General Practice/ Progress Flashcards
An 11yo patient presents to GP with a sore throat, they have exudates on their tonsils, no cough and some elevated lymph nodes in the neck. There is no fever. How will you manage?
10 days of PenV
Supportive management
(CENTOR 3 justifies AB’s)
A young female patient presents with fatigue and is diagnosed with IDA. There are no red flags in the history. How should she be managed?
Ferrous sulphate 200mg Given BD (or TDS if they can tolerate)
Treat for 3-6 months
(FBC checked 2-4 weeks after Tx started)
A patient presents with symptoms suggestive of chlamydia, what are the two main antibiotic options?
Azithromycin - Single dose 1g
Doxycycline - 100mg BD for 7 days (CI in pregnancy)
You diagnose a 31year old female with a UTI. She is 20 weeks pregnant, what is the most appropriate management?
Nitrofurantoin 50mg QDS for 7 days
A 27-year-old woman complains of spasmodic pains in the left iliac fossa. These pains have been present for the past six months and sometimes radiate to the back. She often feels bloated, particularly around her period. She describes her bowels as being ‘stubborn’ but does not take a regular laxative. Vaginal and abdominal examination is unremarkable. MLD?
IBS
This woman has the classic ABC features of irritable bowel syndrome: Abdominal pain, Bloating and Change in bowel habit.
A 26-year-old women develops sudden onset right iliac fossa pains whilst playing netball. She is nauseated and has vomited twice. On examination she is tender in the right iliac fossa.MLD?
Ovarian torsion
The pain of appendicitis is unlikely to be of sudden onset.
A patient presents with painful genital ulcerations. Observations are normal. You suspect genital herpes, what is the most appropriate treatment?
Oral aciclovir TDS for 5 days
A 67yoF presents with a 3 weeks history of bilateral, severe and persistent neck pain and shoulders. She reports her neck and shoulders are often stiff in a morning for around an hour. She has pain when she moves her shoulders, and when you move them for her. What is the first investigation you do and what management do you suggest?
1st test: ESR/ CRP
- If raised very likely polymyalgia rheumatica
Management: Prednisolone (15mg for three weeks, then 12.5 for 3 weeks and gradually reduce)- NB also consider bisphosphates and calcium/vitD to protect against steroid
- PMR occurs almost exclusively in over 50’s (mean 73), with about 1 in 1000 affected. F3:1M
A 70yoF presents with numbness and tingling in her palm, thumb, index and middle fingers for over 8 months. She has a weakened grip and you notice some thenar muscle wasting. She reports that pain is worse at night but shaking her hand relieves the pain. What two tests could you do in the clinic to confirm the diagnosis?
Median nerve compression (Carpal tunnel synd)
- Phalens test: Flex wrist for 60 seconds = pain
- Tinels test: Tapping lightly over the median nerve causes parasthesia in distal nerve distribution
Electroneurography (ENG) is used as Gold Standard. Only needed if diagnostic doubt or if pre-surgery
A 30yoF presents with numbness in her palm, thumb, index and middle fingers for over 3 months. She has a weakened grip. She reports that pain is worse at night but shaking her hand relieves the pain. She is positive for Tinels and Phalens tests. How do you manage?
Symptoms likely to resolve in 6months (if young, short duration of symptoms or pregnant)
- Minimise activities which exacerbate symptoms
If symptoms continue work up from NSAIDS > Steroids > Surgery
A 15yoM presents with greasy skin, papules and pustles on his face and back. He has tried keeping his face clean, but now wants something to help get rid of it. Management?
Benzyl peroxide (5%)
- Start using sparingly, can work upto 10%. Can cause burning after application, especially with greasy skin.
Topical erythromycin/ clindamycin, but only use with Benzyl Peroxide, not alone (try to limit to 12 weeks)
ADD Topical Retinoid if no success
A 60yoM presents with burning, itching and tingling across a band on one side of his his chest. He is on long term steroids for lung fibrosis. It’s been going on for 7 days and over the last 3 days skin lesions (vesicles) have appeared and gone crusty. He describes the pain as intense and sharp. He asks what you’re going to do and if he is infective?
Yes- infective until lesions have dried (upto 21 days post onset)
Treatment:
Aciclovir PO 800mg 5x/day for 7-10days
Steroids/ amitriptyline/ gabapentin/ opioids for pain
A 70yoM presents with a red strip all across the width of his chest, he says it is painful and tells you he has shingles, how do you explain to the man that shingles is very unlikely?
Shingles may not affect the whole dermatome but it will not extend outside it. Hence any rash that crosses the midline is not shingles.
A 68yoM patient comes into your surgery complaining of unilateral deafness in his R ear. He has rheumatoid arthritis and also bronchiectasis, which is currently being treated for an exacerbation with clarithromycin. How do you manage his deafness?
Remove the clarithromycin and start on another agent
Macrolides can be ototoxic
A 2yo boy presents with extensive small, red pustules around the mouth for 2 days, starting with one which spread to more. Some have gone honey coloured and crusty. Mum says he has had some fever and vomiting, his temperature is 36.2. MLD and suggested treatment?
Impetigo- Most common skin infection in children
- Swabs may be taken if bad
- Treat with topical fusidic acid TDS 7days (mupirocin if MRSA suspected)
- Add oral fluclox if needed (7days)
- Note very contagious, avoid contact and sharing towels etc
STAPH AUREUS CAUSE
A 19-year-old female starts Microgynon 30 (combined oral contraceptive pill) on day 8 of her cycle. How long will it take before it can be relied upon as a method of contraception?
7 days
- Time until effective (if not first day period):
Instant: IUD (copper coil)
2 days: POP
7 days: COC, injection, implant, IUS (intrauterine system)
A 21yoF is about to be started on the combined oral contraceptive pill. What do you advise about:
a) When the pill becomes effective?
b) When to take the pill?
a) If the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
b) Taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation
A 22yoF was started on microgynon 30 (COC). She has had unprotected sex during the period that she was not taking the pill (i.e in the week off). She wants to know if she was still protected by the pill or not, as she can’t deal with being pregnant right now. How do you manage?
Give advice that intercourse during the pill-free period is only safe if the next pack is started on time
A 21yoF is about to be started on the combined oral contraceptive pill. What do you advise about harmful effects of the pill?
Potential harms and benefits:
- COC is > 99% effective if taken correctly
- Small risk of blood clots
- Very small risk of heart attacks and strokes
- Increased risk of breast cancer and cervical cancer
Name 3 risk factors for varicose veins?
Prolonged standing Obesity Pregnancy FHx COCP
What is the pathology in varicose veins?
Venous hypertension in long and short saphenous veins (superficial venous system)
Causes valve incompetence in the veins
Name 5 possible symptoms of varicose veins
"My legs are ugly" Pain Cramps Tingling Heaviness Restless legs (all syx not much more common than general pop)
What should prompt a referral with varicose veins?
Bleeding Pain Ulceration Thrombophelbitis or severe impact on QoL
Any others should just be managed conservatively
Name 5 pieces of lifestyle advice for someone with varicose veins?
Avoid prolonged standing Elevate legs Compression stockings Weight loss Regular exercise
What are the symptoms of PAD?
Cramping pain in calf, thigh or buttock, worsening on walking and relieved by rest
If pain at rest (burning, need to hand foot out of bed at night), ulceration or gangrene = critical ischemia
What is the classification of PAD?
1- Asymptomatic
2- Intermittent claudication
3- Rest pain
4- Ulceration and gangrene (critical ischemia)
Name 5 signs which may be seen in PAD?
Absent pulses Pallor Cold Atrophic skin Postural dependant colour change (Buergers angle)
How do you investigate PAD?
If <50: Exclude diabetes, arteritis (CRP/ESR), coagulation disorders, do FBC, U+E etc.
Otherwise do ABPI
- Normal = 1-1.2
- PAD = 0.9-0.5
- Critical ischemia = <0.5
If ABPI shows PAD then do colour US, only do MR/CT angiography if considering intervention
How should PAD be managed?
Conservative - Modify CVS risk factors, encourage exercise to point of maximal pain (improve collateral circulation)
Refer to vascular surgeons for intervention
What are the signs of critical limb ischemia?
Pulseless Pale Pain Perishing cold Paraesthesia Paralysed
(Tx with immediate open surgery or angioplasty)
Suspected gastroenteritis which is associated with bloody diarrhoea should be treated with which antibiotic?
Ciprofloxacin
What is the most common and important viral infection for those with previous solid organ transplants?
Cytomegalovirus
What is fitz-hugh-curtis syndrome?
Complication of PID where liver capsule becomes inflammed = RUQ pain
Cow’s milk protein allergy is to what protein?
Casein
What are some of the key features of SCC vs. BCC?
SCC: Small, ulcerating, also face but can be hands/ feet/ genitals, fast growing
BCC: Mainly head and neck, pearly appearance, ulcer in the middle may give rolled edges, telangiectasia, slow growing
What is the name for when a genetic disorder presents earlier and earlier through generations?
Anticipation
What is the albumin: creatinine ratio used for?
ACR is used to detect kidney disease due to diabetes or HTN (annual screening for diabetics)
- Treat early stage disease with ACEI
Give three examples of Type I hypersensitivity?
Allergic asthma
Allergic rhinitis
Anaphylaxis
Angioedma
What 4 drugs are first-line options for neuropathic pain?
Amitriptyline, duloxetine, gabapentin or pregabalin
What is first line test when suspecting hepatitis C?
Anti-HCV
then do HCV-RNA afterwards if positive
What is the triad/ classic presentation of HUS?
Haemolysis
Acute renal failure
Thrombocytopenia
(Young child, classically following diarrhoeal illness)
What medication is contraindicated with cold-sore?
Steroids
Steroids can cause immunosupression and therefore make it more likely for herpes simplex virus’ to reoccur
4 month old with systolic murmur at mid/upper left sternal edge = ?
Tetralogy of Fallot
How does syphillis present and what is the causative organism?
Painless, indurated ulcer
- Caused by Treponema pallidum
A man has suffered from a chest infection for two weeks, for which he was commenced on antibiotic therapy. Later he develops sinusitis and facial pain, what is the causative organism?
Strep pneumoniae
Commonly linked with sinusitis and a common pneumonia cause
A 20 years old man with Type 1 Diabetes Mellitus. Glycaemic control is getting worse and his GP is getting worry about his compliance with diet and medication. What is the best method to improve his compliance in a short consultation?
Motivational interview
How do you calculate positive predictive value?
Number of true positives / all positives
Women recently diagnosed with cancer. Goes to receive chemotherapy and feels nauseas every time. On a recent admission had to be admitted due to its severity. What theory of learning explains this?
Classical conditioning
- Biologically potent stimulus (chemo) becomes paired with previously neural stimulus (going to the clinic).
What is the difference between approach coping and avoidant coping?
Approach = Do stuff to tackle problem directly Avoidance = Distancing yourself from the problem
A 9 year old girl with known sickle cell disease presents with right hypochondrium pain. What is it?
Cholecystitis
Sickle cell can make gallstones more common
You investigate a 17 year old girl with low weight for secondary amenorrhoea. She has a low FSH and LH, with a normal prolactin. What is the site of the abnormality?
Hypothalamus
- Low FSH and LH in secondary menorrhoea suggests constiturional delay (if primary) or hypothalamus dysfunction (due to stress, anorexia or excessive exercise).
How does premature ovarian failure present?
High FSH and LH in woman under 40 presenting with secondary ammenorrhoea
A 76 year old was started on medication by his GP following beliefs that his neighbours were
spying on him and were listening in on his telephone conversations. His partner brings him to A&E
reporting that he has been confused and dizzy lately and that he faints on standing up from a sitting
position. What is the receptor most likely affected by the medication responsible for his symptoms?
Alpha-1 adrenoceptor
Anti-pyschotics cause significant anti alpha-adrenergic effects
A 45 year old woman suffering from rheumatoid arthritis presents to the GP with increasingly dry
mouth. Upon further investigation large masses are found on the sides of her face and the GP
thought it was parotid. What is this condition?
Sjögren’s Syndrome
can cause swelling of parotid
A 35 year old man presents with a headache, fever , photophobia. The sample shows a diplococci
gram negative organism. What is the causative organism?
Neisseria meningitidis (is gram -ve diplococci)
- E.coli is gram -ve rod
- H.Influenzae is gram -ve coccobaccilus
- Strep pneumonia is gram +ve diploccoi
Which lobe is affected first in Alzheimer?
Temporal
53 old man can’t be resuscitated. The man is of African descent. On autopsy it is found he had a massive inter peritoneal haemorrhage due to the liver bursting through the liver capsule. A 7cm mass is noticed witch yellow-green edges and a necrotic centre. Splenomegaly is also seen. What was the underlying pathogenesis?
Amoebic liver abscess
A Lady has watery diarrhoea. This has appeared after eating cold meats and salad at church the day before. What was the most likely infecting organism?
Salmonella
- A Swimmer presents with discolouration of the left 3 toe nails. What is this?
Onychomycosis, also known as tinea unguium, is a fungal infection of the nail. Symptoms may include white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed.
How do phosphodiesterase inhibitors work?
Accumulation of cGMP
A 15 year old female presents with bleeding after tampon insertion. Ultrasound shows two vaginas, each had a cervix. The doctor explained that this was due to the failed fusion of a certain structure. Which structure was she referring to?
Mullerian ducts
What features on histology suggest carcinoma?
Nuclear enlargement, hyperchromasia and pleomorphism are features that suggest carcinoma in all sites of the body.
For epistaxis when would you anterior packing and when would you cauterise?
Easy to visualise bleed = Cautery
Heavy bleed or hard to visualise = Ant pack
Painful perianal ulcer + lymphadenopathy in MSM?
Lymphogranuloma venereum
Which artery is most likely to bleed with duodenal ulcers?
Gastroduodenal artery
What are the data interpretation findings of PCOS?
Increased ratio of LH:FSH along with oligomenorrhoea and BMI in the overweight range indicates PCOS is most likely. A mild elevation in prolactin is sometimes seen in PCOS.
End of life terminal restlessness should be managed with?
Midazolam
Major abdominal surgery with severe resp disease, what should be avoided in terms of analgesia and what should be used instead?
Avoid opiates
Give epidural instead
Bilateral reticular opacities in both lung bases suggests what diagnosis? What is the next investigation?
Pulmonary fibrosis
- Do high resolution CT
(Doesn’t necessarily need clubbing)
First investigation when suspecting PSC?
MRCP
Patient with sudden onset headache. What does ADPKD increase the risk of?
Sub-archnoid haemorrhage
Patient with poor renal function preparing for contrast CT, best way to manage?
Fluids (volume expansion is protective)
- Avoid diuretics which can be harmful
Rhabdomyolysis will give a CK of what?
> 10,000
What test is used to look for CO in the blood?
Carboxyhaemoglobin
Patients with unprovoked DVT should be offered what?
CT abdo/ pelvis to look for malignancy
An 18 year old woman has had a chronic skin condition for several years. She has noticed that she gets well-defined areas of scale formation at the sites of minor skin injuries, such as scratches or insect bites, typically when the injuries are healing. The scaling can persist for several weeks or months. MLD?
Psoriasis
What is Boerhaave syndrome?
Oesophageal rupture due to vomitting
- Severe chest pain following vomit with surgical emphysema of neck
What is first line treatment for pituitary prolactinoma?
Cabergoline
A 78 year old man has type 2 diabetes. His clinician does not invite him to join an internet-based self-monitoring programme because she considers him to be too old to engage with it effectively. What is being demonstrated here?
Discrimination is the unjust or prejudicial treatment of different categories of people
Name three of the malaria parasites?
Plasmodium falciparum - Most severe (think if CNS involved) and most common
Plasmodium vivax - Second most common
Plasmodium malariae/ plasmodium ovale/ plasmodium knowlesi
How do you distinguish between epididymal cyst and hydrocele?
Epididymal - Seperate lump
Hydrocele - Surrounds testes
(both transilluminate)
What is recommended maintainance fluid for someone with cardiac disease?
Maintenance fluid requirements for someone with underlying cardiac disease is recommended as 20-25 mL/kg
For 70kg patient this is 1750ml/ 24hrs
What test is used to monitor respiratory function in myasthenia gravis?
FVC
Remember MG is restrictive
What is the most common pathogen in cellulitis (including diabetics)?
Streptococcus pyogenes
What is first line treatment for superficial thrombophlebitis?
NSAIDS
A 64 year old woman is due to undergo an arthroscopy of her knee. She has type 2 diabetes and takes metformin (500 mg twice daily) and gliclazide (80 mg each morning). Her glycated haemoglobin is 54 mmol/mol (20–42). She is scheduled first on the morning day case list and is asked to fast from midnight the previous night. How should her diabetic meds be managed?
Omit gliclazide and continue metformin
Principles are to minimise fasting times (hence first on list) and disruption to usual medication. In this setting where the procedure is fairly minor, patient should be eating again at lunchtime and hence there is no call for insulin in any form.
Ovarian cancer most commonly metastasise to which nodes?
Para-aortic nodes
What is standard first line treatment of SVC obstruction secondary to lung ca?
IV dextamethosone
Patient with heavy bleed, INR of 9.6, vit K already given. What else given?
Prothrombin complex concentrate is used to reverse warfarin in medical emergencies. It is quicker to administer than FFP and can reverse anti-coagulation within minutes. FFP also carries the risk of allergic reactions, transfusion-related lung injury and volume overload. PCC is therefore considered first-line to reverse warfarin.
First line investigation for nephrotic syndrome in adults?
Renal biopsy
What cancer is most likely to release PTH?
Squamous cell carcinoma
What hormones are released by small cell cancers?
ACTH
ADH
What is daily recommended fluid replacement for a patient with no co-morbidites?
25-30ml/kg/day of fluid
1mmol/kg/day of Na/ Cl/ K
50-100g/day of glucose
70kg = 2100mls
1st ix for pyloric stenosis?
USS
What muscles attach to lateral epicondyle?
Wrist extensors
What pre-pregnancy folic acid?
5mg if high risk
400mcg otherwise
What area of body affected in DMD?
Striated muscle
What protein is deposited in the brain in alzhiemers?
B-amyloid
1st thing for severe hyperkalaemia?
Calcium gluconate
How do you treat gram +ve cocci?
Amoxicillin
Skin keratosis on scalp leads to which cancer?
SCC
Internally rotated and shortened leg = ?
Posterior hip dislocation
High Na in patient on lithium?
Diabetes insipidus
Wide mediastinum + low BP = ?
Aortic dissection
Best advice for benign intercranial hypertension management?
Lose weight
C.diff treatment?
Metronidazole
Dilated pupils and a ‘trip’ = which drug?
Cocaine
What is the defintion of when labour has started (phase one)?
Cervix at 3cm
Where do you place a chest drain?
5th ICS
Mid-axillary line
Patient was lifting heavy objects at work and showed a positive SLR. Cause?
Disc prolapse
Patient had eaten food and within 15 mins had severe abdominal pain. Had a history of AF. Examination = tender all over. Bowel sounds were present. What is the most likely diagnosis?
Mesenteric ischemia
When should neonates recieve glucose?
High risk mums (using insulin during preg)
Ill child
Glucose <2.75
Otherwise encourage early formula feeding
A patient has carcinoma of the sigmoid, undergoes resection. After surgery they experience abdominal pain, which anastomoses are most likely to be affected?
Inferior mesenteric
A 28 year old woman has presented for her 36 week check. On the USS, there is a possibility of oesophageal atresia. What is the finding on the scan that would best indicate this?
Polyhydramnious
