General Practice Flashcards
What does RAPRIOP stand for?
Reassurance and explanation
Advice and counselling
Prescribing
Referral
Investigation
Observation and follow-up
Prevention
What are some general red flags?
Night sweats
Weight loss - unintentional
Excessive tiredness/fatigue
Changes to bowel habit - timing, consistency, blood
What is social prescribing?
Social prescribing is a key component of Universal Personalised Care. It is an approach that connects people to activities, groups, and services in their community to meet the practical, social and emotional needs that affect their health and wellbeing.
Upper Respiratory Tract Infection - s/s
Sore/irritated throat
Nasal irritation, congestion, rhinorrhoea, sneezing
Cough
Hoarse voice
General malaise
Fever, headache, myalgia, loss of taste/smell, eye irritability, feeling of pressure in ears of sinuses
Upper Respiratory Tract Infection - ix
Usually diagnosed based on clinical features
Upper Respiratory Tract Infection - mx
Symptom relief and rest are most appropriate management
Antihistamines and antibiotics are ineffective, may cause adverse effects
Paracetamol or ibuprofen if needed
Upper Respiratory Tract Infection - f-up
Arrange a follow-up appt if symptoms are worsening or persisting
earlier review advised in people with risk factors for complications
Upper Respiratory Tract Infection - complications
Sinusitis
Lower respiratory tract infections
Acute otitis media
Urinary Tract Infections - causative organism
Caused by Escherichia coli (e.coli) in 75-90% of cases
Starting to be caused by ESBL producing E.coli - extended-specturm beta lactamase producing E.coli; highly resistant to most beta-lactam antibiotics; growing cause of hospital acquired infections (HAI) associated with poor outcomes
Urinary Tract Infections - pathophysiology
UTIs result from colonisation and ascending spread of microorganisms from the urethra to the bladder and/or kidney; can also be caused by haematogenous spread via the blood
In women, infection usually starts at the entrance to the vaginal canal and periurethral area, then ascends the urethra to cause infection of the bladder.
In men, UTIs are uncommon because pf the longer urethra, antimicrobial properties of the prostatic secretions and periurethral area tends to be drier
Haematogenous spread tends to be more uncommon urinary microorganisms - staphylococcus aureus, candida albicans, mycobacterium tuberculosis
Urinary Tract Infections - risk factors
Recent sexual intercourse
Diabetes
History of UTIs
Spermicide use
Catheters - major risk factors in secondary care
Urinary Tract Infections - s/s
Symptoms- dysuria; frequency; urgency; incontinence; suprapubic pain; haematuria; nausea/vomiting
Signs- fever; rigors; flank pain; confusion; costovertebral angle tenderness
Urinary Tract Infections - ix
Urine dipstick - measure leucocyte esterase and nitrites
Urinary MC&S - identify causative organism and guide antibiotic sensitivities
FBC, U&Es, CRP - assess for development of AKI
Urinary Tract Infections - mx
Uncomplicated - nitrofurantoin [100mg BD 3/7women, 7-14men], or trimethoprim [200mg BD 3/7women, 7-14/7men]
Influenza - patho
Acute respiratory illness caused by RNA viruses of the family Orthomyxoviridae (influenza viruses)
Influenza A - occurs more frequently, more virulent
Influenza B - co-circulates with I.A, generally causes less severe clinical illness
Influenza C - usually causes mild or asymptomatic infection, similar to common cold
Influenza - complications
Acute bronchitis
Pneumonia
Exacerbations of asthma and COPD
Otitis media
Sinusitis
Influenza - s/s
Coryza (catarrhal inflammation of mucous membrane of nose)
Nasal discharge
Cough
Fever
GI symptoms
Headache
Malaise
Myalgia
Arthralgia
Ocular symptoms
Sore throat
Influenza - ix
Diagnosis is generally made using clinical features alone when it is known to be circulating the community
Can only be confirmed by lab testing
Rapid testing for influenza should be undertaken in all people with complicated influenza but this is typically done in hospital
Influenza - mx
Otherwise healthy people aren’t usually given antiviral drugs; symptomatic relief and supportive treatment is recommended. Adequate fluids, paracetamol or ibuprofen, rest, stay off of work/school until severe symptoms have resolved
People in ‘at risk’ group should be given antiviral drugs [oseltamivir 75mg BD 5/7] - >65y, pregnant, children <6m, immunocompromised or have a chronic condition
Influenza - consider urgent admission to secondary care
A complication [e.g. pneumonia] occurs
Have a concomitant disease that may be affected by influenza [e.g. T1 diabetes]
Suspicion of a serious illness other than influenza [e.g. meningitis]
Oseltamivir - dosage
75mg BD for 5 days if body weight above 41kg (60mg if <41)
Oseltamivir - side effects
dizziness, GI discomfort, herpes simplex, nausea, sleep disorders, vertigo, vomiting
arrhythmia, consciousness impairment, seizure, skin reactions
angioedema, anxiety, abnormal behaviour, confusion, delirium, delusions, haemorrhage, hallucination, hepatic disorders, self-injurious behaviour, severe cutaneous adverse reactions, thrombocytopenia, visual impairment
Nitrofurantoin - dosage
Immediate-release medication: 50mg QDS for 3/7 in women; 7/7 in men and pregnant women
Modified-release medication: 100mg BD for 3/7 in women; 7/7 in men and pregnant women
Nitrofurantoin - side effects
chest pain, chills, chronic pulmonary reaction, confusion, cough, dizziness, nausea and vomiting, pulmonary fibrosis, skin reactions, vertigo, urine dicolouration
Nitrofurantoin - interactions
Amiodarone - increase risk of peripheral neuropathy
Metronidazole - increase risk of peripheral neuropathy
Phenytoin - increase risk of peripheral neuropathy
Trimethoprim - dosage
200mg BD for 3/7 in women; 7/7 in men
Trimethoprim - side effects
diarrhoea, electrolyte imbalance, fungal overgrowth, headache, nausea, skin reactions, vomiting
anxiety, confusion, cough, lethargy, myalgia, renal impairment, seizure
Trimethoprim - pregnancy
Teratogenic risk in first trimester - folate antagonist
Best to avoid during pregnancy
Trimethoprim - interactions
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
Acute Tonsillitis - patho
Acute inflammation of the palatine tonsils secondary to infection
Most commonly viral, associated with URTI. May also be caused by bacteria (Group A Streptococci)
Acute Tonsillitis - s/s
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
Acute Tonsillitis - ix
Centor and FeverPAIN score are used to guide antibiotic use
Centor criteria for tonsillitis
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)
FeverPAIN score for tonsillitis
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
Acute Tonsillitis - simple mx
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
Acute Tonsillitis - severe mx
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
Acute Tonsillitis - complications
Suppurative (pus-producing): quinsy [peri-tonsillar abscess], acute otitis media, acute sinusitis
Non-suppurative: post-streptococcal glomerulonephritis, acute rheumatic fever
Acute Tonsillitis - referral
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
Phenoxymethylpenicillin - dose
500mg QDS, or 1000mg BD, for 5-10/7
Phenoxymethylpenicillin - side effects
diarrhoea, hypersensitivity, nausea, skin reactions, thrombocytopenia, vomiting
antibiotic associated colitis, arthralgia, leucopenia
angioedema, haemolytic anaemia, seizure
Phenoxymethylpenicillin - interactions
Methotrexate - increase risk of toxicity when given with methotrexate; monitor pt
Warfarin - alters anticoagulant effect of warfarin; monitor INR and just dose accordingly
Clarithromycin - dose for acute tonsillitis
250-500mg BD for 5/7
Clarithromycin - side effects
decreased appetite, diarrhoea, dizziness, GI discomfort and disorders, headache, hearing impairment, insomnia, nausea, pancreatitis, paraesthesia, skin reactions, taste altered, vasodilation, vision disorders, vomiting
Clarithromycin - interactions
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
Acute Otitis Externa - patho
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
Acute Otitis Externa - s/s
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
Acute Otitis Externa - ix
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
Acute Otitis Externa - mx
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
Acute Otitis Externa - prevention
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
Acute Otitis Media - causative organisms
Commonly caused by viruses or bacteria, sometimes both
Bacteria include: streptococcus pneumonia, haemophilus influenzae
Viruses include: RSV, rhinovirus, adenovirus
Acute Otitis Media - patho
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
Acute Otitis Media - s/s
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
Acute Otitis Media - otoscopy
Red, yellow or cloudy tympanic membrane [as opposed to pearly-grey]
Bulging tympanic membrane or perforated membrane
Air-fluid level behind the tympanic membrane
Acute Otitis Media - mx
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
Amoxicillin - dose for acute otitis media
1-11months - 125mg TDS 5-7/7
1-4 years - 250mg TDS for 5-7/7
5-17 years TDS for 5-7/7
Amoxicillin - side effects
diarrhoea, hypersensitivity, nausea, skin reactions, thrombocytopenia, vomiting
antibiotic associated colitis, arthralgia, leucopenia
specific - rare/very rare - black, hairy tongue
Amoxicillin - interactions
Methotrexate - increases risk of toxicity; advised to monitor
Warfarin - alters anticoagulant effect of warfarin; advised to monitor INR and adjust dose
Acute Otitis Media - admission to hospital
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
Persistent Acute Otitis Media - summary
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
Acute Otitis Media - referral
Persistent symptoms of AOM should be referred to ENT, particularly if lasting longer than 6 weeks or there is persistent hearing loss
Recurrent AOM - referral
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
Acute Otitis Media - complications
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
Mastoiditis - as a complication of AOM
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
Benign Paroxysmal Positional Vertigo - patho
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
Benign Paroxysmal Positional Vertigo - s/s
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
Benign Paroxysmal Positional Vertigo - ix
Following history and careful examination, the Dix-Hallpike manoeuvre is typically sufficient to diagnose BPPV
Benign Paroxysmal Positional Vertigo - Dix-Hallpike manoeuvre
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
Benign Paroxysmal Positional Vertigo - mx
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
Benign Paroxysmal Positional Vertigo - driving
DVLA advises all people with a ‘liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness’ to stop driving and inform them.
Sinusitis - patho
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
Sinusitis - s/s
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
Sinusitis - causative organisms
Viral rhinosinusitis- Rhinovirus; influenza virus; parainfluenza virus
Bacterial rhinosinusitis- Streptococcus pneumoniae; haemophilus influenza; staphylococcus aureus; moraxella catarrhalis
Sinusitis - referral
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]
Acute Sinusitis - mx
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
Chronic Sinusitis - mx
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
Pyelonephritis - patho
Infection of one or both kidneys usually caused by E.coli [Escherichia coli] - responsible for 60-80% of infections
Pyelonephritis - s/s
Flank pain
Fever and chills
Nausea and vomiting
Also LUTS - dysuria, frequency, urgency
Costovertebral tenderness due to kidney involvement
Pyelonephritis - ix
Midstream urine sample should be sent for culture and sensitivity
-Dipstick not necessary but may be a useful adjunct to guide diagnosis
Pyelonephritis - diagnosis
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
Pyelonephritis - mx
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
Co-amoxiclav - dose for pyelonephritis
625mg [500/125mg] TDS for 10/7
Review micro sensitivity and change abx if necessary
Co-amoxiclav - side effects
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
Co-amoxiclav - interactions
Amoxicillin- methotrexate - ++ toxicity; warfarin - alters anticoag effect
Clavulanate- alcohol, methotrexate, paracetamol, simvastatin, valproate - ++ hepatotoxicity
Ciprofloxacin - dose for pyelonephritis
500mg BD for 7/7
Ciprofloxacin - side effects
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
Ciprofloxacin - interactions
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
Pyelonephritis - referral
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
Pyelonephritis - f-up
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
Chest infections - examples typically presenting in primary care
Acute Bronchitis
Community-acquired pneumonia
COVID-19
Acute Bronchitis - patho
LRTI causing inflammation in the bronchial airways
Occurs due to viral or bacterial infection; preceded usually by an URTI
Acute Bronchitis - common causative organisms
Influenza A/B; Parainfluenza; Respiratory syncytial virus (RSV); Rhinoviruses
Mycoplasma pneumoniae; Chlamydia pneumoniae; Bordetella pertussis
Acute Bronchitis - risk factors
COPD
Asthma
Smoking
Chronic exposure to air pollution
Acute Bronchitis - s/s
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
Acute Bronchitis - ix
Pulse oximetry
CRP
CXR - rules out pneumonia, not always necessary
Acute Bronchitis - mx
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]
Doxycycline - dose for acute bronchitis
200mg on day 1, then 100mg for 4 further days
Doxycycline - side effects
[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
Doxycycline - interactions
Lithium - ++ lithium toxicity; avoid or adjust dose
Warfarin - ++ anticoag effect; monitor INR
Antacids - greatly – absorption of doxycycline; separate administration by 2-3hrs
Community-acquired pneumonia - patho
Pneumonia that is contracted in the community: atypical and typical pneumonia
CAP - typical causative organisms
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Tend to present with typical features of pneumonia- productive cough, fever, pleuritic chest pain
CAP - atypical causative organisms
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydophila pneumoniae
Chlamydophila psittaci (psittacosis)
CAP - s/s
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
CAP - ix
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]
CAP - mx
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
Amoxicillin - dose for community-acquired pneumonia
500mg TDS for 5/7
COVID-19 - patho
Caused by virus: severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2)
Positive strand RNA viruses
COVID-19 - s/s
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]
COVID-19 - ix
Lateral flow testing - easy, results delivered within minutes; nasopharyngeal swab mixed with a solution and applied to testing area
PCR testing
Pulse oximetry
COVID-19 - mx
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
COVID-19 - advice to general public
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
Vaginal Thrush (Candidiasis) - patho
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
Vaginal Thrush (Candidiasis) - risk factors
*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
Vaginal Thrush (Candidiasis) - s/s
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]
Vaginal Thrush (Candidiasis) - ix
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
Vaginal Thrush (Candidiasis) - mx
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
Vaginal Thrush (Candidiasis) - referral
Consider referral to specialist GUM or gynaecology in the following:
*12-15 years old
*diagnosis doubtful
*treatment failure or ongoing symptoms
*non-albicans candida
Bacterial Vaginosis - patho
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
Bacterial Vaginosis - risk factors
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
Bacterial Vaginosis - s/s
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
Bacterial Vaginosis - diagnosis
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
Bacterial Vaginosis - ix
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
Bacterial Vaginosis - mx
*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
Metronidazole - dose for Bacterial Vaginosis
400mg BD for 7/7
OR 0.75% vaginal gel 5g applicator full at night for 5/7
Metronidazole - side effects, with vaginal use
Pelvic discomfort, vulvovaginal candidiasis, vulvovaginal disorders
Menstrual cycle irregularities, vaginal haemorrhage
Metronidazole - interactions
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
Meningitis - patho
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
Bacterial Meningitis - causative organisms
Neisseria meningitidis (gram negative diplococci)
Streptococcus pneumoniae
Haemophilus influenzae
Listeria monocytogenes
Escherichia coli
Bacterial Meningitis - s/s
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
Bacterial Meningitis - ix
If suspicious, ring 999 immediately as it is a medical emergency
Ix can take place at the hospital [e.g. lumbar puncture]
Bacterial Meningitis - mx
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
Bacterial Meningitis - vaccination
UK vaccination programme is important - includes vaccines against H.influenza, N.meningitidis, S.pnaeumoniae
Chickenpox - patho
Acute, infectious disease caused by varicella-zoster virus
14-16/7 incubation period
Dangerous in pregnancy from wk8-20 - congenital varicella syndrome
Chickenpox - s/s
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
Chickenpox - diagnosis
Usually made clinically with the presence of the characteristic vesicular rash
Chickenpox - mx
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
Fifth Disease - patho
‘Slapped Cheek Syndrome’ or Erythema infectiosum
Caused by parovirus B19
Outbreaks amongst school children; droplet spread through respiratory secretions
Mild and self-limiting disease
Fifth Disease - s/s
Begins with fever, coryza, headache, nausea and vomiting
Malar rash with circumoral pallor; lace-like rash on trunk and extremities
Fifth Disease - mx
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
Conjunctivitis - patho
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
Conjunctivitis - s/s
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
Conjunctivitis - red flags
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]
Viral Conjunctivitis - mx
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
Bacterial Conjunctivitis - mx
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
Conjunctivitis - referral
Referral to ophthalmology nay be required where patients at risk of severe disease and complications or where a serious differential is suspected
Stye - patho
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
Stye - s/s
Acute-onset, painful, localised swelling near eyelid margin that develops over several days
Unilateral symptoms affecting one eyelid; though styes can be bilateral
Stye - mx
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
Sprains/Strains - patho
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
Sprain - s/s
Pain around affected joint, tenderness, swelling, bruising, pain on weight-bearing, decreased function
There may be joint instability following severe injuries
Strain - s/s
Muscle pain, cramping, spasm, muscle weakness, inflammation, bruising
Sprain/Strain - PRICE
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
Sprain/Strain - mx
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
Headlice - patho
Parasitic insect infestation; infect the hair and feed on blood from the scalp
Headlice - s/s
Itching
Live louse found on combing confirms an active headlice infestation
Headlice - mx
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
Scabies - patho
Caused by a parasitic mite
Transmitted through direct skin-to-skin contact
Scabies - s/s
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
Scabies - mx
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]
Nappy Rash - patho
Irritant contact dermatitis
Secondary infection with candidal abicans or staphylococcal aureus can occur
Nappy Rash - s/s
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
Nappy Rash - mx
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
Nappy Rash - referral
Referral to a paediatric dermatologist should be considered:
*Uncertainty about diagnosis
*Rash persists despite optimal treatment in primary care
*Recurrent, severe unexplained episode
Plantar Fasciitis - patho
Condition in which there is persistent pain associated with degeneration of the plantar fascia as a result of repetitive microtears in the contracted fascia
Plantar Fasciitis - s/s
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
Plantar Fasciitis - mx
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
Impetigo - patho
Common superficial bacterial skin infection; highly contagious
Commonly caused by staphylococcus aureus [gram positive coccus]
Impetigo - s/s
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
Impetigo - ix
Commonly a clinical diagnosis based on characteristic appearance
If in doubt, diagnosis can be confirmed with skin swabs for microscopy, culture and sensitivity
Impetigo - mx
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
GORD - patho
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]
GORD - risk factors
High BMI
Smoking
Genetic association
Pregnancy
Hiatus hernia
NSAIDs, caffeine and alcohol
GORD - s/s
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
GORD - ix
pH monitoring and gastroscopy if diagnosis is uncertain/surgery being considered/red flag symptoms
GORD - mx
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]
Omeprazole - dose for Gastro-Oesophageal Reflux Disease
20mg once daily for 2 week trial initially; or 4-8 weeks
Omeprazole - side effects
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
Omeprazole - interactions
Clopidogrel - –efficacy
Diarrhoea - causes
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
Diarrhoea - definition
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
Diarrhoea - mx
Drink lots of water; use rehydration drinks
Eat as normal as possible
See a doctor if you think you are dehydrated
Anti-secretory medications
Constipation - causes
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
Constipation - defintion
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]
Constipation - s/s
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
Constipation - ix
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
Constipation - mx
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
Change in bowel habit - red flags
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
Crohn’s Disease - patho
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
Crohn’s Disease - macro/microscopic changes
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
Crohn’s Disease - s/s
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
Crohn’s Disease - extra-intestinal manifestations
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
Crohn’s Disease - ix
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
Crohn’s Disease - mx
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]
Ulcerative Colitis - patho
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]
Ulcerative Colitis - macro/microscopic changes
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]
Ulcerative Colitis - s/s
Symptoms- weight loss, fatigue, abdominal pain, loose stools, rectal bleeding, tenesmus, urgency
Signs- febrile, pale, dehydrated, abdo tenderness/mass/distension, tachycardic, hypotensive
Ulcerative Colitis - extra-colonic manifestations
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
Ulcerative Colitis - ix
Diagnosis is based on macroscopic assessment [colonoscopy] and histological evidence [biopsy] of colonic inflammation
Faecal calprotectin
Ulcerative Colitis - mx
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
Crohn’s Disease - complications
Fistulae
Colorectal cancer
Strictures
Perforation
Ulcerative Colitis - complications
Fistulae
Colorectal cancer
Strictures
Perforation
Toxic Megacolon
Primary sclerosing cholangitis
Diabetes Mellitus - patho
Type I - autoimmune destruction of beta cells of the pancreas. Insulin deficiency
Type II - insulin resistance, and insulin deficiency in some cases
Diabetes Mellitus - s/s
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
Diabetes Mellitus - ix
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
Diabetes Mellitus - mx
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.
Diabetes Mellitus - complications
Nephropathy
Neuropathy
Retinopathy
Hypertension
Chronic kidney disease
Leg ulcers, poor wound healing, increased risk of infection
Diabetes Mellitus - f-up
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.
Chronic Obstructive Pulmonary Disease - patho
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)
Chronic Obstructive Pulmonary Disease - s/s
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
Chronic Obstructive Pulmonary Disease - ix
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
Chronic Obstructive Pulmonary Disease - mx
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
Chronic Obstructive Pulmonary Disease - f-up
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
Chronic Obstructive Pulmonary Disease - complications
Respiratory failure - PaO2 <8, PaCO2 >7
Pulmonary artery hypertension
Cor pulmonale
Polycythaemia
Pneumothorax
Weight loss
Carcinoma of bronchus
Infective exacerbations
Asthma - patho
Inflammatory disorder of conducting airways. Airways become hyper responsive and construct easily in response to a wide range of stimuli.
