tender/swollen anterior cervical lymph nodes - yes
Temp > 38 - yes
Cough - no
What is the NICE traffic light guidance?
Guidance that you can use to assess how serious an infection is
What is assessed in the NICE traffic light guidance?
Colour, activity, respiratory, hydration and circulation, other
What colour would a child be if they were green on the NICE traffic light guidance?
Normal colour of skin, lips and tongue
What would the activity of a child be like if they were green NICE traffic light guidance?
Responding normally to social cues, content, smiling, stays awake or awakens quickly, strong normal cry/not crying
What respiratory symptoms would a child have if they were green on the NICE traffic light guidance?
None
What hydration and circulation symptoms would a child have if they were green on the NICE traffic light guidance?
Normal skin turgor and eye, moist mucus membranes
What is also important to note in order for a child to be green on the NICE traffic light guidance?
None of amber or red S&S
What colour might a child be if they are amber on the NICE traffic light guidance?
Pallor of skin, lips, or tongue reported by parent or carer
What activity might a child be showing if they are amber on the NICE traffic light guidance?
Not responding normally to social cues, waking only with prolonged stimulation, decreased activity, not smiling
What respiratory symptoms would a child have if they are amber on the NICE traffic light guidance?
Nasal flaring
Tachypnoea
6-12m RR > 50
>12m RR > 40
O2 < 95% in air
Crackles on chest auscultation
What hydration and circulation symptoms might a child have if they are amber on the NICE traffic light guidance?
Poor feeding
Dry mucous membranes
CRT > 3s
Reduced urine output
Tachycardia
< 1 yr > 160
1-2 yrs > 150
2-5 yrs > 140
What other symptoms may be present if a child is amber on the NICE traffic light guidance?
Fever for 5 days or more
Rigors
Temp > 39 if 3-6m
Swelling of limb/joint
Non-weight bearing/not using a limb
What colour may a child be if they are red on the NICE traffic light guidance?
Pale, mottled, ashen, blue skin, lips, or tongue
What activity level may a child be at if they are red on the NICE traffic light guidance?
No response to social cues
Appears ill to a healthcare professional
Unable to rouse, of if roused doesn’t stay awake
Weak, high-pitched or continuous crying
What respiratory symptoms may a child have if they are red on the NICE traffic light guidance?
Grunting
Tachypnoea RR > 60
Moderate/severe chest indrawing
What hydration and circulation symptoms may a child have if they are red on the NICE traffic light guidance?
Reduced skin turgor
What other symptoms may children have if they are red on the NICE traffic light guidance?
Temperature > 38 in 0-3m
Non-blanching rash
Bulging fontanelle
Focal neurological signs
Focal seizures
Status epilepticus
What safety netting may you give a parent of a child that presents with a fever?
Breathless, drowsy, stop drinking, don’t pass urine for more than 6 hours, fever for more than 5 days, or if worried about anything or think they’re worse - bring them back or A&E
How many stages are there to delivery vaccines in babies under 1?
3
When do babies under the age of 1 get vaccines?
8 weeks
12 weeks
16 weeks
What vaccines do babies get at 8 week?
6-in-1 vaccine
Rotavirus
MenB
What vaccines do babies get at 12 weeks?
6-in-1 vaccine (2nd)
Pneumococcal
Rotavirus (2nd)
What vaccines do babies get at 16 weeks?
6-in1 vaccine (3rd)
MenB (2nd)
How many times are primary children given vaccines?
2 times
When are primary school children vaccinated?
1 year
3 years 4 months
What vaccines are 1 year olds given?
HiB (4th)/MenC (1st)
MMR (1st)
Pneumococcal (2nd)
MenB (3rd)
What vaccines are 3 year olds given?
MMR (2nd)
4-in-1 pre-school booster
How many times are teenagers vaccinated?
Twice
When are teenagers vaccinated?
12/13
14
What vaccines do 12/13 year olds get?
HPV
What vaccines do 14 year olds get?
3-in-1 teenage booster
MenACWY
What is given in the 6-in-1 vaccine?
DPT - diptheria, tetanus, polio
HepB
HiB
Whooping cough
What is in the 4-in-1 vaccine?
DTP
Whooping cough
(lose the two H’s)
What is in the 3-in-1 vaccine?
DTP
What are the risk factors for developing dementia?
Hypertension
Smoking
Diabetes
Obesity
Sedentary life
Poor diet
Lots of alcohol
Low levels of cognitive engagement
Depression
Traumatic brain injury
Hearing loss
Social isolation
Air pollution
Increasing age
Female
Down’s syndrome and other learning disabilities
Hypothyroidism
Which dementia is more common in down’s syndrome?
Alzheimers - higher levels of Tau in Downs
How can the presentation of dementia differ in those with learning disabilities?
Earlier onset
Reduced interest in being sociable
Decreased enthusiasm for usual activities
Decline in ability to pay attention
Sadness, fearful, anxiety
Irritability, uncooperative, aggression
Restlessness, sleep disturbances
Sleeping a lot
How can you diagnose dementia?
Needs referral to memory clinic
Demonstrate decline in baseline cognition, functioning, and changes in personality across 3 longitudinal assessments
Confusion screen
How can you diagnose dementia in individuals with learning disabilities?
Screen for dementia from 30 - annual review
Comprehensive baseline assessment at 30 - memory, executive functions, praxis, visual spatial skills, language (written and verbal), attention, processing speed
Special psychiatrist referral
DSQIID - Dementia Screening Questionnaire for Individuals with Intellectual Disability
What does a confusion screen entail?
Bloods
ECG
Urinalysis
CT head
CXR
Sputum culture?
What bloods are done in a confusion screen? What causes of confusion are they looking for?
FBC - infection, anaemia, malignancy
U&E - hyponatraemia, hypernatraemia
LFTs - liver failure, secondary encephalopathy
Coagulation/INR
TFTs - hypothyroidism
Calcium - hypercalcaemia
B12 + folate/haematinics - B12/folate deficiency
Glucose - hypo/hyperglycaemia
Blood cultures
What can B12 deficiency cause?
Subacute combined degeneration of spinal cord
Why do you do a confusion screen?
To ensure no reversible cause of dementia
What other confusion tests are there?
4AT - alertness, cognition, attention, acute change/fluctuating course
10-point cognitive screener
6-item cognitive impairment test
Memory impairment screen
Mini-cog
What are the 5 main points of the mental capacity act?
- Presumption of capacity
- Support individuals to make their own decisions
- Unwise decision do not mean lacking in capacity
- Best interests
- Less restrictive option - must consider whether possible to act in a way that would interfere least with person’s rights/freedoms
What questions do you need to answer when assessing capacity?
- Does the person have an impairment of their mind or brain, whether because of an illness, or external factors such as alcohol or drug use?
- Does the impairment mean a person is unable to make a specific decision when they need to?
- Can they understand the information relevant to the decision?
- Can they retain that information?
- Can they use or weigh up that information as part of the process in making that decision?
- Can they communicate that decision back to you?
What is normal pressure hydrocephalus?
Blockage to outflow of CSF with no raised ICP
What can cause normal pressure hydrocephalus?
SAH
Head trauma
Infection
Tumour
Surgical complications
What is hydrocephalus?
Raised intracranial pressure due to increased fluid in the brain
What can cause hydrocephalus?
Genetics
Strokes
Meningitis
Tumours
Head injury
What is multimorbidity?
People with multiple health conditions
Often long-term and complex conditions requiring ongoing care
What can affect multimorbidity?
Increases with age and poorer socioeconomic status
Individual lifestyle factors and combined effect of lifestyle factors associated with likelihood of simultaneous presence of three or more chronic conditions in the same subject
What is polypharmacy?
Concurrent use of multiple medications in an individual
What is appropriate polypharmacy?
Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to the best evidence
What is problematic polypharmacy?
Prescribing of multiple medications inappropriately or where intended benefit of the medication is not realised
Name 5 anti-cholinergic side effects
Can’t see, can’t pee, can’t climb a tree
Eyes - blurred vision, dry eyes
Brain - drowsiness, dizziness, confusion, hallucinations
Heart - rapid heart rate
Bladder - urine retention (unable to empty your bladder)
Skin - skin-flushing, unable to sweat, overheating
Bowel - constipation
Mouth - dry mouth
What can anti-cholinergics be used to treat?
Asthma
Cardiovascular disease
COPD
Mydriasis
Parkinson’s disease
Urge incontinence
What are the risks of stopping statins?
Associated with 33% increased risk of admission for a cardiovascular event in 75-year-old primary prevention of patients
Lower relative risk of cardiovascular event following discontinuation of statins in a diabetic patient
In whom are hypoglycaemic events be more common in?
Incidence of serious hypoglycaemia higher in insulin users
Recent hospital discharge was strongest predictor of subsequent hypoglycaemia in older persons with diabetes
What can increase risk of orthostatic hypotension including specific medications?
Age (10% over 85s)
Number of medications
Hydrochlorothiazide (65%)
Lisinopril (60%)
Furosemide (56%)
Trazodone (58%) - antidepressant
Terazosin (54%) - alpha blocker
What are the effects of multimorbidity?
Higher risk of safety issues
Poor medication adherence and adverse drug events - polypharmacy
Complex management
More frequent and complex interactions with health care services
Greater susceptibility to failure of care delivery and coordination
Need for clear communication and patient-centred care due to complex needs
Demanding self-management and competing priorities
Vulnerability to safety issues
Possible diagnostic overshadowing
What are the effects of appropriate polypharmacy?
Potential to improve QOL, longevity and minimise harm from medications
What are the effects of problematic polypharmacy?
Hazardous interactions
Pill burden unacceptable to patient
Demands make difficult to achieve clinically useful medication adherence
Medicines prescribed to treat S/E of other medicines where alternative solutions are available to reduce number of medications prescribed
What does the mnemonic SAD PERSONS stand for and what is it used for?
Used for assessing suicide risk
S - sex (male)
A - age (< 19 and > 45)
D - depression
P - previous attempt/parasuicide
E - excess alcohol or substance usage
R - rational thinking loss
S - social supports lacking
O - organised plan
N - no spouse
S - sickness
What is a disability?
Related to anyone with a physical, sensory, or mental impairment which seriously affects their daily activities
What is a visual impairment?
Small percentage see nothing
Some differentiate between light and dark
No peripheral vision
No central vision
Patchwork of blanks and defined areas
Some can see enough to read text, although may have difficulty crossing roads
What is macular disease?
Disease causing damage to the retina
What does the macular do?
Central part of retina which we use for detail (reading/writing)
How is age related macular degeneration treated?
No cure
Can be slowed/halted in some cases with medical treatment, drug therapy, or laser treatment
Most common eye condition in the UK
What are retinitis pigmentosas?
Inherited diseases of the retina
What happens in retitinitis pigmentosa?
Leads to gradual reduction in vision - night and peripheral vision affected first followed by difficulties in reading and colour vision
1 in 3000 affected in the UK
What is glaucoma?
Disease affecting optic nerve
Irreversible
What are the dangers of glaucoma?
In early stages no obvious symptoms
40% optic nerve can be damaged before vision loss noted
How common is glaucoma?
2 in 100 over 40
What is diabetic retinopathy?
Damage to blood vessels due to high glucose
If caught early can be successfully treated with laser treatment
Stops it progressing but cannot restore loss
Leading cause of blindness in adults over 65
What is Charles Bonnet Syndrome?
When people live with sight loss, brain not receiving as many pictures
New fantasy pictures or old pictures stored in brains released and experienced as though seen
Generally affects people who lost sight later in life but can affect someone of any age
How common is sight loss?
> 2000 children in UK
1 in 5 > 75 visually impaired
1 in 2 > 90 visually impaired
8% born with impaired vision
2% see nothing at all
Older visually impaired 3x more likely to experience depression
What is the law around age to consent?
Under 16 - cannot consent to sex with someone over the age of 16
Under 13 - statutory rape even if have sex with someone of the same age
If 14/15 can have sex with someone who is no more than 2 years older than them
What might the symptoms of gonorrhoea be?
Deep dispareunia
Green discharge
What might the symptoms of chlamydia be?
Silent
Deep dispareunia
White discharge
What might the symptoms of trichomonas vaginalis be?
Green/yellow frothy discharge
Vaginal itching and irritation
What might the symptoms of bacterial vaginosis be?
White discharge
Soreness/irritation
Smelly discharge
What questions should you ask about last sexual contact?
Timing
Consent
Relationship
Sex and country of origin
Types of sex - don’t forget oral!
Contraception
Other sexual partners
HIV risk factors
Paid for sex/been paid for sex
What amount of time needs to have elapsed for a vaginal/cervical swab to be accurate?
2 weeks (chlamydia and gonorrhoea)
What amount of time needs to have elapsed for a STI blood test to be accurate?
12 weeks (3m) (syphilis and HIV)
What are the Fraser Guidelines?
Part of Gillick Competency
Young person cannot be persuaded to inform their parents/carers that they are seeking this advice/treatment
Young person understands advice being given
Young person’s physical/mental health or both is likely to suffer unless receive the advice/treatment
Young person’s best interests to receive the advice, treatment, or both without their parent/carers consent
Young person likely to continue having sex with or without contraceptive treatment
What are the child protection concerns with children under 16 having sex and what could be signs of this?
Possible indicator of child exploitation/grooming
Presenting repeatedly with STIs or TOP
Partner > 18
Feeling uncomfortable with having sex
Isolated from partners family/friends
Partner in a position of power eg teacher, scout leader
Being given lots of gifts from partner as rewards for certain behaviours
What are some of the CIs for prescribing the COCP according to the UKMEC guidelines?
Pregnant
> 35 and smoker/stopped smoking less than 1 year ago
BMI > 35
Hypertension
Migraine with aura
Breastfeeding up to 6 weeks
CVS and VTE risk factors
FHx or personal hx breast cancer
What is ectropion?
Columnar epithelium coming out of cervical os
Normal
May cause spotting or bleeding after sex
What are the components of chronic pain?
Physical
Psychological
Environmental
Sensitisation
- Allodynia
- Hyperalgesia
What are the 3 different classifications of opioids?
Naturally occurring compounds
Semi-synthetic
Synthetic
Name 2 naturally occurring opioids
Morphine
Codeine
Thebaine
Papaverine
Name 2 semi-synthetic opioids
Diamorphine (heroin)
Dihydromorphine
Buprenorphine
Oxycodone
Name 2 synthetic opioids
Pethidine
Fentanyl
Methadone
Alfentanil
Ramifentanil
Tapentadol
What are the 3 opioid receptors and where are they?
MOR, KOR, DOR
Distributed throughout the CNS and to a lesser extent the periphery
Also in the vas deferens, knee joint, GI tract, heart and immune system
How do opioids work?
Presynaptic inhibition of neurotransmitter release
What are the GI S/E of opioids?
Constipation
N&V
Weight gain
What are the respiratory S/E of opioids?
Sleep disordered breathing
Respiratory depression
What are the CVS S/E of opioids?
Increased CVD risk
What are the CNS S/E of opioids?
Dizziness
Sedation
Falls (fracture risk)
Respiratory depression
What are the endocrine S/E of opioids?
Hypogonadism
Opiate induced androgen deficiency
Sexual dysfunction - erectile dysfunction
Infertility/reduced fertility
Fatigue
Decreased testosterone
Osteoporosis
Oligomenorrhoea
Galactorrhoea
What are the immune S/E of opioids?
Pneumonia
Reduced immunity
What do you need to look out for in long term opioid prescribing?
Addiction and misuse
Tolerance
Withdrawal
Hyperalgesia
Depression
What non-pharmacological ways are there of treating pain?
Physical - weight loss, smoking cessation, exercise (stretching, physio, yoga, pilates), joint injections
Psychological - counselling, CBT, music, meditation, relaxation
Complementary therapy - massage, reflexology
Occupational - work place based review
What pharmacological ways are there of treating pain?
Non-opioid analgesics - intermittent usage, slow/low
Adjuvant analgesics - anti-convulsant, anti-depressants, lidocaine patches
What are the potential signs of abuse and dependency of opioids?
Use of pain medications for things other than treatment
Impaired control (of self or medication use)
Compulsive use of medication
Continued use of medication despite harm or lack of benefit
Craving or escalation of medication use
Selling or altering prescriptions
Stealing or diverting medications
Calls for early refills/losing prescriptions
Reluctance to try non-pharmacological interventions
What are the key associations with opioid dependency?
Age - higher in younger, decreases as age increases
Marital status - highest in those cohabiting but not married
Employment - highest in those unemployed
Strong association with very bad health
Higher association between buying on the internet and dependency
What is the definition of a total anterior stroke from the Bamford criteria?
All 3 of…
1. Unilateral weakness/numbness
2. Homonymous hemianopia
3. Higher function impairment eg dysphasia
What is the definition of a partial anterior stroke from the Bamford criteria?
2/3 of…
1. Unilateral weakness/numbness
2. Homonymous hemianopia
3. Higher function impairment eg dysphasia
What is the definition of a posterior circulation syndrome from the Bamford criteria?
One of
1. Ipsilateral CN and contralateral body deficit
2. Bilateral deficit
3. Isolated homonymous hemianopia
4. Gaze paresis
5. Cerebellar symptoms - vertigo, ataxia, nystagmus
What is the definition of a lacunar stroke from the Bamford criteria?
Pure motor/sensory symptoms
Sensorimotor
Ataxic hemiparesis
Name 3 posterior circulation syndromes
Weber’s
Wallenberg’s
Lateral pontine
What is Weber’s syndrome?
PCA
Affects midbrain, cerebral peduncles, oculomotor nucleus
Ipsilateral oculomotor palsy + contralateral weakness
What is lateral pontine syndrome?
AI cerebellar, lateral pons, pontine tracts, CN7 nucleus, cerebellum
Ipsilateral facial spinothalamic - loss + contralateral body spinothalamic loss + facial nerve palsy + vertigo/ataxia/nystagmus
What is wallenberg’s syndrome?
PI cerebellar
Lateral medulla, medullary tracts, cerebellum
Ipsilateral facial spinothalamic loss + contralateral body spinothalamic loss + vertigo/ataxia/nystagmus
What is the treatment for hypertension in haemorrhagic stroke?
If S>150 then labetol
What reversal of coagulopathy can be given for warfarin?
Prothrombin complex concentrate + vitamin K
What reversal of coagulopathy can be given for dabigatran?
Idaracizumab
What is the secondary prevention for stroke?
Aspirin 300mg for 2 weeks post stroke
1st line - clopidogrel 75mg lifetime
2nd line - aspirin + dipyriamole
Statin
What is a severe SDH?
> 10mm or > 5mm with midline shift/neurological dysfunction
How is a severe SDH treated?
Surgery
Anti-epileptics (phenytoin/keppra)
What is a moderate SDH?
< 10mm or <5mm midline shift and no neurological dysfunction
How is a moderate SDH treated?
Antiepileptics
FU CT 2-3 weeks
How is a chronic SDH treated?
Same as severe but elective surgery
What is nimodipine used for?
Preventing vasospasm
What are the indications for a CT within 1 hour?
- GCS < 13 at time of injury
- GCS < 15 2hrs post injury
- Depressed/open skull fracture
- Basal skull fracture signs
- Focal neurological deficit
- Post-traumatic seizures
- > 1 episode vomiting
What are the signs of a basal skull fracture?
- Haemotympanum
- CSF rhinorrhoea
- Battle’s sign (mastoid bruising)
- Panda eyes
What are the causes of bacterial meningitis?
Explaining Big Hot Neck Stiffness
0-1 month = E coli, group B strep
1 month-6 years = Hib, Neisseria meningitidis, Strep pneumoniae
6 years + = N meningitidis, Strep pneumoniae
60+/immunocompromised = N meningitidis, Strep pneumoniae, LISTERIA monocytogenes
What is the treatment if there is suspected bacterial meningitis?
IM benpen
What is the treatment for bacterial meningitis by age group?
< 3 months = IV cefotaxime + IV ampicillin/amoxicillin
> 3 months = IV ceftriaxone +/- IV dex
> 60/immunocompromised = IV ceftriaxone and IV amoxicillin +/- dex
When should you give steroids in meningitis treatment?
- Purulent CSF
- Protein > 1g/L
- CSF WCC > 1000/mL
- Bacteria visible on gram stain
What are the scores for the motor section of the GCS score?
6 - obeying commands
5 - localising to pain
4 - withdrawing from pain
3 - flexing
2 - extending
1 - no response
What are the scores for the voice section of the GCS score?
5 - orientated
4 - confused
3 - words
2 - sounds
1 - no response
What are the scores for the eyes section of the GCS score?
4 - spontaneously opening
3 - open to voice
2 - open to pain
1 - no response
What are the symptoms of normal pressure hydrocephalus?
Wacky
Wobbly
Weeing
What are the differentials of dementia?
Depression
NPH
Hypothyroidism
Addison’s
B12/folate/thiamine deficiency
Syphilis
Brain tumour
SDH
Chronic drug/alcohol use
What is Alzheimer’s associated with?
FHx, Caucasian
Down’s syndrome
Slow, steady decline
Memory, understanding, learning
What is Lewy body dementia associated with?
Old men with FHx
Hallucinations, falls, REM sleep disorder, fluctuating, parkinsonism
What is the first line treatment for Alzheimer’s and Lewy body dementia?
Acetylcholine esterase inhibitors - rivastigmine, donepezil, galantamine
What is the second line treatment for Alzheimer’s and Lewy body dementia?
NMDA receptor antagonist - memantine
Anti-psychotics for hallucinations
What is vascular dementia associated with?
Stepwise, focal neurological deficits
Low mood, depression, slowed thinking and reasoning
How is vascular dementia treated?
Aspirin 300mg + clopidogrel 75mg
What is frontotemporal dementia associated with?
FHx
Personality change
< 65
Gambling, memory preserved, lack of insight, speech
What is mild cognitive impairment?
No significant life impact/progression
What drugs can cause falls?
Opioids
Antihypertensives
SSRIs
Drug interactions
Polypharmacy
What are the peripheral causes of dizziness/vertigo?
Ear causes
- BPV
- Acute labyrinthitis
- Meniere’s disease
- Acoustic neuroma
What causes BPV and what are the symptoms?
Debris in semicircular canal
Head movement
Vertigo for a few seconds
What are the symptoms of acute labyrinthitis?
Vertigo + N&V
No hearing loss/tinnitus
Vascular/virus
What are the symptoms of Meniere’s disease?
Vertigo > 20 mins + deafness + tinnitus
Bed rest
What are the symptoms of acoustic neuroma?
Unilateral hearing loss then vertigo +/- raised ICP
What can cause central vertigo?
MS, stroke, migraine, trauma, motion sickness, alcohol
What are the symptoms of pre-eclampsia?
Severe frontal headache
Epigastric pain
N&V
Visual disturbances
Swelling of hands and feet
Liver tenderness
How is pre-eclampsia diagnosed?
Over 20 weeks
Hypertension > 140/90 with proteinuria
How can you treat pre-eclampsia?
Antihypertensives - labetol (1st line), methyldopa, nifedipine
Monitor foetal growth
Fluid restriction
If BP uncontrollable - deliver with MgSO4 before
What is eclampsia?
Tonic-clonic seizures due to uncontrolled pre-eclampsia
Placental distress causing vasospasm widespread in body leading to hypertension that can lead to vasospasm in the brain causing seizures
What is HELLP syndrome?
H - haemolysis
EL - elevated liver enzymes
LP - low platelets
Typically occurs in 3rd trimester
Blood transfusions, platelets, MgSO4
How can you diagnose gestational diabetes?
Fasting > 5.6
2hr plasma glucose > 7.8
What can you do to reduce the risks of pre-term labour?
Tocolytic drugs - slow down contractions (nifedipine)
MgSO4 to promote brain development
Steroids (dexamethasone) to promote lung and brain development
What are the 4 Ts of PPH?
Tone - uterine atony
Trauma - lacerations during birth
Tissue - retained POC
Thrombin - coagulopathy
What is foetal hydrops?
Abnormal fluid accumulation in 2 or more foetal components
When are anti-D injections given during pregnancy?
28 and 34 weeks
What can cause intrauterine growth restriction?
Extremes of maternal age
Interpregnancy gap < 6 months
Previous SGA baby
Placental insufficiency
Substance abuse/medications (warfarin)
Maternal starvation
Maternal infection
Foetal chromosomal/genetic/congenital anormalities
Placental dysfunction
What is a first degree peroneal tear?
Fourchette and vaginal mucosa damaged
Underlying muscles exposed but not torn
What is a second degree peroneal tear?
Posterior vaginal wall and perianal muscles. Sphincter intact
What is a third degree peroneal tear?
Anal sphincter torn but rectal mucosa intact
What is a fourth degree peroneal tear?
Anal canal opened, tear may spread to rectum
What can cause foetal distress during labour?
Cord prolapse
Pre-eclampsia
Placental abruption
Low levels of amniotic fluid
Breech
Hypoxia
Maternal sepsis
Should dystocia
What is cord prolapse?
When cord prevents out of cervix before uterus
Contractions cause cord compression so cuts off O2 supply to foetus
What are the different types of cord prolapse?
Overt - happens after sac burst
Abdo - ill fitting or non-engaged presenting part
Vaginal - can be felt within vagina, if pulsating baby still alive
Name a GnRH receptor antagonist
Zolotex injections
Degarelix
Goserelin
What are the risk factors of fibroids?
Obesity
Early menarche
1st degree relative(s) with fibroids
Hypertension
Alcohol
Poor diet
What are the protective factors for fibroids?
Exercise
Increased parity
Smoking
Name 4 other causes of vaginal bleeding
Endometrial polyps
Ectopic pregnancy
Endometrial hyperplasia
Endometrial cancer (post-menopausal)
POP
IUCD
Anticoagulant treatment
When should you offer antihypertensives with stage I hypertension?
If < 80 and any of the following
- Target organ damage
- Established CVS disease
- Renal disease
- Diabetes
- QRISK > 10%
What HbA1c suggests diabetes and pre-diabetes?
Diabetes > 48
Pre-diabetes 42-47
What is the 1st line treatment for T2DM?
Metformin
When should you add an SGLT2 inhibitor to metformin as first line for diabetes treatment?
If CVD, high risk for developing CVD (QRISK > 10%), HF
eg empagliflozin
Have CVS benefits (protective)
What are the S/E of SGLT2 inhibitors and why?
UTI
Inhibits glucose reabsorption in kidney so glucosuria
What can you give if metformin is not tolerated due to S/E (gastric)?
Modified-release metformin
What can you give if metformin is CI?
If risk of CVD/HF - SGLT2 monotherapy
If not at risk - DPP4 inhibitor or pioglitazone or sulphonylurea
What is the 2nd line treatment for T2DM?
Add one of
- DPP4 inhibitor
- Pioglitazone
- Sulphonylurea
What is the 3rd line treatment for T2DM?
Add another drug
Start insulin therapy
What is the FEVERPAIN score?
FEVER lasting 24 hours
Pus on tonsils
Attend rapidly (ie symptoms onset < 3 days)
severely Inflamed tonsils
No cough or coryza
If >4 then antibiotics
What antibiotics would you give for strep throat?
Phenoxymethylpenicillin
Clarithromycin if penicillin allergic
7/10 days
What is the most common cause of bacterial tonsilitis?
Strep pyogenes (gram positive coccus)
What FEV1/FVC suggests asthma and what improvement with a SABA is required?
< 70% predicted
12% improvement with SABA
What are the symptoms of a moderate asthma attack?
PEFR 50-75% best/predicted
Speech normal
RR < 25
HR < 110
What are the symptoms of a severe asthma attack?
PEFR 33-50%
Can’t complete sentences
RR > 25
HR > 110
What are the symptoms of a life threatening asthma attack?
PEFR < 33%
Sats < 92%
Normal pCO2 4.6-6.0
Silent chest, cyanosis, feeble resp effort
Bradycardia, dysrhythmia, hypotension
Exhaustion, confusion, coma
What treatment can be given for regular migraines?
Beta blockers
CI in asthma - topiramate
What are the problems with topiramate?
May be teratogenic
Reduces effectiveness of oral contraceptives
What are the red flags of a headache?
Thunder clap - SAH
Immunocompromised
Triggered by cough, valsalva, sneeze, exercise - raised ICP until proven otherwise
Impaired level of consciousness + vomiting (> 1) - CT
Progressively worsening + higher functioning impaired - CT
Hx current cancer - ?mets
Worsening with fever
Change in personality
Orthostatic
GCA signs
Meningitis symptoms
When are NSAIDs CI?
NSAID
Nursing and pregnancy
Serious bleeding
Allergic asthma
Impaired renal function - incl renal artery stenosis
Drugs (anticoags)
Name 3 cyanotic congenital heart defects
R -> L shunt
- Truncus arteriosus
- Transposition of the great vessels
- Tricuspid atresia
- ToF
- Total anomalous pulmonary venous return
Hypoplastic L heart syndrome
Name 3 acyanotic congenital heart defects
L -> R shunt
- ASD
- VSD
- AVSD
- PDA
Outflow tract obstructions
- Aortic stenosis
- Pulmonary stenosis
- Coarctation of the aorta
What is Eisenmenger’s syndrome?
Increased flow L -> R through shunt increases pressure
R hypertrophy
Eventually shunt reversal -> cyanotic
What are the S&S of acyanotic heart defects?
Tachycardia, tachypnoea
Faltering growth
Sweating
Pulmonary hypertension leading to HF -> oedema, fatigue, frequent chest infections
When will
i) ASDs close?
ii) VSD close?
i) By 1
ii) By 10
How do babies with cyanotic lesions survive?
Also need acyanotic lesion to counteract cyanotic
What does TGA look like on a CXR?
Egg on a string
What are the RF for TGA?
Male
Maternal age > 40
Maternal diabetes
Rubella
Alcohol
How do you keep acyanotic lesions open?
Prostaglandin E1
What is tricuspid atresia?
No tricuspid valve
RV hypoplasia as underdeveloped
What does ToF look like on CXR?
Boot shaped heart
What are the RF for ToF?
Male
1st degree relative Hx CHD
Teratogens - alcohol, warfarin
VACTERL
CHARGE
DiGeorges
What does VACTERL stand for?
Vertebral defects
Anal atresia
Cardiac defects
Tracheo-Esophageal fistula
Renal abnormalities
Limb abnormalities
What does CHARGE stand for?
Coloboma
Heart defects
Atresia choanae
Retardation of growth/development
Genital/urinary abnormalities
Ear abnormalites/deafness
What is the new most common causes of epiglottitis?
Strep pneumoniae (was Hib)
What are the 4 D’s of epiglottitis?
Dyspnoea
Dysphagia
Drooling
Dysphonia (hot potato voice) + tripod
How is epiglottitis treated?
Do not examine throat
Secure airway - ENT/ anaesthetics
O2
Nebulised adrenaline
IV fluids
Cefotacime/ceftriaxone
What antibiotic can you give for whopping cough and when can you give it?
Clarithromycin
If cough present < 3 weeks
What is CF?
Autosomal recessive genetic disease of CFTR gene
In caucasian population
What is the role of the CFTR protein?
Chloride channel in epithelial tissue
Affects both Cl- and Na+
Reduces water in secretions therefore thickened
What are the problems with thickened fluids in CF?
Lungs - thick mucus, increased risk infection
Pancreas - duct damaged in utero, pancreatic insufficiency, CF-related diabetes, require creon and vitamin ADEK supplements
GI - liver and bowel problems
Reproductive - men infertile (absent vas deferens), women must time pregnancy as causes deterioration of lung health
What signs can you get in CF?
Delayed meconium ileus
Recurrent chest infections
Steatorrhoea - frothy, pale stools
Nasal polyps
Clubbin
What medications can be used to treat OCD?
Clomipramine (TCA)
SSRIs
What are the 3 core symptoms of depression?
Sustained low mood
Reduced energy
Anhedonia
What are the other symptoms of depression?
Reduced libido
Poor sleep - early morning waking
Diurnal mood variation - worse in morning
Agitation, anxious
Poor appetite
Worthlessness, hopelessness, guilt
Poor concentration, memory
Thoughts + speech slowed
Suicidal ideation/attempt
What are the symptoms of psychotic depression?
Derogatory auditory hallucinations
Delusions of guilt
Nilhilistic delusions
Persecutory delusions
How is psychosis diagnosed?
1 or more
- thought alienation
- passivity phenomena
- 3rd person auditory hallucinations
- delusional perception
2 or more
- delusions
- 2nd person auditory hallucinations
- other hallucinations
- thought disorder
- catatonia
- -ve symptoms
- amotive
- poverty of speech
- self neglect
- lack of insight
What are the positive symptoms of psychosis?
Delusions
Hallucinations
Disorganised speech/behaviour
What are the negative symptoms of psychosis?
Lack of emotion
Monotone, one-syllable answers
Few gestures
Difficulties thinking/coming up with ideas
Decreased ability to initiate tasks
Decreased motivation/drive
Lack of interest in other people
Inability to feel pleasure
Lack of spontaneity
What are the S/E of lithium?
LITHIUM
Leukocytosis
Interstitial nephritis/insipidus
Tremor (fine)
Hydration decreased
Increased skin/GI and memory problems
Underactive thyroid
Mum’s beware (Ebsteins anomaly)
What are the symptoms of lithium toxicity?
Coarse tremor
Hyperreflexia
Acute confusion
D&V
Coma
Death
What is in the cluster A of personality disorders?
Paranoid
Schizoid
Schizotypal
What is the difference between the cluster A personality disorders?
Paranoid - distrust and suspicious towards others without adequate reason to be suspicious
Schizoid - avoiding social situations, limited range of emotional expression (Matt)
Schizotypal - intense discomfort with close relationships and social interactions (Tim)
What is in the cluster B of personality disorders?
Antisocial
EUPD
Histrionic
Narcissistic
What is the difference between the types of cluster B personality disorders?
Antisocial - impulsive, irresponsible, criminal behaviour
EUPD - fluctuating emotions (period)
Histrionic - uncomfortable if not centre of attention, feel constantly have to seek attention (Joe)
Narcissistic - self-centred arrogant behaviour, lack of empathy and consideration towards others (G)
What is in cluster C of personality disorders?
Avoidant
Dependant
OCD/anakastic
What is the difference between the cluster C of personality disorders?
Avoidant - chronic feelings of inadequacy, highly sensitive to being negatively judged by others (me)
Dependant - anxious, feel helpless, submissive, incapable of taking care of themselves, trouble making simple decisions (Soph)
Anankastic - obsession with orderliness, rigidity and stubbornness (Ellie)