General Practice (Quesmed) Flashcards
What is the ABCDE approach to assessing Malignant Melanomas?
Asymmetry
Border Irregularity (Melanomas have Scalloped Borders)
Colour Variation (Variegated= many colours)
Diameter> 6mm
Evolves over time
What are the 4 types of Melanoma?
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
What is Breslow Thickness?
It is the thickness of a Melanoma
If >1mm- a Sentinel Node Biopsy should be taken and evidences of Metastasis should be looked for
What is the management of a Melanoma according to the stage?
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
What are the 4 signs of Acute Tonsillitis?
Sore Throat
Headache
Pyrexia
Lymphadenopathy
What are the 4 main complications of Tonsillitis?
Remember King Julien the Lemur
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
What is the recommended Alcohol weekly intake?
14 units per week
Work out number of units= [Strength (ABV) x Volume (ml)] / 1,000
OR just Strength x Volume (litres)
What is the pathophysiology of Asthma?
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
What are the signs and symptoms of Asthma?
When are symptoms worse and when does the cough happen usually?
What are the 2 HYPERS?
Wheeze and Dyspnoea and (Nocturnal) Cough
Symptoms Worse in the Morning
Hyperinflated Chest
Hyperresonance on Chest Percussion
Wheeze on Auscultation
Which 3 investigations should be ordered more urgently in an acute Asthma Attack?
2 Bloods and 1 Chest
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
What is the management of Chronic Asthma (Not an Attack)?
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
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)
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
What is Atopic Dermatitis?
Dry Skin and Itchy Poorly Demarcated Areas
Usually cheeks in Infants and insides of elbows and needs in Children and Adults
How is Atopic Dermatitis diagnosed?
Managed with Emollients and Topical Corticosteroids
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
What are the 4 complications of Eczema?
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
What is Bell’s Palsy and what are the signs?
Which nerve is affected and what are the symptoms?
(Ear, Ear, Eye/ Mouth)
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)
What is the management of Bell’s Palsy? What is Ramsay Hunt Syndrome?
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
What are the signs of Cellulitis? It is usually caused by Streptococcus or Staphylococcus
Is there fever and is there lymphadenopathy?
Erythema, Calor, Pain, Swelling
Poorly demarcated regions
Systemic Upset (fever, malaise)
Lymphadenopathy
Evidence of skin breach (trauma, ulcer etc.)
What is the management of Cellulitis?
Which antibiotic is typically given?
(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
What are the signs of Chronic Sinusitis?
What does it usually follow?
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
What are the 7 differential diagnoses for Sinusitis?
My Terrible Neck Causes Terrible Vascular Headaches
Migraine
TMJ Dysfunction
Neuralgia
Cervical Spine Disease
Temporal Arteritis
Vasculitis (Granulomatosis with Polyangiitis)
Herpes Zoster
What are the 2 red flags for Chronic Sinusitis?
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
What are the signs of Sialadenitis (Salivary Gland infection)?
STAPHYLOCOCCUS AUREUS INFECTION
How is it managed?
Is there a fever?
Is there lymphadenopathy?
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
What are the signs of COPD?
What is the percussion like?
Also remember CORPULMONALE and PERIPHERAL OEDEMA
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
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)
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
What is the management of Chronic COPD?
What vaccinations are offered?
What is done if there are asthma signs?
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
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)
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
What are the indications for Surgery in COPD?
2 of them are >20% remember that
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
What is the mechanism of action of the Combined Oral Contraceptive?
It is the preferred contraception for PCOS
(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)
What are the 12 main contraindications to Combined Oral Contraceptive?
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
What are the 3 types of Combined Oral Contraception?
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
What are the 8 side effects of Combined Oral Contraception?
Breast Tenderness/ Enlargement
VTE
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Headache
Nausea and Vomiting
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Changes to Mood and Libido
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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)
What are the 4 regimes of combined Oral Contraception?
How long is the HFI for Flexible use?
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
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?
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
What are the side effects of the Progesterone Only Pill?
(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)
What are examples of the possible Hormonal Contraception options?
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
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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
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Emergency contraception e.g. Ulipristal acetate (EllaOne), Levonorgestrel
What are the examples of the possible Non-hormonal Contraception options?
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)
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)?
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
What 6 things should be done when confirming a Death?
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
What are the 9 factors of Depression according to DSM-5? (5 needed every day for at least 2 weeks or longer)
- 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
What drugs can often cause Low Mood?
Steroids
Isotretinoin (Roaccutane)
Alcohol
Beta-blockers
Benzodiazepines
Methyldopa
What is the Initial Management of Depression?
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
If a patient presents with a Red Eye, what 3 things should immediately be ruled out?
Acute Angle-Closure Glaucoma
Anterior Uveitis
Scleritis
What 3 questions should be asked when assessing a Red Eye?
Is it Painful?
Is Acuity Affected?
Are the Pupil Reflexes Affected?
What are the signs of Closed Angle Glaucoma?
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
What are the signs of Anterior Uveitis?
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
What are the signs of Scleritis and Episcleritis?
When are the Scleritis symptoms worst?
Give topical NSAID if Episcleritis
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
What are the signs of Conjunctivitis?
What is the management?
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
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Give CHLORAMPHENICOL if bacterial
LUBRICATING GEL if viral
What are the signs of a Subconjunctival Haemorrhage
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
What is the Pathophysiology of Meniere’s Disease? How long does the Vertigo last?
It is the Dilatation of the Endolymphatic Spaces of the Membranous Labyrinth
This causes Vertigo which lasts 12-24 hours
What are the signs of Meniere’s Disease?
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
What is the management of Meniere’s Disease?
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
What are the 7 causes of Lower GI Bleeding?
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
What causes Raynaud’s Phenomenon?
5 causes
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
What is Raynaud’s Phenomenon?
It is the Cold-induced Color Change of the fingertips
White-blue-red
And this colour change is WELL DEMARCATED
What is the management of Raynaud’s Phenomenon?
Dihydropyridine Calcium Channel Blockers
Other options are ACE Inhibitors and IV Prostacyclin
In extreme cases- Nerve block or Digital Amputation
How do you approach Smoking Cessation?
Refer Patients to Smoking Cessation Services for Behavioural Therapies and Medication
If they don’t wish to attend, then Medications can be offered
What is Nicotine Replacement Therapy?
What are the contraindications?
What are the 4 side effects?
NPDD
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
What is Bupropion?
What are the 2 side effects?
- 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)
What is Varenicline (Champix)?
3
- N and D from the NPDD
- Also SUICIDAL THOUGHTs
- 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
How do you work out Pack-Years for Smoking?
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
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?
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
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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
What are the 3 options for Emergency Contraception?
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
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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
How quickly can you reapply for a license once you have an Epileptic Seizure?
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
What Investigations should be ordered if Scleritis is suspected?
Find the Systemic Disease
Urine Dipstick- Renal Disease?
FBC, CRP, U&Es, LFTs- Anaemia of Chronic Disease, Neutrophilia, Renal Function
Autoimmune Serology
What is the management of Scleritis?
NSAIDs- Fluriprofen if Mild
Corticosteroids- Oral Prednisolone/ IV Methylprednisolone if Severe
What are Fibroadenomas in the Breast and what are the signs?
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
What are the Investigations and management of Fibroadenomas of the Breast?
Even though they are safe, DO TRIPLE ASSESSMENT anyway to make sure
Manage with Surgical Excision and may also Regress after Menopause
What are the 10 causes of Gynaecomastia?
CHEAT MO (CHHHEATT MO)
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
What is the management of Gynaecomastia?
Observation and Reassurance
Treat the cause- Hypogonadism with Testosterone
TAMOXIFEN (used for Breast Cancer)
DANAZOL (used for Endometriosis)
Breast Reduction Surgery
How does Gout present and what are its risk factors?
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
What are the main triggers for a Gout Flare-Up?
Seafood/ Protein- Increases Uric Acid Levels
Chemotherapy- Increases Cell Breakdown
Trauma and Surgery- Increases Cell Breakdown
What are the symptoms of Gout?
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)
What 3 differentials should you consider in Monoarthropathy?
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
What Investigations should be ordered in Gout?
What do the Xrays show?
When should the Uric Acid levels be measured?
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
What is the management of Gout?
What is first line for a flare up and when is this not given and colchicine is given instead (3)?
What is a side effect of colchicine?
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
What is the 5 Criteria for starting Allopurinol for Gout management?
- 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
When should Allopurinol be given and why? What can be given if Allopurinol is contraindicated?
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
Septic Arthritis usually presents with a Risk Factor and Fever as well as the pain. What are the Risk Factors?
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
What are Haemorrhoids and how do they present?
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
What are the risk factors for Haemorrhoids?
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)
What is the grading system and management of Haemorrhodis?
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
What are Tension Headaches? How are they managed?
What actually causes the pain, where is it coming from?
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)
What is Trigeminal Neuralgia? How is it diagnosed and managed?
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)
What are the signs of a Raised Intracranial Pressure Headache?
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
What is Systolic and Diastolic Heart Failure and what are the 4 causes of each?
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
What is the difference between Low-output Heart Failure and High Output Heart Failure?
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
What are the causes of High Output Heart Failure?
AAPPTT
Anaemia
Arteriovenous Malformation
Paget’s Disease (impairment in normal cycle of Bone Renewal)
Pregnancy
Thyrotoxicosis
Thiamine Deficiency (Wet Beri Beri)
What are the Signs of Left Heart Failure?
What is the blood pressure like?
What is the pulse strength like in heart failure?
What kind of murmur is heart in left sided heart failure?
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
What are the signs of Right Heart Failure?
What about the lung signs?
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
What Investigations should be ordered in Heart Failure?
What do the BNP levels indicate?
What should be done on referral?
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
What is the management of Heart Failure?
1, 1, 5, 3
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
What 5 blood tests should be ordered in Heart Failure?
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
What are the Chest Xray Findings of Heart Failure?
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
What is the Immediate management of Pulmonary Oedema in Heart Failure?
What is done if there is Cardiogenic Shock?
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
What are the side effects of Beta Blockers?
Bradycardia
Hypotension
Fatigue
Dizziness
it can also mask Hypoglycaemia
ERECTILE DYSFUNCTION AS WELL
What are the side effects of ACE Inhibitors and Spironolactone?
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
What are the side effects of Furosemide?
Hypotension/ Hyponatraemia/ Hypokalaemia
What are the secondary causes of Hypercholesterolaemia?
What 3 drugs can cause Hypercholesterolaemia?
CHOCN
- CKD
- Hypothyroidism
- Obstructive Jaundice
- Cushing’s
- Nephrotic Syndrome
Drugs- Thiazide Diuretics, Glucocorticoids, Ciclosporin
Pregnancy, Obesity, Alcohol
What 2 signs indicate Familial Hypercholesterolaemia?
Premature Arcuate Senilis (deposit around iris)
Tendon Xanthomata
What is the management of Hypercholesterolaemia?
Statins (Atrovastatin 20mg)
If they have had a stroke, heart attack, artery disease or angina- give them 80mg instead
What type of drugs are statins and what are the 4 common side effects?
What are the 2 reasons statins should be stopped?
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
What are the 3 types of Hyperparathyroidisms?
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
What are the signs of Hypercalcaemia?
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)
What are the causes of Primary Hyperparathyrodism?
What increases the risk of Adenomas?
Adenoma (most common- especially if Postmenopausal)
Hyperplasia of all 4 glands
Parathyroid Carcinoma (rare)
What are the 5 causes of Secondary Hyperparathyroidism? What are the Calcium and Phosphate and ALP levels?
What are the 3 conditions that cause a loss of extracellular calcium?
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
What is the management of Tertiary Hyperparathyoidism?
Cinacalcet (mimics the actions of calcium)
What is the Intrauterine System and how long does it work for?
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
What are the Side Effects of the Copper IUD and Levonorgestrel-releasing Intrauterine System?
Remember the Tap analogy
Heavier, more painful periods- Copper IUD
Irregular Bleeding, Spotting, Amenorrhoea- LNG-IUS
What are the contraindications to IUS and IUD?
Abnormal Uterine Anatomy
Pelvic Inflammatory Disease
2 days to 4 weeks Post Partum
Unexplained Vaginal Bleeding
What are the signs of Iron Deficiency Anaemia?
Fatigue
Jaundice
Heavy Periods
Change in Bowel Habit
What investigations should be ordered in Iron Deficiency Anaemia? Order these after Microcytic Anaemia is confirmed before management
Low MCV
Low Hb
High TIBC
Low Ferritin
What is the management of Iron Deficiency Anaemia?
If unexplained- rule out CANCER
Ferrous Sulphate treats the Iron Deficiency
What is Medial Epicondylitis (Golfer’s Elbow)?
What is the indication for surgery?
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
What are the rules for missing Oral Contraceptives?
After how long is Norethisterone and Desogestrel considered missed?
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
What is Olecranon Bursitis?
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
When should COCP be started?
What happens if she starts on any other day?
When can new mothers take COCP after giving birth? How long after?
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
What are the issues with Isoretinoin (Roaccutane)?
What needs to be taken with it (if they are female)?
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
What are the signs and causes of Otitis Externa?
(Which 2 organisms?)
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
What is the management of Otitis Externa?
If Mild-
If Severe-
When to use Oral Antibiotics-
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
How can you differentiate between Otitis Externa and Media?
In Media- the tympanic membrane is MORE INFLAMED, SWOLLEN and IMMOBILE
and there is VISIBLE DISCHARGE
What is Pityriasis Rosea?
WHAT CAUSES IT?
what does it usually follow? what does the rash look like/ turn into? how is it managed?
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
What are the signs of Pneumonia?
What type of chest pain is seen in pneumonia?
What is the name given to the type of breathing?
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
What are the bacterial causes of Pneumonia?
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)
What is the CURB 65 scoring system?
Confusion
Urea>7
RR>30
BP low
>65 years old
One point for each
What is the management of Pneumonia according to the CURB65 Score?
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)
What is a complication of Mycoplasma Pneumonia?
What are the 3 symptoms?
Cold Autoimmune Haemolytic Anaemia- Toe Pain and Low Hb and JAUNDICE
How is Legionella Pneumonia confirmed? (The Hotel/ Travel Pneumonia)
Urine Antigen Testing
What are the signs of a Primary HIV Infecion?
How long after the infection does it present?
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)
What is the Diagnosis and Management of a Primary HIV Infection?
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
What is Kaposi’s Sarcoma?
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
What 8 conditions can Pseudomonas cause?
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
What antibiotics are effective against Pseudomonas?
Which are the only good oral antibiotics against Pseudonomas?
Ciprofloxacin or Levofloxacin (These are the ONLY Oral ones that are good)
Tazocin
Ceftazidime
Meropenem
Gentamicin
If a patient presents with a Fever of Unknown Origin, what 8 things may it be?
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
What is the mechanism (it thickens, thins and does something else) and side effects of Progesterone-only Contraception?
There is NO Pill-Free period (like the COCP has)
3 hours is the limit for missed pills
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
What are examples of Progesterone-only Contraception?
Progesterone-only Pill- Desogestrel, Cerelle, Cerazette
Subdermal Implant- Nexplanon
Contraceptive Injection- Depo Provera, Sayana Press
Intrauterine System- Mirena, Levosert, Kyleena, Jaydess
Where are most Salivary Tumours located?
Within the Parotid Gland, Most of these are Benign (80%)
What is the most common type of Salivary Tumour (benign and malignant)?
Benign- Pleomorphic Adenoma
Malignant- Adenoid Cystic Carcinoma
What is the management of Salivary Tumours?
If they have been present for 1 month, then remove them
What are the risk factors for Schizophrenia?
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
What are the 4 First Rank Features of Schizophrenia?
ATP-ADP
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)
What are the 4 Negative symptoms of Schizophrenia?
Alogia (poverty of speech)
Anhedonia
Incongruity/ Blunting of Affect
Avolition (poor motivation)
What is the ICD 10 requirements for the diagnosis of Schizophrenia?
How long do the symptoms need to be there for?
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
What is the management of Schizophrenia?
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
What 4 differentials should be considered if Schizophrenia is suspected?
which CNS disease in particulaR?
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
What are the 3 signs of Stable Angina?
Constriction pain in chest/ neck/ arm/ jaw
Due to Physical Activity
Alleviated by rest or GTN within minutes
What investigations should be ordered in Stable Angina?
Which of these 4 is first line?
ECG
FBC- look for Anaemia
TFTs- look for Hyperthyroidism
CT Coronary Angiography (First Line for Stable Angina)
What is the management of Stable Angina?
The tale of the G, B and C coming together
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
What is required for the diagnosis of Type 2 Diabetes Mellitus?
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
What are the complications of Type 2 Diabetes Mellitus?
6 complications and their management
What should be checked for in Diabetic Foot Disease?
also Remember Diabetic Retinopathy and Diabetic Neuropathy and Diabetic Nephropathy
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)
What is the management of Type 2 Diabetes Mellitus?
How often do you measure HbA1c?
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
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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
What are the 5 types of Incontinence?
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
What is the management of Stress Incontinence?
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
What is the management of Urge Incontinence?
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
What are the causes of Functional Incontinence?
Sedating medications/ Alcohol/ Dementia/ Arthritis
What causes Overflow Incontinence?
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)
What are the signs of Lower UTI (Cystitis)?
Frequency
Dysuria
Urgency
Foul smelling Urine
SUPRAPUBIC PAIN
What is the key differential for Lower UTI?
Pyelonephritis- if Vomiting/ Febrile and Loin Pain
What is the management of Lower UTI?
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
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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)
What is the management of Pyelonephritis?
Broad Spectrum Antibiotics- Cephalosporin, Quinolone, Gentamicin
What 2 organisms causes Lower UTI? which is the common one?
E. Coli
Proteus Mirabilis if Kidney Stones/ very Old
What are the signs of Vascular Dementia?
A STEPWISE deterioration in Cognition
What investigations should be ordered in Vascular Dementia and what is the management?
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
