General practice (not that good)

Question 1

Whats the reccomended total units of alcohol per week as per the NICE guidelines?

Answer 1

14

Question 2

How do you work out the units of an alcoholic drink?

Answer 2

Units = strength (ABV) x volume (ml) ÷ 1000

Question 3

What is the pathophysiology of asthma?

Answer 3

Asthma occurs due to a reversible airway obstruction.
The pathophysiology of asthma includes airway narrowing due to bronchial muscle contraction, inflammation caused by mast cell degranulation and increased mucus production

Question 4

What are the symptoms of asthma?

Answer 4

wheeze, Dyspnoea (SOB), cough (may be nocturnal), chest tightness, diurinal variation (Often worse in the morning), personal/family history of atopy may be present, and symptoms may be worse after exercising or NSAIDs

Question 5

Signs of asthma

Answer 5

Tachypnoea, hyperinflated chest, hyper resonance on chest percussion, decreased air entry, wheeze on auscultation.
Signs of severe asthma attack: inability to speak in complete sentences, respiratory rate >25, peak flow 33-50% predicted
Signs of life threatening attack: silent chest, confusion, bradycardia, cyanosis, exhaustion

Question 6

IWhat are the investigations in chronic asthma?

Answer 6

Peak flow: variability >20%
Fractional exhaled nitric oxide (FeNO): >40 ppb in adults or >35 ppb in children
Spirometry: FEV1/FVC <0.7 (obstructive spirometry)
Bronchodilator reversibility tests: Improvement of FEV1 >12% after bronchodilator therapy is diagnostic

Question 7

What are the investigations for acute asthma?

Answer 7

ABG: type 2 respiratory failure (low PaO2 and high PaCO2) is a sign of a life-threatening attack.
Routine blood tests (including FBC, CRP): to look for precipitating causes of an asthma attack, such as an infection.
Chest x-ray: to exclude differentials and possibly identify a precipitating infection.

Question 8

What is the management of an acute asthma attack?

Answer 8

Ensure a patent airway
Ensure oxygen saturations of 94-98%
Nebulisers: Salbutamol, Ipratropium
Steroids: oral Prednisolone or IV Hydrocortisone (if severe)
IV Magnesium Sulphate: if severe
IV aminophylline: if severe and inadequate bronchodilatory response from nebulisers
If the patient does not improve following these measures, intensive care input will be required for consideration of an intensive care admission which may involve invasive ventilation.

Question 9

What are some non-pharmacological management of chronic asthma?

Answer 9

Smoking cessation
Avoidance of precipitating factors (eg. known allergens)
Review inhaler technique

Question 10

What are the pharmacological management of chronic asthma?

Answer 10

Step 1: short-acting inhaled B2-agonist (eg. Salbutamol)
Step 2: add low-dose inhaled corticosteroid steroid (ICS)
Step 3: add long-acting B2-agonist (eg. Salmeterol). If no benefit, stop this and increase ICS dose; if benefit but inadequate control, continue and increase ICS dose.
Step 4: Trial oral leukotriene receptor antagonist, high-dose steroid, oral B2-agonist

Question 11

What are some differentials of asthma?

Answer 11

Acid reflux
Churg-Strauss Syndrome
Allergic Bronchopulmonary Aspergillosis (ABPA)

Question 12

What is acid reflux?

Answer 12

Acid reflux is when the acidic contents of the stomach are regurgitated into the oesophagus. This can result in a condition known as gastro-oesophageal reflux disease (GORD)

Question 13

What are the risk factors for acid reflux?

Answer 13

Risk factors that are associated with acid reflux include: obesity; smoking; alcohol and medications that relax the lower oesophageal sphincter tone (eg. calcium-channel blockers).
Symptoms associated with GORD include dry cough, wheeze, shortness of breath, hoarse voice, dental erosion, chest pain. The cough, dyspnoea and wheeze can present like asthma.

Question 14

What are the treatments for acid reflux?

Answer 14

Treatment includes over the counter antacids or alginates such as Gaviscon, in addition to proton pump inhibitors (eg. Omeprazole) or H2 blockers (eg. Ranitidine)

Question 15

What is Churg-Strauss syndrome?

Answer 15

Churg-Strauss syndrome is a granulomatous vasculitis associated with adult-onset asthma and eosinophilia.
Conditions associated with this syndrome include sinusitis, asthma, purpura, and peripheral neuropathy

Question 16

What are the signs of Churg-Strauss syndrome?

Answer 16

Patients are pANCA +ve and have raised IgE levels.

Question 17

What are the treatments for Churg-Straus syndrome?

Answer 17

Treatment includes steroids and immunological agents in treatment-resistant cases such as Rituximab

Question 18

What is Allergic Bronchopulmonary Aspergillosis (ABPA)?

Answer 18

ABPA is a type I and III hypersensitivity reaction to Aspergillus fumigatus. There is an association with both cystic fibrosis (up to 25% of patients) and 1% of patients with asthma.

Symptoms include wheeze, cough, dyspnoea, sputum production as well as reduced exercise tolerance.

ABPA patients characteristically react immediately upon exposure of the skin to Aspergillus fumigatus antigens. Raised IgE levels also raises suspicion of the diagnosis, but a proportion of patients do not exhibit this.

Question 19

What is the treatment of acute episodes of Allergic Bronchopulmonary Aspergillosis (ABPA)?

Answer 19

Treatment in acute episodes involves a Prednisolone regimen. Itraconazole may also be added to treatment regimes, and bronchodilators can be considered for patients with symptoms of asthma

Question 20

What is the Combined Hormonal Contraception?

Answer 20

Combined hormonal contraception (CHC) contains an oestrogen (e.g. ethinylestradiol) and a progestogen (e.g. etonogestrel, levonorgestrel).
It can be administered orally, transdermally in the form of a patch, or intravaginally in the form of the vaginal ring.

Question 21

What is the mechanism of action of the Combined Hormonal Contraception?

Answer 21

• Thickens cervical mucus, making it more difficult for sperm to enter the uterus
• Thins the lining of the endometrium, making it more difficult for implantation to take place
• Inhibits ovulation

Question 22

What are the contraindications of Combined Hormonal Contraception?

Answer 22

Less than 6 weeks postpartum and breastfeeding
Less than 3 weeks postpartum with other risk factors for venous thromboembolism (VTE)
Cardiomyopathy with impaired cardiac function
Atrial fibrillation
Current breast cancer
Positive antiphospholipid antibodies
Being over the age of 25 and smoking >15 cigarettes
Blood pressure ≥160 mmHg systolic or ≥100 mmHg diastolic
Vascular disease
Ischaemic heart disease
History of cerebrovascular accident, including TIA
History of VTE
Major surgery with prolonged immobilisation
Known thrombogenic mutations (e.g. factor V Leiden, prothrombin mutation, protein S, protein C and antithrombin deficiencies)
Complicated (e.g. pulmonary hypertension, history of subacute bacterial endocarditis)
Migraine with aura
Severe (decompensated) liver cirrhosis
Hepatocellular adenoma
Hepatocellular carcinoma)

Question 23

What are the types of oral combined contraceptive pill (COCP)?

Answer 23

Monophasic: each pill contains the same dose of hormones
Phasic: pills contain differing amounts of hormones and must be taken in the correct order
Every day pills: usually contain 21 hormone-containing pills, and 7 hormone-free pills

Question 24

What are the side effects of combined hormonal contraception?

Answer 24

Breast tenderness, enlargement
Headache
Changes to mood and libido
Nausea and vomiting
Irregular menstrual bleeding, spotting, amenorrhoea
Ovarian cysts
Venous thromboembolism

Question 25

What are the different regimines of taking combined hormonal contraception?

Answer 25

• Traditional: The user takes one pill per day, or one patch per week, or one vaginal ring for a period of three weeks. This is followed by a 7-day hormone free-interval (HFI)
• Extended use: The user “tricycles”; rather than having a HFI after three weeks, they can use the method for a period of nine weeks, followed by a 7-day hormone-free interval
• Continuous use: The user uses the method continuously without any HFI
• Flexible extended use: The user uses the method until there is bleeding. When bleeding occurs, the user has a 4-day HFI

Question 26

What is the information surrounding starting the combined hormonal contraceptive?

Answer 26

If the patient starts her pill on the first day of a natural period, she will be protected from pregnancy immediately
If the patient starts at any other time in her cycle, she will need to use additional precautions (e.g. condoms) for 7 days
New mothers can begin to take the pill 21 days after giving birth, providing they are not breastfeeding

Question 27

What are the Absolute Contraindications to Contraception (UKMEC 4) to the oral contraceptive pill?

Answer 27

Known or suspected pregnancy, smoker over the age of 35 who smokes >15 cigarettes, obesity, breast feeding <6 weeks post partum, Fx of thrombosis before 45 years old, breast cancer or cancer within last few years, BRCA genes

Question 28

What are the Disadvantages of a contraceptive outweigh the advantages (UKMEC 3) to starting the oral contraceptive pill?

Answer 28

Breast feeding >6weeks post partum, Previous arterial or venous clots, continued use after heart disease or stroke, migraines with aura, active disease of liver or gallbladder

Question 29

What are the Advantages of a contraceptive outweigh the disadvantages (UKMEC 2) to starting the oral contraceptive pill?

Answer 29

Initiation after current or past history of MI or stroke, multiple risk factors for arterial cardiovascular disease

Question 30

What are the different types of hormonal contraception?

Answer 30

Combined hormonal contraception (CHC)

Combined oral contraceptive pill (COCP) e.g. Rigevidon, Microgynon

Combined hormonal contraceptive patch e.g. Evra

Combined hormonal contraceptive ring e.g. Nuvaring

Progestogen-only contraception

Progestogen-only pill (POP) e.g. Desogestrel, Cerelle, Cerazette

Subdermal implant (SDI) e.g. Nexplanon

Contraceptive injection e.g. Depo, Sayana Press

Intrauterine system (IUS) e.g. Mirena, Levosert, Kyleena, Jaydess

Emergency contraception e.g. Ulipristal acetate, Levonorgestrel

Question 31

What are the types of non-hormonal contraception?

Answer 31

Copper intrauterine device (IUD)
Barrier methods e.g. male condom, female condom, diaphragm/cervical cap
Surgical methods e.g. tubal ligation, vasectomy
Lactational amenorrhoea
Fertility awareness methods (FAM)

Question 32

What are the features of the contraceptive implant?

Answer 32

he contraceptive implant is a small flexible rod that is inserted sub-dermally.

It works for 3 years but can be taken out sooner. When removed, fertility returns to normal quickly.

It is the contraceptive of choice for girls aged 16 and below, as it does not require daily adherence to a medication regimen.

Periods may stop, become irregular or last longer. Acne may occur or worsen.

It is important to warn the patient that a small procedure is required to fit and remove the implant, and a local anaesthetic should be used in order to fit the device

There may be some tenderness, bruising and swelling at the site of implantation.

Question 33

How would you confirm the death of somebody?

Answer 33

confirming the patients identity
checking for any obvious signs of life
checking response to verbal and painful stimuli
Assessing pupils - they should be fixed and dilated
Feeling a central pulse
Listening for heart sounds and respiratory sounds for a total of 5 minutes.

Question 34

What are the features of the Ellaone emergency contraception pill?

Answer 34

Ellaone works by inhibiting ovulation. It can be taken within 5 days of UPSI.

It is contraindicated in liver disease and asthma. Breast feeding must be avoided for one week after taking the medication.

It can cause painful periods, mood swings and back pain.

If the patient vomits within 3 hours, she will need to see the doctor again as the pill will not have been absorbed.

Question 35

What is the gold standard emergency contraception and what are its features?

Answer 35

Emergency contraception is indicated where unprotected sexual intercourse (UPSI) has occured, or where a contraceptive method has been used incorrectly

Copper intrauterine device (Cu-IUD)

Gold standard emergency contraception

Can be used 120 hours after the first episode of UPSI in a cycle, or within 120 hours of the earliest expected date of ovulation

Inhibits fertilization by its toxic effect on sperm and ova.

If fertilization does occur, the Cu-IUD has an anti-implantation effect

Question 36

What are the features of Ellaone emergency contraception and what is the mechanism of action?

Answer 36

Ulipristal acetate (“Ella One”)

Selective progesterone receptor modulator

Binds to human progesterone receptors, suppressing the LH surge and delays ovulation for at least 5 days, until sperm from the UPSI are no longer viable

It delays ovulation even after the start of the LH surge

Can be used within 120 hours of UPSI

Guidance is to wait 5 days before starting ongoing hormonal contraception

Can only be used once per cycle

Question 37

What are the features of Levonorgestrel (“Levonelle”) as an emergency contraception?

Answer 37

Can be used within 72 hours of UPSI

Inhibits or delays ovulation for a period of approximately 5 days, until sperm from the UPSI are no longer viable

Also thickens cervical mucus

Can quick start hormonal contraception

Can take more than once in the same cycle if further UPSI

Ineffective after the LH surge

Question 38

What is the first line of treatment in Hypercholesterolaemia?

Answer 38

Statins are the first line treatment of high cholesterol. They are HMG-CoA reductase inhibitors. This enzyme plays a key role in the production of cholesterol, so inhibiting it reduces the cholesterol in the body.

Question 39

In patients with Hypercholesterolaemia what risk tool is used and what does the outcome mean?

Answer 39

the QRISK score is used to see if they would benefit from statins as primary prevention against cardiovascular disease. If an adult is under 80 years old and their QRISK is greater than 10% then a statin should be offered. Atorvastatin 20mg is the usual starting dose for primary prevention.

Question 40

What causes patients to need a statin as a secondary prevention, and what statin and dose should be started?

Answer 40

For patients who need a statin as secondary prevention, eg following a stroke, heart attack, peripheral arterial disease or angina, atorvastatin at 80mg starting dose should be used.

Question 41

What are the common side effects from statins?

Answer 41

muscle pain, abdominal pain, constipation and headache.

If a patient is struggling with significant myalgia, this may indeed indicate a myositis. Creatinine Kinase can be measured and if it is 5-10 times the upper limit of normal, the statin should be stopped.

Statins can also cause abnormal liver function so this should be monitored with a repeat blood test in 4-6 weeks time. If the transaminases (ALT, AST) are 3 times the upper limit the statin should be stopped.

Question 42

What is the mechanism of Intra-uterine device?

Answer 42

The Intra-uterine device works due to the toxic effect of the copper to both egg and sperm. It prevents implantation.

Question 43

What are the features of an IUD?

Answer 43

The device can stay in for up to 10 years. When removed, fertility returns to normal

It is not suitable for women with current pelvic infection or a distorted uterus. Women with repeated history of STI are not suitable for the device also.

If fitted after 40, the device can stay in place until the menopause. Women need to be taught how to check whether their device is in the right place.

Contraindications include unexplained bleeding and an abnormal cervix

Question 44

What are the features of an IUD as an emergency contraception choice?

Answer 44

The Intra-uterine device is the most effective form of emergency contraception. It prevents implantation and can be used 120 hours after the first episode of UPSI or after the earliest expected date of ovulation.

It is not recommended to be used before 28 days post-partum.

Some women may experience spotting and period type pains. Women should visit their doctor 3-4 weeks later to check they are not pregnant, discuss future contraception and evaluate whether they would like the IUD as a form of contraception for the long term.

Question 45

What is the mechanism of Intra-uterine system?

Answer 45

The Intra-uterine system works by releasing progesterone and preventing implantation.

Question 46

What is the features and life span of the Intra-uterine system?

Answer 46

5 years
Irregular bleeding or spotting is common in the first 6 months, periods may stop altogether. There is a small risk of infection during first 20 days after insertion. The patient may get ovarian cysts.

If fitted after 45, it can stay in place until menopause. Women are also taught to check the IUS is in place.

It is useful for women who experience heavy or painful periods.

Question 47

What are the different types of Intrauterine Contraception?

Answer 47

Levonorgestrel-releasing intrauterine system (LNG-IUS) e.g. Mirena, Levosert, Kyleena, Jaydess
Copper intrauterine device (Cu-IUD, Copper Coil)

Question 48

What is the mechanism of action of both types of intrauterine contraception?

Answer 48

Levonorgestrel-releasing intrauterine system (LNG-IUS)
Thickens cervical mucus, making it more difficult for sperm to enter the uterus
Thins the lining of the endometrium, making it more difficult for implantation to take place
Some types of hormonal intrauterine contraception inhibit ovulation
Copper intrauterine device (Cu-IUD, Copper Coil)
Prevents fertilisation by induce a local inflammatory reaction in the endometrium
Also inhibits implantation

Question 49

What are the features of Levonorgestrel-releasing intrauterine system (LNG-IUS)?

Answer 49

Can remain in place for 3–6 years depending on type
Common side effects: irregular bleeding, spotting, amenorrhoea
Contraindications: abnormal uterine anatomy, unexplained vaginal bleeding, pelvic inflammatory disease, between 48 hours and 28 days postpartum, breast cancer

Question 50

What are the features of Copper intrauterine device (Cu-IUD, Copper Coil)?

Answer 50

Can remain in place for 5–10 years depending on type
Common side effects: heavier, more painful periods
Not affected by other medications
Will not affect menstrual regularity
Any copper coil fitted after the age of 40 can stay in place until the menopause
Can also be used as emergency contraception if inserted within five days of unprotected sex
Contraindications: abnormal uterine anatomy, unexplained vaginal bleeding, pelvic inflammatory disease, between 48 hours and 28 days postpartum

Question 51

Using Levonelle as an Emergency contraceptive (instructions)

Answer 51

Levonelle is a progesterone only tablet that should be taken within 3 days of UPSI. It works by inhibiting ovulation and sperm migration.

Most women can use it, it can be used from day 21 after birth and can be used after miscarriage or abortion.

There are no serious short term or long term side effects.

It is the least effective of the three methods of emergency contraception.

Patients should return to regular contraception 12 hours after taking Levonelle.

Question 52

Explain the mechanism of Metronidazole on cells

Answer 52

Metronidazole is inactive until it is reduced by enzymes like nitroreductase or proteins such as reduced ferredoxin, which have a negative enough redox potential (i.e. a high enough proportion of reduced molecules to oxidized molecules) to reduce metronidazole. These enzymes/proteins are components of the electron transport chains of bacterial and parasitic anaerobes; mammalian cells do not have molecular components with a sufficiently negative redox potential to reduce and therefore activate metronidazole, thus conferring selectivity of action against anaerobic pathogens.

Question 53

What is the management of missed combined oral contraceptive pills?

Answer 53

If vomiting within 2 hours of taking a pill, another one should be taken as soon as possible.

The pill free week is the 7 days between taking packets of pills. There is occasionally a breakthrough bleed, a small bleed similar to a period, however the absence of a breakthrough bleed does not indicate pregnancy.

Missed pill rules:

If pills are missed in week 1: use emergency contraception if she had UPSI in pill free interval for 1 week

If pills are missed in week 2: no need for emergency contraception

If pills are missed in week 3: Take the last pill that was missed, finish the current pack and start the next pack immediately after.

Question 54

What is Olecranon bursitis? And what is the management?

Answer 54

Olecranon bursitis is inflammation of the olecranon bursa.

It will classically occur after repetitive damage, such as leaning on the elbow.

Examination reveals a swelling directly over the olecranon which is fluctuant with no signs of infection.

Management is generally conservative with the use of ice, anti inflammatory medications and an elbow support. If this does not improve the condition and it is affecting the patients activities of daily living a steroid injection can be considered.

Question 55

Oral contraceptive pill instructions?

Answer 55

Types of oral contraceptive pill instructions
Guidance relating to taking the pill is dependent on the regimen that has been prescribed:

Monophasic 21 day pills require 21 days of administration, followed by 7 days off

Phasic 21 day pils require all 21 pills to be taken in the correct order

Everyday pills require one pill to be taken each day. The packets include 21 active pills and 7 inactive pills

Rules for starting the pill
There is specific advice to give patients regarding starting taking the pill:

If the patient starts her pill on the first day of her period (up to 5 days), she will be protected from pregnancy immediately

If the patient starts at any other time in her cycle, she will need to use condoms for 7 days.

New mothers can begin to take the pill 21 days after giving birth, providing they are not breastfeeding.

Question 56

What is severe acne characterised as?

Answer 56

Severe acne is characterized by inflammatory papules and pustules, nodules and scars. It is treated with an oral retinoid named isotretinoin (Roacutane) which should only be prescribed by a dermatologist.
Isotretinoin is a very effective treatment, however it has a number of important side effects.

Question 57

What is Oral isotretinoin prescribed for?

Answer 57

Severe acne

Question 58

What is an important guidance rule on those starting oral isotretinoin?

Answer 58

Isotretinoin is a well established teratogen that results in miscarriages and severe birth defects. As a result, the manufacturer recommends that all female patients taking isotretinoin are also using two forms of contraception from one month before until one month after use.

Question 59

What are the side effects of oral isotretinoin?

Answer 59

Isotretinoin can also cause skin and mucosal dryness, a temporary worsening of acne and photosensitivity. It is advised to use lip balm, moisturizer and sunscreen.

There is a controversial association between isotretinoin and depression/suicide. Recent research has shown that concerns about links between isotretinoin and depression or suicide are not established. This has now been included into the NICE guidelines. However it is still important to screen for depression/suicidal ideation before prescribing and during treatment.

Question 60

What is the definition of Pityriasis rosea?

Answer 60

Pityriasis rosea is a common rash which often occurs after an upper respiratory tract infection and is thought to have a viral cause (HHV 6/7).

Question 61

What are the clinical features of Pityriasis rosea?

Answer 61

It is characterized by a preceding herald patch - a single, large, discoid (coin-shaped), erythematous patch. This patch classically has a ‘collarette’ of scale just inside the edge of the lesion. A few days later a widespread rash appears across the trunk consisting of multiple small, erythematous, scaly patches (similar but smaller than the herald patch). These lesions are classically distributed across the trunk in a ‘christmas tree’ pattern.

Question 62

What is the management of Pityriasis rosea?

Answer 62

Pityriasis rosea is self-limiting and benign. No treatment is required and it will usually resolve over a few weeks.

Question 63

What is the progesterone only contraception?

Answer 63

Progestogen-only contraception contains only a progestogen (e.g. etonogestrel, levonorgestrel). It can be administered via oral, injectable, implant or intrauterine routes. There are few contraindications to progestogen-only contraception.

Question 64

What is the mechanism of action of progesterone only contraception?

Answer 64

For oral, subdermal, injectable): exerts negative feedback on GnRH output from the hypothalamus. This leads to decreased FSH and LH levels. Reduced FSH prevents follicular development in the ovaries
Prevents ovulation by inhibiting the LH surge
Thickens cervical mucus, making it more difficult for sperm to enter the uterus
Thins the lining of the endometrium, making it more difficult for implantation to take place

Question 65

What are the side effects of progesterone only contraception?

Answer 65

Breast tenderness, enlargement
Headache
Changes to mood and libido
Nausea and vomiting
Irregular menstrual bleeding, spotting, amenorrhoea
Ovarian cysts

Question 66

Types of progestogen-only contraception

Answer 66

Progestogen-only pill (POP) e.g. Desogestrel, Cerelle, Cerazette
Subdermal implant (SDI) e.g. Nexplanon
Contraceptive injection e.g. Depo Provera, Sayana Press
Intrauterine system (IUS) e.g. Mirena, Levosert, Kyleena, Jaydess

Question 67

Suitability of the COCP?

Answer 67

The COCP makes periods regular, lighter and less painful. It is a suitable option for healthy non-smokers up to the age of 50. It can also improve acne for some women.

It can reduce the risk of ovarian, uterus and colon cancer, alongside reducing the risk of fibroids, ovarian cysts and non-cancerous breast disease

It is important to stress to patients that when one stops using the COCP, fertility returns to normal

Question 68

Suitability of the POP?

Answer 68

The POP can be used by women who cannot use oestrogen, such as women who smoke >15 cigarettes a day, whom are over 35 and who experience migraine with aura.

It can also be used by those women who breast-feed.