General Practice Flashcards

Question

Nitrofurantoin - interactions

Answer 1

Amiodarone - increase risk of peripheral neuropathy Metronidazole - increase risk of peripheral neuropathy Phenytoin - increase risk of peripheral neuropathy

Answer 2

200mg BD for 3/7 in women; 7/7 in men

Answer 3

diarrhoea, electrolyte imbalance, fungal overgrowth, headache, nausea, skin reactions, vomiting anxiety, confusion, cough, lethargy, myalgia, renal impairment, seizure

Answer 4

Teratogenic risk in first trimester - folate antagonist Best to avoid during pregnancy

Answer 5

Bendroflumethiazide - increase risk of hyponatraemia Candesartan - increase risk of hyperkalaemia Dalteparin - increase risk of hyperkalaemia Furosemide - increase risk of hyponatraemia Ibuprofen - increase risk of hyponatraemia and nephrotoxicity and hyperkalaemia Phenytoin - increases concentration of phenytoin; monitor phenytoin concentration Warfarin - increase anticoagulant effect of warfarin

Answer 6

Acute inflammation of the palatine tonsils secondary to infection Most commonly viral, associated with URTI. May also be caused by bacteria (Group A Streptococci)

Answer 7

Symptoms - fevers, sore throat, dysphagia, trismus (difficulty opening the mouth), malaise Signs - enlarged and inflamed tonsils, whiter exudate on tonsils, lymphadenopathy, pyrexia, tachycardia Exudate is more uncommon and typically suggests a bacterial pathogen, Group A beta-haemolytic streptococcus being the most common bacterial cause

Answer 8

Centor and FeverPAIN score are used to guide antibiotic use

Answer 9

Tonsillar exudate Tender anterior cervical lymphadenopathy or lymphadenitis History of fever >38C Absence of cough Score of 3 or 4/4 is indication for antibiotic therapy - phenoxymethylpenicillin or clarithromycin (pen.allergic)

Answer 10

Fever during previous 24 hrs Purulence [pus on tonsils] Attend rapidly [within 3 days after onset of symptoms] Severely Inflamed tonsils No cough or coryza [inflammation of mucus membranes in the nose] The higher the score, the greater the chance the illness is caused by GABHS

Answer 11

Simple tonsillitis - most can be managed with paracetamol, ibuprofen; C0-2/FP0-1 no abx; FP2-3 may benefit offer a back-up if symptoms persist longer than 3-5 days; C3-4/FP4-5 generally offered antibiotics Phenoxymethylpenicillin is first-choice; clarithromycin or erythromycin may be used in penicillin allergy Safety netting must be given to all patients with advice to return if symptoms persist, worsen or there are other concerns

Answer 12

May have dysphagia and high fevers Severe tonsillitis - may benefit from IV fluids, antibiotics and a dose of IV steroids may be admitted overnight for observation and reassessed after 12-24hr of IV fluids/analgesia

Answer 13

Suppurative (pus-producing): quinsy [peri-tonsillar abscess], acute otitis media, acute sinusitis Non-suppurative: post-streptococcal glomerulonephritis, acute rheumatic fever

Answer 14

Criteria for NHS tonsillectomy: Malignancy suspected 1+ quinsy or airway obstruction Recurrent sore throat with disabling episodes preventing normal function (7+ episodes in 1 years; 5+ in each of the last two years; 3+ in each of last three years) Obstructive sleep apnoea

Answer 15

500mg QDS, or 1000mg BD, for 5-10/7

Answer 16

diarrhoea, hypersensitivity, nausea, skin reactions, thrombocytopenia, vomiting antibiotic associated colitis, arthralgia, leucopenia angioedema, haemolytic anaemia, seizure

Answer 17

Methotrexate - increase risk of toxicity when given with methotrexate; monitor pt Warfarin - alters anticoagulant effect of warfarin; monitor INR and just dose accordingly

Answer 18

250-500mg BD for 5/7

Answer 19

decreased appetite, diarrhoea, dizziness, GI discomfort and disorders, headache, hearing impairment, insomnia, nausea, pancreatitis, paraesthesia, skin reactions, taste altered, vasodilation, vision disorders, vomiting

Answer 20

Amiodarone - both prolong QT interval; advised not to prescribe both at the same time Bendroflumethiazide - predicted to cause hypokalaemia Insulin - hypoglycaemia risk Simvastatin - increases exposure to Simvastatin; advised to avoid Ticagrelor - increases exposure to Ticagrelor; advised to avoid Warfarin - increase anticoagulant effect of warfarin; monitor INR and adjust dose accordingly

Answer 21

Inflammation of the external auditory canal - pinna to the tympanic membrane Infection by bacteria is the most common cause - pseudomonas aeruginosa or staphylococcus aureus; can also be fungal - candida albicans or aspergillus species Can also be caused by dermatitis - seborrheic or contact dermatitis

Answer 22

Tend to present with a short history of ear pain [otalgia], frequently associated with discharge. In severe cases, swelling of the external auditory canal and debris may result in hearing loss. Symptoms- itch, tenderness, hearing loss, discharge Signs- inflamed external auditory canal, erythema, scaly skin, pre-auricular lymphadenopathy

Answer 23

Often no investigations aside from a thorough history and examination are necessary. If presentation is atypical, recurrent or treatment-resistant, an ear swab sent for MC&S may be of use

Answer 24

Analgesia- paracetamol and ibuprofen Topical therapy- topical antibiotics +/- topical steroid Acetic acid 2% spray Oral abx aren't usually indicated Systemically unwell should be urgently reviewed by ENT Patients should avoid swimming for a minimum of 7-10/7

Answer 25

Ears should be kept dry and clean; ear plugs and swimming caps can help to reduce the incidence If allergies are a precipitating factor, they should be identified and avoided Acidifying ear drops can be used prior to sleeping or before and after swimming that may reduce the incidence of otitis externa

Answer 26

Commonly caused by viruses or bacteria, sometimes both Bacteria include: streptococcus pneumonia, haemophilus influenzae Viruses include: RSV, rhinovirus, adenovirus

Answer 27

Inflammation of the middle ear with effusion and clinical features of a middle ear infection - AOM Associated with a preceding upper respiratory tract infection; transmission via the eustachian tube to the middle ear may result in AOM In young children, the less acute angle of the eustachian tube within the wall of the pharynx results in increased transmission of pathogens, particularly when coughing or sneezing

Answer 28

Dependent on age group of patient Neonate- irritability, difficulty feeding, fever Young children- holding or tugging ear, irritability, fever Older children and adults- ear pain, hearing loss, fever Otoscopy is key to identifying signs of AOM

Answer 29

Red, yellow or cloudy tympanic membrane [as opposed to pearly-grey] Bulging tympanic membrane or perforated membrane Air-fluid level behind the tympanic membrane

Answer 30

General advice- generally self-limiting, analgesia and anti-pyretics advised Antibiotics- three main approaches no abx, delayed abx, immediate abx Delayed used when symptoms don't improve after 3 days; also safety netted if given no abx Amoxicillin first-line for 5-7/7, clarithromycin if pen allgeric

Answer 31

1-11months - 125mg TDS 5-7/7 1-4 years - 250mg TDS for 5-7/7 5-17 years TDS for 5-7/7

Answer 32

diarrhoea, hypersensitivity, nausea, skin reactions, thrombocytopenia, vomiting antibiotic associated colitis, arthralgia, leucopenia specific - rare/very rare - black, hairy tongue

Answer 33

Methotrexate - increases risk of toxicity; advised to monitor Warfarin - alters anticoagulant effect of warfarin; advised to monitor INR and adjust dose

Answer 34

Severe systemic infection Suspected acute complications [meningitis, mastoiditis, intracranial abscess, sinus thrombosis, facial nerve paralysis] Children younger than 3m with temp >38C Consider: Children younger than 3m Children 3-6m with temp >39C

Answer 35

Should be reviewed, re-examined. Consider other potential causes of similar symptoms [e.g. glue ear- otitis media with effusion] Some patients may develop chronic suppurative otitis media as a complication of their AOM

Answer 36

Persistent symptoms of AOM should be referred to ENT, particularly if lasting longer than 6 weeks or there is persistent hearing loss

Answer 37

ENT referral should be considered, especially if there is a craniofacial abnormality, an adult patient, or debilitating/complicated AOM. If nasopharyngeal cancer is suspected an urgent ENT referral is required. Suspect nasopharyngeal if: *presistent symptoms and signs of otitis media with effusion in between episodes due to obstruction of the eustachian tube orifice *persistent cervical lymphadenopathy [usually in upper levels of neck] *epistaxis and nasal obstruction

Answer 38

Typically resolves without complication Although can cause: *Persistent AOM *Recurrent AOM *Perforation of tympanic membrane *Hearing loss Rarely very serious complications like mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve paralysis can occur

Answer 39

Most commonly occurring serious complication. Potentially life-threatening infection of the mastoid air cells causing pain, swelling and erythema behind the ear and systemic upset. Tends to affect younger patients [<5] Early antibiotics and other management including myringotomy [draining of middle ear with hole in tympanic membrane] or mastoidectomy [removal of infected tissue/bone] my be required

Answer 40

Inner ear disorder, causes episodes of positional vertigo Caused by otoconia [loose debris composed of calcium carbonate] within the semilunar canals of the inner ear Attacks are triggered by head movements that result in movement of the otoconia, abnormal motion of endolymph and the feeing of vertigo

Answer 41

Typically presents between 5th and 7th decade, but can occur at any age. More commonly affects women. S/S- short episodes of positional vertigo typically lasting <1 minute Triggered by head movements or positional changes [e.g. turning over in bed]; can result in nausea and vomiting Some patients get symptoms that persist longer than expected, and other neurological causes should be considered and excluded Important negative findings- hearing loss and tinnitus are NOT features of BPPV and should raises suspicions of alternative or concomitant pathology

Answer 42

Following history and careful examination, the Dix-Hallpike manoeuvre is typically sufficient to diagnose BPPV

Answer 43

Contraindications- neck trauma, spinal fractures, cervical disc prolapse, vertebrobasilar insufficiency, carotid sinus syncope, recent stroke or CABG, back/spinal pain Patient upright on couch, when they lay back their head hangs off end of cough; Turn head 45` to one side, keep eyes open and look straight ahead; Move patient swiftly and smoothly from sitting to supine; Observe eyes for 30s [often a latent period] for any nystagmus while continuing to support head/neck; Slowly return patient to sitting up position and repeat the test with the head turned 45` to other side. The ear being tested is the one facing the floor

Answer 44

May be watchful waiting or canalith repositioning manoeuvres to displace the otoconia from the semicircular canals into the utricle Should be counselled on BPPV and treatments options Majority of cases resolve over several weeks [50% at 3m] Recurrence is common; affecting around half of patients within 5 years

Answer 45

DVLA advises all people with a 'liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness' to stop driving and inform them.

Answer 46

Symptomatic inflammation of the paranasal sinuses Acute - triggered by a viral URTI and is defined by symptoms that last for less than 12wks Chronic - defined by symptoms that last longer than 12wks with objective evidence of sinonasal inflammation on examination

Answer 47

Nasal blockage or nasal discharge with facial pain/pressure [or headache] and/or reduction of sense of smell Examination may reveal purulent discharge, mucosal oedema, tenderness over sinuses, and fever

Answer 48

Viral rhinosinusitis- Rhinovirus; influenza virus; parainfluenza virus Bacterial rhinosinusitis- Streptococcus pneumoniae; haemophilus influenza; staphylococcus aureus; moraxella catarrhalis

Answer 49

Acute: unilateral polyp or mass, bloody discharge - could suggest a neoplasm Chronic: unilateral symptoms, epistaxis, bloody discharge, crusting, orbital symptoms [diplopia or reduced visual acuity], neurological signs or symptoms Urgently refer to ENT if above s/s are present Urgent admission if severe systemic infection, or if complication/s occurs [e.g. orbital or intracranial involvement]

Answer 50

Advise about natural course and cause of infection Symptomatic relief - painkillers for pain or fever Antibiotics considered High-dose intranasal corticosteroids considered in adults with more severe/prolonged symptoms

Answer 51

Manage the existing associated disorder [e.g. allergic rhinitis or asthma] Avoid exacerbating triggers Symptomatic relief - nasal irrigation with saline solution Intranasal corticosteroids considered Long-term antibiotics considered

Answer 52

Infection of one or both kidneys usually caused by E.coli [Escherichia coli] - responsible for 60-80% of infections

Answer 53

Flank pain Fever and chills Nausea and vomiting Also LUTS - dysuria, frequency, urgency Costovertebral tenderness due to kidney involvement

Answer 54

Midstream urine sample should be sent for culture and sensitivity -Dipstick not necessary but may be a useful adjunct to guide diagnosis

Answer 55

Made in people with loin pain and/or fever if a UTI is confirmed by culturing a urinary pathogen from urine and other causes of loin pain +/- fever have been excluded

Answer 56

Severe s/s or s/s suggesting serious illness or condition should be admitted to hospital All others should be offered abx - Ciprofloxacin [500mg BD 7/7]; Trimethoprim [200mg BD for 14/7]; Co-amoxiclav [500/125mg TDS 7-10/7]; Cefalexin [500mg BD/TDS 7-10/7] ---LEICESTER GUIDELINES: co-amoxiclav [625mg TDS for 10/7]; ciprofloxacin in pen allergic [500mg BD 7/7] Pregnant women should be prescribed Cefalexin [500mg BD/TDS for 7-10/7] if no response to abx within 24hrs consider admission

Answer 57

625mg [500/125mg] TDS for 10/7 Review micro sensitivity and change abx if necessary

Answer 58

diarrhoea, hypersensitivity, nausea, skin reactions, thrombocytopenia, vomiting antibiotic associated colitis, arthralgia, leucopenia Co-amoxiclav specific s/e increased risk of infection dizziness, dyspepsia, headache black hairy tongue, cholangitis

Answer 59

Amoxicillin- methotrexate - ++ toxicity; warfarin - alters anticoag effect Clavulanate- alcohol, methotrexate, paracetamol, simvastatin, valproate - ++ hepatotoxicity

Answer 60

500mg BD for 7/7

Answer 61

May induce convulsions- esp when taking NSAIDs Tendon damage - rupture may occur within 48/24 of staring treatment Small risk of aortic aneurysm and dissection arthralgia, dizziness, fever, nausea, vomiting, tinnitus

Answer 62

Diclofenac, ibuprofen, naproxen - ++ seizures; prescribe with caution and monitor Methotrexate - ++ toxicity; monitor and adjust dose Phenytoin - ++ conc of phenytoin; monitor and adjust dose Warfarin - ++ anticoag effect; monitor INR Antacids decrease absorption of cipro; take 2hrs before or 4hrs after

Answer 63

Considered: *Significantly dehydrated or unable to take oral fluids and medicines *Pregnant *Higher risk of developing complications - known or suspected structural/functional abnormality of GU tract or underlying disease [e.g. diabetes mellitus, or immunosuppression] *Recurrent UTI [e.g. 2+ episodes in 6/12] *Men, after single episode with no obvious cause *Women with recurrent pyelonephritis Suspicion of urological cancer? 2ww pathway

Answer 64

Reassess if symptoms worsen at any time If symptoms don't improve within 48hrs of taking abx Consider: other diagnoses; any s/s suggesting something more serious [sepsis], whether previous abx use has led to abx-resistance, referral for specialist urological assessment is needed

Answer 65

Acute Bronchitis Community-acquired pneumonia COVID-19

Answer 66

LRTI causing inflammation in the bronchial airways Occurs due to viral or bacterial infection; preceded usually by an URTI

Answer 67

Influenza A/B; Parainfluenza; Respiratory syncytial virus (RSV); Rhinoviruses Mycoplasma pneumoniae; Chlamydia pneumoniae; Bordetella pertussis

Answer 68

COPD Asthma Smoking Chronic exposure to air pollution

Answer 69

Cough Chest pain form coughing Wheeze Rhonchi that clear with coughing [low-pitched sounds similar to snoring, indicating secretions in the airway] Mild dyspnoea Malaise URTI preceding the above symptoms

Answer 70

Pulse oximetry CRP CXR - rules out pneumonia, not always necessary

Answer 71

Hospital admission: acute cough with s/s suggesting more serious condition [e.g. PE or lung malignancy] Advise self-care [paracetamol, good fluid intake] Stop smoking Seek further medical help if symptoms worsen rapidly/significantly; do not improve after 3/4 weeks; or if they become systemically unwell CRP <20mg/L don't offer abx; 20-100mg/L delayed; >100mg/L offer abx Doxycycline [200mg on day 1, then 100mg OD 4/7]

Answer 72

200mg on day 1, then 100mg for 4 further days

Answer 73

[for all TETRACYCLINES] angioedema, diarrhoea, headache, hypersensitivity, nausea, pericarditis, photosensitivity reaction, skin reactions, SLE exacerbated, vomiting [specific to doxycycline] dyspnoea, hypotension, peripheral oedema, tachycardia, GI discomfort

Answer 74

Lithium - ++ lithium toxicity; avoid or adjust dose Warfarin - ++ anticoag effect; monitor INR Antacids - greatly -- absorption of doxycycline; separate administration by 2-3hrs

Answer 75

Pneumonia that is contracted in the community: atypical and typical pneumonia

Answer 76

Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Tend to present with typical features of pneumonia- productive cough, fever, pleuritic chest pain

Answer 77

Mycoplasma pneumoniae Legionella pneumophila Chlamydophila pneumoniae Chlamydophila psittaci (psittacosis)

Answer 78

Symptoms- fever, malaise, cough (with purulent sputum), dyspnoea, pleuritic chest pain Signs- dull percussion, reduced breath sounds, bronchial breathing, coarse crackles/crepitations, increased vocal resonance, tachycardia, hypotension, confusion, cyanosis

Answer 79

Pulse oximetry CRP CXR - will show consolidation Sputum culture - not always done in primary care; only if moderately unwell Temperature CURB-65 [CRB65 in 1` care]

Answer 80

Refer to hospital if s/s suggest more serious illness or s/s are not improving as expected with abx - always use clinical judgement to determine urgency CRB65- 3+ hospital admission; 1/2 hospital admission considered; 0 treatment as home considered, taking patient into consideration Self-care: fluids, rest, painkillers Offer abx- amoxicillin [500mg TDS 5/7] Stop smoking Safety net Explain symptoms can be around for up to 6m, but should feel significantly better after 3/7 of abx

Answer 81

500mg TDS for 5/7

Answer 82

Caused by virus: severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2) Positive strand RNA viruses

Answer 83

Fever, chills, cough, fatigue, dyspnoea, anorexia, myalgia, anosmia, cutaneous rash, other non-specific symptoms [e.g. diarrhoea, abdo pain, nausea, headache, dizziness, sore throat, loss of taste]

Answer 84

Lateral flow testing - easy, results delivered within minutes; nasopharyngeal swab mixed with a solution and applied to testing area PCR testing Pulse oximetry

Answer 85

Admission should be arranged if patient is moderately/severely unwell or has a suspected acute/life-threatening complication Self-manage symptoms [painkillers, fluid, rest] Stay isolated to prevent spread

Answer 86

Get vaccinated Good hygiene Consider wearing a face covering/mask when adequate ventilation is not available Access mental health support if needed Check travel/entry requirements when travelling abroad

Answer 87

Superficial fungal infection of the vulva/vagina Very common condition; caused by a candida infection - typically Candida albicans (92% of cases) Alteration in vaginal pH, sex hormones, sexual activity or even foreign bodies [e.g. contraceptive devices] may disrupt the balance between candida and host immune response leading to overgrowth and superficial infection

Answer 88

*Poorly controlled diabetes mellitus *Oestrogen exposure [rarely seen post-menopausal; cases rise post-menarche though] *Immunocompromised state [e.g. systemic corticosteroids] *Broad-spec antibiotics affect/alter vaginal flora *Local irritants [e.g. vaginal hygiene products] *Sexual activity [not an STI, but can be triggered by sex] *Hormone replacement therapy

Answer 89

Symptoms- vaginal itching, soreness and discharge [characteristically thick and white ('cheese-like') and non-malodourous], superficial dyspareunia [painful sexual intercourse], dysuria Signs- vulvovaginal irritation [erythema affecting vulva, and sometimes labia majora and perineum], vaginal fissuring, excoriation [scratching]

Answer 90

Diagnosis is typically made on the history alone, further investigations not required Investigations may be required where an alternative diagnosis is suspected or thrush is severe, recurrent or chronic Vulval examination and speculum examination Vaginal discharge testing - tested for pH Microbiology - high vaginal swabs and MSU Blood tests - HIV and HbA1c STI screen - chlamydia, gonorrhoea, trichomoniasis, HIV/syphilis - consider referring to a GUM clinic in patients who are considered high-risk

Answer 91

Treated typically with over the counter anti-fungal creams Intravaginal anti-fungal cream or pessary: Clotrimazole 10% cream Oral or topical can also be considered: fluconazole 150mg single dose/clotrimazole 1% BD/TDS for vulval symptoms

Answer 92

Consider referral to specialist GUM or gynaecology in the following: *12-15 years old *diagnosis doubtful *treatment failure or ongoing symptoms *non-albicans candida

Answer 93

Overgrowth of predominantly anaerobic microorganisms in the vaginal flora and loss of normal lactobacilli Not an STI but more common in sexually-active women Seen more commonly in black women; women who have sex with women are more at risk due to shared vaginal flora patterns A rise in pH >4.5 creates an alkaline environment that favours colonisation by anaerobic organisms [e.g. Garnerella vaginalis] and the loss of usually dominant lactobacilli Absence of inflammation hence the name 'vaginosis', instead of vaginitis

Answer 94

Sexual contact - sexual activity, change in sexual partner, women who have sex with women Hygiene - use of vaginal hygiene products Menstruation Black women Copper coil Smoking

Answer 95

Symptoms- asymptomatic [50% of cases], vaginal odour [may only be noticed after sexual intercourse], vaginal discharge [typically thin, off-white/grey and homogeneous], irritation of vulva, dysuria, dyspareunia Signs- vaginal discharge [may be adhered to vaginal mucosa], normal speculum

Answer 96

Diagnosis is based on Amsel criteria; when 3 out of 4 are met diagnosis can be made *Vaginal pH >4.5 *Typical discharge *Positive whiff-amine test *Clue cells on microscopy

Answer 97

Investigations are required or a formal diagnosis of Bacterial Vaginosis Vulval and speculum examination Vaginal discharge testing - samples should be taken from lateral wall and tested for pH; can also be checked using microscopy STI screen - chlamydia, gonorrhoea, trichomoniasis, HIV/syphilis

Answer 98

*Conservative advice on reducing risk factors *Oral metronidazole [400mg BD 7/7] or *Intravaginal metronidazole gel [0.75% OD 5/7] *Single dose high-dose metronidazole [2g] if adherence to treatment would be an issue

Answer 99

400mg BD for 7/7 OR 0.75% vaginal gel 5g applicator full at night for 5/7

Answer 100

Pelvic discomfort, vulvovaginal candidiasis, vulvovaginal disorders Menstrual cycle irregularities, vaginal haemorrhage

Answer 101

Disulfiram - ++ risk of acute psychoses Alcohol - could cause disulfiram-like reaction Amiodarone - ++ risk of peripheral neuropathy Nitrofurantoin - ++ risk of peripheral neuropathy Phenytoin - ++ risk of peripheral neuropathy

Answer 102

Inflammation of the meninges - outer membranes covering the brain and spinal cord Bacterial meningitis is life-threatening Usually acquired through droplets/secretions from URT; invasion via bloodstream or direct contiguous spread [usually as a result of ENT infection] Bacteria penetrate the BBB, quickly spreading within the meninges; mild cases are usually confined to the subarachnoid space, but severe cases can affect brain parenchyma underlying pia mater

Answer 103

Neisseria meningitidis (gram negative diplococci) Streptococcus pneumoniae Haemophilus influenzae Listeria monocytogenes Escherichia coli

Answer 104

Symptoms- neck stiffness, photophobia, headache [>80%], fever [70%], nausea/vomiting, fatigue, confusion, irritable/unsettled behaviours [children], altered mental status [>70%] Signs- tachycardia, hypotension, marked neck stiffness, photophobia, non-blanching rash [concerning sign of meningococcal septicaemia], seizures, focal neurological deficits, reduced consciousness and coma Classic signs- Kernig's sign - inability to fully extend at the knee when the hip is flexed at 90` due to pain Brudzinski's sign - spontaneous flexion of the knees and hips on active flexion of the neck due to pain

Answer 105

If suspicious, ring 999 immediately as it is a medical emergency Ix can take place at the hospital [e.g. lumbar puncture]

Answer 106

All suspected cases of meningitis are medical emergencies requiring immediate hospital admission by phoning 999 Suspected meningococcal disease [meningitis with a non-blanching rash] requires parenteral abx IM or IV benzylpenicillin at earliest opportunity 1200mg benzylpenicillin IM after arranging hospital transfer via 999 Close contacts should also be managed - prophylactic measure should be undertaken in conjunction with local/regional health protection unit

Answer 107

UK vaccination programme is important - includes vaccines against H.influenza, N.meningitidis, S.pnaeumoniae

Answer 108

Acute, infectious disease caused by varicella-zoster virus 14-16/7 incubation period Dangerous in pregnancy from wk8-20 - congenital varicella syndrome

Answer 109

Signs/Symptoms- fever, malaise, feeding problems, vomiting/diarrhoea, headache, rash Rash starts as small erythematous macules on the scalp, face, trunk and proximal limbs - then progresses to papules and intensely pruritic vesicles before becoming pustules

Answer 110

Usually made clinically with the presence of the characteristic vesicular rash

Answer 111

Usually self-limiting and management is supportive - paracetamol but not NSAIDs; calamine lotion and anti-histamines can be helpful with pruritus Maintain adequate hydration and children should stay away from school until all vesicles have crusted over; stay away from high risk groups e.g. immunocompromised, pregnant, neonates

Answer 112

'Slapped Cheek Syndrome' or Erythema infectiosum Caused by parovirus B19 Outbreaks amongst school children; droplet spread through respiratory secretions Mild and self-limiting disease

Answer 113

Begins with fever, coryza, headache, nausea and vomiting Malar rash with circumoral pallor; lace-like rash on trunk and extremities

Answer 114

Self-care - analgesia, inform patient and family that they should no longer be infectious once rash develops - not necessary to stay off of work or school

Answer 115

Viral is most common [~80%] of cases; adenovirus typically; can also be herpes simplex, molluscum contagiosum, varicella zoster, EPV Bacterial is second most common, more commonly seen in children and elderly; organisms include streptococcus pneumoniae, staphylococcus aureus, haemophilus influenzae

Answer 116

Conjunctival erythema [red eye], watery eye, irritation/discomfort, pruritus Hyperacute conjunctivitis- red-eye, significant purulent discharge, pre-auricular lymphadenopathy Herpes simplex- red-eye, watery eye, vesicular lesions on eyelid

Answer 117

Presence of these should prompt referral to ophthalmology *Reduced visual acuity *Marked eye pain, headache or photophobia *Red sticky eye in a neonate [within 30/7 of being born] *History of trauma or possible foreign body *Copious rapidly progressive discharge [indicative of gonococcal infection] *Infection with herpes virus *Soft contact lens use with corneal symptoms [e.g. photophobia and watering]

Answer 118

Normally self-limiting Symptomatic relief- cool compress and lubricating eye drops Prevent spread- good hand hygiene and use of separate towels Safety netting- if vision changes, eye pain, headache, photophobia, worsening purulent discharge or persistent symptoms then return or seek urgent medical attention

Answer 119

Normally self-limiting Symptomatic relief- cool compress and lubricating eye drops Prevent spread- good hand hygiene and use of separate towels Safety netting- if vision changes, eye pain, headache, photophobia, worsening purulent discharge or persistent symptoms then return or seek urgent medical attention Chloramphenicol drops/ointment - firstline choice, typically for 5/7 Fusidic acid eye drops - second line, typically for 7/7

Answer 120

Referral to ophthalmology nay be required where patients at risk of severe disease and complications or where a serious differential is suspected

Answer 121

Also known as 'hordeola' Acute localised infection or inflammation of the eyelid margin, usually caused by staphylococcal infection External- appears on eyelid margin, caused by infection of an eyelash follicle or associated gland; far less common Internal- occurs on conjunctival surface of eyelid, caused by infection of a Meibomian gland

Answer 122

Acute-onset, painful, localised swelling near eyelid margin that develops over several days Unilateral symptoms affecting one eyelid; though styes can be bilateral

Answer 123

Reassuring styes are usually self-limiting and rarely cause serious complications Arrange hospital admission urgently is there are signs of significant periorbital or orbital cellulitis Urget referral to ophthalmology is malignant eyelife tumour is suspected Self-care advice: warm compress until stye drains/dissolves, avoid using eye makeup or contact lenses until area has healed Manage co-existing conditions [e.g. blepharitis; acne rosacea] to reduce reoccurrence Topical antibiotic if there are clinical features of infective conjunctivitis

Answer 124

Sprain- stretch and/or tear of a ligament, classified by severity; typically affect ankles, knees, wrists, thumbs Strain- stretch and/or tear of muscle fibres and/or tendon, classified by severity; typically affects foot, hamstring, back

Answer 125

Pain around affected joint, tenderness, swelling, bruising, pain on weight-bearing, decreased function There may be joint instability following severe injuries

Answer 126

Muscle pain, cramping, spasm, muscle weakness, inflammation, bruising

Answer 127

Protection- protect from further injury Rest- avoid activity for the first 48-72hrs following injury Ice- apply ice wrapped in a damp towel for 15-20min every 2/3hrs during first 48-72hrs post-injury Compression- simple elastic bandage or elasticated tubular bandage, should be snug but not too tight, to help control swelling and support the injury Elevation- keep injured area elevated and supported until the swelling is controlled

Answer 128

Use analgesia for symptom relief - paracetamol or ibuprofen gel, or ibuprofen orally start active mobilisation and flexibility exercises as soon as tolerated without excessive pain NHS patient leaflets are available Consider medical review after 5-7/7 if worsening symptoms or lack of expected improvement Consider physio if symptoms are ongoing Consider orthopaedics if recovery is slow, worsening or new symptoms, symptoms are out of proportion

Answer 129

Parasitic insect infestation; infect the hair and feed on blood from the scalp

Answer 130

Itching Live louse found on combing confirms an active headlice infestation

Answer 131

A mixture of the following three treatments may be effective *Wet combing *Physical insecticide - dimeticone 92% spray *Chemical/traditional insecticide - malathion 0.5% aqueous liquid Direct parents to NHS website for

Answer 132

Caused by a parasitic mite Transmitted through direct skin-to-skin contact

Answer 133

Clinical features primarily result from a local allergic reaction to the presence of the mite rather than being directly caused by the mite itself Erythematous papules or vesicles, surrounding dermatitis Burrows - irregular tracks ~1cm long

Answer 134

General advice- highly contagious; good hygiene is important [wash all linen, clothes, toys, other items to eradicate scabies]; close contacts need to be examined and treated concurrently Topical tx- Permethrin 5% cream, applied to whole body ad left on for 8hrs, repeated in 7 days; Benzyl benzoate 25% emulsion in cases of allergy or treatment failure Systemic tx- Ivermectin [oral scabicide]

Answer 135

Irritant contact dermatitis Secondary infection with candidal abicans or staphylococcal aureus can occur

Answer 136

Child may be distressed, agitated, uncomfortable- rash can be itchy and painful Well-defined areas of confluent erythema and scattered papules over convex surface in contact with nappy There may be skin erosions, oedema, ulceration if there is severe involvement

Answer 137

Self-management- use nappies with high absorbency; leaving nappies off for as long as possible; changing nappy frequently and as soon as possible after soiling; using water based baby wipes; dry gently; avoid potential irritants Advise on sources of written information and support Use of a barrier preparation to protect the skin Topical hydrocortisone 1% once a day if rash is inflamed and causing discomfort

Answer 138

Referral to a paediatric dermatologist should be considered: *Uncertainty about diagnosis *Rash persists despite optimal treatment in primary care *Recurrent, severe unexplained episode

Answer 139

Condition in which there is persistent pain associated with degeneration of the plantar fascia as a result of repetitive microtears in the contracted fascia

Answer 140

Symptoms- initial insidious onset of pain, intense pain during first few steps, pain that reduces with moderate activity Signs- tenderness on palpation of the plantar heel, limited ankle dorsiflexion, tightness of Achilles tendon, antalgic gait

Answer 141

Most people recover within a year Conservative measures- resting foot, wear supportive shoes, avoid walking barefoot, weight loss, regular stretching exercises Symptom relief- oral analgesics and ice packs Referral to podiatry or physio if severe or not improved after conservative measures Consider corticosteroid injection, given with ultrasound guidance Consider referral to orthopaedic or podiatric surgeon if pain persists following podiatry and physio treatment

Answer 142

Common superficial bacterial skin infection; highly contagious Commonly caused by staphylococcus aureus [gram positive coccus]

Answer 143

Small vesicles or pustules develop at site of infection, then rupture leading to release of exudate that crusts over wit ha classic golden/brown colour May be itchy, but commonly asymptomatic

Answer 144

Commonly a clinical diagnosis based on characteristic appearance If in doubt, diagnosis can be confirmed with skin swabs for microscopy, culture and sensitivity

Answer 145

Topical antibiotics are usually treatment of choice Lesion heal without scarring and should maintain good hygiene to reduce transmission; shouldn't attend school or work until lesion have at least crusted over Localised vesicles: hydrogen peroxide 1% cream; fusidic acid 2% [5/7] Widespread vesicles: topical fusidic acid 2%; topical mupirocin 2%; oral flucloxacillin

Answer 146

Increased acid production from gastric cells Contents from the stomach re-enter the oesophagus, leading to a burning sensation retrosternally or in the back of the throat Can have complications [e.g. Barrett's oesophagus]

Answer 147

High BMI Smoking Genetic association Pregnancy Hiatus hernia NSAIDs, caffeine and alcohol

Answer 148

Main symptom is heartburn- a burning sensation in the middle of the chest; typically after meals and made worse by lying down or bending forward Regurgitation, dyspepsia, chest pain, dysphagia, odynophagia [painful swallowing], cough, hoarse voice, nausea and/or vomiting

Answer 149

pH monitoring and gastroscopy if diagnosis is uncertain/surgery being considered/red flag symptoms

Answer 150

Conservative- weight loss, smoking cessation and dietary modification, avoid eating within two hours of sleep and elevate the head of the bed Medical- PPI [inhibition of H+/K+ ATPase in parietal cells]; two week trial; Omeprazole [20mg OD 14/7]

Answer 151

20mg once daily for 2 week trial initially; or 4-8 weeks

Answer 152

abdominal pain, constipation, diarrhoea, dizziness, dry mouth, GI disorders, headache, insomnia, nausea, skin reactions, vomiting omeprazole specific - aggression, agitation, bronchospasm, encephalopathy, GI candidiasis, muscle weakness

Answer 153

Clopidogrel - --efficacy

Answer 154

Infection - gastroenteritis; causes: norovirus, Clostridioides difficle, Escherichia coli, campylobacter, salmonella Side-effects from some medications Anxiety IBD - Crohn's disease, Ulcerative colitis IBS - irritable bowel syndrome Diet

Answer 155

Loose or watery stool and frequent bowel movements, typically at least three times a day Can also include other symptoms if infective- vomiting, cramping, fever, headache, aching limbs

Answer 156

Drink lots of water; use rehydration drinks Eat as normal as possible See a doctor if you think you are dehydrated Anti-secretory medications

Answer 157

Idiopathic [primary] Secondary causes: Parkinson's' disease, Hirschsprung disease, spinal cord injury, MS, hypercalcaemia, diabetes mellitus, hypokalaemia, panhypopituitarism, hypothyroidism, iron supplements, antispasmodic medication, calcium-channel blockers, opiates, tricyclic antidepressants, systemic sclerosis, myotonic dystrophy, amyloid, IBS, colonic strictures, IBD, rectal prolapse, pregnancy

Answer 158

Passing infrequent and/or hard stools, difficulty passing stools [e.g. straining], and/or feeling of incomplete emptying <3 spontaneous bowel motions a week Can be primary [constipation in the absence of an underlying cause] or secondary [due to an underlying pathology: medications, GI disorders, endocrine disorder]

Answer 159

Infrequent bowel motions; hard, lump stools; straining; manually extracting faeces; overflow diarrhoea [liquid stool leak around stool]; overflow incontinence [loss of control over defecation]; feeling of incomplete emptying

Answer 160

Majority of patients don't require extensive investigations Usually targeted to patients to exclude secondary causes or when there are red flags Stool tests- faecal calprotectin [FCP], quantitative faecal immunochemical test [qFIT; measures Hb in stool] Bloods- FBC, renal profile, bone profile, HbA1c, TFTs Imaging not usually required but can be helpful for diagnosing secondary causes

Answer 161

Lifestyle modifications [high in fibre, good fluid intake, exercise] First-line laxatives [osmotic, bulk-forming, softeners] Second-line laxatives [stimulants, suppositories and/or enemas] Consider biofeedback

Answer 162

Weight loss [unintentional] Rectal bleeding Family history of colorectal cancer Sudden change in bowel habit Abdominal pain Iron deficiency anaemia Pt with red flags should be referred on lower gastrointestinal cancer pathway for 2ww assessment

Answer 163

Form of inflammatory bowel disease characterised by patchy, transmural inflammation of intestinal mucosa; can affect any part of GI tract from mouth to anus Incidence peaks between ages of 15-30 and 60-80 Family history is important - genetic predisposition Smoking increases the risk of CD

Answer 164

Macro- cobblestone appearance [caused by superficial ulcers], bowel wall thickening, lumen narrowing, deep ulcers, fistulae, fissures Micro- lymphoid hyperplasia, non-caseating granulomas, skip lesions and transmural ulceration

Answer 165

Symptoms- nausea/vomiting, fatigue, low grade fever, weight loss, abdo pain, diarrhoea [+/- blood], rectal bleeding, perianal disease Signs- pyrexia, dehydration, angular stomatitis, aphthous ulcers, pallor, tachycardia, hypotension, abdominal tenderness/mass/distension

Answer 166

MSK- arthritis [large joints affected in up to 20%; ankylosing spondylitis and sacroiliitis may occur] Skin- erythema nodosum [reddened, raised, tender nodules] and pyoderma gangrenosum [ulcerating nodules characterised by black edges and central pus] Eyes & mouth- episcleritis, uveitis, conjunctivitis, aphthous ulcers Hepatobiliary- primary sclerosing cholangitis [more common in UC]; fatty liver and gallstones are seen with increased frequency Other- renal calculi, osteoporosis, vit B12 deficiency, pulmonary disease, venous thrombosis, anaemia

Answer 167

Diagnosis is based on macroscopic assessment [endoscopy] and histological evidence [biopsy] of inflammation typical of CD Faecal calprotectin - stool sample; sensitive marker of intestinal inflammation

Answer 168

Main aim is to induce and maintain remission Tailor mx to phase of disease [acute flare or remission] Surgery may be required to manage complications Lifestyle modification [smoking cessation] Regular monitoring, and screening for complications Corticosteroids are used to manage acute flares [prednisolone] Biologics are used to maintain remission [infliximab- anti TNF-alpha antibodies]

Answer 169

Disease of the colonic mucosa; relapsing-remitting course Characterised by inflammation of the mucosa, affecting the rectum and may progress proximally through the colon - terminal ileum is only usually affecting in those with extensive colitis Most common form of IBD; peaks in incidence at 15-25 and 55-65 Often a family history Smoking is protective [i.e.helps in flares]

Answer 170

Macro- continuous inflammation that extends proximally along the colon; surface of mucosa is erythematous and inflamed; 'easily friable to touch'; evidence of inflammatory polyps Micro- Goblet cell depletion; crypt abscesses; inflammatory infiltrate in lamina propria [largely neutrophilic]

Answer 171

Symptoms- weight loss, fatigue, abdominal pain, loose stools, rectal bleeding, tenesmus, urgency Signs- febrile, pale, dehydrated, abdo tenderness/mass/distension, tachycardic, hypotensive

Answer 172

MSK- arthritis; osteopenia/osteoporosis; clubbing of hands and feet Eyes, mouth, skin- uveitis is strongly associated; episcleritis, aphthous ulcers, erythema nodosum Hepatobiliary- fatty liver disease and autoimmune liver disease; primary sclerosing cholangitis [70-95% pts with PSC have UC] Haematological- anaemia and thromboembolism

Answer 173

Diagnosis is based on macroscopic assessment [colonoscopy] and histological evidence [biopsy] of colonic inflammation Faecal calprotectin

Answer 174

General principle is to induce and maintain remission Acute flare- steroids Maintenance- biologics [anti tnf-alpha antibodies] Surgery is an option; usually in those who aren't responding to medical management

Answer 175

Fistulae Colorectal cancer Strictures Perforation

Answer 176

Fistulae Colorectal cancer Strictures Perforation Toxic Megacolon Primary sclerosing cholangitis

Answer 177

Type I - autoimmune destruction of beta cells of the pancreas. Insulin deficiency Type II - insulin resistance, and insulin deficiency in some cases

Answer 178

Type I - thin, thirsty, polyuria, tired/fatigue. Consider signs of DKA as well as this may be the first presentation of TIDM Type II - obesity/overweight, thirst, polyuria. May be asymptomatic and only found as an incidental finding

Answer 179

Random blood glucose In TII and asymptomatic, two blood glucose >11mmol/L are required for a diagnosis Urine dip, FBC, U&E, TFT Imaging not required usually

Answer 180

TI - insulin, either through multiple daily injections or through a pump. Will require daily glucose monitoring as well. Should be referred to other services for monitoring of eye health and foot health. GP should ensure there are regular checks of HbA1c and glucose. ACEi can have kidney protective effects too, so perhaps one should be taken at some point. TII - can be controlled with diet and exercise alone, smoking cessation and alcohol intake reduction. May require oral hypoglycaemic drugs (metformin, gliclazide, dapagliflozin, for example) to manage hyperglycaemia. May require insulin if deficiency is so great or oral hypoglycaemic drugs are not working. Will require check ups to manage complications. Should be checking glucose at home as well.

Answer 181

Nephropathy Neuropathy Retinopathy Hypertension Chronic kidney disease Leg ulcers, poor wound healing, increased risk of infection

Answer 182

Organs most seriously affected by DM are: kidney, eyes, macrovasculature (coronary arteries, cerebral circulation, peripheral vasculature), skin, nervous system, sexual dysfunction Optimal glycaemic control helps to minimise risk of complication.

Answer 183

A respiratory disorder characterised by airflow obstruction, which is usually progressive, not fully reversible and does not change markedly over several months. Chronic airflow obstruction is caused by a combination of small airway disease (obstructive broncholitis) and parenchyma damage (emphysema)

Answer 184

Clinical features include: - chronic progressive dyspnoea - chronic cough - regular sputum production - frequent winter bronchitis - wheezing and chest tightness Also can have fatigue, weight loss, anorexia, syncope during cough, rib fractures due to coughing, ankle swelling, depression/anxiety O/E can have hyperinflated chest, wheeze, quiet breath sounds, pursed lip breathing, use of accessory muscles, paradoxical movement of lower ribs, peripheral oedema, cyanosis, raised JVP, cachexia

Answer 185

Spirometry - decrease in both FEV1 and FVC; used to monitor disease progression; doesn’t change after being given a bronchodilator CXR - r/o other possible diagnoses FBC - anaemia and polycythaemia Pulse oximetry to assess need for oxygen therapy ECG - for cor pulmonale Sputum culture - if IECOPD

Answer 186

Goals are to: - reduce long-term lung function - prevent and treat exacerbations - reduce hospitalisations and mortality - relieving disabling dyspnoea - improve exercise tolerance and health related QOL - prevent and treat complications Smoking cessation Vaccination Active lifestyle and exercise Self mx education - risk factor management, inhaler technique, written action plan Manage co-morbidities

Answer 187

Patients with mild/moderate/severe should be reviewed at least once a year Review should cover smoking status, desire to quit smoking, adequacy of symptom control, presence of complications, effects of each drug treatment, inhaler technique, need for referral to specialist and therapy services, need for pulmonary rehabilitation, measurement of FEV1/FVC Very severe COPD patients should be reviewed at least twice a year, review is about the same with extra focus on things like cor pulmonale, oxygen therapy, depression/psychological affects of diagnosis, nutritional state

Answer 188

Respiratory failure - PaO2 <8, PaCO2 >7 Pulmonary artery hypertension Cor pulmonale Polycythaemia Pneumothorax Weight loss Carcinoma of bronchus Infective exacerbations

Answer 189

Inflammatory disorder of conducting airways. Airways become hyper responsive and construct easily in response to a wide range of stimuli.

Answer 190

Typically present with characteristic symptoms such as wheezing, dyspnoea, chest tightness, cough (+/- sputum) varying over time and intensity.

Answer 191

Spirometry - FEV1/FVC Bronchodilator reversibility will be present; improvement of 12% or greater is a positive test Peak flow - used for monitoring

Answer 192

Intermittent reliever inhaler - salbutamol (beta 2 agonist) Regular prevent inhaler - inhaled corticosteroids

Answer 193

Exacerbations of asthma

Answer 194

Should have asthma review for inhaler technique, avoidance of triggers, experience with asthma since last review, exposure to tobacco smoke, co-morbidities/atopic conditions

Answer 195

90% is caused by coronary heart disease * Atherosclerosis of coronary arteries * Platelet aggregation * Coronary vasospasm * Non-atherosclerotic coronary artery disease * Hemodynamic derangements

Answer 196

Four principle presentations: * Angina * Heart failure * ACS * Sudden cardiac death

Answer 197

Investigate how you would for angina, hf, acs

Answer 198

Primary prevention - use QRISK2 for assessing CVD risk in people up to 84y; can be put on atorvastatin 20mg for cholesterol mx Secondary prevention - smoking cessation, dietary advice, bp control, ACEi, dual antiplatelet therapy (aspirin + clopidogrel), b-blocker, statin

Answer 199

Review with medications and blood tests to monitor HbA1c, lipids/cholesterol, clotting (esp if they're on warfarin)

Answer 200

ACS, sudden cardiac death, heart failure, angina

Answer 201

Persistently raised arterial blood pressure 1` htn has no identifiable cause; 2` htn has an underlying cause [e.g. renal, endocrine, vascular disorder] Stage 1 - 140/90mmHg Stage 2 - 160/100mmHg Stage 3 - systolic bp of >180, or diastolic bp of >120 Be wary of htn with papilloedema and/or retinal haemorrhage

Answer 202

Typically asymptomatic Can have signs of end organ damage [e.g. retinal haemorrhage/papilloedema]

Answer 203

Assess for organ damage - haematuria; HbA1c; albumin:creatinine ratio; electrolytes; ophthalmoscopy; 12 lead ECG Assess cardiovascular risk - cholesterol and HDL cholesterol; QRISK score Consider investigations to find a secondary cause of HTN, typically in pts under 40y

Answer 204

Investigate fr target organ damage Diet and exercise - healthy diet and regular exercise can reduce blood pressure Caffeine - discourage consumption of caffeine Dietary sodium - keep intake low, salt can increase bp Smoking - stop smoking Alcohol - encourage reduced intake, has more health benefits than just lowering blood pressure Patient advise leaflets can be useful Pharmacological - ACEi/ARB if under 55 or TIIDM; if >55 or BlackCarribean offer CCB first; then add the other one; then consider a thiazide-like diuretic; depending on K offer spironolactone [K <4.5mmol/L] or alpha-blocker [K >4.5mmol/L]

Answer 205

Increases risk of HF; CAD; stroke; CKD; PAD; vascular dementia

Answer 206

Use bp monitoring to assess response to tretment Review annually - encourage adherence to treatment; offer lifestyle advice; check bp; check renal function; measure QRISK score

Answer 207

Caused by a structural and/or functional abnormality that produces increased intracardiac pressures and/or inadequate cardiac output at rest or with exercise

Answer 208

Symptoms- breathlessness [on exertion, lying flat, at rest, nocturnal cough, waking up from sleep breathless] Fluid retention - ankle swelling, bloated feeling, abdominal swelling, weight gain Fatigue, decreased exercise tolerance, increased recovery time after exercise Lightheaedness or hx of syncope Sings - tachycardia; laterally displaced apex beat; heart murmurs; HTN; raised JVP; hepatomegaly; respiratory signs [tachypnoea; basal crepitations; pleural effusions]; oedema in legs/sacrum; ascites; obesity

Answer 209

If symptoms are severe - arrange hospital admission NT-pro-BNP [elevated levels could mean HF] 12 lead ECG Other ix - CXR; bloods [U&Es, eGFR, FBC, iron studies, TFTs, LFTs, HbA1c, fasting lipids]; urine dipstick [haematuria?]; lung function tests Assess for underlying causes - valve disease?

Answer 210

Preserved EF - loop diuretic; stop drugs causing/worsening HF; refer to specialist; consider antiplatelet/statin; optimise mx of co-morbidities screen for mental health problems; offered referral to a supervised exercise-based rehabilitation programme; vaccinations; assess nutritional status Reduced EF - stop drugs causing/worsening HF; loop diuretic; ACEi and B-blocker; refer to cardiologist if still symptomatic despite optimal mx; consider antiplatelet/statin; optimise mx of co-morbidities; screen for mental health problems; vaccines; nutritional status

Answer 211

Atrial fibrillation, ventricular arrhythmias Depression Cachexia Anaemia CKD AKI Sexual dysfunction Sudden cardiac death

Answer 212

All pts require follow-up - individualised to the severity and stability of symptoms, treatment and co-morbidities Assess symptoms of HF, functional capacity, cognitive status and psychosocial needs, nutritional status Medication review Provide a self-management plan Monitor U&Es, eGFR every 6m Consider referral to specialty services

Answer 213

A higher than normal level of cholesterol or triglycerides in your blood Found in patients who are overweight or have an unhealthy diet. Can also be as a result of too much alcohol. Can also be genetic. Secondary causes - diabetes, hypothyroidism, obstructive jaundice, cushing's syndrome, anorexia nervosa, nephrotic syndrome, CKD

Answer 214

Often asymptomatic, typically found during routine screening or part of an annual health check May have premature arcus senilis, tendon xanthomata, xanthelasma

Answer 215

Fasting lipids are best investigation to use to diagnose

Answer 216

Diet and exercise Statin - HMG-CoA reductase inhibitor medications

Answer 217

Monitoring blood tests should be used to monitor response to treatment Assess cardiovascular risk in follow-up appts using a QRISK score

Answer 218

Cardiovascular events

Answer 219

Most prevalent causes: hypertension, diabetes, glomerulonephritis, urinary tract obstructions HTN - elevated bp causes hypertrophic response diabetes - chronic hyperglycaemia causes glomerular hyperfiltration glomerulonephritis - inflammatory and non-inflammatory mechanisms [more in medicine]

Answer 220

Stage 1: kidney damage with normal/increased GFR [>90ml/min/1.73m^2] Stage 2: [mild] 60-89ml/min/1.73m^2 Stage 3a: [mild-moderate] 45-59ml/min/1.73m^2 Stage 3b: [moderate-severe] 30-44ml/min/1.73m^2 Stage 4: [severe] 15-29ml/min/1.73m^2 Stage 5: [kidney failure] <15ml/min/1.73m^2

Answer 221

Typically asymptomatic in early stages Incidental findings

Answer 222

bed: urine dip [early morning for ACR] blood: U&Es, eGFR

Answer 223

Identify and manage underlying causes Monitor renal function with serum creatinine and eGFR as well as ACR Assess/monitor for anaemia [FBC] Assess/monitor for calcium, phosphate, vit D, parathyroid disorders/dysfunctions haematuria? 2ww refer to nephrologist if case is complex/severe assess for and manage risk factors and co-morbidities manage htn lipid-lowering medications [atorvastatin] antiplatelet counsel family and patient vaccinations

Answer 224

Identify and manage underlying causes Monitor renal function with serum creatinine and eGFR as well as ACR Assess/monitor for anaemia [FBC] Assess/monitor for calcium, phosphate, vit D, parathyroid disorders/dysfunctions

Answer 225

AKI HTN and dyslipidaemia CVD Renal anaemia Renal mineral and bone disorders Peripheral neuropathy and myopathy Malnutrition Malignancy End-stage renal disease - may require renal replacement therapy [dialysis or kidney transplantation] Mortality increases with progressive CKD

Answer 226

AF is a supraventricular tachyarrhythmia resulting from irregular, disorganised electrical activity and ineffective contraction of the atria Paroxysmal- episodes longer than 30s but less than 7d, self-terminating and recurrent Persistent- episodes longer than 7d, or less than7 requiring pharmacological or electrical cardioversion Permanent- AF fails to terminate following cardioversion; terminated AF but relapses within 24hr; longstanding AF in which cardioversion has not been indicated/attempted

Answer 227

Irregularly irregular pulse Breathlessness; palpitations; chest discomfort; syncope/dizziness; reduce exercise tolerance; malaise; decrease in mentation; polyuria Complications may be presenting feature - stroke, transient ischaemic attack, heart failure

Answer 228

To confirm, 12lead ECG is required paroxysmal may require 24hr ambulatory monitoring

Answer 229

onset within 48hrs- urgently admit for electrical cardioversion if haemodynamically unstable admit to 2`care if there are signs of complex disease arrange investigations to confirm or r/o underlying causes refer to a cardiologist for rhythm control assess for stroke risk/bleeding risk modify risk factors DOAC and/or b-blocker typically - apixaban and bisprolol

Answer 230

rate-control [b-blocker] f-up after a week to check tolerance and review of disease warfarin- monitor INR regularly review annually once symptoms are controlled and any treatments are established

Answer 231

Stroke/TIA/thromboembolism - main complication heart failure is commonly associated Can have lower quality of life increased risk of mortality

Answer 232

++ mortality HTN dyslipidaemia TIIDM coronary heart disease stroke gallbladder disease obstructive sleep apenoa restrictive lung patterns/spirometry - dyspnoea some types of cancer

Answer 233

healthy balanced diet regular exercise lose weight manage complications/underlying causes or factors 'Your Weight, Your Health' booklet from the Department of Health

Answer 234

Check in with patient to assess progress with losing weight and psychological impact of their health and their weight loss journey Consider referral to specialty services if required

Answer 235

cholecystitis; pyelonephritis; ureteric colic; hepatitis; pneumonia; peptic ulcer disease; pancreatitis; MI; gastric ulcer; LB/SB obstruction; appendicitis; AAA; diverticulitis; hernia; IBD; UTI; gynae/testicular problems/; ectopic pregnancy

Answer 236

bed: urine dip; ECG; pregnancy test in women stool: cultures; faecal calprotectin; occult blood test blood: FBC, U&Es, LFTs, amylase; CRP; G&S; ABG; blood cultures [if sepsis is expected] imaging: CXR; AXR; ultrasound of the abdomen; CT abdo/pelvis with contrast

Answer 237

If patient is clinically unstable; admit Use good clinical judgement to decide whether management at secondary care would be more appropriate

Answer 238

Not routinely followed-up in 1` care?

Answer 239

Infection [measles, mumps, meningitis, encephalitis, otitis] Kawasaki disease Malignancy

Answer 240

A to E assessment ask parent/guardian for information about symptoms, severity, timing, etc - how different to normal they are ask about urine output and bowel movements - very important for assessing a child bed: urine dip; swabs? blood: FBC, U&Es, LFTs, CRP imaging: not needed typically?

Answer 241

Red on the traffic light system provided by NICE - tachypnoea; non-blanching rash; no response to social cues - for example Always use clinical judgement, if patient appears unwell then admission will probably help as treatment is faster/easier in hospital or secondary care

Answer 242

Check recovery from illness/disease Manage complications in 1` care if necessary

Answer 243

ACS; pneumonia; pneumothorax; stable angina; malignancy; MSK pain; costochondritis; pancreatitis; oesophagitis; cholecystitis; rib fracture; arthritis; fibromyalgia; psychogenic chest pain; aortic dissection/aneurysm rupture; cardiac tamponade; acute congestive HF; arrhythmias; pulmonary embolism

Answer 244

bed: full respiratory and cardiovascular examination; ECG blood: FBC, U&Es, amylase; troponins; glucose; lipid profile; TFTs, LFTS, CRP imaging: CXR; CTPA; ultrasound of the abdomen [pancreatitis; gallstones]

Answer 245

admit if you suspect ACS; PE; acute heart failure; pancreatitis; cardiac tamponade; aortic dissection/aneurysm rupture; pneumothorax use clinical judgement to decide if patient is stable enough to withstand treatment in 1` care; if not then admission is vital

Answer 246

Follow-up may be required if patient had ACS or PE or other causes to manage complications of treatment after the event

Answer 247

cardiac- acute pulmonary oedema; arrhythmia; cardiac tamponade; HF; MI pulmonary- asthma; bronchiectasis; COPD; Covid-19; lung/lobar collapse; pleural effusion; pneumonia; PE; malignancy other- anaemia; anaphylaxis; anxiety

Answer 248

CXR within 2wks if cough, fatigue, sob, chest pain, weight loss, appetite loss bed: ECG, peak flow, pulse oximetry blood: FBC, U&Es, TFTs, LFTs, kidney function tests, BNP, CRP imaging: CXR, abdominal ultrasound

Answer 249

urgent admission if rapid onset or worsening symptoms; suspected sepsis; anaphylaxis; ECG suggesting MI or arrhythmia; features of PE/pneumothorax/cardiac tamponade/pulmonary oedema/severe or life-threatening asthma/severe or life-threatening COPD exacerbation; CRB score of 3+ always use clinical judgement when considering admission

Answer 250

Consider follow-up to assess recovery and manage any complications of SOB episode Manage co-morbidities

Answer 251

Stroke TIA Bell's palsy

Answer 252

use FAST to screen for stroke or TIA exclude hypoglycaemia

Answer 253

Acute onset of unilateral weakness is often a cause for admission - life-threatening/altering events can occur - important not to miss them

Answer 254

Manage complications of stroke/tia event if indicated Sometimes referral may be required esp for Bell's palsy if not recovered within 3-4m

Answer 255

Exposure to allergens Type I hypersensitivity reaction Basophils and mast cells degranulate and release ++histamine and other chemical mediators after exposure to a specific antigen

Answer 256

A to E; quick assessment required; patient will usually require adrenaline - wouldn't typically present to 1` care with severe angioedema due to severity Milder forms [e.g. urticarial rash] may present to GP - good history and examination required

Answer 257

Adrenaline - 500micrograms of 1mg in 1000[1mg/1mL]; 0.5ml and repeat after 5m in no response Other antihistamines can b3e used if not life-threatening/milder forms of an allergic reaction Avoid triggers and carry an Epi-pen for emergency exposure

Answer 258

999 for emergency admission if severe/life-threatening anaphylaxis signs of shock - admit

Answer 259

Allergy specialist can help to identify the trigger if unknown Self-written management plan Encourage pt to wear a medical emergency identification bracelet or similar

Answer 260

-Leaflet -Patches/gum/spray - NRT -Nicotine vapes can be used -Local stop smoking service -Rely on family and friends for support if you can -List reasons why you're quitting to help maintain abstinent from smoking -Reward progress -Enjoy the benefits

Answer 261

*try and identify whether you're dependent or not; with the help of your doctor or self-assessment tools *know the signs of withdrawal - irritable, shaky, tired, poor concentration, difficulty sleeping, bad dreams, trembling hands, sweating, nausea, headache, vomiting, palpitations, hallucinations, convulsions, fever *Make your intentions known so family/friends can help *Avoid temptation *Reward progress *Enjoy benefits *Alcohol support services: Alcoholic anon, Drinkline

Answer 262

14 over at least 3 days, with 2 days not drinking, no bingeing

Answer 263

ABV x ml / 1000 4% x 568ml / 1000 = 2.2 40% x 50ml / 1000 = 2 12% x 175ml / 1000 = 2.1

Answer 264

psychological: anxiety, stress, emotional shock, grief, depression physical: anaemia, hypothyroidism, sleep apnoea, pregnancy, overweight/obesity, underweight, cancer treatments, side effects of medications lifestyle: alcohol, exercise, caffeine, night shifts, daytime naps

Answer 265

blood: FBC, U&Es, LFTs, TFTs explore psychological reasons with good history taking investigate lifestyle aspects with the patient

Answer 266

Treat underlying cause *change medications if necessary *iron-tablets/fix anaemia through other methods depending on cause of anaemia *therapy/psychiatric medications *weight loss/weight gain *thyroid medications - levothyroxine *reduce alcohol; modify exercise; reduce caffeine; reduce amount slept during the day

Answer 267

Monitor symptoms and other signs of their disease/underlying cause of fatigue

Answer 268

Group A Streptococcus

Answer 269

starts with flu-like symptoms [fever, sore throat, swollen lymph nodes]; progresses to a rash after 12-48hrs [starts on chest/abdomen then spreads] feels like sandpaper Strawberry tongue - red, swollen tongue covered in little bumps

Answer 270

Consider throat swab for Group A streptococcus but not routinely required Diagnosis is made clinically if features/signs/symptoms are present

Answer 271

Consider hospital admission if symptoms are severe and can't be managed in 1`care; complications are present abx can be given regardless of severity - 10/7 course of phenoxymethylpenicillin or clarithromycin for 10/7 if pen.allergic notify public health patinet information leaflet is available

Answer 272

Infection most commonly caused by the Epstein-Barr virus

Answer 273

fever, sore throat, fatigue, lymphadenopathy, tonsillar enlargement, splenomegaly [rarely splenic rupture]

Answer 274

FBC with differential white blood cell count Monospot test LFTs - hepatitis is a complication

Answer 275

Admit if symptoms are severe - stridor, difficulty swallowing liquids, serious complication paracetamol/ibuprofen for pain and fever self-resolving illness in about 2-4 weeks, but fatigue can stay for a while no need for bed rest; return to normal activities as soon as possible

Answer 276

Chronic active gastritis caused by H.pylori oral-to-oral or faecal-to-oral route of transmission

Answer 277

PUD; gastritis; dyspepsia

Answer 278

Urease breath test Stool antigen test

Answer 279

Triple therapy - amoxicillin [clarithromycin if pen.allergic], metronidazole and lansoprazole

Answer 280

Measure stool antigen to monitor presence of H.pylori Retesting for H.pylori isn't usually recommended

Answer 281

Outpouching of mucosa through circular muscle

Answer 282

Diverticulosis is usually asymptomatic - incidentally found on colonoscopy or CT; but can cause lower left abdo pain, constipation or rectal bleeding Diverticulitis refers to inflammation of diverticula - pain/tenderness in LIF, fever, diarrhoea, n/v, rectal bleeding, palpable mass

Answer 283

bed: stool sample for culture blood: FBC, U&Es, TFTs, LFTs, clotting, CRP imaging: colonoscopy, CT scan

Answer 284

1` - Oral co-amoxiclav, analgesia, only taking clear liquids until symptoms improve, follow-up within 2 days to review symptoms 2` - NBM/clear fluids only, IV abx/fluids/analgesia, urgent investigations, urgent surgery

Answer 285

Perforation, peritonitis, peridiverticular disease, large haemorrhage, fistula, ileus/obstruction

Answer 286

Inflammation of the prostate Acute or Chronic [symptoms for at least 3m]

Answer 287

Chronic - pelvic pain, LUTS, sexual dysfunction, pain with bowel movements, tender and enlarged prostate Acute - similar symptoms ^ but more acute onset, may also be systemic symptoms of infection [e.g. fever, myalgia, nausea, fatigue, sepsis]

Answer 288

urine dip - presence of infection urine MC&S can identify causative organism and abx sensitivities STI screen if STI if considered

Answer 289

Acute- hospital admission for systemically unwell or septic patients; oral abx; analgesia; laxatives if bowel movements are painful Chronic- alpha-blockers [tamsulosin]; analgesia; psychological tx where indicated; abx if <6m hx; laxatives if bowel movements are painful

Answer 290

Inflammation of the glans penis, and posthitis describes inflammation of the foreskin Caused by a range of different conditions - dermatitis; other infections; skin conditions; trauma; pre-malignant conditions

Answer 291

Penile soreness and itch Bleeding from the foreskin and/or odour, usually developso over a few days Dysuria, difficulty passing urine, and/or dyspareunia o/e - redness and swelling of the glans penis with exudate; tightening of the foreskin; inability to retract the foreskin

Answer 292

good history and examination consider STI screen measure HbA1c for underlying DM, and HIV if appropriate

Answer 293

good hygiene - clean under foreskin everyday patient information leaflet non-specific dermatitis: 1% topical hydrocortisone cream bacterial balanitis: flucloxacillin 500mg QDS for 7/7

Answer 294

Inflammation and an accumulation of pus underneath the skin, in the tissues of the breast Caused by staphylococcus aureus

Answer 295

Physical presence of a painful lump Fever +/- flu-like symptoms Skin on breast is hot to touch, erythematous

Answer 296

Examination Sample can be sent for culture and sensitivities

Answer 297

Needle aspiration [<3cm] Catheter drainage [>3cm] Surgical incision and drainage Antibiotics are also usually prescribed

Answer 298

Bacterial sexually transmitted infection Caused by Chlamydia trachomatis 70% women, 50% men infected are asymptomatic

Answer 299

W- +discharge, post-coital/intermenstrual bleeding, purulent discharge, deep dyspareunia, dysuria, pelvic pain/tenderness, inflamed/friable cervix M- dysuria, mucopurulent urethral discharge, urethral discomfort, epididymo-orchitis, reactive arthritis

Answer 300

W- vulvovaginal swab or endocervical swab can be taken; FCU [first catch urine] can also be collected M- FCU is specimen of choice; urethral swab is an alternative Sent for nucleic acid amplification tests

Answer 301

Refer to a GUM clinic, but can also be managed in 1` care Offer written information about disease Contact tracing Treat infection - doxycycline 100mg BD for 7/7

Answer 302

Superficial skin infection predominantly caused by dermatophytes such as Trichophyton rubrum

Answer 303

Sclay, itchy skin Single or multiple red or pink, slightly raised annular patches of varying sizes Typically have an active, red advancing edge and a clear central area

Answer 304

Diagnosis is made based on clinical features and history

Answer 305

Advise on self-care strategies Topical antifungal cream Short-term topical hydrocortisone Severe/extensive disease - oral antifungal considered

Answer 306

Inflammation of a bursa [closed, fluid-filled sac] Most common causes are injury or overuse, can also be caused by infection

Answer 307

Pain, localised tenderness, limited ROM, swelling/redness if bursa is superficial

Answer 308

X-ray; MRI; ultrasound; aspiration Blood to rule out other causes - RA, OA, gout, e.g.

Answer 309

Aseptic- RICE, anti-inflammatory [NSAIDs], steroid injection, splints/braces to limit movement Septic- antibiotics, repeated aspiration, surgical drainage and removal of the bursa

Answer 310

Inflammation of bone and bone marrow, usually caused by a bacterial infection Staphylococcus aureus is causative organism in most cases of osteomyelitis

Answer 311

Typical presentation- fever, pain and tenderness, erythema, swelling Can be quite non-specific with generalised symptoms of infection

Answer 312

bed: examination blood: FBC, U&Es, CRP, blood cultures imaging: X-rays; MRI special: bone cultures for organism and sensitivities

Answer 313

Surgical debridement and antibiotic therapy 6wks of flucloxacillin for acute osteomyelitis chronic osteomyelitis requires >3m of abx

Answer 314

Infection within a joint This is an emergency as infection can quickly destroy the joint and cause systemic illness Common and important complication of joint replacement Most common causative organism - staphylococcus aureus can also be caused by Neisseria gonorrhoea in sexually active individuals [gram negative diplococcus]

Answer 315

Single joint is affected Rapid onset of hot, red, swollen and painful joint Stiffness and reduced ROM, unable to weight bear Systemic symptoms such as fever, lethargy, sepsis

Answer 316

Aspirate the joint prior to antibiotics, send sample for gram-staining, crystal microscopy, culture and antibiotic sensitivities bloods: cultures [2x], FBC, CRP, U&Es, serum urate and LFTs imaging: plain X-ray of affected joint, MRI and USS all justified

Answer 317

Low threshold for treating a patient for septic arthritis Empirical abx given until sensitivities are known Typically on abx for 3-6wks Flucloxacillin 2g QDS IV

Answer 318

Autoimmune condition triggered by streptococcus bacteria [typically strep pyogenes] Type 2 hypersensitivity reaction

Answer 319

Symptoms start 2-4wks after a streptococcal infection *fever *joint pain *rash *sob *chorea *nodules *migratory arthritis - hot, swollen, painful joints; typically large joints *heart involvement - carditis can lead to tachy/brady, murmurs [mitral valve], pericardial rub on auscultation, heart failure *skin involvement - subcutaneous nodules +/- erythema marginatum rash *nervous system involvement - chorea [irregular, uncontrolled and rapid movements of the limbs]

Answer 320

Throat swab for bacterial culture ASO antibodies ECG, echo and CXR to assess heart involvement

Answer 321

Tonsillitis [first infection of strep pyogenes] should be managed with phenoxymethylpenicillin for 10/7 Rheumatic fever pts should be referred immediately for specialist management *NSAIDs *aspirin and steroids *prophylactic abx *monitoring and management of complications

Answer 322

Systemic, medium sized vasculitis Affects young children, typically <5 No clear cause/trigger

Answer 323

persistent high fever [>39`] for more than 5 days unhappy and unwell child widespread erythematous maculopapular rash and desquamation [skin peeling] on the palms and soles also: strawberry tongue, cracker lips, cervical lymphadenopathy, bilateral conjunctivitis

Answer 324

bed: urinalysis blood: FBC, LFTs, CRP/ESR imaging: echo

Answer 325

High dose aspirin to reduce risk of thrombosis [despite risk of Reye's syndrome] IV immunoglobulins to reduce risk of coronary artery aneurysms

Answer 326

anal fissure, constipation, hard stools, haemorrhoids, foreign object, STI, colorectal cancer, ulcers, IBD, angiodysplasia, colitis, infection

Answer 327

bed: DRE blood: FBC, U&Es, CRP stool: culture, calprotectin imaging: flex sigmoidoscopy, colonoscopy, CT abdo/pelvis with contrast

Answer 328

Depends on the cause Typically, don't get constipated - eat daily requirement of fibre, good oral intake can use topical steroids for fissures watchful waiting while referrals/other investigations are arranged

Answer 329

Typically a 2ww referral for rectal bleeding if: occult blood test is positive; 50+ with unexplained rectal bleeding

Answer 330

illness, stress, excess alcohol, bad posture, eyesight problems, dehydration, too many painkillers, muscular tension, dental problems, hormones, medication side effect more serious causes: head injury, brain tumour, ++ICP

Answer 331

bed: examination of cranial nerves and neuro examination of upper/lower limb; fundoscopy blood: FBC, U&Es, LFTs, TFTs, CRP, coag/clotting screen imaging: CT head if indicated

Answer 332

Depends on the cause Medication overuse- stop medication Migraine- b-blocker can be used to prevent episodes Hormonal headache- cocp can improve symptoms trigeminal neuralgia- carbamazepine 1st line; surgery for compression or intentional damage to trigeminal nerve can help tension headache- reassure; analgesia; relaxation techniques; hot towels to local area

Answer 333

Emergency admission/urgent referral should be arranged with clinical judgement if there are any red flags or a serious underlying cause of secondary headache is suspected

Answer 334

muscle/ligament sprain; joint dysfunction; herniated disc; scoliosis; degenerative changes; sciatica; whiplash red flag causes: spinal fracture; cauda equina; spinal stenosis; ankylosing spondylitis; spinal infection

Answer 335

good history and examination bed: urine dip, culture and sensitivities blood: FBC, U&Es, CRP, LFTs, HbA1c, glucose, HIV imaging: ultrasound abdomen [r/o AAA, kidney stones, cholecystitis/gallstones], X-ray spine if suspected fracture or malignancy

Answer 336

lower back pain - risk assessment offer advice about sources of reliable information reassurance and self-care advice drug options- no paracetamol alone; offer NSAIDs otc first [consider PPI], consider codeine/co-codamol if NSAIDs wouldn't be tolerated exercise programmes, manual therapy, +/- psychological support advise to request occupational health assessment advise to arrange review if symptoms persist or are worsening after 3/4wks

Answer 337

Urgent hospital admission or specialist referral if red flag s/s suggesting potentially serious underlying cause

Answer 338

8wks: 6 in 1 [diphtheria, tetanus, pertussis, polio, haemophilus influenza B, hep B]; meningococcal type B; rotavirus 12wks: 6 in 1; pneumococcal; rotavirus 16wks: 6 in 1; meningococcal type B 1y: 2 in 1; pneumococcal; MMR; meningococcal type B yearly from 2-8: influenza 3y4m: 4 in 1; MMR 12/13y: HPV [2 doses, 6-24m apart] 14: 3 in 1; meningococcal ACWY

Answer 339

'a state of real or apparent loss of consciousness with loss of awareness, characterised by amnesia for the period of unconsciousness, abnormal motor control, loss of responsiveness, and a short duration' Syncope - 'TLOC due to cerebral hypoperfusion characterised by a rapid onset, short duration, and spontaneous complete recovery'

Answer 340

Syncope- vasovagal reflex, situational syncope, carotid sinus syndrome, orthostatic hypotension, cardiac syncope Non-syncopal causes- epilepsy, seizure, psychogenic pseudosyncope or non-epileptic seizures

Answer 341

bed: obs, BP, glucose, cardio and neuro exam, ECG blood: FBC, U&Es, HbA1c, glucose, CK, myoglobin imaging: depends on possible cause special: 24hr BP monitoring, echocardiogram

Answer 342

*advice about reliable sources of information *advise about fitness to drive and safety at work *referral to specialist if suspected cardiac cause or epilepsy *advise about triggers, early recognition of prodromal symptoms *medication review *provide lifestyle modification

Answer 343

refer to falls and syncope service or cardiologist if: *diagnostic uncertainty *unexplained syncope *vasovagal syncope during high-risk activity or affecting quality of life *reflex syncope with an absent or short prodrome *suspected but unconfirmed OH *persistent OH despite lifestyle modification

Answer 344

chronic systemic inflammatory disease of the joints 3x more common in women; typically develops in middle age; FHx relevant !anti-CCP antibodies!; also RF

Answer 345

Typically presents with symmetrical distal polyarthropathy - joint pain, swelling and stiffness systemic s/s- fatigue, weight loss, flue-like illness, muscle aches and weakness pain is worse after rest but improves with activity o/e - Zshaped deformity to the thumb; swan neck deformity; Boutonnieres deformity; ulnar deviation of the fingers at the knuckle extra-articular manifestations- pulmonary fibrosis with pulmonary nodules [Caplan's syndrome]; bronchiolitis obliterans; Felty's syndrome [RA, neutropenia, splenomegaly]; secondary Sjogren's syndrome; anaemia of chronic disease; CVD; episcleritis and scleritis; rheumatoid nodules; lymphadenopathy; carpal tunnel syndrome; amyloidosis

Answer 346

Diagnosis is clinical in patients with features of RA blood: rheumatoid factor; anti-CCP antibodies; CRP/ESR imaging: X-ray of hands and feet; ultrasound scan of the affected joints can be used to evaluate/confirm synovitis

Answer 347

Joint destruction and deformity Soft tissue swelling Periarticular osteopenia Boney erosions

Answer 348

MDT approach is essential short course of steroids at first presentation and during flare ups to settle disease NSAIDs/COX-2 inhibitors are often effective, but risk GI bleeds, often avoided or co-prescribed with a PPI DMARDs - methotrexate, leflunomide, sulfasalazine Biologics: anti-TNF [infliximab]; anti-CD20 [rituximab]

Answer 349

joint 'wear and tear' occurs in synovial joints and is a result of a combination of genetic factors, overuse and injury RF: obesity, age, occupation, trauma, being female, FHx thought to be a result of an imbalance between cartilage wearing down and chondrocytes repairing it leading to structural issues within the joint

Answer 350

Joint pain ad stiffness; worsened by activity; also leads to deformity, instability and reduced function of the joint X-ray changes - LOSS loss of joint space osteophytes subarticular sclerosis subchondral cysts o/e of hands - Heberden's nodes; Bouchard's nodes; squaring at the base of the thumb at the carpometacarpal joint; weak grip; reduced ROM

Answer 351

Diagnosis can be made without any investigations if patient is over 45, has typical activity related pain and has no morning stiffness or stiffness lasting less than 30min X-ray can be useful

Answer 352

Patient education and advise on lifestyle changes [weight loss, physio, occupational therapy and orthotics] Stepwise approach to analgesia: oral paracetamol and topical NSAIDs/topical capsaicin; add oral NSAIDs and PPI; consider codeine and morphine Intra-articular steroid injections can provide temporary reduction in inflammation and improve symptoms Joint replacement in severe cases - typically knee and hip

Answer 353

A reduction in the density of the bones RF: older age, female, reduced mobility and activity, low BMI, RA, alcohol and smoking, long term corticosteroids, SSRIs, PPIs, anti-epileptics, anti-oestrogens

Answer 354

Usually presents with fragility fractures

Answer 355

FRAX tool: predicts the risk of a fragility # over 10y put in info about BMI, co-morbs, smoking, alcohol, FHx, BMD from a DEXA scan DEXA scan shows how dense bones are WHO classification of T score more than -1= normal -1 to -2.5= osteopenia less than -2.5= osteoporosis less than -2.5 with a #= severe osteoporosis

Answer 356

Lifestyle - activity and exercise; maintain a healthy weight; adequate calcium and vit D intake; avoid falling; stop smoking; reduce alcohol consumption Bisphosphonates - 1st line; interfering with osteoclasts and reducing their activity; s/e include reflux and oesophageal erosions, atypical fractures, osteonecrosis of the jaw; alendronate 70mg 1x weekly

Answer 357

Crystal arthropathy associated with chronically high uric acid levels RF: male, obese, high purine diet, alcohol, diuretics, existing CV or kidney disease, FHx typical joints: base of the big toe, wrists, base of thumb

Answer 358

Typically presents as a single acute hot, swollen and painful joint [important to r/o septic arthritis] Gouty tophi are subcutaneous deposits of uric acid typically affecting the small joints and connective tissues of the hands, elbows and ears [DIP joints in hands most affected]

Answer 359

Diagnosed clinically or by aspiration of fluid from the joint - exclude septic arthritis Aspirate will show: no bacteria, needle-shaped crystals, negatively birefringent of polarised light, monosodium urate crystals Joint x-ray can show joint space remains unaffected, lytic lesions in the bone, punched out erosions, erosions can have sclerotic borders with overhanging edges

Answer 360

Acute flare: NSAIDs; colchicine; steroids prophylaxis: allopurinol is xanthine oxidase inhibitor [reduces uric acid level]; lifestyle changes can reduce risk of developing gout [weight loss, hydration, minimising consumption of alcohol and purine-based food]

Answer 361

Stepwise approach to analgesia Wise to start off simple and then add in more dangerous/addicting substances such as opioids

Answer 362

Result of repetitive use and injury to the tendons at the point of insertion Commonly affects patients in middle age

Answer 363

Pain and tenderness at lateral epicondyle [outer elbow] Pain often radiates down he forearm Can lead to weakness in grip strength

Answer 364

Clinical diagnosis based on s/s Mill's test + indicates lateral epicondylitis Cozen's test + indicates lateral epicondylitis

Answer 365

Most pts it is self-limiting and resolves with time, however s/s can take several years to resolve Mx can include: *rest *adapting activities *analgesia *physio *orthotics *steroid injections *platelet rich plasma injections *extracorporeal shockwave therapy

Answer 366

Often called golfer's elbow Inflammation at the point where the tendons insert into the epicondyles at the elbow Specific type of repetitive strain injury The result of repetitive use and injury to the tendons at the POI

Answer 367

Pain and tenderness at the medial epicondyle [inner elbow]. Pain often radiates down the forearm. Can lead to weakness in grip strength

Answer 368

Clinical diagnosis based on s/s Golfer's elbow test + indicates medial epicondylitis

Answer 369

Most pts it is self-limiting and resolves with time, however s/s can take several years to resolve Mx can include: *rest *adapting activities *analgesia *physio *orthotics *steroid injections *platelet rich plasma injections *extracorporeal shockwave therapy

Answer 370

Inflammation and swelling of the bursa over the elbow Bursitis causes thickening of the synovial membrane and increased fluid production [causing swelling] Can be caused by a number of things: friction from repetitive movements or leaning on the elbow; trauma; inflammatory conditions; infection [septic bursitis]

Answer 371

Typical presentation is a young/middle-aged man with a swollen, warm, tender, fluctuant [fluid-filled] elbow Infective causes also have these features: hot to touch, more tender, erythema spreading to the surrounding skin, fever, features of sepsis

Answer 372

Aspiration from the bursa is recommended if infection is suspected aspirate prior to starting antibiotics; send fluid to lab for microscopy, culture; examine for crystals and gram-staining

Answer 373

rest, ice, compression, analgesia, protect elbow from pressure or trauma, aspiration of fluid to relieve pressure, steroid injections can be used in problematic cases where infection has been excluded if infection is suspected/cant be excluded: aspiration for culture and microscopy as well as antibiotics [flucloxacillin, with clarithromycin as alternative]

Answer 374

Chronic atopic condition caused by defects in the normal continuity of the skin barrier, leading to inflammation in the skin There is significant variation of the severity of the condition.

Answer 375

Usually presents in infancy with dry, red, itchy and sore patches over flexor surfaces [inside of elbows and knees] and on face and neck

Answer 376

Diagnosis can be made clinically

Answer 377

Maintenance and management of flares Create artificial barrier over the skin using emollients, used as often as possible particularly after washing and before bed [e45 cream, aveeno cream, 50:50 ointment, epaderm ointment] topical steroids - use weakest steroid for the shortest period required to get skin under control [hydrocortisone, eumovate, betnovate, dermovate]

Answer 378

Caused by chronic inflammation, with/out localised infection

Answer 379

Presents with red, inflamed sore 'spots' on the skin, typically distributed across the face, upper chest and upper back There is significant variation in the severity of acne

Answer 380

Diagnosis is made clinically typically

Answer 381

Am is to reduce symptoms, reduce risk of scarring, minimise psychosocial impact of condition Stepwise approach to severity and response to tx 1- no treatment may be acceptable if mild 2- topical benzyl peroxide can reduce inflammation 3- topical retinoids slow production of sebum 4- topical abx [clindamycin] 5- oral abx 6- oral contraceptive pill 7- only used by specialists - oral retinoids

Answer 382

Caused by the release of histamine and other pro-inflammatory chemicals by mast cells in the skin May be part of an allergic reaction in acute urticaria or an autoimmune reaction in chronic idiopathic urticaria

Answer 383

Hives are small itchy lumps that appear on the skin - pruritic weals or hives; round or ring-shaped They can be localised to a specific area or widespread May be associated with angioedema and flushing of the skin

Answer 384

Diagnosis is usually made clinically; no further investigations required

Answer 385

Antihistamines are the main treatment for urticaria Oral steroids may be considered as a short course for severe flares In very problematic cases referral to a specialist may be required to consider tx with anti-leukotrienes [montelukast]; omalizumab; cyclosporin

Answer 386

Basal cell carcinoma Squamous cell carcinoma Malignant melanoma

Answer 387

Abnormal collection of squamous epithelial cells in the middle ear Non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear. Can predispose to significant infections

Answer 388

Typical presenting symptoms are: foul discharge from ear and unilateral conductive hearing loss

Answer 389

Otoscopy CT head can be used to confirm the diagnosis and plan for surgery MRI may help assess invasion and damage to local soft tissues

Answer 390

Surgical removal of the cholesteatoma

Answer 391

Relates to a problem with sound travelling from the environment to the inner ear Sensory system may be working correctly but sound isn't reaching it

Answer 392

Ear wax or foreign object blocking the canal Infection Fluid in the middle ear Eustachian tube dysfunction Perforated tympanic membrane Otosclerosis Cholesteatoma Exostoses Tumours

Answer 393

Caused by a problem with the sensory system or vestibulocochlear nerve in the inner ear

Answer 394

Sudden sensorineural hearing loss [over <72hrs] Presbycusis [age-related] Noise exposure Meniere's disease Labyrinthitis Acoustic neuroma Neurological conditions [stroke, MS, brain tumour] Infections [meningitis] Medications [furosemide, gentamicin, cisplatin]

Answer 395

1- strike tuning fork to make it vibrate 2- place in middle of patient's forehead 3- ask if they can hear the sound and if it's louder in any particular ear Normal = equal in both ears SN = louder in normal ear C = louder in affected ear

Answer 396

1- strike the tuning fork to make it vibrate 2- place flat end on the mastoid process 3- ask pt to tell you when they can't hear the humming noise 4- when they can no longer hear the noise, remove the tuning fork and hover it 1cm from the same ear 5- ask patient if they can hear the sound now 6- repeat process on the other side Normal/Rinne's positive = patient can hear the sound when bone conduction is lost and fork is hovered over the ear Rinne's negative = bone conduction is better than air, can't hear the tuning fork after bone conduction is lost and hovered over the ear - typically suggests a conductive cause of hearing loss

Answer 397

long term inner ear disorder causing recurrent attacks of vertigo and symptoms of hearing loss, tinnitus, and fullness in the ear Associated with a build up of endolymph in the labyrinth of the inner ear

Answer 398

Typical presentation: 40-50y, unilateral episodes of vertigo, hearing loss, and tinnitus Vertigo comes in episodes, last for 20m to several hours Hearing loss typically fluctuates at first, then gradually becomes more permanent. SN hearing loss, unilateral and affects low frequencies first Tinnitus occurs with episodes of vertigo before eventually becoming more permanent, unilateral

Answer 399

Diagnosis is clinical, is made by an ENT specialist Patients require audiology assessment to evaluate hearing loss

Answer 400

Managing acute attacks: prochlorperazine; antihistamines Prophylactic medication to reduce frequency of attacks: betahistine

Answer 401

Sensorineural hearing loss that occurs as people get older Occurs gradually and symmetrically Causes are complex - several different mechanisms including loss of hair cells in cochlea, loss of neurones in cochlea, atrophy or stria vascularis and reduced endolymphatic potential RF: advancing age, male sex, FHx, loud noise exposure, diabetes, HTN, ototoxic medications, smoking

Answer 402

Gradual and insidious Loss of high-pitched sounds at first - makes speech difficult to understand, particularly in loud environments May present after others have noticed they are not paying attention or missing details of conversations Patients can present with concerns about dementia May be associated tinnitus

Answer 403

Audiometry is ix of choice Will give a SN hearing loss pattern, with normal or near-normal hearing at lower frequencies and worsening hearing loss at higher frequencies

Answer 404

Effects cannot be reversed Mx involves supporting the person to maintain normal functioning: *optimising the environment *hearing aids *cochlear implants [for pts where hearing aids are not sufficient]

Answer 405

Inflammation and infection in the bronchioles Usually caused by RSV [respiratory syncytial virus] common in the winter When a virus affects an infants airway, because they are so small to begin with, any swelling/mucus can have a significant effect on infant's ability to circulate air to the alveoli

Answer 406

Coryzal symptoms - snotty nose, sneezing, mucus in throat, watery eyes Signs of respiratory distress - raised rr; use of accessory muscles of breathing [intercostal for example]; intercostal and subcostal recessions; nasal flaring; head bobbing; tracheal tugging; cyanosis; abnormal airway noises Dyspnoea Tachypnoea Poor feeding Mild fever [>39] Apnoeas [episodes where child stops breathing] Wheeze and crackles on auscultation

Answer 407

Clinical diagnosis is usually made Can be admitted to hospital for further investigations and treatment is there are red flags *existing conditions or under 3m *clinical dehydrations *50-75% or less of their normal intake of milk *respiratory rate over 70 *oxygen sats below 92% *moderate to severe rd *apnoeas *parent not confident in their ability to manage at home

Answer 408

supportive management only needed usually adequate intake saline nasal drops and nasal suctioning supplementary oxygen ventilatory support if indicated

Answer 409

Acute infective respiratory disease affecting children typically 6m to 2y URTI causing oedema in the larynx Parainfluenza virus typically causes croup

Answer 410

increased work of breathing "barking" cough, occurring in clusters of coughing episodes hoarse voice stridor low grade fever

Answer 411

Clinical diagnosis

Answer 412

Mostly managed at home with simple supportive tx [fluids and rest] Take steps to avoid spreading infection - hand washing, staying off school Oral dexamethasone is very effective - single dose of 150mcg/kg Prednisolone sometimes used as an alternative

Answer 413

Inflammation and swelling of the epiglottis caused by haemophilus influenza type B Can swell to the point of completely obscuring the airway within hours of symptoms developing It is a life-threatening emergency Rare now due to vaccination programme

Answer 414

Pt presenting with sore throat and stridor Drooling Tripod position - leaning forward with one hand on each knee High fever Difficulty/painful swallowing Muffled voice Scared and quiet child Septic/unwell appearance

Answer 415

If pt acutely unwell and epiglottitis is suspected, the ndo not perform investigations A lateral neck x-ray can show a characteristic 'thumb sign' - soft tissue shadowing neck x-rays used to exclude a foreign body

Answer 416

It is an emergency and there's an immediate risk of airway closing Do not distress the patient - leave them alone and within their comfort zone Alert a senior paediatrician and anaesthetist right away Mx centres around ensuring the airway is secure most don't require intubation but there's an ongoing risk of sudden upper airway closure Additional treatment includes IV antibiotics and steroids

Answer 417

Chronic inflammatory skin disease due to hyperproliferation of keratinocytes and inflammatory cell infiltration

Answer 418

Well demarcated erythematous scaly plaques Can sometimes be itchy, burning and painful Common on the extensor surfaces of the body and over the scalp 50% have associated nail changes - pitting, onycholysis

Answer 419

Clinical diagnosis

Answer 420

Avoid known precipitating factors, emollients to reduce scales Topical therapies for localised/mild psoriasis - vit D, corticosteroids Phototherapy for extensive disease Oral therapies for extensive and severe psoriasis, or psoriasis with systemic involvement - methotrexate, retinoids

Answer 421

Growths of the nasal mucosa that can occur in the nasal cavity or sinuses. Often associated with inflammation Usually grow slowly and gradually obstruct the nasal passage Associated with several conditions: chronic rhinitis, sinusitis, asthma, cystic fibrosis

Answer 422

May be found o/e in patients presenting with chronic rhinosinusitis, difficulty breathing through the nose, snoring, nasal discharge, loss of smell Examine the nose with a nasal speculum, or an otoscope Specialists perform nasal endoscopy to visualise the cavity and assess any polyps They appear round, pale grey/yellow growths on the mucosal wall

Answer 423

O/e in pts with symptoms Nasal speculum or otoscope with a large speculum attached Specialists can perform nasal endoscopy

Answer 424

Unilateral polyps should be referred for specialist assessment to exclude malignancy Medical mx involves intranasal topical steroid drops or spray Surgical mx involves removing the polyps

Answer 425

https://zerotofinals.com/paediatrics/development/milestones/ https://abg.ninja/milestones

Answer 426

allergic rhinitis is an IgE-mediated type 1 hypersensitivity reaction Allergic inflammatory response in the nasal mucosa Very common and can significantly affect sleep, mood, hobbies, work and school performance, and quality of life

Answer 427

Runny, blocked, and itchy nose Sneezing Itchy, red, and swollen eyes

Answer 428

Typically diagnosed based on the history Skin prick testing can be useful, particularly testing for pollen, animals and house dust mite allergy

Answer 429

Avoid trigger hoovering and changing pillows regularly and allowing good ventilation of the home staying indoors during high pollen counts minimise contact with pets that are known to trigger allergies Oral antihistamines are taken prior to exposure to reduce allergic symptoms - cetirizine, loratadine Nasal corticosteroid spray [fluticasone] can be taken regularly to suppress local allergic symptoms Nasal antihistamines may be a good option for rapid onset symptoms in response to a trigger Referral to an immunologist may be necessary if symptoms are unmanageable

Answer 430

Oestrogen - peaks just before ovulation, another smaller peak around day 22 Progesterone - peaks in the luteal phase around day 24 LH - peaks day 14, stimulates ovulation FSH - fairly low, small peak around the same time as LH Menstruation occurs between days 1-8 - shedding of the superficial and middle layers of the endometrium

Answer 431

First period - occurs around age 8-16

Answer 432

12m after a woman's last period Occurs due to hormone levels being insufficient Occurs between 45 and 55y

Answer 433

Pain associated with menstruation

Answer 434

Heavy menstrual bleeding or menstrual bleeding lasting for longer than 10 days

Answer 435

Abnormal bleeding from the uterus

Answer 436

Infrequent or very light menstruation Periods occuring at intervals of greater than 35 days

Answer 437

Failure to reach menarche

Answer 438

Absence of three or more periods in a row by someone who has had periods in the past Common cx - stress, pregnancy, eating disorder, perimenopause, ovarian insufficiency

Answer 439

High blood glucose and visible haematuria 55y+ - endometrial low Hb - endo appetite loss/early satiety 50y+ - ovarian abdo distention 50+ - ovarian abdo/pelvic mass - ovarian IBS symptoms, change in bowel habit, unexplained fatigue, urine urgency, unexplained weight loss within 12m in 50y+ - ovarian vaginal mass, vulval bleeding, vulval lump or ulceration - vulval

Answer 440

Vaginal bleeding [other than post-coital] at any time during the menstrual cycle other than normal menstruation cx - pregnancy-related [ectopic]; physiological [vaginal spotting at ovulation, hormonal fluctuation during perimenopause]; vaginal causes [adenosis, vaginitis, tumours]; cervical causes [infection, cancer, polyps, cervical ectropion]; uterine causes [fibroids, polyps, cancer, adenomyosis, endometritis]; ovarian secreting tumours; tamoxifen; post-smear test; missed oral contraceptive; drugs altering coagulation/clotting

Answer 441

non-menstrual bleeding that occurs immediately after sexual intercourse cx - infection, cervical ectropion, cervical or endometrial polyps, vaginal or cervical cancer, trauma/sexual abuse, vaginal atrophic change important to note that no specific cause for bleeding is found in 50% women

Answer 442

Irregular bleeding associated with hormonal contraception cx - COCP, POP, Depot injections, IUS or implant, emergency hormonal contraception Common when a new contraceptive method is started, often settles without intervention important to exclude pregnancy and also any underlying infection bleeding problems are more common with p-o methods smokers have a higher risk of this type of bleeding

Answer 443

Refers to heavy bleeding [typically >80mL]. Women may pass clots and/or experience flooding/ Women may have to wear tampons and pads simultaneously Local causes - adenomyosis, fibroids, endometrial polyps Systemic causes - clotting problems, hypothyroidism

Answer 444

Polyps and pelvic inflammatory disease Endometriosis and endometrial carcinoma Really bad hypothyroidism Intrauterine contraceptive device [copper coil] polycystic Ovary syndrome Dysfunctional uterine bleeding Submucosal fibroids

Answer 445

Diagnosis is made upon agreement between patient and clinician that menstrual bleeding experienced is heavy Investigations may be warranted depending on PC and examination of patient All red flags and/or intermenstrual bleeding and/or postcoital bleeding should be explored

Answer 446

1` care interventions - IUS [progesterone coil/mirena coil], tranexamic acid, COCP, long-acting progestogens 2` care interventions - GnRH analogues, surgical [endometrial ablation, hysterectomy]

Answer 447

Painful periods 1` dysmenorrhoea - beginning when first periods start 2` dysmenorrhoea - pain starts later, previously had normal periods cx - endometriosis/adenomyosis, fibroids [myomas], PID, ovarian cancer, cervical cancer, IUD insertion

Answer 448

good history examination - abdo and pelvic examination ultrasound - r/o fibroids, endometriosis, assess IUD high vaginal and endocervical swabs pregnancy test

Answer 449

1` - NSAIDs, paracetamol, 3-6m trial of hormonal contraceptive non-drug alternatives - hot water bottle, TENS 2` - if serious cause or red flags - refer to gynaecologist consider and manage other 2`ry causes of dysmenorrhoea

Answer 450

Absence of periods 1` [periods never started, no menarche] - pregnancy, constitutional delay, genitourinary malformation, ovarian failure, hypothalamic failure 2` [periods began but then stopped] - pregnancy, PCOS, hyperprolactinaemia, primary ovarian insufficiency, menopause, contraceptive use, weight loss, thyroid disease, Cushing's, adrenal or ovarian carcinoma

Answer 451

good history examination - BMI, abdo/vaginal/external genitalia/pelvic exam may be appropriate bed: pregnancy test blood: FSH, LH, prolactin, testosterone, TFTs imaging: pelvic ultrasound

Answer 452

Referral to secondary care if there are genetic causes Referral to fertility clinic Contraception HRT for women with premature ovarian failure reassurance and waiting for constitutional late puberty surgery for structural abnormalities

Answer 453

Initial change to menstrual pattern Hot flushes/night sweats Cognitive impairment and mood disorders Urogenital symptoms [vulvovaginal irritation, discomfort, burning, itching, dyspareunia, reduced libido, urinary frequency/urgency/recurrent UTIs] Altered sexual function Sleep disturbance

Answer 454

Ix not always required; possible to make a clinical diagnosis of perimenopause [vasomotor symptoms and irregular periods]; menopause [no periods in 12m]

Answer 455

Hormonal - COCP, POP, IUS, Implant, Depot injections Non-hormonal - IUD [copper coil] Barrier methods - condoms [male and female]

Answer 456

Lifestyle measures Vasomotor symptoms - oral/transdermal combined preparation Mood disorders - oral or transdermal HRT Urogenital symptoms - low-dose vaginal oestrogen 1st line Altered sexual function - seek specialist advice Give combined HRT to women with a uterus to protect the uterus from oestrogen Review after 3months; and at least annually thereafter Non-hormonal options are available SSRIs for vasomotor symptoms CBT, antidepressants for low mood/depression/anxiety Vaginal lubricants for urogenital symptoms

Answer 457

Going to the toilet more often than usual Typically more than 7 times a day

Answer 458

Excessive or an abnormally large production or passage of urine

Answer 459

Complaint from an individual having to wake up during the night one or more times for voiding

Answer 460

Condition in which you have difficulty urinating - challenging to start a stream or keep it flowing

Answer 461

Weak urine flow typically means that the bladder is not emptying properly

Answer 462

When a pt continues to leak urine after micturition has ceased Denotes abnormal sphincter function

Answer 463

any involuntary loss of urine Stress -involuntary leakage on effort/exertion/sneezing/coughing Urge -involuntary leakage accompanied by a sudden compelling desire to pass urine which is difficult to defer Mixed -stress and urgency; involuntary leakage is associated with both urgency and physical stress Overflow -incontinence as a result of urinary retention and leakage of urine

Answer 464

Refer urgently if cancer is suspected Refer to appropriate specialist if there are complex symptoms [palpable bladder, voiding difficulty, persistent bladder pain, pelvic mass, associated faecal incontinence, neurological disease, UTIs] Manage reversible contributing factors Lifestyle advice - reduce caffeine, monitor fluid intake, weight loss, smoking cessation Self-help resources Offer trial of at least 3m supervised pelvic floor muscle training Surgical mx - colposuspension, autologous rectus fascial sling Offer duloxetine as 2nd-line but only if pt prefers drug to surgical mx

Answer 465

Refer is cancer is suspected or there are complicated s/s Exclude or manage treatable causes of overactive bladder syndrome Advise about lifestyle measures and fluid intake Self-help resources Offer bladder training [at least 6wks] Offer oxybutynin if symptoms persist Review after 4wks of drug mx Post-menopausal pts may require intravaginal oestrogen therapy

Answer 466

refer is symptoms are troublesome - cancer, etc Manage the patient according to the most predominant type or urinary incontinence

Answer 467

This is common in older people There are no particular stress or urge symptoms Aetiology is often related to a combination of wider health problems - disability, cognitive impairment, mobility problems

Answer 468

good history examination - abdomen, external genitalia, DRE, perineum and/or lower limbs for motor and sensory function ask pt to complete a urinary frequency volume chart for at least 3 days Exclude serious causes - cancers, infection, sciatica urine dipstick; eGFR; PSA

Answer 469

active surveillance - reassurance, lifestyle advice, regular followup conservative mx - pelvic floor muscle training and bladder training, advise about fluid intake, use of containment products moderate to severe symptoms: alpha-blocker [tamsulosin] enlarged prostate and high risk of progression: finasteride Acute urinary retention - send to 2` care for catheterisation

Answer 470

Exclude or manage treatable causes of OAB Advise about fluid intake, lifestyle measures Offer temporary urine containment products Offer referral for supervised bladder training Offer oxybutynin if symptoms persist Review every 4-6wks to assess symptoms and tolerance to mx until symptoms are stable

Answer 471

Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance cx - vasculogenic [CVD, HTN, PAD, hyperlipidaemia, TI and TIIDM, metabolic syndrome, smoking, obesity]; Neurogenic central [Parkinson's disease, MS, stroke, spinal cord trauma]; Neurogenic peripheral [DM, CKD, CLD, polyneuropathy]; anatomical/structural [penile cancer, congenital curvature, phimosis]; endocrine [hypothyroidism, hypogonadism] psychogenic causes - lack of arousability, disorders of sexual intimacy, partner/relationship problems, stress, depression, psychosis Drugs - antihypertensives, diuretics, antidepressants, antiepileptics

Answer 472

good hx - psychosexual factors, other pmhx examination - obs, bmi, external genitalia, DRE for prostate if indicated blood: HbA1c, serum lipid profile, fasting serum total testosterone, PSA, TFTs, LFTs, renal function

Answer 473

evidence of priapism - emergency hospital admission referral to specialist if there are serious underlying causes mental health services advise about sources of reliable information lifestyle modification - weight loss, smoking cessation, alcohol reduction optimise mx of reversivble/modifiable RF review medications consider sildenafil [Viagra] if not at high risk of cardiac issues review 6-8wks after tx started

Answer 474

evidence of priapism - emergency hospital admission referral to specialist if there are serious underlying causes mental health services advise about sources of reliable information lifestyle modification - weight loss, smoking cessation, alcohol reduction optimise mx of reversible/modifiable RF review medications consider sildenafil [Viagra] if not at high risk of cardiac issues review 6-8wks after tx started

Answer 475

Levenorgestrel-only contraception - 0-96hrs following UPSI; no c/i Ulipristal acetate - 0-120hr following UPSI; IUD [copper coil] - effective up to 120hr post UPSI; can be used long term

Answer 476

Male - vasectomy; Vas deferens is interrupted, preventing sperm from entering the ejaculate Female - tubal occlusion; Fallopian tubes are tied/clipped so they are occluded and eggs cannot reach the uterus

Answer 477

low mood loss of interest/pleasure significant weight change insomnia/hypersomnia psychomotor agitation or retardation fatigue feelings of worthlessness diminished concentration recurrent thoughts of death or suicide

Answer 478

Feeling down, depressed or hopeless Little interest or pleasure in doing things -present most days, most of the time, for at least 2 weeks

Answer 479

PHQ-9 questionnaire blood: FBC, U&Es, TFTs Consider other psychiatric conditions - anxiety, substance misuse, schizophrenia Consider drug s/e

Answer 480

provide patient information leaflet Advice about activities to improve wellbeing - running, walking, gardening Social support for family/carers Urgent referral to MHS if psychotic or severe depression and at risk of self-harm/suicide/risk to others/self-neglect Local safeguarding if child/vulnerable adult CBT as a first-line in less severe depression SSRIs are an option in more severe depression Active monitoring and follow-up

Answer 481

Excessive anxiety and worrying [more days than not for 6m+] Worry and anxiety is difficult to control Three of the following have been present for more days than not for 6m+: *restlessness *fatigue *sleep disturbance *irritability *muscle tension *trouble concentrating

Answer 482

GAD7 questionnaire Consider thyroid dysfunction and other endocrine disorders Perform medication review Consider impact of any alcohol or illicit drug use

Answer 483

1- explain diagnosis and meaning to the patient; provide written information that will allow patient to understand their diagnosis better; manage co-morbs; advise about triggers/stressors; sleep hygiene advice 2- not improved after ^ measures, offer low-intensity psychological interventions 3- not improved after ^ measures, offer high-intensity psychological intervention or pharmacological treatment [SSRIs] 4- refer to specialist care, especially for those at risk of self harm or suicide, sig. co-morbs, self neglect

Answer 484

Commonly used set of questions for screening cognitive function

Answer 485

There is a 10 fold increased risk of suicide in people receiving treatment for a mental health condition compared with the general population Male sex

Answer 486

Coping strategies Supportive relationships Dependent children Religious beliefs

Answer 487

Assess current risk factors Assess current intent and plans Assess needs

Answer 488

Sometimes the methods are similar -self-poisoning Done with intent to harm themselves/release overwhelming feelings

Answer 489

Frequency - self harm more often; suicide/suicide attempts less often Methods are often different Severity - self harm often less severe; suicide more severe, sometimes lethal Purposes of the two are different

Answer 490

Helplines Supportive relationships Emergency department - for their own safety Mental Health services available to local area Removal of access to means by friends/family/patient

Answer 491

Socioeconomic disadvantage Social isolation Stressful life events Mental and physical problems Alcohol or drug misuse Age [F16-24; M25-34] Involvement in the criminal justice system

Answer 492

Following an episode of self-harm, suicide risk is significantly increased, particularly in people who have repeatedly self-harmed, who are male, have expressed suicidal intent, and who have physical health problems

Answer 493

Examine physical injuries Assess pt's emotional and mental state Assess for presence of protective factors [coping strategies, supportive relationships, dependent children, religious beliefs] Assess any safeguarding concerns Urgent referral to nearest emergency department if physical injuries/mental state are thought to pose a sig. risk

Answer 494

pregnancy haemoglobinopathies post-transfusion anaemia splenectomy CKD HIV dialysis

Answer 495

Systemic vasculitis of the medium and large arteries Typically presents with symptoms affecting the temporal arteries [temporal arteritis] Strong link with polymyalgia rheumatica

Answer 496

Severe unilateral headache typically around temple and forehead Scalp tenderness may be noticed when brushing hair Jaw claudication Blurred or double vision Irreversible painless complete sight loss can occur rapidly Fever Muscle aches Fatigue Weight loss Loss of appetite Peripheral oedema

Answer 497

Definitive diagnosis is made with clinical presentation; raised ESR; temporal artery biopsy findings [multinucleated giant cells] also FBC, LFTs, CRP, duplex ultrasound [hypoechoic halo sign]

Answer 498

Start steroids immediately before confirming diagnosis to reduce risk of permanent sight loss 40-60mg pred/day Review within 48hr Aspirin 75mg/day PPI for gastric prevention while on steroids Refer to vascular surgeons, rheumatology and ophthalmology if visual symptoms

Answer 499

visual disturbances - high dose prednisolone Risk of permanent sight loss

Answer 500

occurs when a person experiences certain symptoms after a particularly stressful event - symptoms develop quickly but don't last long Typically occurs after an unexpected life crisis S/S- psychological symptoms [anxiety. low mood, poor sleep and concentration]; recurrent dreams/flashbacks; avoidance of triggers; reckless/aggressive behaviour; emotionally numb; palpitations/nausea/chest pain/headaches [caused by adrenaline] Self care and supportive treatments - usually self-limiting; CBT can help, counselling, b-blocker can relieve symptoms but usually not prescribed

Answer 501

'a grievous loss; particularly the loss of a relative or friend by death' There is no right or wrong way to bereave; most will feel grief Stages: shock, denial, anger and guilt, sadness, acceptance There are many sources of support for bereavement and grief - Samaritans, Bereavement advice centre, Child Bereavement UK

Answer 502

no phone in bedroom restful environment bedroom should be used for sleep, sex, getting dressed only no caffeine after 3pm alcohol doesn't improve sleep quality exercise regularly exposure to natural sunlight everyday is essential have a calming nightly routine don't take naps during the day don't force sleep

Answer 503

False perception of objects or events involving your senses You can hear, see, smell, taste or feel things that appear to be real but only exist in your mind

Answer 504

A belief that is clearly false and that indicates an abnormality in the affected person's content of thought An unshakeable belief in something untrue

Answer 505

An episode where a person is detached from reality A symptom of sleep deprivation, substance use, mental illness, for example S/S- hallucinations, delusions, agitation, disorganised thought and behaviour

Answer 506

A mental illness that impacts thought processes, emotions, and behaviour To be diagnosed, one must experience at least two of the following symptoms for six months: delusions, hallucinations, disorganised or incoherent speaking, disorganised or unusual movements, negative symptoms [lack of motivation, decrease in emotion, for example]

Answer 507

anti TTG IgA

Answer 508

Children under the age of 16 can consent to their own treatment if they're believed to have enough intelligence, competence and understanding to fully appreciate what's involved in their treatment. Otherwise, someone with parental responsibility can consent for them. Not just used in regards to sexual health and contraception, but with a wider context

Answer 509

Applies specifically to advice and treatment about contraception and sexual health *can't be persuaded to inform their parents/carers about their treatment *understands the advice being given *physical/mental/both would suffer unless they receive this advice or treatment *it's in the patient's best interest to receive advice/treatment without parent's consent *very likely to continue having sex with or without contraceptive treatment