Conditions Flashcards
How would the acute abdomen present?
sudden onset, severe abdomen pain,
Pain!! may be unremitting/ radiating/ sharp/ focal/ N+V
What red flags would concern you with an acute abdomen?
bleeding - internal AAA, ruptured ectopic, peptic ulcer
peritonism - vicseral perforation?
falling vitals - tachycardia, hypotension etc
What differentials would you consider in the case of an acute abdomen?
severe pain out of proportion to signs, raised lactate - ischaemic bowel
bowel obstruction
lower right quadrant pain/ peritonism if ruptured - Appendicitis
colic - biliary causes
strangulated hernia
how would you manage an acute abdomen in general practise?
Hx and examination if possible, urine dip?
conduct A to E and determine need fro stabilisation with IV funds and then A&E if severe causes
consider referrals for admission or surgery (appendicitis)
What would you look for when assessing an unwell child?
appearance, breathing, circulation
fluid status
temperature
eating and drinking
urine output
sepsis?
How would you assess a patient presenting with SOB? what would you ask?
A : r/o obstruction, anaphylaxis, tension pneumothorax
B: RR, SATS, correct O2 needs (COPD with caution)
C: HF and pulmonary oedema?
ask about onset, duration, triggers, relieving and aggravating factors, exercise tolerance
PMH, drug hx, travel history
allergies? new pets? new changes into life?
SOB at night/ needs to prop up onto pillows?
infection? cough/ productive?
examination - CVS, resp, neuro exam, investigations like FBC for anaemia, D-dimers etc
What differentials would you be considering in a patient presenting with sob?
PULMONARY
acute asthma, COPD exacerbations, pneumonia, collapse, PE, pleural effusion, pneumothorax, lung cancer
CARDIAC
cardiac tamponade, CAD, SVT, MI, CCF, HTN
OTHER
acute blood loss, hyperventilation. anxiety, metabolic, neuromuscular, anaemia, obesity
how are you managing a patient with SOB in GP?
if saturations are low give oxygen until waiting
*assess and determine if admission required eg: asthma attack, COPD exacerbation, PE
- treat cause : anxiety, anaemia, pneumonia abx etc
- 2 week cancer referral if appropriate
- further investigations
- inhalers etc as required
How would you assess a pt with unilateral weakness in GP?
neuro exam
what differentials would you want to rule out with this presentation of uni weakness?
TIA
Bells palsy
how would you assess a pt presenting with anaphylaxis?
how would you manage???
Ambulance
how would you want to stabilise a patient before sending them to hospital?
oxygen and BP?
How might you assess back pain presenting in gp?
- ask about onset, time frame, radiation, morning stiffness
- exclude any red flags such as caudal equina symptoms, malignancy and fracture
- assess impact on day to day life
- examine gait, anal tone, neuro exam for lower limb and reflexes
- assess underlying cause
- MSK examination of affected
What differentials would you want to rule out and why in back pain?
BL leg weakness and pain, incontinence, saddle parasthesia –> caudal equina
severe central spinal pain, relieved by lying down –> spinal fracture
unremitting back pain, even at night affecting sleep, weight loss –> cancer
systemically unwell, IVDU, DM –> vertebral osteomyelitis, spinal or epidural abscess
N+V, urinary symptoms –> pyelonephritis kidney infection
how would you manage back pain ?
cause depending
- reassurance
- rest, offer sick note
- analgesia : paracetamol, IB gel or spray, physiotherapy if it gets worse
- lifestyle advice to lose weight and stop smoking
*admission with red flags
- review in 3-4 weeks if persisting
how would inflammatory joint disease present in gp?
- joint stiffness
- reduced range of motion
- red, swollen, hot to touch joint
- systemic illness like in lungs etc
- general lethargy and weakness
what differentials would you be considering for inflammatory joint disease?
RA
lupus
psoriatic arthritis
ankylosing spondylitis
psoriatic arthritis
( juvenile idiopathic arthritis )
gout
pseudo gout
how would you manage inflammatory joint disease in primary care?
*depends on cause
- anti-inflammatories such as NSAIDS
- DMARDs for RA
- physiotherapy
- MDT support
*exclude septic arthritis as risk of osteomyelitis developing
*referral to rheumatology
how would RA be presented in GP?
persistent symmetrical joint swelling (synovitis)
boggy feeling swelling, not bony
bilateral
morning weakness lasting longer than 1h
better with movement
*other symptoms like vasculitis (a rash of red, inflamed capillaries), malaise, fever, RA FH
how is RA managed and followed up in GP?
*referral to rheumatology where specialists will usually offer DMARDs 3m since onset of sympt
- regular blood checks for FBC, LFT : BM suppression
- glucocorticoids offered to treat flare ups
- ensure rapid access to specialists during flares
- drug monitoring, assess treatment targets, complications, lease with specialists
- pneumococcal and influenza vaccines
- offer help understanding of condition
When would you suspect a RA flare up?
- stiffness, joint pain, swelling, general fatigue worsening
- joint synovitis, joint tenderness, loss of joint function
- increased inflammatory markers CRP
how is OA presented in GP?
morning stiffness less than 1h or none
unilateral
functional impairment
activity related joint pain
bony swellings on joints, crepitus on movement
how Is OA managed in GP?
provide advice and support
weight loss, exercise, physio
psychological help
analgesia - topical NSAIDs
arrange referral according to clinical judgement
referral to physio, MSK clinic, OT, pain clinic and mental health help
how would osteoporosis present in GP?
what in hx would make you suspect?
- often no specific symptoms but a low impact fracture would make you suspect, loss height due to vertebral collapses
- diagnosed with a DEXA scan to measure density
- menopause, steroid use, female, older age, smoking, alcohol, previous fragility fracture, parental hx of hip fracture, high BMI
how is osteoporosis managed in GP?
treat underlying condition
bisphosphonates for bone protection
calcium and vitamin D
HRT for younger menopausal women to prevent
exercise, diet, stop smoking, drink alcohol within limits
how would bursitis present in GP?
dull achy pain
red, hot to touch over joint + surrounding area
painful when you press
swollen area over affected
how would you manage bursitis in GP?
rest, ice and reduced activity
compressive bandaging
analgesic for pain relief - paracetamol or NSAIDs
consider aspiration if swelling uncomfortable
if persisting suspect septic arthritis : aspirate, flucloxacillin
REFER? especially if not getting better
how would gout present to GP?
what are the indications in hx?
rapid onset, often overnight, and painful joint
swelling, redness in one or both MTP (usually big toe)
tophi - hardened nodules of crate crystals
family history, PMH
r/o septic arthritis
?previous bouts, high red meat, diuretic use, CKD, chemo
how are common analgesics used in primary care?
ladder?
how would bronchitis present?
child
how would croup present in GP?
barking cough
how would head lice present in GP and what would you do?
hygeine
how would chicken pox present in GP and why would parents concerned?
spots, strep A
how would viral wheeze present in GP in a child?
whistling sound heard on expiration during viral infection, which continues following infection
- presents with wheeze, chest tightness, cough, cold/ chest infection
*r/o differentials of asthma, respiratory infection or foreign body!
how would you manage a viral wheeze in gp?
blue reliever inhaler of salbutamol with spacer
nebuliser if very breathless
2-3 days of prednisolone sometimes to settle chest inflammation
how would toddler diarrhoea present in gp?
chronic non-specific diarrhoea which is a diagnosis of exclusion of frequent poorly formed offensive stool
- food material recognisable in stool
- active, unimpaired growth and otherwise well
- normal or increased fluids
*r/o infection, dietary intolerances, IBD, coeliac
how would toddler diarrhoea be managed in gp?
avoid full strength fruit juice as could act as osmoles
reassurance
reduce peas, corn as not chewed adequately
*usually faeces become firm by age 3 when toilet trained
how would GORD in a child present?
despite reflux being normal in children with sphincter relaxation, if severe may require treatment
- heartburn, retrosternal pain, epigastric pain
*if forceful voting, bile stained vomit, blood in stool present consider other causes
*r/o psychological, migraine, mesenteric adenitis
how is GORD in child managed?
4 week trial of PPI or H2 antagonist if persistent
if no improvement refer to endoscopy
weight loss may help if obese
how does osgood-schlatters present in gp, in children?
self listing in adolescents, caused by inflammation at tibial tuberosity where patellar ligament attaches
- anterior knee pain worsening with exertion
- palpable visible tender lump over tibial tuberosity
*r/o injury, Perthus (bone necrosis), slipped upper femoral epiphysis
how is osgood-schaltters managed?
reduce activity and rest
ice over tibial tuberosity
reassess and consider referral to paeds, physio or orthopaedic surgeon
how would a child with threadworms present in gp?
faeco-oral transmission by ingesting eggs
-might be asymptomatic but could have perianal itching particularly in nighttime and girls may get vulval symptoms
*r/o candida
how are threadworms managed?
anthelmintic - mebendazole
hygiene to prevent transmission
safety net with white discharge
how would you identify infantile colic?
crying uncontrollably, otherwise healthy and normal growth
- less than 5m old, recurrent and prolonged crying, fussing or irritability
- clench fists, red face, knees to tummy and arch back, tummy rumbles and windy
*r/o infantile reflux, dietary intolerance, pyloric stenosis
how is infantile colic managed?
soothe baby with cuddles
warm baths
distractions
*usually stops at 6m
what is functional constipation in a child?
decrease in bowel movements, less than 3 complete stools a week, hard and large stool, rabbit droppings with associated straining and pain
idiopathic - caused by low fibre?
how is functional constipation managed in a child?
- only if red flags excluded
- reassure, laxatives like macrogol first line
- dietary advice, toileting advice
- referral if red flags or no response or distressed
*safety net with abdomen distension, vomiting (intestinal obst), ribbon stool (anal stenosis), faltering growth, motor delays
How would you follow up functional constipation?
- tailor follow up as per families needs
- lease with others in primary care health visitor, school health adviser
- advice on reducing maintenance laxative dose
how would a child with atopic eczema present in GP?
dry, red, sore, itchy patches inside elbows, knees, face and neck - in flare ups
increases likelihood of asthma etc
*in children 5 and below
how is topic eczema managed in gp?
emollients
topical corticosteroids - hydrocortisone
sedating antihistamines if sleep affected
clinical psychologists
self care
*referral if eczema herpeticum, herpes simplex via vesicles and punched out erosions
how would you manage hay fever in gp?
advice on windows closed, limit time outside, filters to prevent pollen in cars or house
meds - chlorpheniramine (piriton drowsy), loratidine (non drowsy), citerezine // eye drops, nasal spray, steroid spray, steroid tablets if severe
safety net for anaphylaxis as allergy high risk
how would URTI presenting GP?
cough, fever, hoarse voice, runny noise, fatigue, ore throat, lymphadenopathy
assessed with symptoms, respiratory exam
how are URTI managed in gp?
mostly viral hence self limiting : give advice for fluids, steam inhalation, analgesia
decongestants maybe prescribed for any post nasal drip
tonsilitis managed with phenoxymethylpenicillin
(penicillin V)
how do UTI present in GP?
increased frequency, urgency
dysuria - burning sensation when urinating
fever, N+V, rigours and back pain if pyelonephritis
*diagnosed with urine dip
how are UTI managed in GP?
*hospitalisation for pyelonephritis
abx - nitrofurantoin or trimethoprim 3 days if uncomplicated and 7 if complicated
encourage lot of fluid intake to wash out infection
advice on self care measures such as wiping techniques
how do chest infections present in gp?
cough - productive or dry (if productive think colour, yellow/green suggests bacterial)
dyspnoea, fever, crackles
*assess CRB-65 to see if needed admission
r/o sepsis
how are chest infections treated?
doxycycline or amoxicillin
acute bronchitis - self limiting, 3-4 weeks and won’t need abx, offer abx (doxy) if acutely unwell, delayed if high risk
pneumonia - first line amoxicillin
reassess as required
how do abscesses present in gp?
swollen, pus filled lump under skin
hot to touch
painful in area
high temperature and generally unwell
*if multiple abscesses diabetes status maybe assessed
how are abscesses managed in gp?
abx prescribed - flucloxacillin
moist heat application to assist drainage
drainage maybe offered to alleviate pain
how is candidiasis presented at gp?
vaginal - itching, soreness, pandering sex, discomfort when urinating, abnormal discharge
oral - white patched on inner cheek, tongue, roof of mouth
invasive - immunocompromised
how is candidiasis managed in gp?
antifungals - oral or pessary
- miconazole oral gel, fluconazole oral
*hospitalise if invasive and oesophageal shown as swallowing difficulty
*refer if recurrent
how does influenza present in gp?
nasal discharge, cough, fever, headache, malaise, ore throat
*if complicated may show lower resp infection signs
kids may also have more generalised symptoms like nausea, vomiting, diarrhoea etc
how is influenza managed?
reassurance and fluids in healthy
oseltamivir for high risk, not immunosuppressed
zanamivir for immunosuppressed
how does GORD present in GP?
*As dyspepsia (indigestion)
heartburn
acid regurgitation
retrosternal or epigastric pain
bloating
nocturnal cough
hoarse voice
when is GORD referred?
referral to endoscopy can be made when peptic ulcers or malignancy suspected
evidence of GI bleed (coffee ground vomiting or malaena) emergency admission and endoscopy
suspected cancer sent in 2 week pathway so endoscopy done within 2w (dysphagia, weight loss, treatment resistant dyspepsia, low Hb, over 55y/o)
how is GORD managed in GP?
lifestyle - reduce caffeine, lighter meals, upright after meals, weight loss and smoking cessation
acid neutralising medication - gaviscon, rennie
PPI - omeprazole, lansoprazole
H2 receptor antagonist - ranitidine
*offer H pylori testing for dyspepsia
how would you assess change in bowel habit in GP?
- important to establish what normal for them is, how many bowel movements a day
- constipation? passing gas? fibre in diet?
- diarrhoea? any blood or mucus?
- short term suggests infection : ask about food recently, travel, allergies etc. but if any signs of dehydration seek help
- long term may suggest more IBS
- alternating bouts of diarrhoea and constipation needs further assessing
- if persisting check stool sample, bloods, and colonoscopy if needed
- DRE to assess
how would you assess perianal symptoms?
haemorrhoids, prolapses, skin tags, malignancy
DRE –> assess any prolapses, any stool
how would you approach a headache in gp?
ask - duration, frequency, pain pattern, triggers
aura, N+V, autonomic features like tearing eye
systemic illness like limb weakness
family history
any relieving factors, impact on daily activities
examine - vital signs, mental state exam, assess neck for meningeal irritation, fundoscopy, near exam
r/o any red flags - sudden onset of severe headache, new onset if over 50, seizures, change dramatically, meningism, papilloedema, visual disturbance, pregnancy
how would you manage headache in gp?
emergency treatment with red flags!!!
- cause depending
- manage triggers
- analgesia - triptan for migraine, NSAIDs etc
- self care measures
*referral for suspected GCA, meningitis for admission
how would you approach transient loss of consciousness?
- abrupt/ brief/ complete recovery?
- trauma/ intoxication/ hypoglycaemia/ haemorrhage
- cardiac? TIA? arrhythmia?
- PMH, FH
*USE COLLATERAL HX WHERE POSSIBLE
How is chicken pox assessed and managed in GP?
- fever, malaise, pruritic, vesicular rash
- usually self limiting manage with rest and paracetamol, antihistamines, emollients and calamine lotion for pruritus
- during pregnancy mother high risk of complications
how would you manage and sprain/ strain in gp?
*common presentation of ankle sprain
- self management advice with rest, ice, compression, elevation + begin exercises as soon as pain allows
- simple analgesics like paracetamol or topical NSAID
- routine physio referral if symptoms not improving
- even after then if no improvement ortho referral
how would shingles present in gp?
immunocompromised individual risk activation of latent varicella zoster within dorsal root ganglion
- history of chicken pox
- dermatomal painful rash
- headache, generally unwell
- pruritus, corneal ulcerations
*paracetamol, consider antivirals in risk category
*if not working suggest NSAIDs or amitryptilline
*refer if new vesicles appearing 7 days after antivirals
*SHINGLES CANNOT SPREAD SHINGLES BUT SHINGLES CAN CAUSE CHICKENPOX if previously not had or vaccinated
how would fifth disease present in gp?
common infection caused by parvovirus B19, in children causing macular erythematous rash on cheek, temperature, runny nose, sore throat and headache
*spreads by coughing, sneezing
- manage nu reassurance as self limiting, simple analgesics for symptom relief
- avoid pregnant women as high risk of complications like fatal death
what are the common eye infections presenting in GP?
conjunctivitis - erythematous conductive with sparing of sclera, grittiness in eyes
*exclude red flags like visual acuity affected, eye pain
stye - inflamed eye margin by staph infection, meibomian gland infected, painful swollen eyelids
*exclude orbital cellulitis which is sight threatening
how would otitis media present and how would you treat?
middle ear infection, with fluid build up behind ear, common in children due to short Eustachian tube and easy access for infection
younger children may tug on ear, have other URT signs
otoscope exam shows red, yellow, bulging TM
- children usually recover in few days, analgesia
- consider delayed prescription or immediate if risk of complications of amoxicillin or clarythromycin
- safety net for perforation (for sudden hearing loss), facial nerve involvement
what is an aphthous ulcer?
very common, small painful oral ulcers, erythematous and well circumscribed
- stress, vitamin deficiencies and mucosal trauma may cause
- could indicate underlying IBD, coeliac, HIV
- usually heals within 10-14 days without scarring , topical analgesic, antimicrobial mouth wash can be given
- if more severe give topical steroids
- if over 3w refer to specialist for biopsy to r/o malignancy
how would you manage scabies in gp?
pt, household members, sexual partners in last month needs treatment too
- bedding, clothing decontaminated washing over 60 degrees
- permethrin 5% cream once a week to kill eggs
- topical hydrocortisone to help itching
- antihistamines to help sleep
*safety net for cellulitis
*crusted scabies requires hospital admission and specific treatment
how would you manage headlice in gp?
dimeticone lotion to hair left overnight or upto 8h and washed off
- lice lifespan 1-2 days so no need to change bedding frequently etc
- use detection comb
how would you mange a nappy rash in gp?
*irritant contact dermatitis caused by urea
- ensure self care, change nappies keep them clean
- high absorbency nappies, leaving nappies off for as long as possible
- fragrance free wipes
- topical 1% hydrocortisone cream if baby uncomfortable and rash erythematous
*if initial unsuccessful consider non-adherence, secondary infections and alt causes
*refer to paeds if persists and recurrent
how would you manage plantar fasciitis in gp?
*heel pain worse with first few steps in morning and towards end of day // feels better with exercise, returns after exercise
- reassurance of complete recovery in 1 year
- rest, ice, up to 20 mins, every 2-3h
- cushioned heel, stretching exercise, weight loss
*referral to orthopaedics or podiatry if persists
how would you manage impetigo in gp?
thin walled vesicles or pustules which appear golden with crust following exudate
personal hygiene to stop spread
stay away from school until scabbed over or 48h since abx
hydrogen peroxide or topical abx or oral abx if severe
how would you manage an insect bite in GP?
antihistamines for itchiness and swelling
cold compress for swelling
monitor for infection
*if target like lesions suspect Lyme disease!
how would you manage heavy periods?
first line treatment is levonorgestrel intrauterine system
- NSAIDs, tranexamic acid
- COCP, oral progesterone (prog only may suppress menstruation)
- if not helping with meds investigate other causes
*with red flags such as weight loss refer onto 2 week pathway
- if severe ablation or hysterectomy?
how would you manage lower urinary tract symptoms in a man?
*storage, voiding and post micturition symptoms
- r/o any UTI, PSA testing
- offer advise and support
- limit caffeine, weight loss, stop smoking and alcohol
- bladder train, limit nighttime fluids
- oral desmopressin at nighttime?
- BPH finasteride, oxybutinin for overactive bladder
how would you manage menopausal symptoms?
- cessation of periods, or oligomenorrhoea, hot flushes, mood swings, depressive episodes, vulval irritation, sleep affected, “brain fog”, joint pain and age –> suspect
*FSH monitoring not routine : consider if young onset - information important
- advise OT help, bone health supplements, support around them and CBT, encourage screening, lifestyle advise
- HRT: oestrogen orally, patch, gel, or implant // take progesterone orally as unopposed put higher endometrial cancer risk
- vaginal oestrogen for dryness
how would you manage erectile dysfunction in GP?
*admission if priapism (constant erection)
- referral to urology if trauma, endocrinology for hypogonadism, radiology for for CVSD, mental health for any stress
- ensure diabetes, hypertension and medication
- sildenafil (viagra) PDE5 inhibitor *choice depends on frequency of intercourse, preference and cost
- importance of advise and information
how is otitis externa managed in GP?
keep ears clean and dry
OTC drops of acetic acid
clean external ear canal
topical abx (with or without steroids), steroids for 7 days - 24 days
chronic - self care, analgesia, topical ear preps, follow up and reassess
how is noise related hearing loss managed?
hearing aids and cochlear implants may be offered
education about further damage prevention like no loud music etc
*pt may try and involve GP in sue claims but not their responsibility
how is menieres managed?
- labyrinthine sedatives buccal prochlorperazine for acute attacks, fluids for hydration if vomiting
- ENT referral for diagnosis
- MDT approach with OT, physio, counsellor, audiologist
- alleviate nausea with antihistamines,
- betahistine to reduce frequency and intensity
*inform DVLA and stop driving
how is age related hearing loss managed?
audiometry referral or at local opticians
hearing aid, information and follow up accordingly, provide batteries too
personal communicators, tv amplifiers, doorbell sensors etc
offer F2F where possible
how is chronic supparative otitis media managed?
*ongoing chronic otitis media where TM not intact
r/o red flags with nystagmus, vertigo, headache, facial paralysis
- referral to ENT
- secondary care on abx, steroids, cleaning of ear
*reassure that hearing loss will return with perforation heal
- keep ear dry
how are tympanic membrane perforations managed?
*can be dry due to loud noises or wet due to infection
- dry heals in about 6-8 weeks, avoid water
- wet requires abx if otitis media (amoxicillin)
*safeguarding domestic violence concern
how is mastoiditis managed?
secondary care abx - IV vancomycin/ ceftriaxone followed by oral
analgesia, anti-pyrexial
myringotomy to drain middle ear for IX or Mx
mastoidectomy if severe and persistent
*of secondary to otitis media referral to ENT?
how is a cholesteotoma managed?
*otoscopy shows crust in upper TM
ENT referral for surgical removal
- CT head or MRI to assess invasion
how would you assess referred ear pain?
*common site for referred pain due to the cranial nerves travelling in close proximity
- dental disease, cervical spine arthritis, TMD, pharyngitis, GCA, etc
- perform otoscope, R&W if no abnormality consider referred pain and do cranial nerve exam
*treat cause accordingly
how would you manage otitis media with effusion?
most resolve spontaneously in 2-3m
persisting in children may affect school performances
grommet to help equilibrate pressure
how would you manage congenital deafness?
ENT specialist management
- hearing aids, cochlear implants
- sign language
- educational psychology
- speech and language therapy
how is alcohol misuse managed in primary care?
*offer hospitalisation for immediate withdrawal to prevent seizures and delirium, wernickes encephalopathy, high risk suicide
- refer to specialist alcohol planned withdrawal
- in primary care - brief advice on consumption in non-judgemental way, psychological intervention, prophylactic oral thiamine, Alcoholics Anonymous referral
- help address underlying issues leading to misuse
how is substance misuse managed?
- referral to services, local drug treatment services can be helpful too
- ask about drug they use, family, work, home, support, ask for urine or saliva sample
- maybe offered CBT
- methadone for heroin or opioids to avoid withdrawal
- detox for complete stop
- narcotics anonymous for self help
- be non judgemental and patient
how is smoking cessation managed in gp?
- offer v brief advise, behavioural support
- bupropion : dopamine reuptake inhibitor helping anti cravings and withdrawals
- nicotine replacement therapy
- varenicline : partial nicotinic receptor agonist, displaces nicotine so doesn’t have the same effect // so if smoking while taking it not the same high
- e-cigarrettes
- offer support with helplines community support groups
how is weight reduction carried out in gp?
*measure BMI, circumference, BP
- diet : food diary, for GP or nurse to identify habits
- exercise: chat about it, measure steps, free gym prescription
- set personal goals, 2-4 weeks follow ups
- referral to weight loss groups
- medications orlistat prevents fat being absorbed –> offer if lifestyle measures not // liraglutide to feel full quicker
- bariatric surgery if other measures fails, 40+ BMI
how is exercise and diet improvement encouraged in gp?
- dietary advice by identifying patterns using food diary
- NHS app for meal plans, dietary advice
- exercise : may suggest gym, offer NHS gym memberships
how would you assess a rash in GP?
A-F method
Asymmetry
Borders
Colour
Diameter
Elevated
Firm
*any other symptoms like fever, neck stiffness, photophobia // strep throat
*onset, distribution, PMH, drug hx etc
how eczema manifest?
dry, red, itchy and sore patched of skin on the face and neck *affected flexor surfaces like inside elbows and knees –> to undergo flares
how is eczema managed?
- maintenance : thick emollients, soap substitutes
- topical steroids : weakest for shortest time, can lead to skin thinning
- Abx if organisms invade
- sedative antihistamines if sleep affected
*r/o eczema herpeticum caused by herpes simplex virus as hospitalisation required (or varicella zoster)
how is acne vulgaris seen?
chronic inflammatory condition where face, back and chest affected where lesions caused by blockage and inflammation of pilosebaceous unit
inflamed, red sore spots on skin, macules/ papules/ pustules
how is acne managed in gp?
- clear information on reasons for acne, discuss psychological impact, adherence importance as may take 6-8 weeks to see change
- against over cleaning, scratching, oil based makeup etc
- topical retinoids, topical abx, azelaic acid, ABX tablets and COCP for women
8first line 12 w adapalene (retinoid to exfoliate) and topical benzoyl peroxide (antiseptic) for mild to moderate
*referral to dermatology if scarring remains after 1 yr
how does psoriasis present?
distribution - extensor surfaces like elbows, knees, scalp
size - large plaques in plaque psoriasis, smaller droplet lesions in guttate
number - depends
severity - assessed using 6 point static physicians global assessment (PGA) 5 severe etc
surface - smooth, scaly or pustular
colour - pink or red, scale silvery // not as obvious in coloured skin
auspitz sign - pinpoint bleeding when scaled scraped away
nail changes, joint tenderness or swelling with psoriatic arthritis
how is psoriasis managed in gp?
*depends on type etc
- lifestyle advice like weight loss, smoking cessation
- stress, anxiety, depression manage
- emollients, corticosteroids, vitamin D analogues, coal tar
*rheumatology referral for psoriatic arthritis
*assess CVS risk every 5 years and advice on reducing venous thromboembolism if psoriasis severe
how would you assess urticaria in gp?
- onset : acute or chronic, distribution, severity using urticaria activity score
- any triggers or causes
- PMH, FH, GI symptoms, travel etc
*examine weals, central swelling/ itching/ burning
*emergency if angioedema or anaphylaxis suspected
how would you approach potential skin cancers?
Asymmetry
Border
Colour
Diameter
Evolving
*other systemic features like weight loss, fatigue etc
*fast changing, evolving
*family history of skin cancers
how would a BCC present?
small, shiny pink or pearly-white lump with a translucent or waxy appearance. It can also look like a red, scaly patch.
- may crust, bleed and ooze
*manage with excision or radiotherapy
how would a SCC present?
scaly red patches, open sores, rough, thickened or wart-like skin, or raised growths with a central depression
how does diabetes present in general practise?
type 1 –> polydipsia, polyuria, weight loss, general malaise
type 2 –> maybe asymptomatic and be an incidental finding during health check
how is diabetes managed and followed up in gp?
first line - lifestyle changes, weight loss, exercise, dietary modifications
second line - medications like metformin + others according to need
*stop smoking and alcohol
DESMOND or DAPHNE course
*arrange follow up and management of complications
how is depression seen in gp?
- affected sleep
- loss of interest in passions
- low mood persisting
- loss of energy
- lossof concentration
- suicidal idealisations, self harm
*use questionnaires like PHQ-9, HADS
how is depression managed?
assess protective factors, make a plan of management with pt
advice information, helplines like samaritans, SANEline
provide activities for wellbeing
support groups
- antidepressants SSRI (when prescribing bear overdose likelihood in mind)
- counselling and CBT
how is anxiety seen in gp?
excessive worrying for over 6m
restless, difficulty in sleeping
muscle tension
autonomic symptoms with GI disturbances
difficulty concentrating
how is anxiety managed?
take a comprehensive history of duration, onset, impact on daily life, FH etc
assess using GAD2 or GAD7 questionnaire
assess suicide risk and self harm risk
physical examination with thyroid levels, heart problems
CBT, support groups
SSRI first line, follow up assessment with side effects etc
assess depression
how would you carry out a mental state exam?
behaviour - engagement, rapport, facial expression, body language
speech - rate, quality, tone
mood and effect - assess current mood by asking
thought processes
perceptions like hallucinations
cognition and orientation of time and place
assess judgement and see if impaired
how would you assess self harm risk in gp?
*way of releasing overwhelming emotion, adrenaline rush from cutting becomes addictive
- assess physical risk, psychological state or safeguarding concern
- reassess with each episode important as circumstances change
- urgent referral to crisis team is physical risk
- minor self injury and non psychological harm treat in primary care
- see in primary care in 48h following episode
- MDT management : involve family
how would you assess suicide risk in gp?
TASR-AM for suicide risk screening
*crisis team for immediate physical risk
*A&E for emergency risk
*poisoned take to A&E of treatment
communicate risk to family
*urgent referral to secondary care in mental health services
*assess capacity
*arrange follow up 48h after discharge from hospital following attempt
How is CKD diagnosed in GP?
when eGFR is less than 60ml/min repeat in 2 weeks and then in 3m to see if persistent
measure albumin:creatinine ratio and repeat in 3m
*if still less than 60ml/min diagnose
dipstick to exclude haematuria, assess CVS risk, consider USS if obstruction suspected
What are the symptoms and the complications of CKD?
pruritus, loss of appetite, nausea, oedema, cramps, peripheral neuropathy, hypertension
anaemia of chronic disease - EPO, blood loss, iron deficiency
renal bone disease - can’t activate vitamin D (into calcitrol)
CVS disease as RAAS and hypertension
peripheral neuropathy as electrolyte imbalance
How would CKD present to GP?
initially with high BP
increased need to urinate overnight
tiredness
reduced eGFR?
swollen ankles (fluid retention), leg cramps at night, itchy skin, painful gout or reduced appetite.
How is CKD managed and monitored in GP?
- information, advice, healthy lifestyle like low salt diet, no NSAIDs, assess CVS risk, offer immunisations for influenza and pneumococcal
- ACEi or ARB
- regular monitoring of renal function with eGFR, albumin:creatinine ratio, every 3m to assess rate of progression
- stop nephrotoxic drugs as higher AKI risk
- monitor anaemia, serum calcium, phosphate vit D, PTH
*referral if red flags, renal artery stenosis, complications, obstruction
How is hypertension diagnosed in general practise?
- measure BP in clinic 140/90 mmHg or higher take another
- 140/90 and 180/120 mmHg offer ambulatory monitoring or home monitoring // take 2 measurements 1 minute apart
- higher than 180/120 mm/Hg refer to specialist care to r/o haemorrhage etc
*confirm diagnosis if clinic BP 140/90 or higher AND ABPM daytime average 135/85 mmHg or higher
What are the symptoms and complications of HTN?
- MOSTLY ASYMP; blurred vision, dizziness, headache, SOB
- IHD, cerebrovascular accident (stroke or haemorrhage), hypertensive retinopathy, hypertensive nephropathy, HF
How is hypertension managed and monitored?
ACEi/ ARB, BB, CCB, Diuretic
lifestyle - low salt diet, exercise, weight loss
- monitored in clinic and aim for below 135/85
- annual review of adherence, offer lifestyle advice, check BP, check renal function, assess QRISK
What is hyperlipidaemia and QRISK?
hyperlipidaemia is a level of elevated fat within blood, which can increase risk of cholesterol deposition an atherosclerosis deposition predisposing them to CVS events
- QRISK measures probability of you having a cardiac event in the next 10 years by taking into account age, FH, PMH, MH etc
- Statin is recommended for those with a QRISK higher than 10%
Why is a statin so beneficial for patients with high lipid levels?
statins help to lower levels of circulating cholesterol by increasing LDL uptake by cells
however why its so beneficial for atherosclerosis comes from its ability to stabilise plaques that have formed already and prevent rupture and embolisation
20mg for primary prevention and 80mg for secondary prevention
How is hyperlipidaemia managed in general practise?
- lifestyle management of weight loss, diet modifications, smoking cessation and alcohol reduction
- exercise
- aim for 40% reduction in non HDL levels : statin 20mg primary prevention
- do a non fasting lipid profile, LFT, renal functions, HbA1C, CK, TSH
*follow up to assess side effects to medications ( myalgia, GI disruption and rarely rhabdo) and to see if there is an improvement in levels
What are common causes of chest pain seen in general practise?
MSK pain
costrochondritis
reflux related
anaemia?
*angina less common
What are the risk factors for ischaemic heart disease?
(ACS, angina)
modifiable - high BP, hyperlipidaemia, smoking, diabetes, overweight, obesity, lack of physical activity, unhealthy diet, stress
non modifiable - age, sex (male), family history, race
What are the risk factors for HF (preserved and not)?
modifiable - unhealthy lifestyle such as diet, smoking, cocaine, illicit drug use, physical inactivity, obesity, high BP, diabetes
non modifiable - ageing, FH if HF as genetics may play a role, black/ African race
other co-morbidities - sleep apnoea, CKD, anaemia, thyroid disease, iron overload, chemo, AF
what are risk factors for AF?
modifiable - alcohol consumption (esp binge drinking), illegal drugs like cocaine, physical activity like endurance sports, smoking/ secondhand smoking, stressful situations, (?panic disorders) and emotional stress
non modifiable - age, FH and genetics in combo with weight etc, race
other co-morbidities - CKD, COPD, diabetes, HF, valvular disease, hyperthyroidism, sleep apnoea etc
?post surgery
How’s is IHD diagnosed?
Angina (stable)
- clinical assessment
- rapid access chest pain clinic for exercise ECG with treadmill tolerance to assess stable angina following hx (not to be used for ppl without known CAD)
ACS (unstable angina, STEMI, NSTEMI)
- ECG to see ST changes
- troponins
- CT angiogram to locate occlusion
How is HF diagnosed?
*admission for severe symptoms
- clinical presentation
- BNP levels
- 12 lead ECG
- echocardiogram to assess ejection fraction
How is AF diagnosed?
- clinical presentation of irregular pulse, palpitations, breathlessness *may require carotid palpation
- PMH like HTN, CAD, thyroid disease, alcohol misuse
- suspect paroxysmal AF if episodical less than 48h
- 12 lead ECG // if paroxysmal suspected 24h ECG monitor
What are some other differentials for irregular pulses?
- atrial flutter : sawtooth ECG
- ectopics
- sinus tachycardia
- SVT
how is IHD managed and monitored?
lifestyle - healthy diet (mediterranean), exercise programmes, stop smoking, reduce alcohol, lose weight
secondary prevention of CVD - Aspirin (clopidogrel 12m), Atorvastatin 80mg, Atenolol (BB), ACEi
monitoring - review every 6m to 1 year with blood tests etc ***
What is the New York Heart Association classification?
*to assess how much limited during physical activity
1 - no limitation
2 - slight limitation, comfortable at rest, ordinary physical activity results in fatigue, palpitations
3 - marked limitation of physical activity, comfortable at rest, less than ordinary activity causes fatigue, SOB
4 - unable to carry any physical activity without discomfort
ABCD - objective evidence of minimal CVD
how is HF managed and monitored?
medications - ACEi and BB to help reduce morbidity and mortality // diuretics for symptom relief
*medicines optimisation with titrating loop diuretics, ACEi, BB pt likely already on
referral: to cardiology based on New York heart association classification (2-4)
screen for depression and anxiety as maybe precipitated
referral to community heart failure nurse, rehab, give vaccinations, lifestyle advice etc
How is AF managed and monitored?
*r/o underlying causes such as thyroid related
assess stroke risk using CHA2DS2VASc, bleeding risk with ORBIT
monitor and support risk factors like HTN, poor INR, alcohol consumption etc
anticoagulation for score of 2+ - DOAC (unless creatinine clearance is low)
rate control - beta blocker
provide information on AF, stroke risk and detection, support groups
*monitor pulses during flu vaccination clinics (no extra work created)
*don’t de-anticoagulate unnecessarily - esp in falls
What is the CHA2DS2VASC score?
*assess stroke/ embolism risk
Congestive heart failure = 1
Hypertension over 140/90 on meds = 1
Age 75 or over = 2
Diabetes 7.0 or over with treatment = 1
Stroke = 2
Vascular disease = 1
Age 65-74 = 1
Sex (female) = 1
- higher the score higher the chance -
What is a HAS-BLED score?
*estimates 1 year risk for major bleeding in pt with AF
Hypertension
Abnormal renal or liver function
Stroke
Bleeding
Labile INR
Elderly
Drugs or alcohol
What is the ORBIT screening tool?
*identifies people at high risk of bleeding to help guide anticoagulation decisions
assessed Hb, history of bleeding, age over 74, eGFR less than 60, treated with anti plt before etc
0-2 low risk
4-7 high risk
What is the concept of “numbers needed to treat”?
no of ppl needed to treat to prevent 1 adverse event
- to show effectiveness of drug
*for AF treat 40 ppl to prevent 1 stroke
Define palliative care and why is it important in the care of people with advanced disease?
WHO - approach that improves QOL of pt and families facing problems associated with life-threatening illness, through prevention and relief of suffering by identifying and assessing and treating pain and other physical, psychosocial and spiritual problems
- this should involve patients needs as well as families/ carers needs during key points of treatment
*offering a support system to pt and family, treating dying as normal process, team approach through treatment and bereavement, to positively influence a distressing yet inevitable course is vital
What does palliative care entail?
assessing and managing
- preferred care setting
- anticipatory prescribing
- managing physical symptoms like N+V or breathlessness
- psychological needs
- social needs like personal care/housework/shopping help
- family and carers needs
how does general practise deliver palliative care? and how does it differ to specialist?
general - primary care teams should aim to meet needs of pt and family within limits of own knowledge and competence, specialist advice sought where necessary –>
information, signposting, holistic assessing, co-ordination of care teams, basic symptom control, psychosocial supports, open and sensitive communication with carers etc.
*specialist manages complex, advanced disease, MDT approach, bereavement support // can be charity or voluntary organisations, hospices or hospitals in community
what does approaching the “end of life” mean and how might you identify these patients?
assess for clinical signs and look at available investigations suggesting
- agitation, deterioration in consciousness, mottled skin, noisy resp secretions, progressive weight loss and cheyne-stokes breathing (rapid breathing followed by apnoea)
- involve MDT team in assessing deterioration
- monitor pt for further changes
gather info on needs, signs, clinical context, goals and wishes, views of those important to him about future care
how can you take an ethical approach with people who have advanced illness?
- keep them and loved ones informed and involved
- try and involve family but if pt refuses, duty is to confidentiality
- autonomy is vital and it is imporant to have information regarding care ready for when it is time, hence keeping them informed about trajectory is important
- nonmaleficence - benefit vs harm
- DNACPR being pt decision unless family have LPA
- mental capacity
Define the RESPECT process?
*recommended summary plan for emergency care and treatment - can be for anyone, increasing relevance for those with complex health needs, nearing end of lives, risk of sudden deterioration
conversation between to, their families and their healthcare professionals
provides healthcare professionals a guide to make decisions about patients care and treatment by identifying what’s important to pt , as a part decision regarding CPR is made, preference for care, clinical recommendation for care, mental capacity decisions (LPA or legal proxy), emergency contacts, clinician retails etc
What are the risk factors of asthma?
personal hx or FH of atopy (asthma, allergic rhinitis/ conjunctivitis, eczema)
childhood asthma - males pre-pubertal, female persistence to adulthood
infant resp infections
exposure to tobacco smoke - prenatally too
premature birth
obesity
social deprivation with damp, mould, pollution
work place - dust and pain isocyanates
How is asthma diagnosed in a primary care setting?
*wheeze, cough, breathlessness and chest tightness episodic, with triggers, at specific places
- FeNO (fractional exhaled nitric oxide) –>may be available in GP to confirm eosinophilic airway inflammation
- referral for spirometry –? shows less than 70% FEV1/FVC ratio and 12% improvement with bronchodilators
- peak flow readings 2-4 weeks to assess for variability
*usually spirometry and FeNO or peak flows and FeNO
*r/o bronchiectasis, COPD, CF, GORD, HF, ILD, PE, TB
how is asthma managed (pharmacologically and non)?
*aim to control disease - no nighttime waking, no daytime symptoms, no need for rescue meds, no attacks, no limitations for exercise, no side effects, normal FEV1/FVC
- assess baseline status, asthma action plan with medication details, emergency numbers, symptoms to look out for
- refer if occupational suspected, ensure unto date with vaccines, advise on avoiding triggers, weight loss, smoking cessation, manage mental health, give peak flow meter, inhaler use, offer spacer/ nebuliser if required
- medically SABA blue inhaler for reliever therapy, ICS brown inhaler as preventer therapy as baseline
*if not managed with these offer LTRA addition to low dose ICS, then LABA with ICS, then MART which is ICS and LABA in one inhaler for maintenance and relief daily
how do you treat asthma exacerbations?
how would you assess need for admission?
*not all may appear distressed despite being a severe exacerbation
- note agitation (hypoxia), exhaustion (complete sentences), cyanosis, accessory muscles, obs, peak flow if possible (best of 3)
- moderate if 50-75% normal peak, speech normal
- acute severe is peak 33-50%, RR over 25, inability to complete sentences, accessory muscles
- life threatening if peak less than 33%, O2 less than 92%, altered consciousness, cyanosis, hypotension, silent chest
hospital - ALL with life-threatening, and severe persisting after initial bronchodilators, and worsening moderate despite initial broncho/ if previously near fatal attack
*while waiting give O2 if required, keep at 94-98%, SABA, nebuliser O2 driven ideally, follow O-SHITME?
*if not required hospital quadruple ICS consider, follow up within 48h and 2 working days after hospital admission
what are the risk factors of COPD?
- tobacco smoking - 90% cases associated with smoking
- occupational exposure - dusts (coal), fumes (isocyanates, welding fumes)
- air pollution - coal burning, outdoor
- genetics - alpha-1-antitrypsin
- lung development - prenatal smoking, resp infections
- asthma 12x higher risk than those without
explain how COPD is diagnosed in a primary care setting?
*clinical features like over 35 w/ progressive breathlessness, chronic cough, regular sputum, frequent LRTI, wheeze with associated smoking/ work exposure // spirometry
- referral for spirometry shows post dilator FEV1/FVC less than 70% irreversible
- assess cor pulmonale - raised JVP, peripheral oedema, systolic parasternal heave
- referral for CXR may show hyperinflation, bull, flat hemidiaphragm *exclude lung cancer
- do FBC to exclude secondary polycythaemia as a response to chronic hypoxia
*severity assessed with FEV1 >80% mild to <30% stage 4 very severe all with ratio less than 70%
where would a COPD pt be referred to?
- refer if cancer suspected: haemoptysis, CXR features, uncertain diagnosis, worsening
- specialist for O2 therapy, non invasive ventilation, lung surgery for bullae
- refer to pulmonary rehab for exercise training, nutrition, psychological and behavioural interventions for those grade 3 or above on MRC dyspnoea scale (SOB on walking)
- refer for O2 therapy if less than 92%, severe COPD less than 49% FEV1, caused JVP
- physio referral for sputum clearance, OT, psychological help
How is COPD managed? (meds and non)
non : make personalised action plan, diet and activity, smoking cessation, offer vaccinations, rehab if indicated
meds : SABA as reliever, consider delivery agents with age (nebulisers, spacer etc)
no asthmatic features offer LABA or LABA+ICS if still struggling
with asthmatic features offer LABA+ICS anyway
*refer if still persistent
add ons - oral steroids, oral theophylline, prophylactic abx etc
follow up once a year if mild, twice a year if less than 50% FEV1 // assess symptoms, review med, record smoking status, assess complications like cor pulmonale, spirometry, consider referral
how would you treat COPD exacerbations and how would you assess when admission if needed?
worsening SOB, sputum vol, cough wheeze, fever, RR, HR
severe - makes dyspnoea, tachypnoea, pursed lip breathing, accessory muscles, cyanosis, confusion
- check vitals (temp, O2, BP, HR), assess for confusion, examine chest, check ability to cope at home
hospital –> severe breathlessness, inability to cope, rapid onset, cyanosis, confusion, O2 90%>, failure to initial treatment (give O2)
if no admission increase bronchodilator dose and frequency, oral steroids, abx like amoxicillin
what are palliative approaches to end stage COPD, including breathlessness?
*frequent, severe exacerbations, hospitalisation, poor lung function, low BMI, CVS disease and malignancy
- advanced care plan if agreed, coordinate with resp nurse specialist, optimise treatment, hospice?
- benzodiazepine, opiates, tricyclics, oxygen if unresponsive to others for breathlessness
- advanced care planning addressing concerns, preferences, with family, DNACPR
Why might steroids not be recommended to a patient with COPD?
harm vs good
- immunosuppressive effects put them at higher risk of pneumonias compared to benefit
- those with asthma characteristics may benefit from ICS so assess accordingly
