GP Flashcards
Name 3 risk factors of ADHD
Preterms oppositional defiant disorder mood disorders epilepsy looked-after children close family history neurodevelopmental disorders history substance misuse acquired brain injury
DSM-5; how many criteria for inattention or hyperactivity/impulsivity for a) up to 16, b)17 and over
a) at least 6
b) at least 5
Must be present for 6 months
First line medication for over 5s with ADHD
methylphenidate (stimulant medication)
2nd line and 3rd line medications ADHD
2nd=(lis)dexamfetamine, 3rd=atomexetine, guanfacine
Monitoring requirements for stimulant medications
Height (6/12) and weight (3/12) in children, HR and BP.
Methylphenidate side effects
Increased BP and HR, loss of appetite, trouble sleeping, headaches, stomach aches, mood swings
5 causes of breast pain leading to breast-feeding problems
Engorgement, blocked ducts, galactocele, ductal infection, mastitis and breast abscess
How to manage breast engorgement?
Feed infant with no restrictions, simple analgesia, massage breast, express to relieve full breasts, heat before feeding, cold after
How to manage blocked breast ducts?
Feed from affected breast frequently, heat packs, warm showers pre feeding, gentle massage with firm movements towards nipple
How to manage galactocele?
Continue breastfeeding, refer
How to manage bacterial breast ductal infection?
Flucloxacillin 500mg QDS 10-14 days
How to manage fungal/candida infection (breast duct)?
Fluconazole 150-300mg single dose then 50-100mg bd 10-14 days
5 causes of nipple pain leading to breast-feeding problems?
Physiological milk let-down pain, nipple damage, blocked duct, nipple infection, skin conditions eg eczema/paget’s disease of nipple/psoriasis, nipple vasospasm
How do you distinguish bacterial from candidal nipple infection?
Bacterial=purulent discharge, crusting, redness, fissuring
Candidal=bilateral burning, itching, hypersensitivity
How do you manage a bacterial nipple infection?
Fusidic acid 2% cream 5-7 days, applied after each feed
How do you manage candida nipple infection?
Miconazole 2% cream, treat woman and infant at same time
Paget’s disease of the nipple management?
Urgent 2 week cancer pathway referral
3 causes of low milk supply to baby
Insufficient access to breast, ineffective infant positioning and attachment, maternal prolactin deficiency
2 causes of milk oversupply
Ineffective infant positioning and attachment (lots of suckling), breastfeeding pattern
Signs and symptoms of hypothyroidism
Fatigue, cold intolerance, wt gain, constipation, weakness, arthralgia, myalgia, menstrual irregularities, infertility, depression, dry skin, hair loss, oedema, goitre, bradycardia, pericardial effusion, peripheral neuropathy
TFTs for primary, secondary, postpartum thyroiditis for hypothyroidism
Primary=TSH above normal, FT4 low
Secondary= TSH low and FT4 low
Postpartum= TSH raised within a year of giving birth
Treatment of overt primary hypothyroidism?
Levothyroxine-empty stomach in morning before other food or medication
If autoimmune thyroid disease suspected, what to test?
Thyroid peroxidase antibodies (TPOAb)
Red flags of infantile GOR and what they suggets
projectile (pyloric stenosis), bile-stained vomit (obstruction), haematemesis (bleed), peristing after 1 year or onset after first 6 months (consider alternate diagnosis eg UTI), blood in stool (inflammation or infection), abdo distension/mass (obstruction), chronic diarrhoea (cows’ milk protein allergy)
Management of infantile GOR:
breastfeeding assessment, review formula fed infants- try smaller feeds. Consider 4 week trial PPI of H2RA who seem distressed and have faltering growth
What type of anaemia is caused by B12 and folate deficiency?
Macrocyctic
Most common causes of severe vit B12 deficiency?
Pernicious anaemia (autoimmune, reduced production of intrinsic factor),anti-intrinsic factor antibodies
Causes of folate deficiency?
Problems with dietary intake, increased folate usage, malabsorption eg coeliac (anti-endomysial or anti-transglutaminase antibodies)
Treatment of vitamin B12 deficiency anaemia?
IM Hydroxocobalamin. Foods with good B12- eggs, fortified products, meat, milk and dairy, salmon and cod. If dietary related, offer oral cyanocobalamin
How to treat folate deficiency anaemia?
Oral folic acid. Dietary sources=asparagus, broccoli, brown rice, brussels sprouts, chickpeas, peas
What type of care plan is used in generalised anxiety disorder?
Stepped care plan:
1=identify and assess-education on GAD and treatment options, active monitoring
2=Hasn’t improved after 1-low intensity pyschological interventions; individual non-facilitated or guided self help and psychoeducational groups
3=GAD not responding to 2-choice of high intensity psychological intervention or drug treatment
4=Very marked functional impairment/refractory to complex treatment GAD- specialist treatment
First line pharmacological treatment of GAD?
Second line?
Third line?
SSRI eg sertraline
Second= SNRI (serotonin noradrenaline reuptake inhibitor) or other SSRI eg paroxetine or venlaxafine
Third= pregabalin
What non pharmacological treatment options are there for GAD?
CBT, applied relaxation, self help (facilitated or guided)
How to treat Social anxiety disorder in children? and in adults?
Children-CBT
Adults-CBT then try SSRI
Microvascular complications of type 1 diabetes mellitus
retinopathy, nephropathy and neuropathy
Macrovascular complications of T1DM?
myocardial infarction, stroke, peripheral arterial disease
What clinical features in an adult for a diagnosis of T1DM?
Hypergylcaemia + at least one of:
Ketosis, rapid weight loss, age of onset <50 (don’t discount if over), BMI below 25 (don’t discount if over), personal/family history of autoimmune disease
Clinical features for diagnosis of T1DM in children?
Hyperglycaemia and polyuria, polydipsia, weight loss, excessive tiredness
When to suspect DKA?
known diabetes or significant hyperglycaemia with increased thirst/urinary frequency, wt loss, inability to tolerate fluids, D/V, abdo pain, visual disturbance, lethargy/confusion, fruity smell of acetone on breath, dehydration, acidotic breathing (Kussmaul respiration), shock
Signs and symptoms of hypoglycaemia?
Mild=hunger, anxiety, sweating, tingling lips, irritability, palpitations, tremor
As glucose levels falls= weakness, lethargy, impaired vision, incoordination, confusion, deterioration of cognitive function
Severe=convulsions, inability to swallow, loss of consciousness, coma
Target HbA1c for insulin therapy in T1DM? How often to measure HbA1c?
48mmol/mol (6.5%) or lower.
Measure every 3-6 months.
Optimal targets for glucose self-monitoring?
At least 4 times a day
Fasting plasma glucose=5-7mmol/L on waking
Plasma glucose 4-7 mmol/L before meals
5-9mmol/L at least 90 minutes after eating
Examples of lifestyle advice for T1DM?
Smoking cessation, regular exercise, avoid drinking on an empty stomach, carb-counting
DKA treatment?
Admit immediately for confirmation and emergency treatment with IV insulin, sodium chloride, include potassium chloride in fluids (unless anuria suspected)
Options for insulin regimes?
Multiple daily injection basal-bolus insulin regimens.
Mixed/biphasic regimen (2 or 3 insulin injections per day)
Continuous insulin infusion (pump).
5 factors that show an increased prevalence of autism?
Sibling with autism, CNS malformation/dysfunction, gestation <35 weeks, parental schizophrenia-like psychosis, maternal use of sodium valproate during pregnancy, learning disability, ADHD, encephalopathy, chromosomal disorders, genetic disorders, neurofibromatosis, tuberous sclerosis
What domains are assessed to aid a diagnosis of autism (broad categories of signs and symptoms)?
spoken language, responding to others, interacting with others, eye contact/pointing/gestures, ideas and imagination, interest and behaviours, other factors
How to help manage autism in adulthood?
Social learning programmes, structured leisure activity programmes, anti-victimisation interventions, supported employment programmes.AVOID medications
5 intrinsic risk factors of DVT?
5 RF that temporarily raise likelihood of DVT?
Intrinsic: history of DVT, cancer, age>60, overweight, male, HF, acquired or familiar thrombophilia, inflammatory disorders, varicose veins, smoking
Temporary: recent majoro surgery, recent hospitilisation, recent trauma, chemotherapy, significant immobility, prolonged travel, trauma to a vein, pregnancy and postpartum period, dehydration
Signs and symptoms of DVT?
Unilateral localised pain occurring when walking or bearing weight, and calf swelling. Tenderness. Skin changes-oedema, redness, warmth. Vein distension
What score (GP) to assess probability of DVT in suspected DVT? Describe
Two-level DVT Wells Score:
1 point for each of: active cancer, paralysis/paresis/recent plaster immobilisation of legs, recently bedridden for 3 days or more/major surgery within last 12 weeks, localised tenderness along distribution of deep venous system, entire leg swollen, calf swollen by more than 3cm compared to asx leg, pitting oedema confined to symptomatic leg, collateral superficial veins, previously documented DVT
Subtract two points if alternative cause is considered at least as likely as DVT
DVT likely if score is two points of more.
People with ‘likely’ DVT; what investigations?
Proximal leg vein ultrasound scan with results in 4 hours.
If can’t, then D-dimer, then interim therapeutic anticoagulation (apixaban or rivaroxaban are first line, if not use LMWH with vit K anatagonist) and ultrasound with results within 24 hours
Choices of anticoagulant for DVT? With classes
Warfarin (vit K antagonist), apixaban (factor Xa inhibitor), dabigatran (thrombin inhibitor), edoxoban (factor Xa inhibitor), rivaroxaban (factor Xa inhibitor)
DOACs = apixaban, dabigatran, edoxaban, rivaroxaban
What should be included in discussions for advance care planning for people with motor neurone disease?
Advance decisions to refuse treatment (ADRT), DNACPR, lasting power of attorney. Discuss providing anticipatory medications for in the home.
What medication to you give for muscle problems eg cramps in MND?
Quinine for cramps.
2nd line=baclofen. 3rd line=gabapentin
4 types of MND?
Amyotrophic lateral sclerosis (ALS), progressive bulbar palsy, progressive muscular atrophy, primary lateral sclerosis
How might MND present?
functional effects of muscular weakness eg trips
speech/swallowing problems or tongue fasciculations
muscle problems
breathing problems
effects of reduced respiratory function
may have cognitive features; behavioural changes, emotional lability, frontotemporal dementia
How does androgenic alopecia affect women and men?
Women-thinning in density of hair at crown and frontal scalp, widening of central parting. Rarely results in areas of total hair loss. 1/3 of white women over 70.
Men-initially involves front and sides of scalp and progresses towards back of head. 2/3 of white men by age 30.
How to treat alopecia?
Aesthetic solutions eg wigs
Pharmacologically:
Women=topical minoxidil 2% solution indefinitely (private)
Men=topical minoxidil or finasteride (private)
What scale is used to assess severity of hair loss in women?
Ludwig scale
What are cataracts?
Opacity that forms within lens. Leads to gradual and painless reduction in visual clarity and sharpness.
Causes of cataracts?
Most due to ageing and most common over age of 60.
Trauma, eye disease, systemic disease eg diabetes, congenital and developmental cataracts in children
What is glaucoma?
Damage to the optic nerve; asymptomatic to begin with but slowly deteriorates, affecting peripheral vision first (chronic open angle glaucoma)
What must you monitor in COAG?
Visual field assessments, optic nerve assessments, fundus examinations, central corneal thickness measurement, gonioscopy.
Intra-optical pressure measurement!
What IOP is optical hypertension and risks visual impairment at some stage in life? How to treat?
More than 24mmHg Prostaglandin analogue (PGA) eg lantanoprost
Serious differential diagnoses for red eye? (name 4)
acute glaucoma, corneal ulcer, contact-lens related, corneal foreign body, anterior uveitis, scleritis, trauma, chemical injuries, neonatal conjunctivits
Who must you always refer on to ophthalmologist with red eye?
Contact lens wearer! Anyone with suspected serious, potentially sight-threatening cause of red eye
Non-urgent causes of red eye? Name 3
Subconjunctival haemorrhage, episcleritis, ectropian/entropian trichiasis, blepharitis, infective/allergic conjunctivitis, corneal abrasion, dry eye, subtarsalar conjunctival foreign body
Describe common migraine presentation
Unilateral, pulsating or throbbing and lasts 4-72 hours
Symptoms aggravated by or cause avoidance of routine ADLs
With or without aura (transient focal neurolhical symptoms)
A/w nausea and/or vomiting and/or photophobia and phonophobia
Episodic vs chronic migraine?
Episodic=less than 15 days per month
Chronic=occurs on at least 15 days per month for more than 3 months
Management migraine?
Headache diary, avoidance known triggers, restriction of acute medication to max of 2 days per week (if medication overuse headache), ensure women who have migraine with aura not using combined hormonal contraceptive
Acute treatment=simple analgesia, oral triptan eg sumatriptan, consider offering anti-emetic eg metoclopramide
Preventative if indicated= propranolol or topiramate or amitriptyline
Differential diagnoses of acute cough (less than 3 weeks)?
Upper respiratory tract infection, coronavirus disease, acute exacerbation of pre-existing condition, acute bronchitis, pneumonia, pneumothorax, pulmonary embolism
Alcoholism which questionnaires can be used?
AUDIT-C then AUDIT if scores over 3 (Alcohol use disorders identification test). Total out of 40- if over 8 indicator of hazardous use, if over 20-assisted alcohol withdrawal needed
SADQ-severity of alcohol dependence questionnaire (20qs) or LDQ - leeds dependence questionnaire
APQ-alcohol problems questionnaire
Assisted alcohol withdrawal using which class of drug?
Benzodiazepine eg chlordiazepoxide or diazepam
After successful alcohol withdrawal, use what medications for maintenance?
Acamprosate-asap after withdrawal 1998mg unless less than 60kg=max 1332mg/day. Prescribe for up to 6 months
or Naltrexone-25mg/day and aim for maintenance of 50mg/day for up to 6 months
How does disulfiram work (alcohol withdrawal)?
Given at least 24 hours after last alcholic drink. 200mg/day. Produces an acute sensitivity to ethanol.
Natural history of HIV
Primary HIV infectiom/HIV seroconversion illness= flu-like. Between 10 days-6 weeks
Asymptomatic stage after PHI symptoms resolve
Advanced HIV disease (AIDS) when CD4<200 with AIDS-defining illnesses
Name for AIDS defining conditions: 1 neoplasm, 1 bacterial infection, 1 viral infection, 1 parasitic infection and 1 fungal infection
Neoplasm: cervical cancer, NHL, Kaposi’s sarcoma
Bacterial: TB, recurrent pneumonia, salmonella septicaemia
Viral: cytomegalovirus retinitis, cytomegalovirus, herpes simplex, progressive multifocal leukoencephalopathy
Parasitic: cerebral toxoplasmosis, cryptosporidiosis diarhhoea, isosporiasis, atypical disseminated leishmaniaisis
Fungal: pneumocystis pneumonia (PCP), candidiases, cryptococcosis, histoplasmosis, coccidioidomycosis, penicillosis
Who should we test for HIV?
People who request testing, people with RFs, people with another STI, have an indicator condition/clinical features of HIV, newly registered with a GP , all pregnant women, all children at risk of HIV infection
What should be involved in pre-HIV test counselling?
Benefits of HIV testing, details of how results will be given, significance of window period (repeat test may be needed during the 4-6 weeks it takes for antibodies to appear, may be up to 12 weeks), result will need to go into medical records, ensure informed consent given for the test
When to suspect prepatellar bursitis?
Localised swelling over patella, swelling is fluctuant (movable and compressible), normal range of joint movement (in contrast to septic arthritis), person reports max discomfort at extreme flexion of knee, preceding trauma or bursal disease (eg RA, gout, traumatic bursitis)
What investigations for pre-patellar bursitis?
Examination; swelling, erythema overlying patella, systemic signs of infection eg fever, increased warmth of skin overlying affected bursa compared to contralat knee, traumatic skin lesions overlying bursa
Diagnostic aspiration to differentiate septic bursitis from aseptic, bloods, imaging if dx unclear
Management pre-patellar bursitis?
Consider admission if systemically unwell or systemic bursitis, abscess, or immunocompromised
If clinically confident non-septic bursitis-advice RICE, simple analgesia.
If uncomplicated septic bursitis: aspirate bursal fluid, treat empirically to cover staph and strep eg flucloxacillin
Risk factors for osteoarthritis?
Genetic
Biological-increasing age, female sex, obesity, high bone density (development), low bone density (rapid progression)
Biomechanical-joint injury and damage, joint laxity and reduced muscle strength, joint malalignment, exercise stresses, occupational stresses
Features of osteoarthrtis?
Activity related joint pain, no morning joint-related stiffness (or less than 30 mins), functional impairment, tend to be over 45 years old
On examination: bony swelling and joint deformity, joint effusions(mostly knee), joint warmth, muscle wasting and weakness, restricted and painful range of joint movement, crepitus, joint instability
OA of the knee features?
Compartments and associated pain?
Bilat and symmetrical. Pain localised to associated compartment (medial or lateral tibiofemoral or patellofemoral).
Unilat OA of knee usually secondary to trauma or disease
Medial tibiofemoral-anteromedial pain mainly on walking
Lateral tibiofemoral-anterolateral pain mainly on walking
Patellofemoral-anterior knee pain worsened on inclines or stairs especially going down and progressive aching on prolonged sitting which is resolved on standing
Management OA of knee?
Self care management-wt loss, muscle strengthening exercises, appropriate footwear, heat/cold packs
Simple analgesia-paracetamol and topical NSAIDs
If simple analgesia doesn’t work- consider oral NSAIDs, opioids, topical capsaicin
Consider referrals for physio, OT, orthopaedics, podiatrist
What would COPD show on spirometry?
Peristent airflow obstruction
FEV1/FVC less than 0.7
If abnormal, what may be seen on examination with COPD?
Cyanosis, raised JVP, cachexia, hyperinflation of the chest, use of accessory muscles/purse lip breathing, wheeze and/or crackles on auscultation of the chest
What scale to assess breathlessness in COPD?
MRC (medical research council) dyspnoea scale
1=not troubled by breathlessness except during strenuous exercise
2=SOB on slight hill or hurrying
3=walks slower than contemporaries due to SOB
4=stops for breath after 100m or few minutes
5=breathless when dressing, too breathless to leave the house
How to treat acute exacerbation of COPD?
Consider admission.
If no admission required, increase dose or frequency of short-acting bronchodilators eg salbutamol or terbutaline. If no CIs, consider oral corticosteroids. Consider need for antibiotic-first choice is amoxicillin/doxycycline/clarithromycin
Management stable COPD?
Smoking cessation, pneumococcal and influenza vaccinations, pulmonary rehabilitation if indicated.
SABA (salbutamol, terbutaline) or SAMA (ipratropium) for breathless people and exercise limitation.
If no asthmatic features/steroid responsivenss; LABA (formoterol, salmeterol, indaceterol) and LAMA (tiotropium)
If asthmatic features, consider LABA plus ICS
Differential diagnoses of D+V?
Gastroenteritis-children tend to be norovirus
Food poisoning
Name 3 causes of shoulder pain
Rotator cuff, frozen shoulder, instability disorders, acromioclavicular joint disorders, glenohumeral joint OA, inflammatory or septic arthritis
Red flags in shoulder pain and what they might suggest?
Sudden loss of ability to actively raise arm-?rotator cuff tear
Mass or swelling-?malignancy
Red skin/painful joint/fever-?septic arthritis
Loss of rotation and abnormal shape-?shoulder dislocation
Inflammation in several joints-?Inflammatory arthritis
Management of a frozen shoulder?
Maintain movement but avoid movements which worsen pain
Analgesic ladder
Hot packs
Support arm with pillows in bed
Physiotherapy
Consider glenohumeral corticosteroid injection
How to manage rotator cuff disorder?
Rest in the acute phase
Physio
Corticosteroid injection
Analgesia
Name 4 risk factors for CKD?
Hypertension, DM, glomerular disease, AKI, nephrotoxic drugs (eg aminoglycosides, ACEi, ARBs), structural renal tract disease, BPH, SLE, vasculitis, myeloma, cardiovascular disease, obesity with metabolic syndrome
Describe the staging of CKD
Stage 1=>90mL/min/1.73m2 (eGFR)=normal Stage 2=60-89=mild reduction Stage 3a=45-59=mild to moderate Stage 3b=30-44=moderate to severe reduction Stage 4=15-29=severe Stage 5=<15=kidney failure
Management of CKD?
Assess for and manage RFs and co-morbidities of CKD.
Assess for htn and treat (caution)
Healthy lifestyle measures
Avoid over-the-counter NSAIDs
Monitor renal function-serum creatinine and eGFR and urinary albumin:creatinine (ACR), FBC
Management of dyspepsia?
Lifestyle: lose weight, avoid trigger foods, smaller meals and evening meal 3-4 hours before bed, stop smoking, reduced alcohol
Assess for stress and anxiety
Review medications esp. NSAIDs
Prescribe PPI eg omeprazole/lansoprazole for 1 month
Test for H.pylori
How do you confirm diagnosis of GORD?
Endoscope
RFs for GORD? Name 4
Stress and anxiety, smoking, alcohol, trigger foods (eg coffee, chocolate, fatty foods), obesity, drugs decreasing LOS pressure (alpha and beta blockers, NSAIDs, CCB, nitrates etc), pregnancy, hiatus hernia, family history
Management of proven GORD?
Lifestyle measures Sleep with head of bed raised Medication review Full dose PPI for 4 weeks If persistent/recurrent, consider switching to H2RA for a month eg ranitidine
Name 5 causes of scrotal swelling
Testicular torsion, testicular cancer, squamous cell carcinoma of scrotum, inguinal hernia, epididymo-orchitis, haematocele, epidiymal cyst or spermatocele, hydrocele, varicocele
When should you admit someone with inguinal hernia?
Features of strangulation or obstruction immediately
Infant or young boy-refer urgently to paeds surgeon
All others routinely referred
Indirect inguinal hernia position?
Why do they occur?
Hernia sac comes through inguinal floor medial to inferior epigastric artery and deep inguinal ring
If inguinal hernia extends into scrotum almost always indirect
Usually occurs because of a persistent processus vaginalis
Direct inguinal hernia position?
Why do they occur?
Hernia sac through the deep inguinal ring lateral to inferior epigastric artery
Occurs due to degeneration and fatty changes in aponeurosis of transversa;is fascia
Key things assessed in 6-8 week baby check?
Eyes (cataracts, red reflex), heart (murmurs), hip (DDH), testicles (see if undescended, if not descended by 6 months refer for surgery), weight, length, head circumference
Who is at risk of an AKI? (Name 5 risk factors)
CKD, HF, liver disease, DM, history AKI, oliguria, neuro/cognitive impairment, hypovolaemia, drugs (aminoglycosides, NSAIDs, ACEi, ARBs, diuretics), iodine-based contrast in past week, history urological obstruction, sepsis, deteriorating EWS, over 65
Definition of AKI
Increased serum creatinine by more than 26micromol/L in under 48 hours OR increased by 1.5 times the baseline OR urine volume<0.5ml/kg/hr for at least 6 hours
How do ACEi/ARBs affect AKI?
Cause hyperkalaemia. Altered haemodynamics-impair renal ability to maintain GFR when perfusion compromised
How do thiazide and loop diuretics affect AKI?
Potassium sparing?
Thiazide and loop: hypokalaemia, hypocalcaemia, hypomagnesaemia, hyponatraemia. Overdiuresis leading to hypoperfusion of kidneys can exacerbate AKI.
Preferred in AKI: loop>thiazide>K sparing
K sparing: hypoperfusion of kidney. Avoid in AKI
Overall effect of anti-hypertensives in AKI?
Hypotension and may exacerbate renal hypoperfusion
Positives of combined oral contraceptive?
Menstrual bleeding normally regular/lighter/less painful, decreased risk of ovarian and endometrial cancer, decreased acne severity, normally fertility returns immediately after stopping, sex uninterrupted (if started on day 1 of menstrual cycle, no additional contraception required), more effective than barrier methods (9% unintended pregnancies, 0.3% with perfect use)
Disadvantages of progestogen only pill?
Must be taken at same time every day, no STI protection.
Adverse effects: menstrual irregularities, breast tenderness, ovarian cysts, ectopic pregnancy, increased risk of cancer
Contraindications to COC pill?
MIGRAINE esp with aura, acute porphyrias, AF, Budd-Chiari, cardiomyopathy, current breast cancer, hepatocellular carcinoma, htn, IHD, less than 3 weeks postpartum, major surgery, PVD, antiphospholipid syndrome, DVT, smoking in patients over 35, stroke, SLE, TIA
Most effective contraceptive offered on NHS?
Progestogen-only implant
How to take POP?
Daily at same time, no pill-free interval. Started on days 1-5 of cycle (no barrier method required) if started later, other method of contraception required for 48 hours
Describe the WHO analgesic ladder
Step 1=non-opioid (± adjuvant) eg NSAID, paracetamol
Step 2=mild opioid (± non-opioid ± adjuvant) eg codeine
Step 3= strong opioid (±non-opioid ± adjuvant) eg morphine or hydromorphone
Where adjuvants=antidepressants, anticonvulsants, corticosteroids, anxiolytics etc
ECG signs for AF?
No p waves, irregularly irregular rhythm, absence of isoelectric baseline, variable ventricular rate, QRS less than 120ms, 100-175 bpm
What scoring system used to calculate risk of stroke in AF and whether anticoagulation needed? Describe
CHA2DS2VASc score
Congestive heart failure Hypertension Age over 75 (2 points) Diabetes mellitus Stroke or TIA (2 points) Vascular disease Age 65-74 Sex category
What scoring system to assess risk of bleeding in people on anticoagulation?
HAS-BLED
Hypertension Renal disease Liver disease Stroke history Prior major/disposition to bleeding Labile INR >65 Medication to predisposing to bleeding Alcohol use (>8/week)
Name 2 anticoagulants that are direct inhibitors of factor xa?
Apixaban
Rivaroxaban
Mechanism of action of warfarin? Monitoring requirements?
Vitamin K antagonist
Calculate time to therapeutic range (TTR), monitor INR (aim for between 2-3)
How does dabigatran etexilate work?
Direct thrombin inhibitor
How do we manage chronic AF?
Anticoagulation
Rate control-standard beta blocker or rate limiting CCB, if all fails then consider digoxin
Name 4 common side effects of ramipril. What is the class?
Angiontensin converting enzyme inhibitor (ACEi)
Persistent dry cough, headaches, dizziness, rash.
Also: alopecia, chest pain, constipation, diarrhoea, drowsiness, palpitations, myalgia, altered taste, sleep disorder, syncope. GI disorders, increased risk of infection, muscle spasms
What class for amlodipine? Name 5 common side effects?
Calcium channel blocker (CCB)
Headaches, dizziness, flushing, pounding heartbeat, swollen ankles
Also: abdo pain, skin reactions, vomiting, asthenia, joint disorders, cramps
Describe mechanism of action of metformin?
Class=biguanide
Decreases gluconeogenesis and increases peripheral utilisation of glucose. Only acts in presence of endogenous insulin.
Common side effects of metformin? Name 5
Nausea, diarrhoea and vomiting, stomach ache, loss of appetite, metallic taste in mouth
Name 5 common side effects of atorvastatin?
Nausea, headaches, myalgia, nosebleeds (epistaxis), sore throat, cold-like symptoms and asthenia, constipation or flatulence, diarrhoea
Class of furosemide? Name 5 common side effects
Loop diuretic-ascending limb of loop of Henle
Polyuria, polydipsia with dry mouth, headache, dizzy, muscle cramps, N/V, fast or irregular heartbeat
Key points in the history pointing to atopic eczema?
Presence of itching, usually starting in infancy, episodic, history of atopy (personal or family), possible trigger factors (irritant allergens, clothing, skin infections, contact allergens, inhalant allergens, hormonal triggers, climate, diet)
Where is eczema normally found on infants?
Face, scalp and extensor surfaces of limbs. Nappy usually spared
Where is eczema found in children and adults with long-standing disease?
Flexure of limbs
Management of eczema?
Avoid triggers, generous emollients, topical corticosteroid (eg hydrocortisone 1% for mild, betemathasone valerate 0.025% for moderate or 0.1% for severe). If severe itch consider antihistamine one month-trial.
If not responding to topical steroids, consider calcineurin inhibitor eg tacrolimus
If signs of infected eczema, swab skin and prescribe oral antibiotic (flucloxacillin)
Abdominal aortic aneurysm (AAA) screening available to men? When for women?
Men over 66
Women over 70 if they have risk factors
RFs for AAA
COPD, coronary disease, cerebrovascular disease, peripheral arterial disease, family history AAA, hyperlipidaemia, hypertension, smoke/history of smoking
When should aneurysm repair be considered in AAA?
Symptomatic
Asymptomatic >4cm and grown by more than 1cm in 1 year
Asymptomatic and at least 5.5cm
Key differentials for back pain? Name 6
Cauda equina, spinal fracture, cancer, infection, lumbar muscular strain, herniated nucleus pulposus, spinal stenosis, abnormal posturing, depression, osteoarthritis, pregnancy, sciatica
Red flags for cauda equina?
Severe/progressive bilateral neurological deficit of legs, recent-onset urinary retention and/or incontinence, recent-onset faecal incontinence, perianal or perineal sensory loss, unexpected laxity of anal sphincter
Red flags for spinal fracture?
sudden onset of severe cerebral spinal pain relieved by lying down, history major or minor trauma, structural deformity of spine, point tenderness over vertebral body
Red flags for cancer as cause of back pain?
Over 50, gradual onset symptoms, severe unremitting pain, aching night pain disturbing sleep. thoracic pain, pain aggravated by straining, localised spinal tenderness, no symptomatic improvement after 4-6 weeks of conservative low back pain therapy, unexplained weight loss, PMH cancer
Name 5 life threatening causes of low back pain?
AAA, adrenal haemorrhage, aortic dissection, cauda equina, cervical fracture ,, chronic stable angina, epidural abscess, PE, retroperitoneal haematoma, traumatic aortic rupture, vertebral fractures
Management of non specific low back pain?
Continue with normal activities, NSAID, consider physiotherapy
Management of short term insomnia (less than 3 months)
Sleep hygiene and sleep diary for 2 weeks (to deduce patterns )
If sleep hygiene measures ineffective and insomnia likely to resolve soon, consider short course (3-7 days) of a non-benzodiazepine hypnotic medication/z-drug eg zoplicone or zolpidem
If unlikely to resolve-CBT-I, with potential adjunct if short term hypnotic
Management of long term insomnia (more than 3 months)
Sleep hygiene
CBT-I
Avoid pharmacological treatment if possible
For over 55s, consider treatment with modified-release melatonin
Differential diagnoses of insomnia?
Obstructive sleep apnoea, circadian rhythm disorders (jet lag, shift work), restless legs syndrome, narcolepsy, parasomnias, depression, leg cramps
How to manage restless legs?
Prevent attacks: Sleep hygiene, decrease caffeine and alcohol, stop smoking, moderate regular exercise
Relieve attack: walking and stretching, applying heat, relaxation, mental distraction, massaging
For moderate to severe symptoms- non-ergot dopamine agonist eg pramipexole or ropinirole or an alpha-2-delta ligand eg pregabalin or gabapentin
How to manage newly diagnosed asthma?
Annual influenza vaccination, avoid trigger factors, advice on weight loss and smoking cessation, inhaler demonstration
- Inhaled SABA eg salbutamol, terbutaline
- If SABA 3/7 ± asthma symptoms 3/7 ± woken at night use ICS eg beclometasone, budenoside, ciclesonide, fluticasone, mometasone
- Add on therapy- oral LTRA (leukotriene receptor antagonist) eg montelukast or zafirlukast then switch to LABA eg formeterol or salmeterol
Moderate asthma exacerbation features?
PEFR 50-75%,normal speech
Acute severe asthma exacerbation features?
PEFR 33-50%, RR at least 25/min (over 12 years), HR 110bpm (over 12), inability to complete sentences in one breath, accessory muscle use, sats at least 92%
Life threatening asthma exacerbation features?
PEFR less than 33%, sats less than 92%, altered consciousness, exhaustion, cardiac arrhythmia, hypotension, cyanosis, poor respiratory effort, silent chest, confusion
When to admit for asthma exacerbation?
Life threatening features
Severe features persisting after initial bronchodilator treatment
Worsening symptoms on moderate and/or have had previous near-fatal asthma attack
How to manage asthma exacerbation while waiting for hospital admission?
Oxygen to hypoxic people
SABA-nebulized salbutamol (5mg to all over 5, 2.5mg to children 2-5 years)
Consider addition of nebulized ipratropium bromide
Quadruple ICS at onset of attack. If not suitable, course prednisolone
Monitor PEF and sats
Follow up 2 workings days within discharge
How to manage asthma exacerbation that does not required admission?
SABA adults=4 puffs, then 2 puffs every 2 minutes according to response up to 10 puffs
Quadruple ICS, if not, oral prednisolone
Follow up within 48 hours of presentation
Main cause of haemorrhoids? 3 other minor causes?
Constipation with prolonged straining.
Congestion from pelvic tumour, pregnancy, CCF, portal hypertension, age, heavylifting, chronic cough
Difference between internal and external haemorrhoids?
External-below dentate line, covered by modified squamous epithelium (anoderm). Itchy and painful
Internal-above dentate line, columnar epithelium, no pain fibres
Describe 1st/2nd/3rd/4th degree internal haemorrhoids.
1st=do not prolapse
2nd=prolapse on straining but reduced spontaneously when straining stops
3rd=required manual reduction
4th=prolapse and incarcerated, can’t reduce
Describe the blood seen in haemorrhoids?
Bright red, coats (doesn’t mix in with) stools, streaks on toilet paper and on toilet bowl
Management of haemorrhoids?
Clean and dry anal region, pat dry, don’t withhold stool and don’t overly strain.
Soft and easy to pass stools (laxative), adequate fibre and fluid intake
Simple analgesia
Referral: non-surgical eg rubber band ligation and surgical eg haemorrhoidectomy
Signs and symptoms of possible lung cancer-name 6
DVT, unexplained loss of appetite, persistent or recurrent chest infection, history of asbestos exposure, history of smoking, unexplained chest pain, cough, fatigue, shortness of breath, weight loss, finger clubbing, haemoptysis, lymphadenopathy
When should I refer people using cancer pathway for lung cancer?
CXR findings suggesting lung cancer or over 40 with unexplained haemoptysis
When should I offer an urgent CXR for lung cancer?
Over 40 with at least two of the following, or if they have ever smoked and have at least one of the following:
Cough, fatigue, SOB, chest pain, wt loss, appetite loss
Also consider if over 40 with any one of the following:
Persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy, chest signs consistent with lung cancer, thrombocytosis
Describe DSM-5 diagnostic criteria for depression
At least 5 out of possible 9 defining symptoms, present for at least 2 weeks
2 core symptoms: bothered by feeling down/depressed/hopeless, little interest or pleasure in doing things
Associated symptoms: disturbed sleep, weight/appetite changes, fatigue/loss of energy, agitation or slowing of movements, poor concentration or indecisiveness, feelings of worthlessness/excessive or inappropriate guilt, suicidal thoughts/acts
Differential diagnoses of depression?
Grief reaction. Anxiety disorders, bipolar, premenstrual dysphoric disorder, PD, MS, dementia, CO poisoning, substance misuse, hypothyroidism, obstructive sleep apnoea
Management of depression?
Assess risk of suicide
Depression questionnaires-PHQ-9, HADS, BDI-II
Active monitoring for those who don’t want intervention
Mild-mod or persistent subthreshold depressive symptoms-low intensity psychological intervention
Mod-severe-antidepressant and high intensity psychological intervention eg CBT
What would you offer for first episode of depression pharmacologically?
How long until effects seen?
When should you stop?
SSRI eg citalopram/sertraline/fluoxetine/paroxetine
Usually takes 2-4 weeks for symptoms to improve
Take for at least 6 months after recovery to prevent relapse
Other choices of antidepressants?
SSRI (selective serotonin reuptake inhibitor) eg sertraline
SNRI (serotonin noradrenaline reuptake inhibitor) eg duloxetine
Tricyclic antidepressants eg amitriptyline
When to review depressed patients with no increased risk suicide? and with increased risk suicide?
No=initially after 2 weeks then every 2-4 weeks for first 3 months
Yes (and for under 30s)=initial review within 1 week, then frequently thereafter
Side effects of antidepressants?
Suicidal thoughts/attempts, anxiety/agitation, insomnia, hyponatraemia, sexual dysfunction
Under mental health act what can you do under section 2 and 3?
2: compulsory admission for up to 28 days for assessment (need 2 doctors, one known to patient and one with specialism)
3: compulsory admission for up to 6 months for treatment
How do you differentiate postnatal depression from normal changes?
PND: PERSISTENT and marked depressed mood/sadness/irritability/absence of pleasure/difficulty concentrating or making decisions, hopelessness and overwhelming feelings of responsibility, feelings of guilt/worthlessness/being ‘bad’ mother, social withdrawal, symptoms of anxiety
Differential diagnoses of PND?
Baby blues (low mood after childbirth, mild and short term-starts 2nd/3rd day after birth and normally resolves by day 5) Postpartum psychosis Bipolar disorder PTSD OCD GAD
How to manage PND?
Mild-mod: facilitated self help
Mild-mod but history of severe depression: TCA/SSRI/SNRI
Mod-severe: high-intensity psych intervention eg CBT. Antidepressant as second line.
Paroxetine and sertraline are SSRIs of choice for breast feeding women
Potential complications of UTI?
Pyelonephritis, impaired renal function, urosepsis, pre-term delivery and low birth weight
How to diagnose UTI?
If less than 65, ad no RFs for complicated UTI=urine dipstick-UTI likely if positive for nitrites or leukocytes and RBC
If pregnant, over 65, persistent symptoms not resolving with antibiotics, recurrent UTI (2 in 6/12 or 3 in 12/12), urinary catheter or recent catheter, atypical symptoms, haematuria, RFs for complicated UTI=urine sample for culture
Treatment of uncomplicated UTI?
Simple analgesia
Encourage adequate intake of fluids
Nitrafurantoin 100mg bd for 3/7 or Trimethroprim 200mg bd 3/7
Which drug for uncomplicated UTI in pregnant women?
Nitrofurantoin, avoid at term, 100mg bd for 7/7
2nd line=amoxicillin or cefalexin
How to manage recurrent UTI?
Discuss behavioural and personal hygiene-avoid douching, wipe front to back, avoid occlusive underwear, avoid delay of habitual and post-coital urination, maintain adequate hydration
Manage the acute UTI, send urine sample before antibiotics started
Consider antibiotic prophylaxis eg trimethropim/nitrofurantoin single dose when exposed to a trigger
Presentation of trichomoniasis
Women= 50% asx, 50%=vaginal discharge, vulval itching, dysuria, offensive odour
Men=15-50%, rest urethral discharge and/or dysuria
Investigations for trichomoniasis?
Women=vaginal pH (more than 4.5 suggestive), high vaginal swab, speculum exam, inspect vulva, palpate abdomen
Men=urethral swab and/or first void urine
Treatment trichomoniasis?
Metronidazole 400-500mg bd for 5-7 days or 2g as a single dose (no single dose for breastfeeding women).
Screen for other STIs, treat partners ranging from 4 weeks prior to presentation, advise abstinence for at least 1 week
Presentation of chlamydia?
Women=70% asx, if sxs: increased vaginal discharge, post-coital or intermenstrual bleeding, purulent vaginal discharge, mucopurulent cervical discharge, deep dyspareunia, dysuria, pelvic pain and tenderness, cervical motion tenderness, inflamed or friable cervix
Men=50% asx, if sxs: dysuria, mucoid or mucopurulent urethral discharge, urethral discomfort, urethritis, epididymo-orchitis, reactive arthritis
Investigations for chlamydia?
(Annual screening for all sexually active under 25)
Women=endocervical or vulvovaginal swabs (first catch urine if preferred)
Men= first catch urine, rectal swabs
Send for NAAT
Treatment of chlamydia?
Doxycycline 100mg bd 7/7 (not in pregnancy)
If contraindications= azithromycin 1g 1/7 then 500mg od 2/7 or erythromycin 500mg bd 10-14 days
Screen for other STIs, sexual abstinence until treatment completed, partner notification
Complications of chlamydia?
Pelvic inflammatory disease can lead to tubal infertility, ectopic pregnancy, chronic pelvic pain
Chlamydia during pregnancy/vaginal labour can lead to infections of eyes, lungs, nasopharynx and genitals
Complications of gonorrhoea?
Men-epidiymitis, infertility, prostatitis.
Women-PID, a/w spontaneous abortion
Presentation of gonnorhoea?
Women=asx in up to 50%, otherwise, discharge, lower abdo pain, dysuria, intermenstrual bleeding, dyspareunia. Pharyngeal infection usually asx.
Men= mostly symptomatic; mucopurulent urethral discharge, dysuria, pharyngeal and rectal infection usually asx
Investigations for gonorrhoea?
NAAT; vulvovaginal swab or first pass urine (men). Ideally refer to GUM
Management gonorrhoea?
Ceftriaxone 1g IM STAT
If anogenital or pharyngeal=ciprofloxacin 500mg oral STAT
Screen for other STIs, partner notification, abstain for 1 week
Classification of syphilis?
Early syphilis within 2 years of infection= primary, secondary, early latent
Late syphilis after 2 years of infection=late latent syphilis, tertiary
Complications of syphilis?
Neurosyphilis, cardiovascular syphilis, gummatous syphilis, adverse outcomes in pregnancy, facilitation of HIV transmission
What is the usual defining sign of primary syphilis?
Primary chancre (genital lesion)
Signs suggestive of secondary syphilis?
Non pruritic maculopapular rash
Condylomata lata (moist wart like lesion)
Patchy lesions on oral mucosa/snail tract lesion
Generalised lymphadenopathy
Unexplained neurological or ophthalmological symptoms
Management of syphilis?
REFER TO GUM (not licensed for in GP, benzathine and procaine penicillin)
Specialist tests-dark field microscopy, PCR, serology
Partner notification, abstinence
Management of pelvic girdle pain in pregnancy/symphysis pubis dysfunction
Physio, manual therapy, pelvic floor/stomach/back/hip strengthening exercises, water exercises, positions for labour/birth/baby/sex, pain relief eg TENS, pelvic support belt and or crutches
Active as possible within pain limits, sit down to get dressed, get help with chores, flat supportive shoes, keep knees together getting in and out of car, sleep in comfortable position-pillow between legs, stairs 1 at a time or up on your bottom
Name 6 different symptoms of menopause
Hot flushes/night sweats, cognitive impairment and mood disoders, urogenital symptoms, genitourinary syndrome of menopause (vulvovaginal irritation, discomfort, burning, itching, dryness, dyspareunia, decreased libido, dysuria, frequency and urgency), altered sexual function, sleep disturbance, joint/muscle pain, headaches
When can women stop taking contraception? What age can you take COC up until?
In general, from age 55.
Potentially fertile for 2 years if menopause at <50
Potentially fertile for 1 year if menopause >50
Stop COC at 50
How to manage menopause?
Lifestyle management for flushes eg wt loss, exercise, fans, avoid triggers, light clothing. Sleep hygiene.
HRT-for vasomotor symptoms use a combined preparation (if uterus) or oestrogen-only prep (if no uterus). For urogenital symptoms-vaginal oestrogen.
Non-hormonal treatment options; vasomotor symptoms=SSRI or SNRI for 2 weeks, mood-CBT, vaginal moisturisers and lubricants
Risks of HRT?
VTE, CHD, stroke, breast cancer
Benefits of HRT?
decreased risk of fragility fracture, controls symptoms. Before 50, can use COC as symptomatic control.
Adverse effects of HRT?
Oestrogen related= fluid retention, nausea, bloating, headaches, cramps
Progestogen related=fluid retention, breast tenderness, headaches, migraine, mood swings, PMS like symptoms, depression, acne vulgaris, lower abdo and back pain
Vaginal bleeding
Contraindications to HRT?
Current/past breast cancer, oestrogen-dependent cancer, undiagnosed vaginal bleeding, VTE, arterial thromboembolic disease, acute liver disease, pregnancy, thrombophilic disorder
Describe the presentation of rheumatoid arthritis
Symmetrical, polyarticular, mainly small joints of hand and feet (although any synovial joint can be affected). Early morning stiffness over 30-mins-1hour, pain worse at rest
May present with: Rheumatoid nodules, vasculitis, malaise/fatigue/fever/sweats/weight loss, family history
What investigations for rheumatoid arthritis?
Rheumatoid factor present in 60-70%
Anti-cyclic citrullinated peptide (anti-CCP) in 80%
Arrange x-ray of hands and feet
FBC, U/E, LFT, CRP, ESR
How to manage confirmed rheumatoid arthritis? (secondary care)
cDMARD as monotherapy eg methotrexate, leflunomide, sulfasalazine.
Hydroxychloroquine may be used as alternative for people with palindromic disease
Consider use of biologics eg TNF inhibitors-adalimumab, etanercept or other agents eg rituximab
How to manage a RA flare?
Glucocorticoid injection or NSAID and PPI
What does cervical cancer screening involve?
Primary human papillomavirus (HPV) screening, liquid based cytology to detect abnormalities of cervix, colposcopy to diagnose cervical intraepithelial neoplasia
Who is cervical screening offered to?
What happens to pregnant women requiring screening?
25-49 year olds= every 3 years
50-64 year olds=every 5 years
First invitation by 24 and a half
Rearrange for pregnant women until at least 12 weeks post partum
When can you not take a cervical sample for screening purposes?
Menstruating, less than 12 weeks post partum, less than 12 weeks after termination of pregnancy or miscarriage, vaginal discharge or pelvic infection, ideally avoid if pregnant (but if abnormality previously continue)
Stages of CIN (cervical intraepithelial neoplasia)
CIN1=1/3 thickness of surface layer of cervix affected
CIN2=2/3
CIN3=full thickness
When should you suspect endometriosis?
If at least one of the following:
Chronic pelvic pain (>6 months cyclical or continuous pain), period-related pain affecting daily activities and quality of life, deep pain during or after sexual intercourse, period-related or cyclical GI symptoms, period-related or cyclical urinary symptoms (haematuria or dysuria), infertility in association with the above
How to manage suspect endometriosis?
Only can diagnose definitively by laparoscopic visualisation of the pelvis (referral)
Short term trial (3 months) of paracetamol and/or NSAID
Hormonal treatment eg COC/POP
In secondary care=surgical management or combination (excision/ablation then hormonal treatment)
Name 5 differential diagnoses of endometriosis.
Uterine-fibroids, primary dysmenorrhoea, uterine myoma
Urological-cystitis, recurrent UTIs
GI-IBD, IBS, appendicitis, gastroenteritis, coeliac disease
When should you consider offering a PSA test?
Men with LUTS, erectile dysfunction, visible haematuria, unexplained symptoms that could be due to advanced prostate cancer eg lower back pain/bone pain/wt loss
Avoid offering to asymptomatic men
Limitations of PSA testing?
False negatives (15% may have prostate cancer and 2% of those will have high-grade cancer) False positives (75% of positives will have a negative prostate biopsy) Unnecessary investigations Unnecessary treatment (clinically not evident)
Can’t perform if: active urinary infection, ejaculated in last 48 hours, vigorous exercise in last 48 hours, prostate biopsy in previous 6 weeks
What is a normal PSA?
0-4ng/ml
If 50-69 years old and at least 3.0ng/ml urgent cancer pathway referral
What are the signs and symptoms of bacterial meningitis?
Name 4 non specific
Name 5 specific
Non specific= fever, nausea/vomting, lethargy, irritability, ill appearance, refusing food/drink, headache, muscle ache/joint pain, resp symptoms/breathing difficulties
Specific=non-blanching rash, stiff neck, cap refill more than 2 seconds, cold hands and feet, unusual skin colour, shock and hypotension, leg pain, back rigidity, bulging fontanelle, photophobia, Kernig’s sign, Brudzinksi’s sign, unconsciousness, paresis, focal neurological deficit, seizures
Describe the rash in bacterial meningitis or meningococcal septicaemia.
Non blanching-either petechial (less than 2mm diameter) or purpuric/haemorrhagic rash (more than 2mm diameter)
Can use the glass test
Main differential diagnoses of bacterial meningitis
Viral/fungal/tuberculous/drug-induced meningitis Sepsis Pneumonia Encephalitis Malignancy HIV infection SAH
Initial management of suspected bacterial meningitis
Call 999
Paranteral benzylpenicillin (IM-into warmest part of limb) 300mg if younger than 1, 600mg if 1-9 years old, 1200mg for over 10 year olds
Manage close contacts (notifiable disease) with antibiotic prophylaxis ideally within 24 hours of the first presentation
Risk factors for bacterial meningitis
Young age (younger than 2), winter, absent/non-functioning spleen, older age (over 65), immunocompromised, incomplete immunisation, cancer, organ dysfunction, smoking, overcrowded living, cranial anatomical defects, cochlear implants, contiguous infection, sickle cell disease
Common causes of bacterial meningitis in a) neonates, b)adults
A) Streptococcus agalactiae, Escherichia coli, S pneumoniae, Listeria monocytogenes
B) S. pneumoniae, Neisseria meningitidis, H. influenzae type b
NB/ MenC vaccination so group B (MenB) accounts for most meningococcal cases
Potential complications of bacterial meningitis?
Complications more common following pneumococcal meningitis
Cerebral infarction in 1 in 4 lead to focal neuro deficits: hearing loss, seizures, cognitive impairment, motor deficit, visual impairment
Hydrocephalus
Amputations and scars
Name 7 differential diagnoses of falls
General=mechanical eg poor footwear, visual impairment, polypharmacy
Cardiovascular=arrhythmias, orthostatic hypotension, bradycardia, valvular heart disease
Neurological=stroke, peripheral neuropathy
Genitourinary=incontinence, UTI
Endocrine=hypoglycaemia
Musculoskeletal=arthritis, disuse atrophy
ENT=benign paroxysmal positional vertigo, ear wax
Who is usually affected by otitis media?
0-4 years old
Especially those subject to passive smoking, attend daycare/nursery, are formula fed or have craniofacial abnormalities
Differential diagnoses of ear discharge
Otitis media, otitis media with effusion (glue ear), chronic suppurative otitis media (more than 2 weeks), myringitis
Management of otitis media
Simple analgesia
Advise usual course is 3 days but may be up to 1 week
If antibiotics required (bacterial not viral cause) 5-7days amoxicillin
What is the weighted 7 point checklist for melanoma?
Major (2 points each)=change in size, irregular shape or border, irregular colour
Minor (1 point each)=largest diameter at least 7mm, inflammation, oozing/crusting, change in sensation (including itch)
Urgent referral if at least 3 points/new nodules pigmented or vascular/nail changes
Name the 4 different types of melanoma
Superficial spreading, nodular, lentigo or acral lentiginous
Differential diagnoses of melanoma (pigmented lesion)
Moles/naevi, sebarrhoeic keratoses, dermatofibromas, freckles, lentigines, pigmented BCC
Differences between BCC and SCC
BCC-pearly or waxy nodule, prominent fine blood vessels around lesion, raised rolled edges, slow growing. Routine referral
SCC-faster growth (weeks-months), may ulcerate, tender/painful, smoking is a big RF. Urgent referral
What is an actinic keratosis? How to manage?
Solar keratosis, precancerous SSC.
Flat or thickened papule/plaque, white/yellow scaly/warty/horny surface, skin coloured/red/pigmented, tender or asx
Removal, or use creams-diclofenac, 5-fluorouracil (efudix), imiquimod
Differential diagnoses of abdominal pain.
Name 6
GI: gastroenteritis, obstruction, hernia, intussuscpetion, Meckel’s diverticulum, colic/cholecystitis, ulcer, diverticulitis, pancreatitis, IBS, IBD, constipation
Urological: ureteric colic, pyelonephritis, UTI, urinary retention, testicular torsion
Gynaecological: ectopic pregnancy, ruptured ovarian cyst, ovarian torsion, PID, endometriosis, fibroids, dysmenorhhoea
What is the difference between diverticulosis, diverticular disease and diverticulitis?
Diverticulosis=diverticula but no symptoms, normal incidental finding
Diverticular disease= diverticula causing symptoms, no inflammation/infection. Intermittent LLQ pain, may be triggered by eating, may be relieved by passage of stool or flatus, constipation or diarrhoea, occasional large rectal bleeds, bloating and passage of mucus rectally
Diverticulitis=diverticula have become inflamed and infected
Management of diverticular disease
Diet management-increase fibre intake gradually up to 30g/day, balanced diet, regular meals, adequate fluid intake
Analgesia-avoid NSAIDs and opioids
Encourage weight loss if applicable, smoking cessation
Consider prescribing bulk forming laxatives if high fibre diet insufficient or if symptoms persist eg ispaghula husk (psyllium) and sterculia, or methylcellulose or wheat/oat bran
Consider referral to specialist in colorectal surgery
What is polymyalgia rheumatica?
Symptoms and additional features
Chronic systemic rheumatic inflammatory disease characterised by aching and morning stiffness in the neck, shoulder and pelvic girdle
Most common inflammatory rheumatic disease in older people (over 50)
Pain worse with movement and interferes with sleep, may radiate to elbow/knees, stiffness for at least 45 minutes after waking
Potential additional features=low-grade fever, fatigue, anorexia, wt loss and depression, bilat upper arm tenderness, peripheral MSK signs eg carpal tunnel, peripheral arthritis, swelling with pitting oedema
How to diagnose PMR?
Exclusion blood tests. ERR/CRP raised=supportive of diagnosis
How to manage PMR?
If most likely diagnosis:
Trial of oral prednisolone 15mg/day and arrange follow up within 1 week to assess clinical response
Reduce dose slowly when symptoms fully controlled
Blue steroid card for patient
Name 5 differential diagnoses of weight gain
Increased intake; dietary, social/behavioural, iatrogenic
Decreased expenditure; sedentary lifestyle, smoking cessation
Neuroendocrine; polycystic ovarian syndrome, hypothyroidism, Cushing’s syndrome, hypogonadism, GH deficiency, hypothalamic obesity
Genetic causes
Name 3 common drugs that cause weight gain
Antidepressants eg citalopram, fluoxetine (Prozac), sertraline
Diabetic medications eg insulin, sulfonylureas
Corticosteroids-methylprednisolone, prednisolone, prednisone
Antiepileptics- amitriptyline, valproic acid
Beta blockers-atenolol, propanolol
Describe gout
Disorder of purine metabolism associated with hyperuricaemia and deposition of urate crystals in joints and other tissues
What are the causes of hyperuricaemia?
Normally due to impaired renal excretion of urate (around 90%)
10% due to over-production of urate
Secondary causes=hypertension, hyperparathyroidism, Down’s syndrome, lead nephropathy, sarcoidosis, medication, chronic renal disease, volume depletion, glycogen storage disorders, polycythaemia
Risk factors for Gout
alcohol intake, dietary intake purines (red meat and seafood, fructose in sugary drinks), use of drugs (ACEi, beta blockers, ciclosporin, diuretics, pyrazinamide, tacrolimus), family history, older age, men
What investigations for gout?
Joint fluid microscopy and culture-negatively birefringent needle shaped monosodium urate crystals
Serum uric acid 4-6 weeks after acute attack
Consider XRay
Management of gout:
Acute and prevention
Acute= Rest, elevate, avoid trauma, keep joint exposed, wt loss/exercise/diet/alcohol consumption/fluid intake advice. NSAID at max dose and co prescribe PPI or colchicine until 1-2 days after attack resolved
Prevention=allopurinol (titrate upwards) until SUA less than 300. When initiating treatment or increasing dose also take colchicine for prophylaxis against acute attack.
Febuxostat is second line after allopurinol.
Name 5 differential diagnoses of weight loss
Most common=malignancy, GI conditions, psychiatric causes
Cachexia syndromes a/w organ failure eg HF, COPD, renal failure
Endocrinopathies eg hyperthyroidism, diabetes mellitus, adrenal insufficiency
Serious infections eg HIV, TB
Medication side effects eg fluoxetine, sulphasalazine, topiramate
Substance abuse
Social factors preventing adequate access to food
How to manage a child presenting with a fever?
Over 38 degrees
Use NICE traffic light system to assess child
Advice on antipyretic drug eg paracetamol every 4-6hours or ibuprofen every 8 hours
NOT ASPIRIN
General self care advice eg fluids, dressing appropriately, checking regularly, don’t use tepid sponging, keep away from school/nursery
Safety netting advice for more serious cause eg meningitis signs
Presentation of measles infection
15-20 new cases from original 1 case
Infectious from when symptoms first appear to 4 days after onset of rash
Cough and coryzal symptoms, conjunctivitis, fever, maculopapular rash
May have Koplik’s spots on buccal mucosa at end of prodomal phase (for 2-4 days, 10-12 days after contraction)
Describe the rash in measles
Erythematous and maculopapular
Face and behind ears originally then descends down to the trunk and limbs, affecting hands and feet last
3-4 days
May have Koplik’s spots (2-3mm red spots with white centres)
Management of measles
Usually self limiting, rest and drink fluids, paracetamol/ibuprofen, stay away from school, avoid contact with susceptible people (not vaccinated, infants, pregnant, immunosuppressed)
Close contacts to be vaccinated (MMR)
Differential diagnoses of measles-like rash
Parvovirus B19, strep infection eg scarlet fever, herpes virus type 6 (roseola infantum), rubella, early meningococcal disease
Also think: Kawasaki disease and infectious mononucleosis
Name 4 risk factors for hypertension
Which ethnicity most at risk?
Age, sex (<65 more men, 65-74 more women), ethnicity (Black African and Black Caribbean), genetics, social deprivation, lifestyle-smoking/alcohol/salt/obesity/lack of physical activity, anxiety and emotional stress
How to achieve diagnosis of hypertension?
If 140/90mmHg in clinic, take a second measurement (may need third) and take the lowest recorded as the reading
If between 140/90mmHg and 180/120, offer ABPM to confirm, or home BPM (HBPM) if ABPM unsuitable
If over 180/120 or life threatening symptoms refer for same day specialist assessment for sign of retinal haemorrhage or papilloedema
Name the different stages of hypertension
Stage 1=140/90 to 159/99 clinic BP and ABPM/HBPM 135/85 to 149/94
Stage 2=clinic at least 160/100 and A/HBPM at least 150/95
Stage 3/severe hypertension= clinic at least 180 systolic or diastolic at least 120
Name 5 secondary causes of hypertension
5Cs
Renal disorders eg PKD, glomerulonephritis, RCC, diabetic nephropathy
Vascular disorders
Endocrine disorders eg primary hyperaldosteronism, phaeochromocytoma, Cushing’s syndrome, acromegaly, hypo/hyperthyroidism
Drugs eg alcohol, cocaine, EPO, corticosteroids
Obstructive sleep apnoea, connective tissue disorders
CKD, conn’s, COC, coarctation aorta, cushing’s
Management of hypertension?
Lifestyle advice-no excessive caffeine, diet (reduce sodium) and exercise, smoking cessation, reduce alcohol etc
Step 1: <55 and not black=ACEi/ARB. If >55 and/or black=CCB. IF evidence of HF offer thiazide like diuretic
Step 2: ACEi/ARB and CCB/thiazide-like diuretic
Step 3: ACEi/ARB and CCB and thiazide-like diuretic
Step 4: resistant hypertension; add a 4th drug or specialist. If K<4.5 use diuretic therapy with spirinolactone, if K>4.5 use alpha or beta blocker
Annual review
Name an ACEi, ARB, CCB, thiazide-like diuretic, alpha and beta blocker
ACEi-ramipril, lisinopril, enalapril
ARB-candersartan, valsartan, olmesartan
CCB-amlodipinem felodipine, nimodipine, nifedipine
Thiazide-like diuretic-indapamide, bendroflumethiazide
Alpha blocker-tamsulosin, doxazosin, prazosin
Beta blocker-atenolol, propranolol
Describe the 3 different classifications of heart failure
- By ejection fraction: HF-REF and HF-PEF
- By time course: chronic or acute
- New York Heart Association (NYHA) functional classification based on on symptom severity
Describe NYHA classification of heart failure
Class 1=no limitation on physical activity
Class 2=slight limitation, comfortable at rest but ordinary physical activity leads to undue breathlessness/fatigue/palpitations
Class 3=marked limitation
Class 4=unable to carry out any physical activity without discomfort, symptoms at rest may be present
What are the typical symptoms of HF?
Breathlessness (OE, at rest, orthopnoea, nocturnal cough, waking from sleep/paroxysmal nocturnal dyspnoea)
Fluid retention (ankle swelling, bloated feeling, abdo swelling, weight gain)
Fatigue
Decreased exercise tolerance, increased recovery time after exercise
Light headedness, syncope
What could be found on examination in a person with heart failure?
Tachycardia, laterally displaced apex beat, heart murmurs, 3rd and 4th heart sounds (gallop rhythm), hypertension, raised JVP, hepatomegaly, resp signs eg tachypnoea/basal crepitations/pleural effusions, dependent oedema/ascites, obesity
Investigations for suspected heart failure?
N-terminal pro-B-rype natriuretic peptide level (NT-proBNP): if over 2000 2 week urgent referral, between 400 and 2000 6 week referral, less than 400=HF unlikely
Arrange 12 lead ecg
Consider other tests
What things may lead to increased BNP?
HF, age over 70, left ventricular hypertrophy, RV overload, hypoxia, pulmonary hypertension, PE, CKD (less than 60ml/min eGFR), sepsis, COPD, diabetes mellitus, cirrhosis
How to manage HF?
HF-PEF?
HF-REF?
General: symptom report, monitor weight at home, avoid excessive salt, severe symptomatic should limit fluid intake (less than 1.5-2L/day), smoking cessation, drink safely, regular low intensity physical exercise if stable HF, maintain healthy weight
PEF: loop diuretic -up to 80mg furosemide
REF: loop diuretic, ACEi and beta blocker (start one at a time). Consider if antiplatelet and/or statin therapy required. Influenza and pneumococcal vaccine
Name 6 causes of dementia
Main ones: Alzheimer’s disease, vascular dementia, dementia with lewy bodies, frontotemporal dementia
Rarer causes: PD, progressive supranuclear palsy, HD, prion disease, normal pressure hydrocephalus, chronic subdural haematoma, benign tumours, vitamin deficiencies eg B12 and thiamine
Describe Alzheimer’s disease (pathophysiology) and defining features
50-75% of dementia
Atrophy of cerebral cortex and formation of neurofibrillary tangles. ACh production in affected neurones reduced
Early impairment of episodic memory
Describe vascular dementia defining features
Up to 20% of dementia
Often co-exists with AD
Stepwise increase in severity
Describe dementia with Lewy bodies and defining features
Cortical and subcortical Lewy bodies (abnormal protein deposits inside nerve cells)
May have similar features to Parkinson’s disease dementia, Parkinsonian motor features
Describe frontotemporal dementia and defining features
Progressive degeneration of front and/or temporal lobes
Generally insidious onset
Personality changes
Potential presentation of dementia (generalise)
Cognitive impairment: memory problems, receptive or expressive dysphasia, difficulty with coordinated movements, disorientation, impairment of executive function
Fluctuating behavioural and psychological symptoms: psychosis, agitation, depression, withdrawal/apathy, disinhibition, motor disturbance eg wandering, sleep cycle disturbances
Difficulties with ADLs
Name 3 different dementia screening tools that can be used to aid diagnosis
6-CIT (6 item cognitive impairment test) 10-CS (10 point cognitive screener) MIS (memory impairment screen) Mini-cog TYM (test your memory)
How to manage confirmed dementia?
Must inform DVLA
Refer on for specialist assessment and management
Specialist drugs if AD: acetylcholinesterase inhibitors eg donepezil/galantamine/rivastigmine, or can use memantine
Advance care planning
Non-pharm interventions eg animal therapy, massage
Monitor the care-giver
Differential diagnoses of abnormal vaginal discharge?
Vaginal infections: bacterial vaginosis, vaginal candidiasis, trichomoniasis
Endocervical infections: chlamydia, gonorhhoea
Non infective causes: retained foreign body, inflammation due to allergy/irritation, tumours, atrophic vaginitis, cervical ectopy/polyps, fistulae, recent childbirth
Physiological causes (normal!): pregnancy, contraceptive use, sexual stimulation, menopause
Describe the different vaginal discharge seen in BV, vaginal candidiasis and trichomoniasis
BV: fishy-smelling, thin, grey-white homogeneous, ph over 4.5
Candidiasis: odourless, white, curdy, pH less than 4.5
Trichomoniasis: yellow-green, frothy, fishy odour, pH over 4.5
Describe presentation of TB
Pulmonary=persistent productive cough a/w breathlessness and haemoptysis
Extra pulmonary features;
Lymphatic=lymphadenopathy, Spinal/joint=bone pain, Genitourinary or Gastrointestinal=abdo/pelvic pain/constipation/obstruction, Renal=sterile pyuria
TB meningitis=headache/vomiting/confusion, Cutaneous=erythema nodosum/lupus vulgaris, TB pericarditis=chest pain
General: wt loss, fever, night sweats, anorexia, malaise
Investigations for TB
CXR, deep cough sputum sample
Mantoux test or interferon gamma release assay (IGRA)
Management of TB?
Specialist assessment and management-NAATs
Rifampicin and isoniazid for 6 months
Pyrazinamide and ethambutol for first 2 months
Multi-drug resistant TB will be 18-24 months with more drugs
Immediate contact tracing (BCG) and infection control
May need DOT-directly observed therapy
Potential side effects of Rifampicin
Red urine, hepatitis, drug interactions (enzyme inducer)
Potential side effects of isoniazid
Hepatitis, neuropathy
Potential side effects of pyrazinamide
Hepatitis, gout, rash
Potential side effects of ethambutol
Optic neuritis
