General Practice (Quesmed) Flashcards

Question 1

Q

What is the ABCDE approach to assessing Malignant Melanomas?

Answer

A

Asymmetry
Border Irregularity (Melanomas have Scalloped Borders)
Colour Variation (Variegated= many colours)
Diameter> 6mm
Evolves over time

Question 2

Q

What are the 4 types of Melanoma?

Answer

A

Superficial Spreading- Most common type- Horizontally first and then Vertically
- Different colours within the lesion
- Flat or slightly raised

Nodular Melanoma- Grows Vertically. Very Aggressive
- usually Black but also Pink, Red, Brown
- Dome shaped or raised

Lentigo Maligna Melanoma- Arises from Lentigo Maligna
- Flat
- Tan or Brown

Acral Lentiginous Melanoma- Palms/ Soles and Under Nails
- Looks like a Bruise
- More common in Dark Skin
- Under nails, palms and soles

Question 3

Q

What is Breslow Thickness?

Answer

A

It is the thickness of a Melanoma

If >1mm- a Sentinel Node Biopsy should be taken and evidences of Metastasis should be looked for

Question 4

Q

What is the management of a Melanoma according to the stage?

Answer

A

Excision of the melanoma

Stage 0- 0.5 cm around the melanoma
Stage 1- 1cm
Stage 2- 2cm

Stage 3 and 4 are metastatic so give Chemotherapy or Immunotherapy

Question 5

Q

What are the 4 signs of Acute Tonsillitis?

Answer

A

Sore Throat
Headache
Pyrexia
Lymphadenopathy

Question 6

Q

What are the 4 main complications of Tonsillitis?

Remember King Julien the Lemur

Answer

A

Recurrent Tonsillitis

Retropharyngeal Abscess- more common in young children- stiff, extended neck and refusal to eat

Peritonsillar Abscess (Quinsy)- (Throat is tight and painful cos of the abscess) Sore throat, Dysphagia, Peritonsillar bulge, Uvular deviation, Trismus (tightening of jaw muscles) and Muffled Voice

Lemierre’s Syndrome- Inflammation leads to Pharyngotonsillitis and leads inflammation within the Internal Jugular Vein and Septic Emboli. Give them High Dose Benzylpenicillin and Debridement

Looks like Meningitis following a Sore Throat

Question 7

Q

What is the recommended Alcohol weekly intake?

Answer

A

14 units per week

Work out number of units= [Strength (ABV) x Volume (ml)] / 1,000

OR just Strength x Volume (litres)

Question 8

Q

What is the pathophysiology of Asthma?

Answer

A

It is a Type 1 Hypersensitivity Reaction

It is associated with a family history of Atopy (The Atopic Triad are Asthma, Atopic Eczema and Allergic Rhinitis)

TH2 Helper T Cells produce Cytokines such as:
- IL4 which facilitates class switching to IgE
- IL5 which facilitates release of Eosinophils
- IL13 which stimulates mucus production

Question 9

Q

What are the signs and symptoms of Asthma?

When are symptoms worse and when does the cough happen usually?

What are the 2 HYPERS?

Answer

A

Wheeze and Dyspnoea and (Nocturnal) Cough

Symptoms Worse in the Morning

Hyperinflated Chest

Hyperresonance on Chest Percussion

Wheeze on Auscultation

Question 10

Q

Which 3 investigations should be ordered more urgently in an acute Asthma Attack?

2 Bloods and 1 Chest

Answer

A

ABG- Type 2 Respiratory Failure (Low PaO2 and High PaCO2) is a sign of LIFE THREATENING ASTHMA

Routine Bloods- to look for a cause of the asthma (an infection)

Chest Xray- to exclude differentials and identify an infection

Question 11

Q

What is the management of Chronic Asthma (Not an Attack)?

Answer

A

Smoking Cessation/ Avoid Precipitants/ Review Inhaler Technique

Step 1- SABA (Salbutamol)
Step 2- add low dose inhaled ICS (<400)

Step 3- Add LTRA

Step 4- Add LABA

Step 4- Swap LABA and Low Dose ICS for MART (which is basically just low dose ICS and LABA)

Step 5- Then make it MEDIUM DOSE ICS (400-800) instead

Question 12

Q

What are the 3 main Asthma Mimics?

Which of these is associated with pANCA?
What is the management of each of these?

(Acid, Autoimmune, Fungus)

Answer

A

Acid Reflux-
- Risk Factors= Obesity, Smoking, CCBs, Alcohol
- Management- Antacids or Alginates + PPIs (Omeprazole) + H2 Blockers (Ranitidine)

Churg-Strauss Syndrome-
- Granulomatous Vasculitis associated with Asthma and Eosinophilia
- Conditions associated with this= Sinusitis, Asthma, Purpura and Peripheral Neuropathy
- pANCA positive and High IgE
- Management- Steroids and Immunological Agents (Rituximab)

Allergic Bronchopulmonary Aspergillosis (ABPA)-
- Type 1 and 3 hypersensitivity reaction to Aspergillus Fumigatus
- Symptoms= Wheeze, Dyspnoea, Sputum Production
- They IMMEDIATELY react to Aspergillus Fumigatus on the skin
- High IgE may also be there
- Management- Prednisolone in Acute. Itraconazole added to treatment regimes. Bronchodilators for Asthma Symptoms

Question 13

Q

What is Atopic Dermatitis?

Answer

A

Dry Skin and Itchy Poorly Demarcated Areas
Usually cheeks in Infants and insides of elbows and needs in Children and Adults

Question 14

Q

How is Atopic Dermatitis diagnosed?

Managed with Emollients and Topical Corticosteroids

Answer

A

Itchy Skin + 3 of the following

Flexural eczema (or cheeks/ extensors if <1.5 years)
History of Flexural eczema (or cheeks/ extensors if <1.5 years)
History of Dry Skin
History of Asthma or Allergic Rhinitis
Onset < 2 years old

Question 15

Q

What are the 4 complications of Eczema?

Answer

A

Eczema Herpeticum- Caused by Disseminated HSV infection due to Impaired Skin protection. It results in a PROGRESSIVE, PAINFUL MONOMORPHIC VESICULAR RASH which can ulcer and crust. IV Acyclovir needed to treat

Superficial Bacterial Infection- Staph or Strep

Erythroedema- Erythema affecting >90% of the skin surface. Results in Heat and Fluid Loss

Side effects of Corticosteroids= Skin Thinning, Striae, Telangiectasia

Question 16

Q

What is Bell’s Palsy and what are the signs?

Which nerve is affected and what are the symptoms?

(Ear, Ear, Eye/ Mouth)

Answer

A

It is an Idiopathic Syndrome affecting the Facial Nerve

Signs
- Acute Onset (not sudden) Unilateral Lower Motor Neuron Facial Weakness- sparing the Extraocular Muscles and Muscles of Mastication. It does NOT SPARE THE FOREHEAD

PostAuricular Otalgia (which may precede paralysis)
Hyperacusis (sensitive to sounds)
Nervus Intermedius symptoms (altered taste and dry eyes/ mouth)

Question 17

Q

What is the management of Bell’s Palsy? What is Ramsay Hunt Syndrome?

Answer

A

50mg OM (Cortico)Steroids for 10 days followed by a taper- Acyclovir if viral cause- Ramsay Hunt

Artificial tears and ocular lubricants help with the dry eyes

It is difficult to Distinguish Bell’s Palsy from Ramsay Hunt Syndrome (also facial weakness, otalgia, Vesicular rash in the auditory meatus, palate or tongue)

But Ramsay Hunt is caused by VARICELLA ZOSTER and there will be a VESICULAR RASH around the EAR

Question 18

Q

What are the signs of Cellulitis? It is usually caused by Streptococcus or Staphylococcus

Is there fever and is there lymphadenopathy?

Answer

A

Erythema, Calor, Pain, Swelling

Poorly demarcated regions
Systemic Upset (fever, malaise)
Lymphadenopathy
Evidence of skin breach (trauma, ulcer etc.)

Question 19

Q

What is the management of Cellulitis?

Which antibiotic is typically given?

Answer

A

(Find out what it is and give the antibiotics then elevate and debride)

Blood tests and Culture
Skin Swab and Culture

Oral or IV Antibiotics depending on the Severity
- Usually Flucoxacillin, otherwise give MACROLIDES
Mark the area of Erythema to identify whether it is rapidly spreading
ELEVATE if possible
Wound Debridement may be needed

Question 20

Q

What are the signs of Chronic Sinusitis?

What does it usually follow?

Answer

A

Sinusitis follows an Upper Resp Tract Infection

Tenderness and pain in Cheeks, Eyes, Forehead

Usually Bilateral Pain, Intense

Nose is Bilaterally Blocked

There may be Purulent Discharge

Pain is worse when sitting forward

Question 21

Q

What are the 7 differential diagnoses for Sinusitis?

My Terrible Neck Causes Terrible Vascular Headaches

Answer

A

Migraine
TMJ Dysfunction
Neuralgia
Cervical Spine Disease
Temporal Arteritis
Vasculitis (Granulomatosis with Polyangiitis)
Herpes Zoster

Question 22

Q

What are the 2 red flags for Chronic Sinusitis?

Answer

A

If the nose block is UNILATERAL (Unilateral Nasal Polyps are a red flag for Nasopharyngeal Carcinoma so REFER ASAP (2WW))

If there is UNILATERAL nose BLEEDING

Question 23

Q

What are the signs of Sialadenitis (Salivary Gland infection)?

STAPHYLOCOCCUS AUREUS INFECTION

How is it managed?

Is there a fever?
Is there lymphadenopathy?

Answer

A

Severe, Unilateral Tenderness and Pain in mouth with Fever (Over Parotid Gland if it infects the Parotid Gland)

There may also be PURULENT DISCHARGE

Submandibular Swelling and Lymphadenopathy

Manage with BROAD SPECTRUM ANTIBIOTICS and Supportive care

Question 24

Q

What are the signs of COPD?

What is the percussion like?

Also remember CORPULMONALE and PERIPHERAL OEDEMA

Answer

A

PRODUCTIVE Cough for at least 3 MONTHS in 2 Consecutive Years
Wheeze
Dyspnoea
Reduced Exercise Tolerance
Tachypnoea

Hyperinflation
Cyanosis
Reduced Chest Expansion
Decreased Breath Sounds
COR PULMONALE and therefore PERIPHERAL OEDEMA
Hyperresonant Percussion
REDUCED CRICOSTERNAL DISTANCE

Question 25

Q

What investigations should be ordered in COPD?

What is the FEV1? and what is the severity?

What is seen in the FBC? What blood condition?

What is the ECG of COPD? (2 things- 2 hypertrophies)

What blood disease is looked for in COPD?

What is seen in the Chest Xray? (4 signs)

Answer

A

Spirometry- FEV1 <80% of predicted/ FEV1/FVC< 0.7
- Mild= FEV1 >/= 80%
- Moderate= FEV1 50-79% of Predicted
- Severe= FEV1 30-49% of Predicted
- Very Severe= FEV1 <30% of Predicted

Bloods-
- FBC (raised PCV= Polycythaemia), ABG (reduced PaO2 +/- raised PaCO2 or Type 2 Resp Failure)
- ECG- P Pulmonale (right atrial hypertrophy) and right ventricular hypertrophy if there is Cor Pulmonale

CXR-
- Hyperinflated Chest (> 6 anterior ribs)
- Bullae
- Decreased Peripheral Vascular Markings
- Flattened Hemidiaphragm

Question 26

Q

What is the management of Chronic COPD?

What vaccinations are offered?

What is done if there are asthma signs?

Answer

A

Stop Smoking First
Offer Pneumococcal and Influenza Vaccinations
If needed- offer Pulmonary Rehab

THEN start the inhaled treatment

1) SABA or SAMA

Still breathless?

2) LABA and LAMA if No Asthma Signs

3) LABA + ICS If Asthma Signs (Add on LAMA for a 3 month trial if this isn’t enough)

If still isn’t enough

4) Specialist Referral

Question 27

Q

What are the indications for Long Term Oxygen Therapy in COPD? (ONLY if they do NOT SMOKE) (keeping O2 above 8kPa for at least 15 hours a day)

Answer

A

PaO2<7.3kPa on 2 readings more than 3 weeks apart and are Non Smokers

Or

PaO2 of 7.3-8kPa alongside Nocturnal Hypoxia, Polycythaemia, Peripheral Oedema and Pulmonary Hypertension

Question 28

Q

What are the indications for Surgery in COPD?

2 of them are >20% remember that

Answer

A

If given maximum therapy then Lung Reduction Surgery if

1) Emphysema is mainly Upper Lobe
2) FEV1>20% of Predicted
3) PaCO2< 7.3kPa
4) TICO>20% of Predicted

Question 29

Q

What is the mechanism of action of the Combined Oral Contraceptive?

It is the preferred contraception for PCOS

Answer

A

(Thickens Mucus and Thins Endometrium)

It thickens the Cervical Mucus so it is more difficult for sperm to enter the uterus

It thins the Lining of the Endometrium, making it more difficult for Implantation to take place

It inhibits Ovulation

It contains an Oestrogen (-estradiol) and a Progestogen (-gestrel)

Question 30

Q

What are the 12 main contraindications to Combined Oral Contraceptive?

Answer

A

BRAVIC BLIC 35/15/160

<6 weeks post partum and breast feeding
<3 weeks post partum and other risk factors for VTE
Atrial Fibrillation
Vascular Disease
Ischaemic Heart Disease
History of VTE/ Cerebrovascular Disease (even TIA)
Current Breast Cancer
Liver Adenoma/ Carcinoma/ Cirrhosis
Major Surgery with Prolonged Immobilisation
Complicated- Pulmonary Hypertension, History of Subacute Bacterial Endocarditis
> 35 years old and >15 cigarettes
Blood pressure >160/100

Question 31

Q

What are the 3 types of Combined Oral Contraception?

Answer

A

Monophasic- each pill contains the same amount of hormone (21 days then 7 days without pills)

Phasic- each pill contains different amounts of hormone and must be taken in the right order (Varying levels of hormones to mimic the Menstrual Cycle better)

Every day pills- Contain 21 hormone-containing pills and 7 hormone-free pills

Question 32

Q

What are the 8 side effects of Combined Oral Contraception?

Answer

A

Breast Tenderness/ Enlargement

VTE

//////////////////

Headache

Nausea and Vomiting

//////////////////////

Changes to Mood and Libido

/////////////////////

Irregular Menstrual Bleeding, Spotting, Amenorrhoea

Ovarian Cysts

Lower risk of Ovarian and Endometrial Cancer and Higher risk of Breast and Cervical Cancer (Lower risk of Vowels and Higher risk of constanants)

Question 33

Q

What are the 4 regimes of combined Oral Contraception?

How long is the HFI for Flexible use?

Answer

A

Traditional- One pill per day/ One patch per week/ One Vaginal Ring for 3 weeks, followed by 7 days of being Hormone Free. 3 weeks then HFI

Extended Use- They “tricycle” rather than having a Hormone Free Interval (HFI) after 3 weeks. This is done for 9 weeks and THEN they have a HFI

Continuous use- No HFI

Flexible Extended Use- They keep using until there is bleeding, then they have a 4 day HFI

Question 34

Q

What are 3 points about when to start Combined Oral Contraception?

How long should they use condoms for?

How long should mothers wait to take the pill after giving birth?

Answer

A

If the patient starts on the first day of a natural period, they will be protected from pregnancy immediately

If they start at any other time in their cycle, they will need to use precautions for 7 days- same as HFI

New mothers can take the pill 3 weeks after they give birth as long as they are NOT breastfeeding

Question 35

Q

What are the side effects of the Progesterone Only Pill?

Answer

A

(rule of 1/3rds)

1/3 stop having periods

1/3 continue

1/3 experience irregular bleeding- irregular bleeding, light bleeds between periods, bleeding throughout the cycle (spotting)

Question 36

Q

What are examples of the possible Hormonal Contraception options?

Answer

A

Combined hormonal contraception (CHC)- Pill/ Patch/ Ring

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

2) Combined hormonal contraceptive patch e.g. Evra

3) Combined hormonal contraceptive ring e.g. Nuvaring

////////////////

Progestogen-only contraception- Pill/ Implant/ Intrauterine/ Injection

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

2) Subdermal implant (SDI) e.g. Nexplanon

3) Contraceptive injection e.g. Depo, Sayana Press

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

//////////////

Emergency contraception e.g. Ulipristal acetate (EllaOne), Levonorgestrel

Question 37

Q

What are the examples of the possible Non-hormonal Contraception options?

Answer

A

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 38

Q

How does the Subdermal Contraceptive Implant (Nexplanon) work and what are its features?

How long does it work for?
What are the side effects (periods and acne)?

Answer

A

It releases Progestogen which interferes with Ovulation, Thickens the Cervical Mucus and Thins the Lining of the Uterus

It is the MOST EFFECTIVE Contraceptive Option

It works for 3 years but can be taken out sooner. When removed, fertility returns to normal
It does not require daily administration/ adherence to a Medication Regimen
Periods may stop, become irregular or last longer. Acne may occur or worsen
A small procedure with a Local Anaesthetic is needed to fit and remove the implant and their may be tenderness, bruising or swelling at the site of insertion

Question 39

Q

What 6 things should be done when confirming a Death?

Answer

A

Confirm the patient’s identity

Check for obvious Signs of Life

Check for response to Verbal and Painful stimuli

Assess the pupils (Afferent Pupillary Defect)- they should be Fixed and Dilated

Feel a Central Pulse (Carotid, not Radial)

Listen for Heart and Respiratory sounds for 5 minutes

Question 40

Q

What are the 9 factors of Depression according to DSM-5? (5 needed every day for at least 2 weeks or longer)

Answer

A

Depressed mood or irritable every day
Anhedonia
Significant Weight change (5%) or Change in Appetite
Change in Sleep
Change in Activity
Fatigue
Guilt/ Worthiness
Concentration is Worse
Suicidality

Question 41

Q

What drugs can often cause Low Mood?

Answer

A

Steroids

Isotretinoin (Roaccutane)

Alcohol

Beta-blockers

Benzodiazepines

Methyldopa

Question 42

Q

What is the Initial Management of Depression?

Answer

A

Low Intensity Psychological Interventions or Group-based CBT

Then move on to Pharmacological Therapy (SSRI) or a High Intensity Psychological Intervention like CBT or Interpersonal Therapy

If they have moderate or severe Depressive episodes then medications can be given with the Psychological Therapy

Continue Antidepressants for at least 6 months until after symptoms have stopped and wean off them over 4 weeks

Question 43

Q

If a patient presents with a Red Eye, what 3 things should immediately be ruled out?

Answer

A

Acute Angle-Closure Glaucoma

Anterior Uveitis

Scleritis

Question 44

Q

What 3 questions should be asked when assessing a Red Eye?

Answer

A

Is it Painful?

Is Acuity Affected?

Are the Pupil Reflexes Affected?

Question 45

Q

What are the signs of Closed Angle Glaucoma?

Answer

A

Patients are usually SYSTEMICALLY unwell with Nausea and Headaches

In some, there is severe Ocular Pain with Blurred Vision and Haloes around Lights

The Pupil is typically in a FIXED DILATED position

This is an EMERGENCY so refer to Ophthalmology asap

Question 46

Q

What are the signs of Anterior Uveitis?

Answer

A

Red Eye, Blurred Vision and PHOTOPHOBIA

There is also INCREASED LACRIMATION from the affected eye

The pupil may be Irregular due to Adhesions between the lens and the iris (Synechiae)

Conjunctival Injection is typically concentrated around the Junction of the Cornea but may not always be the case in practice

Question 47

Q

What are the signs of Scleritis and Episcleritis?

When are the Scleritis symptoms worst?

Give topical NSAID if Episcleritis

Answer

A

Scleritis-
- Inflammation of the Sclera
- Patients complain of SEVERE pain on the orbit and pain on EYE MOVEMENT
- There is Photophobia
- Pain is WORSE AT NIGHT
- In Severe Scleritis- The White of the Eye may have a Blueish Tinge
- Half of patients are systemically unwell with associated Rheumatological Conditions such as Rheumatoid Arthritis or Granulomatosis with Polyangiitis- so look for SYSTEMIC SYMPTOMS

Episcleritis
- Inflammation of the Episclera (layer Underneath Conjunctiva)
-There is also TENDERNESS over the inflamed area
- It usually resolves in 6-8 weeks on its own

Differences between Scleritis and Episcleritis-
- Episcleritis- Pain is mild/ Scleritis- Pain is severe
- Scleral Vessels do not Move on Blanch when pressed with a cotton bud, but Episcleral Vessels do

Question 48

Q

What are the signs of Conjunctivitis?

What is the management?

Answer

A

Can be Allergic, Viral, Bacterial

Itchy, Irritated RED Eyes that Lacrimate a Lot
Patients often report Eyelids Sticking together
Visual Acuity and Pupillary Reflexes are in tact

/////////////////////

Give CHLORAMPHENICOL if bacterial

LUBRICATING GEL if viral

Question 49

Q

What are the signs of a Subconjunctival Haemorrhage

Answer

A

Red Eye

Haemorrhage between Conjunctiva and Sclera
Common causes= Coughing, Sneezing and Eye trauma but ask about Warfarin and check their Blood Pressure

Patients can be Reassured and Discharged

Question 50

Q

What is the Pathophysiology of Meniere’s Disease? How long does the Vertigo last?

Answer

A

It is the Dilatation of the Endolymphatic Spaces of the Membranous Labyrinth

This causes Vertigo which lasts 12-24 hours

Question 51

Q

What are the signs of Meniere’s Disease?

Answer

A

It usually only affects one ear- first producing symptoms between 30-60 years of age

It involves episodes of Sudden Paroxysmal Vertigo as well as Deafness and Tinnitus

These episodes occur in Clusters with periods of Remission between them where function is back to normal

The patient is often Bed Bound and suffering from Nausea and Vomiting with a Fluctuating Hearing

Question 52

Q

What is the management of Meniere’s Disease?

Answer

A

Betahistine is given as Prophylaxis to prevent the attacks from happening as often

Prochlorperazine is given for Acute Attacks

Surgery does not help according to literature

Question 53

Q

What are the 7 causes of Lower GI Bleeding?

Answer

A

Vascular Causes- Angiodysplasia and Ischaemic Colitis

Inflammatory causes- IBD

Infective causes- Infectious Colitis

Neoplastic causes- Colorectal Cancer and Anal Cancer

Anatomical Causes- Haemorrhoids, Anal Fissures, Meckel’s Diverticulum, Diverticular Disease, Colonic Polyps

Upper GI Bleeding can cause Lower GI Bleeding due to Rapid Transit

Endometriosis

Question 54

Q

What causes Raynaud’s Phenomenon?

5 causes

Answer

A

Caused by the Vasospasm of Small Arteries and Arterioles that decrease blood flow to the skin

It can occur on its own or due to other conditions like Systemic Sclerosis, SLE, Sjogren’s, Thrombocytosis and Polycythaemia Rubra Vera

Question 55

Q

What is Raynaud’s Phenomenon?

Answer

A

It is the Cold-induced Color Change of the fingertips

White-blue-red

And this colour change is WELL DEMARCATED

Question 56

Q

What is the management of Raynaud’s Phenomenon?

Answer

A

Dihydropyridine Calcium Channel Blockers

Other options are ACE Inhibitors and IV Prostacyclin

In extreme cases- Nerve block or Digital Amputation

Question 57

Q

How do you approach Smoking Cessation?

Answer

A

Refer Patients to Smoking Cessation Services for Behavioural Therapies and Medication

If they don’t wish to attend, then Medications can be offered

Question 58

Q

What is Nicotine Replacement Therapy?

What are the contraindications?

What are the 4 side effects?
NPDD

Answer

A

Nicotine Replacement Therapy-

Oral and Patches can be used up to 8 weeks
Works by reducing Cravings caused by Nicotine Withdrawals
Should be started on the Quit Day
Do not use this with Varenicline, Bupropion or if they have a Severe Cardiovascular Disease
Side Effects= Nausea, Dizziness, Vivid Dreams and Palpitations

Question 59

Q

What is Bupropion?

What are the 2 side effects?

Answer

A

It inhibits Dopamine, Serotonin and Noradrenaline reuptake
It is taken as an Oral Medication and should be started 1-2 weeks before quitting

It is contraindicated in WECEP-
- Withdrawal (Benzodiazepine or Alcohol)
- Epilepsy
- CNS Tumours
- Eating Disorders and Bipolar
- Pregnancy and Breastfeeding

-Side effects= Seizures and Severe Hypersensitivity (this is rare)

Question 60

Q

What is Varenicline (Champix)?

3
- N and D from the NPDD
- Also SUICIDAL THOUGHTs

Answer

A

It is a partial nAChR Agonist
It is taken orally and taken 1-2 weeks before the Quit Date
It is Contraindicated in Pregnancy
Side effects= Suicidal Thoughts/ Behaviours, Nausea and Abnormal Dreams

Question 61

Q

How do you work out Pack-Years for Smoking?

Answer

A

1 pack year is 20 cigarettes per day per year

so 30 per day for 1 year is 1.5 Pack years
and 30 per day for 2 years is 3 Pack years

Question 62

Q

What is EllaOne? (Ulipristal Acetate)

What type of Pill is it?

How soon after UPSI can it be used?

What are the 2 contraindications?

For how long must breast feeding be avoided?

What are the 3 side effects?

For how long must Hormonal Contraception be stopped for

What makes the pill less effective?

What must be done if they vomit 3 hours after taking the pill?

Answer

A

It is an ORAL Progesterone Receptor Modulator that Inhibits/ Delays Ovulation

You can use it within 5 days of Unprotected Sex. It does NOT harm an ongoing pregnancy if there is a chance the patient may be pregnant

//////////////////////////////////////////////////////////////

Don’t use if: 1) Severe Asthma controlled by Steroids, 2) Severe Liver Impairment

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Breast Feeding must be avoided for ONE WEEK after taking the medication

Common Side Effects= Headache, Nausea, Dysmenorrhoea

The next menstrual period may start Early or Late

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Do NOT use Hormonal Contraception for 5 days following administration of UPA

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It may be less effective if a woman is taking an (CP450) Enzyme Inducer or has taken a Progestogen (Think a Contraceptive)

If they vomit within 3 hours, then a Repeat Dose should be admitted

Question 63

Q

What are the 3 options for Emergency Contraception?

Answer

A

Copper IUD-
- Gold Standard Emergency Contraception
- Can be used 5 days after the first episode of Unprotected Sex, or within 5 days of expected Ovulation
- It is toxic on Eggs and Sperms
- Even if Fertilisation occurs, the Copper IUD has anti-implantation effects
- It is Not Affected by other medications

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Ulipristal Acetate (“Ella One”)-
- Selective Progesterone Receptor Modulator
- It binds to the Human Progesterone Receptors- suppressing the LH Surge and delays Ovulation for 5 days
- It delays Ovulation even after the start of the LH Surge
- Can be used 5 days after Unprotected Sex
- Also wait 5 days before starting Hormonal Contraception
- Can be used Once per Cycle

////////////////////////////////////////////////////////////////////

Levonorgestrel (“Levonelle”) tablet
- Can be used within 3 days of Unprotected Sex
- Inhibits or delays Ovulation for 5 days
- It thickens the CERVICAL MUCUS
- When on this, you can quick Start Hormonal Contraception
- Can take MORE than Once in the same cycle if there is further Unprotected Sex
- Ineffective After the LH Surge
- Less effective if BMI>26
- It is the LEAST EFFECTIVE
- It can be used from day 21 post partum and after Miscarriage/ Abortion

Question 64

Q

How quickly can you reapply for a license once you have an Epileptic Seizure?

Answer

A

Car/Motorbike License
- One-off Seizure= Reapply in 6 months
- >1 Seizure= Reapply in 1 year
- Seizure following change in Antiepileptic Medication= Reapply to drive if Seizure was >6 months ago or if you’ve been back on the Previous Medication for 6 months

Bus/ Coach/ Lorry License
- One-off Seizure= Reapply in 5 years OR if you haven’t taken Antiepileptic medication for 5 years
- >1 Seizure= Reapply once you haven’t had a Seizure for 10 years or if you haven’t taken any Antiepileptic medication for 10 years

Answer 65

A

Find the Systemic Disease

Urine Dipstick- Renal Disease?
FBC, CRP, U&Es, LFTs- Anaemia of Chronic Disease, Neutrophilia, Renal Function

Autoimmune Serology

Answer 66

A

NSAIDs- Fluriprofen if Mild

Corticosteroids- Oral Prednisolone/ IV Methylprednisolone if Severe

Answer 67

A

Benign Tumours of Fibrous and Epithelial Tissues which arise from Lobules

Young Age of Presentation (20 years old)
Firm, Non tender Masses
Rounded with Smooth Edges
Highly Mobile
Normally <3cm

Answer 68

A

Even though they are safe, DO TRIPLE ASSESSMENT anyway to make sure

Manage with Surgical Excision and may also Regress after Menopause

Answer 69

A

Chronic Illness (Testosterone is suppressed more than Oestrogen during Malnourishments)

Hyperthyroidism/ Hyperprolactinaemia (hyper pituitary function)/ Hypogonadotrophic Hypogonadism

Exogenous Oestrogen

Anabolic Steroid

Testicular Failure (Infiltration/ Chemotherapy)

Tumours (Sertoli Cell, Leydig Cell, Germ Cell)

Medications (Spironolactone, GnRH Agonists, Chemotherapy, Ketoconazole)

Obesity

Answer 70

A

Observation and Reassurance

Treat the cause- Hypogonadism with Testosterone

TAMOXIFEN (used for Breast Cancer)

DANAZOL (used for Endometriosis)

Breast Reduction Surgery

Answer 71

A

It presents as Arthritis of the 1st Metatarsophalangeal Joint. Usually in 40-50 year olds

It is characterised by Sudden, Severe attacks of Pain, Swelling, Redness and Tenderness in the Joint- usually at the base of the Big Toe

Risk Factors-
- Obesity
- Hypertension
- Age
- DIABETES and CHRONIC KIDNEY DISEASE
- Metabolic Syndrome
- Thiazide Diuretics, ACE Inhibitors, Aspirin

Answer 72

A

Seafood/ Protein- Increases Uric Acid Levels
Chemotherapy- Increases Cell Breakdown
Trauma and Surgery- Increases Cell Breakdown

Answer 73

A

Sudden, Painful, Burning Pain at the Affected Joint
Swelling, Redness, Warmness and Stiffness at the Joint
Asymmetrical join distribution
Mild Fever
Tachycardia (Transient Response to pain in an Acute Attack)

Answer 74

A

Septic Arthritis (so ANY patient with an acute, hot, swelling joint should have joint aspiration to rule this out)

Crystal Arthropathy- Gout/ PseudoGout

Inflammatory Arthritis- Rheumatoid and Seronegative Arthritis

Answer 75

A

Arthrocentesis with Synovial Fluid Analysis

Needle-shaped Monosodium Urate Crystals with Negative Birefringence Confirms Gout. The fluid should ALSO be sent for Gram Stain and Culture to rule out Septic Arthritis

Uric Acid Level should also be obtained 2 weeks after the attack as it may be Low or Falsely Normal during the attack. Also Gout can develop with Normal Serum Uric Acid Levels
X rays of Affected Joints- Normal Joint Space, Soft Tissue Swelling, Periarticular Erosions

Answer 76

A

Manage the Acute Attack and then give Ongoing Management

Acute Flare Up- NSAIDs, Colchicine, Steroids and Paracetamol.
- INDOMETHACIN is usually used first line.
- If high risk of GI side effects/ history of CKD or Heart Failure - then Colchicine may be used instead

Diarrhoea is a side effect of Colchicine and if this is intolerable, then Intraarticular Administration of Steroids can be given

Then LIFESTYLE ADVICE
- Reduce Alcohol, Meat and Seafood
- Review Meds (look for Chemotherapy, Diuretics and Low-dose Salicylates

And Start Allopurinol at a low dose at least 2 weeks following the attack if Criteria is met

Answer 77

A

More than 2 attacks per year
Tophaceous Gout (Nodules of Tophii)
Xray changes showing Chronic Destructive Joint Disease
Urate Nephrolithiasis (KIDNEY STONES)
Patients experience Severe and Disabling Polyarticular Attacks

Answer 78

A

Give it 2 weeks after the attack. If it is still too early after the attack (<1 week) as Allopurinol causes a Gout flare when it breaks down the Urate Crystals (so give it with Colchicine or an NSAID). But continue if they experience a flare while already on Allopurinol.

Give Febuxostat instead

Answer 79

A

1) Ways for the Pathogen to get in (3)-

Trauma
IV Drugs
Recent Surgery

2) Ways for the immune system to be unable to fight back-

Immunocompromisation

Answer 80

A

Cushions within the anal canal expand and protrude outside the anal canal

Bright Red PR Bleeding associated with Defecation
Pain is NOT a typical feature
If Pain IS there then it suggests- Thrombosed External Haemorrhoid/ Anal Fissure
There may be Anal Pruritus

Answer 81

A

Constipation, Pregnancy, Other things that increase Intraabdominal Pressure (Space-Occupying Lesion)

Portal Hypertension secondary to Cirrhosis increases the risk of Haemorrhoids (due to increased risk at Porto-systemic Anastamosis)

Answer 82

A

Grade 1 (No Prolapse)- Topical Corticosteroids for the Pruritus

Grade 2 (Prolapse on Straining which goes down after)- managed with Rubber Band Ligation (otherwise Scleropathy/ Infrared Photocoagulation)

Grade 3 (Prolapse on Straining that you need to push back in)- Rubber Band Ligation

Grade 4 (Prolapse on Straining that you can’t push back in)- External Haemorrhoids, or Lower Grade Haemorrhoids failing to respond to less invasive measures can be managed with Surgical Haemorrhoidectomy

(Reduce risk of Constipation with Fibre and Fluids in Diet)

If Thrombosed Haemorrhoids= Ice packs/ Laxatives/ Lidocaine. Otherwise Haemorrhoidectomy

Answer 83

A

They are the most common type of Chronic Recurring Headache

They are Bilateral, Pulsatile Headaches. They feel Tight like a Band around the Head. They may be associated with Tenderness of the Scalp Muscles as the contraction of these muscles is what causes the pain

Paracetamol/ NSAIDs can be given to alleviate the pain. Also address the cause of the pain (Stress)

(The most obvious management option)

Answer 84

A

It is Sharp/ Stabbing Pain affecting One Side of the Face in the Trigeminal Nerve Distribution. Pain may be triggered by touching the face, eating or talking. Patients are usually over 50 years old

Diagnosis- History is Enough, BUT do an MRI to exclude potential causes (Tumours and Aneurysms)

Treatment- Carbamazepine or Microvascular Decompression (Surgical)

Answer 85

A

Headaches that are worse in the morning or when bending over. May occur due to Compression of structures by a Tumour or Haemorrhage

Send them for CT to find the cause

Answer 86

A

Systolic Dysfunction (Impaired Myocardial Contraction during Systole)
Diastolic Heart Failure (Impaired Ventricular Filling during Diastole)

Systolic-
- Ischaemic Heart Disease
- Dilated Cardiomyopathy
- Myocarditis
- Infiltration (Haemochromatosis or Sarcoidosis)

Diastolic-
- Hypertrophic Obstructive Cardiomyopathy
- Cardiac Tamponade
- Constrictive Pericarditis
- Restrictive Cardiomyopathy

Answer 87

A

Low Output- issue is with the Heart (Systolic/ Diastolic)

High Output- issue is that the rest of the body has high demand, but heart is fine

Answer 88

A

AAPPTT

Anaemia
Arteriovenous Malformation
Paget’s Disease (impairment in normal cycle of Bone Renewal)
Pregnancy
Thyrotoxicosis
Thiamine Deficiency (Wet Beri Beri)

Answer 89

A

Pulmonary Congestion (Pressure builds up behind the left heart- the Lungs)
- Shortness of Breath on Exertion
- Orthopnoea
- Paroxysmal Nocturnal Dyspnoea
- Nocturnal Cough (with Pink Frothy Sputum)
- Tachypnoea
- Bibasal Fine Crackles

Systemic Hypoperfusion (Reduced Left Heart Output)
- Cyanosis
- Prolonged Capillary Refill Time
- Hypotension

Less common signs-
- Pulsus Alternans (an Alternating Strong and Weak Pulse)
- S3 Gallop (large amounts of blood striking the Left Ventricle)
- Mitral Regurgitation

Answer 90

A

Venous Congestion (Pressure builds up behind the Right Heart)
- Ankle Swelling
- Raised JVP
- Pitting ankle/ sacral oedema
- Tender Smooth Hepatomegaly
- Ascites
- Transudative Pleural Effusions (typically bilateral)

Pulmonary Hypoperfusion (Reduced Right Heart Output)

-Fluids go into the pleural space of the lungs but not into the pulmonary circulation itself

Answer 91

A

Measure BNP
Perform ECG/ Chest Xray/ Blood Tests/ Urinalysis/ Spirometry/ Peak Flow

BNP< 400- Heart Failure not confirmed

BNP- 400-2,000- Refer to be seen urgently in 6 weeks

BNP> 2,000- Refer to be seen urgently in 2 weeks

On referral- perform a Transthoracic Echocardiography to CONFIRM Heart Failure

Answer 92

A

Lifestyle- Smoking cessation/ Salt and Fluid Restriction/ Cardiac Rehab

1) Loop Diuretics (Furosemide/ Bumetanide) for symptoms

2) ACE Inhibitor and Beta Blocker to improve Mortality
- If they can’t tolerate ACE, give them ARB, if they can’t tolerate this, give them Hydralazine and Nitrate

(Assess Sodium/ Potassium and Renal Function with ACE)

3) If Symptoms persist-
- Spironolactone/ Eplerenone
- Add Hydralazine and Nitrate (especially if AfroCaribbean)
- Add Ivabradine if Sinus Rhythm and HR>75 and LVEF<35%
- Replace ACE or ARB with Sacubitril Valsartan if LVEF<35%
- Give Digoxin for Symptoms if Atrial Fibrillation

4) Cardiac Resynchronisation (ICDs)
- QRS<120ms with high risk of sudden cardiac death
- QRS 120-149ms without LBBB
- QRS 120-149ms with LBBB and no impairment to daily life

Answer 93

A

U+Es (to assess renal function for the medication and check for Hyponatraemia)
LFTs- to look for Hepatic Congestion
TFTs- check for Hyperthyroidism
Glucose and Lipid Profile- to check for modifiable risk factors
BNP

Answer 94

A

ABCDEF

Alveolar Oedema (Batwing perihilar shadowing)

Kerley B lines (Interstitial Oedema)

Cardiomegaly (Cardiothoracic Ratio >0.5)

Dilated Upper lobe vessels Diversion of blood to Upper Lobe

Effusions (Bilateral Transudate)
Fluid in Horizontal Fissure

Answer 95

A

1) Sit the patient up
2) Oxygen therapy (aim for sats>94%)
3) IV Furosemide and aim for a NEGATIVE fluid balance
4) SC Morphine

Then-
- CPAP (for hypoxia and pushes fluid out of the alveoli)
- Intubation and Ventilation
- IV Furosemide and Dopamine over 24 hours
- If Cardiogenic Shock- Intra-aortic balloon pump
- Ultrafiltration- If resistant to or contraindicated diuretics

Answer 96

A

Bradycardia
Hypotension
Fatigue
Dizziness

it can also mask Hypoglycaemia
ERECTILE DYSFUNCTION AS WELL

Answer 97

A

Both Cause HYPERKALAEMIA and RENAL IMPAIRMENT

ACE- (the 2 side effects in beta blockers that are not heart related as well)
- Dry Cough
- Light headedness
- Fatigue
- GI Disturbances
- Angioedema

Spironolactone-
- Gynaecomastia
- Breast Tenderness and Hair Growth in women
- Changes in Libido

Answer 98

A

Hypotension/ Hyponatraemia/ Hypokalaemia

Answer 99

A

CHOCN
- CKD
- Hypothyroidism
- Obstructive Jaundice
- Cushing’s
- Nephrotic Syndrome

Drugs- Thiazide Diuretics, Glucocorticoids, Ciclosporin

Pregnancy, Obesity, Alcohol

Answer 100

A

Premature Arcuate Senilis (deposit around iris)

Tendon Xanthomata

Answer 101

A

Statins (Atrovastatin 20mg)
If they have had a stroke, heart attack, artery disease or angina- give them 80mg instead

Answer 102

A

HMG-CoA Reductase Inhibitors

Side Effects
- Muscle Pain
- Abdominal Pain
- Constipation
- Headache

If they have Significant Myalgia this may indicated Myositis. Measure Creatine Kinase and if it is 5 times the upper limit, then stop the statin

Statins can also cause abnormal liver function so monitor LFTs and stop if AST or ALT are 3x the upper limit

Answer 103

A

Primary- One or more parathyroid gland produces excess PTH (can lead to Hypercalcaemia)

Secondary- Increased PTH in response to LOW CALCIUM because of the Kidney, Liver or Bowel Disease

Tertiary- ther is Autonomous (meaning without hypocalcaemia) PTH Secretion- usually because of CKD

Answer 104

A

Bones, Stones, Groans, Psychiatric Moans

Painful Bones

Renal Stones

Abdominal groans- GI Symptoms, Nausea, Vomiting, Constipation, Indigestion

Psychiatric Moans- Effects on the Mental State (Lethargy, Memory Loss, Psychosis, Depression)

Answer 105

A

Adenoma (most common- especially if Postmenopausal)
Hyperplasia of all 4 glands
Parathyroid Carcinoma (rare)

Answer 106

A

1) Vitamin D Deficiency (Low Phosphate, Normal or Low Calcium, HIGH ALP)

2) Loss of Extracellular Calcium
- Pancreatitis
- Rhabdomyolysis
- Hungry Bone Syndrome

3) Calcium Malabsorption (Low Calcium, Low Phosphate and Normal ALP)

4) Abnormal Parathyroid Hormone Activity (only one where PHOSPHATE is HIGH)
- CKD (High Calcium, Phosphate and ALP)- everything is high in CKD
- Pseudohyperparathyroidism (Low Calcium BUT High Phosphate- ALP may be Normal or HIGH)

5) Inadequate Calcium Intake

Answer 107

A

Cinacalcet (mimics the actions of calcium)

Answer 108

A

It releases progesterone to prevent implantation

It works for 5 years

Features
- Irregular Bleeding/ Spotting is common in first 6 months- Periods may even stop all together
- Small risk of infection in first 3 weeks
- If fitted after 45, it should stay until Menopause
- It is useful if women have Heavy or Painful Periods

Answer 109

A

Heavier, more painful periods- Copper IUD

Irregular Bleeding, Spotting, Amenorrhoea- LNG-IUS

Answer 110

A

Abnormal Uterine Anatomy

Pelvic Inflammatory Disease

2 days to 4 weeks Post Partum

Unexplained Vaginal Bleeding

Answer 111

A

Fatigue

Jaundice

Heavy Periods

Change in Bowel Habit

Answer 112

A

Low MCV
Low Hb
High TIBC
Low Ferritin

Answer 113

A

If unexplained- rule out CANCER

Ferrous Sulphate treats the Iron Deficiency

Answer 114

A

Tendinopathy of the Wrist Flexor Tendons which attach to the Medial Epicondyle of the Distal Humerus

It presents as a Gradual-Onset Medial Elbow Pain which is exacerbated by Activity (specifically Flexion of the Wrist and Pronation of Forearm (P for Putt)

It is managed with Rest and Rehab
- Surgical Debridement may be needed if they go for 6 months with no change despite rest and rehab

Answer 115

A

If vomiting with 2 hours of taking it, just take another one, or 3 hours if COCP

//////////////////////////////////////////////////////////////

Norethisterone POP- Missed if 3 hours late
Desogestrel POP- Missed if 12 hours late

= remember the word eND and N is before D so is smaller
///////////////////////////////////////////////////////////////
Missed Pill Rules

1) Missed in Week 1-
- Emergency Contraception if she has UPSI in the Pill Free Interval. And take ONLY 1 pill even if multiple pills are missed.
- Also Condoms for 2 days or 7 days if POP or COCP respectively

2) Missed in Week 2-
- No need for Emergency Contraception

3) Missed in Week 3-
- Take the last pill that was missed, finish the current pack and start the next pack immediately after (forget the pill omission week if 2 or more pills are missed).
- Use Condoms for the next 2 days if POP, 7 days if COCP

Answer 116

A

Inflammation of the Olecranon Bursa

It occurs after Repetitive damage such as leaning on the Elbow repeatedly

Examination reveals swelling around Olecranon with no signs of Fever/ Infection

Management-
- Ice pack, Anti Inflammatory Medication, Elbow Support. It this doesn’t improve the condition, then give Steroid Injection

Answer 117

A

Anywhere in the first 5 days of her cycle. She will be protected from pregnancy immediately

If she starts in any other day, she needs 7 days of Condoms

New mothers can take it 3 weeks after giving birth

Answer 118

A

It is Teratogenic- so take contraception (2 forms of it) for one month before and after use

Skin Dryness
Temporary Worsening of Acne
Photosensitivity- use Lipbalm, Moisturiser and Sunscreen
Potentially causes Depression as well

Answer 119

A

Severe Ear pain- on Palpation and itchiness with MINIMAL Discharge
- Hearing is only impaired if the Meatus is blocked by the swelling or discharge

Caused by Pseudonomas Spp and Staph Aureus

Answer 120

A

Mild-to-Moderate
- Topical Drops (Antibiotics and Steroids), Acetic Acid
- Patients should keep ears dry for a week

Severe-
- If Meatus is COMPLETELY OCCLUDED
- Treat with Ribbon Gauze (Pope Wicks)- which is used for the application of antibiotics like Gentamicin

Consider ORAL Antibiotics if (remember the ones above are topical)
1) Cellulitis extends beyond the external ear canal
2) When the ear canal is occluded by swelling and debris so that the wick can’t be inserted
3) If they have Diabetes/ are Immunocompromised / at higher risk of infection

Systemic Antibiotics if Fever

Answer 121

A

In Media- the tympanic membrane is MORE INFLAMED, SWOLLEN and IMMOBILE

and there is VISIBLE DISCHARGE

Answer 122

A

It is a common rash which occurs after an Upper Resp Tract Infection and is thought to have a viral cause

Caused by HHV7

There will be a HERALD PATCH (single Coin-shaped Erythematous Patch)
It usually has a little collar of scaliness just inside the Edge of the Lesion
A few days later, a widespread rash appears across the trunk consisting of similar scaly, red patches following a Christmas Tree distribution

TEAR DROP= Guttate Psoriasis

It is self-limiting and benign- so no management needed

Answer 123

A

High Grade Fever
Pleuritic Chest Pain
Purulent Sputum and Haemoptysis
Productive Cough
Bronchial Breathing (higher pitch and inspiration and expiration are equal. There is an audible pause between inspiration and expiration)
Pleural Rub may be heard
Cyanosis

Answer 124

A

Typical (rapid onset symptoms)- High Fever and Productive Cough
- Strep Pneum.
- Staph Aureus
- Haemophillus Influenzae (Negative Rod, beta lactam)
- Moraxella (Negative Coccus- beta lactam)
- Pneumococcus- most common in COPD
- Pseudonoma- most common in Hospital Acquired Pneumonia

Atypical (gradual onset)- General symptoms first (fever, dry cough, myalgia- No sputum)
- Any bacteria whose first name ends in A (apart from Moraxella and Pseudonoma)

Answer 125

A

Confusion
Urea>7
RR>30
BP low
>65 years old

One point for each

Answer 126

A

0/1- home-based care= Amoxicillin for 5 days (give a -mycine of -cycline if Penicillin-allergic)

2- hospital-based care- 7-10 day course of Dual Antibiotic Therapy (Amoxicillin and a Macrolide (-Mycin))

3- hospital/ ITU care- 7-10 day course of Dual Antibiotic Therapy (IV Co-amoxiclav/ Ceftriaxone/ Tazocin and a Macrolide)

Answer 127

A

Cold Autoimmune Haemolytic Anaemia- Toe Pain and Low Hb and JAUNDICE

Answer 128

A

Urine Antigen Testing

Answer 129

A

Flu-like illness 2-6 weeks after Infection

Fever and Lymphadenopathy

There may also be a Maculopapular Rash (in the Upper Chest usually)

There may also be Mucosal Ulcers- White patches in Mouth (Oral Thrush)

Answer 130

A

Serum HIV ELISA, with a positive result confirmed using a second test

Additional tests=
- HIV Viral Load
- FBC
- Lymphocyte Panel (CD4 count- this is diagnostic of AIDS, not HIV)
- Screen for Other STIs
- Screen for liver and kidney function
- Glucose and Lipids
- Antigen and Antibody tests give the most Accurate Diagnosis

Management- cART- regardless of CD4 count

Answer 131

A

It is a type of cancer caused by a virus (usually HHV 8 or AIDS)
There will be lesions in arms, legs and mouths, face and genital areas

It can cause breathing difficulties if in the lungs as well

Answer 132

A

Pneumonia (especially if Ventilator-associated, Also Pneumonia in Cystic Fibrosis)

UTI- usually hospital acquired and associated with recent Catheterisation/ Surgery

Surgical wound and skin infections

Sepsis in Hospital and Nursing homes

Infective Endocarditis- especially in IV Drug users/ people with Prosthetic Valves

Ear Infections- Chronic Otitis Media and Otitis Externa

Eye Infections- Bacterial Keratitis and Endophthalmitis (if they are wearing contact lenses)

Bone and Joints- it can cause Osteomyelitis or Septic Arthritis

Answer 133

A

Ciprofloxacin or Levofloxacin (These are the ONLY Oral ones that are good)

Tazocin

Ceftazidime

Meropenem

Gentamicin

Answer 134

A

Abscesses (Liver, Kidney, Lung)

Bacterial Infections (Infective Endocarditis, Brucellosis, Typhus, Lyme Disease)

Parasitic and Fungal Infections- Malaria/ Schistosomiasis

Malignancy (Hodgkin’s Lymphoma)

Drug Reactions

Connective Tissue Disorders (SLE, Vasculitides, Kawasaki’s)

Thromboembolic Disease

Autoimmune Inflammatory Conditions- FMF, TRAPS, Hyper Ig-D Syndrome

Answer 135

A

1) Inhibits the LH Surge and prevents Ovulation

2) Thickens the Cervical Mucus, making it more difficult for Sperm to enter the Uterus

3) Thins the lining of the Endometrium, making it more difficult for implantation to take place

Side Effects-
(remember irregular vaginal bleeding)

Irregular Menstrual Bleeding/ Spotting/ Amenorrhoea
Nausea and Vomiting
Ovarian Cysts
Headache
Breast Tenderness/ Enlargement
Changes to Mood and Libido

Answer 136

A

Progesterone-only Pill- Desogestrel, Cerelle, Cerazette

Subdermal Implant- Nexplanon

Contraceptive Injection- Depo Provera, Sayana Press

Intrauterine System- Mirena, Levosert, Kyleena, Jaydess

Answer 137

A

Within the Parotid Gland, Most of these are Benign (80%)

Answer 138

A

Benign- Pleomorphic Adenoma

Malignant- Adenoid Cystic Carcinoma

Answer 139

A

If they have been present for 1 month, then remove them

Answer 140

A

Family History of Schizophrenia

Traumatic Events in childhood
Heavy cannabis use in childhood
Poor Maternal Health (Malnutrition and Infections)
Birth Trauma
Living in the city
Living in and Emigrating to more developed countries

Answer 141

A

Auditory Hallucinations (third person running commentary)

Thought Disorders (Insertion, Withdrawal, Broadcasting)

Delusion Perceptions (a normal object is seen, then a delusion is assigned to it- I saw the Queen on TV and now the Mafia are tryna kill me)

Passivity Phenomena (an External Influence is controlling the patient)

Answer 142

A

Alogia (poverty of speech)

Anhedonia

Incongruity/ Blunting of Affect

Avolition (poor motivation)

Answer 143

A

At least 1 of:
- Thought Disorders
- Delusions
- Auditory Hallucinations

At least 2 of:
- Breaks in the train of thought
- Catatonic Behaviour
- Negative Symptoms (Avolition, Anhedonia, alogia, Incongruity)
- Change in overall personality

They need to have been present for at least 1 Month

Answer 144

A

Risperidone (cos Haloperidol carries Extra Pyramidal Effects)

Lorazepam may be used if there is Acute Behavioural Disturbance

If Schizophrenia does not respond to at least 2 different Antipsychotics for 6-8 weeks then give them Clozapine

Answer 145

A

Substance-induced Psychotic Disorder (can include Steroids)

Organic Psychosis- Infection, Brain Injury, CNS Diseases such as Wilson’s Disease

Metabolic Disorder- Hyperthyroidism and Hyperparathyroidism

Dementia and Depression

Answer 146

A

Constriction pain in chest/ neck/ arm/ jaw

Due to Physical Activity

Alleviated by rest or GTN within minutes

Answer 147

A

ECG

FBC- look for Anaemia

TFTs- look for Hyperthyroidism

CT Coronary Angiography (First Line for Stable Angina)

Answer 148

A

Lifestyle Measures and Secondary prevention medication= Aspirin/ Statin

1) GTN and (Beta Blocker or rate-limiting Calcium Channel Blocker) (or Ivabradine, Nicorandil, Ranolozone)

If pain does not subside after 1 dose of GTN, TAKE ANOTHER, if still not gone, seek HELP ASAP

2) Then GTN and Beta Blocker and long-acting dihydropyridine Calcium Channel Blocker (ALL THREE but CCB is now long acting and not rate limiting)

3) Arrange Coronary Angiography and PCI

Answer 149

A

If symptomatic one of-
- Random Blood Glucose>11.1
- Fasting Plasma Glucose>7
- 2 hour Glucose Tolerance>11.1
- HbA1C>48

If asymptomatic 2 of the above are needed

Answer 150

A

Blood sugar damages NERVES that lead to stomach, blood pressure, poo and pee and feet, BLOOD VESSELS in peripheries and sexual organs and heart

1) Gastroparesis- Nerve Damage to the Autonomic Nervous System (Vagus Nerve). Leads to delayed gastric emptying/ egg burps cos of bacterial growth/ early satiety/ morning nausea

Managed with Motility Agents (Metoclopramide, Domperidone)/ Antibiotics (Erythromycin)/ Botox to relax the Gastric Outflow Obstruction
Gastric Pacemakers are used if all else fails

2) Autonomic Neuropathy- Postural Hypotension (BP falls by 20 when changing posture). They become light headed after standing

Managed with Dietary Salt and Salt-retaining Hormones (Fludrocortisone or Midodrine)

3) Peripheral Arterial Disease- COLD, NUMB, SORES TAKE A WHILE TO HEAL, FOOT PAIN and DISCOLORATION and NO PULSES Foot discoloration/ Gangrene/ Rest Pain/ Night Pain/ Absent Peripheral Pulses (confirmed on Doppler)

Managed with MDT review and Diabetic Foot Team

4) Diabetic Foot Infections- In patients who have Vascular and Neuropathic Complications of Diabetes, they are at high risk of Foot Ulcers and therefore Infections

Managed with Glycaemic and Blood Pressure Control/ Improving Circulation (Angioplasty or Bypass)/ Debridement of the Wound/ use of Maggots and Antibiotics
MRI for Osteomyelitis

5) Sexual Dysfunction (Erectile Dysfunction)

Manage by checking for testosterone levels (9am Testosterone Blood Test) and gonadotrophin levels

6) Cardiac Complications (MI due to thickening of blood vessels)

Answer 151

A

Diet Advice, Encourage Physical Activity and Stop Smoking

Measure HbA1c at 3-6 month intervals

1) Metformin is first line
1a) Add an sGLT2 if High risk of CVD (QRISK>10%), Current CVD or Heart Failure
1b) Titrate the Metformin UP first before giving the sGLT

1c) If Metformin is contraindicated (Kidney, Liver, Pregnant)- then sGLT2 if above criteria, otherwise DPP4, Sulphonylurea, Pioglitazone

2) Dual therapy (Metformin + above) if HbA1c is 58 or more

3) Triple therapy or insulin (isophane first) if HbA1c is still 58 or more

4) Add a GLP1-mimetic if BMI>35

5) Blood pressure high?- give an ACE

///////////////////////////////////////////////////////////////

1) Give 1.5g Metformin first (Pioglitazone, DPP-4 Inhibitors, Sulphonylureas or sGLT2 inhibitors if they can’t take Metformin)
2) Dual Therapy with the above drugs
3) Triple Therapy with the above drugs

4) Insulin Therapy (Isophane Insulin first
- add on short acting insulins (Humalog/ Novorapid) if there is a big post meal glucose excursion
- examples of long acting insulins are Levemir, Lantus, Insulin Degludec and Abasaglar

Blood pressure control needs to be STRICT

Answer 152

A

Stress (urine leaks when Intra-abdominal Pressure is raised)- coughing, laughing, sneezing- usually because muscles have weakened after something like giving birth

Urge- Sudden involuntary release of Urine associated with urgency- usually because of polyuria

Functional Incontinence- They have the urge to pass urine but are unable to (unable to function)- for example- arthritis may stop them

Overflow- Small amounts of urine leak without warning when the pressure in the bladder overcomes the pressure outside- like in an enlarged prostate or nerve condition that makes the bladder muscles weaker

Mixed Incontinence

Answer 153

A

Avoid Caffeine, Fizzy Drinks and Excessive Fluid Intake

1) Pelvic Floor Exercises can also help

2) Surgical- Mid Urethral Slings

3) Duloxitene if these dont work

Answer 154

A

Avoid Caffeine, Fizzy Drinks and Excessive Fluid Intake

1) Bladder Retraining

2) Anticholinergics First (Oxybutynin, Tolterodine, Fesoterodine, Solifenacin).

3) If Conraindicated- give Mirabegron

Botox into Bladder
Sacral Nerve Stimulation (as it may be overactive in urge incontinence)- this is kinda like a pacemaker

Answer 155

A

Sedating medications/ Alcohol/ Dementia/ Arthritis

Answer 156

A

Underactivity of the Detrusor Muscle

Also
1) Obstruction
2) Neurological Condition (cos the nerve controlling it can be affected)
3) Medications- antihistamines/ antidepressants and antipsychotics (mental health and allergies cause overflow)

Answer 157

A

Frequency
Dysuria
Urgency
Foul smelling Urine
SUPRAPUBIC PAIN

Answer 158

A

Pyelonephritis- if Vomiting/ Febrile and Loin Pain

Answer 159

A

Non Pregnant Women-

1) Trimethoprim or Nitrofurantoin for 3 days

Culture if haematuria or >65

Men-

1) Trimethoprim or Nitrofurantoin for 7 days

Always culture

Catheterised-

1) Do not treat ASYMPTOMATIC Bacteruria
2) If Symptomatic- same treatment as men

Pregnant Women-

1) Nitrofurantoin (unless in third trimester)

otherwise Amoxicillin or Cefalexin

Culture always

//////////////////////////////////////////////////////
1) Nitrofurantoin (if eGFR>45) (if Non Pregnant and >16)
otherwise Trimethoprim
- If they are in the THIRD TRIMESTER- give AMOXICILLIN

If No help- Nitrofurantoin or Pivmecillinam or Fosfomycin

If 3 months- 16 years

Trimethoprim
otherwise Nitrofurantoin (if eGFR>45)

Answer 160

A

Broad Spectrum Antibiotics- Cephalosporin, Quinolone, Gentamicin

Answer 161

A

E. Coli

Proteus Mirabilis if Kidney Stones/ very Old

Answer 162

A

A STEPWISE deterioration in Cognition

Answer 163

A

MRI imaging- Infarcts (may occur following a stroke)
+ Cognition Screen, Medication Review, Rule out Reversible Organic Causes or medication causes

Management-
- Treat Symptoms
- Address Cardiovascular Risk Factors
- Non pharmacological therapies (no medications unless AD is also there)
- Stimulatory therapies

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General Practice (Quesmed) Flashcards

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