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Year 4 Med > GP > Flashcards

GP Flashcards

1
Q

Anaphylaxis is what type of hypersensitivty reaction?

A

Anaphylactic shock is a rapid onset Type 1 IgE-mediated hypersensitivity reaction.

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2
Q

What dose of adrenaline is given in anaphylaxis for adults?

A

500micrograms
(0.5ml of 1 in 1000units)

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3
Q

What medications are used alongside adrenaline to manage anaphylaxis?

A

High flow oxygen and fluid challenge.
Hydrocortisone and Chlorphenamine after initial resuscitation.

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4
Q

What is septic shock?

A

Septic shock is sepsis with a systolic blood pressure <90mmHg that is not responsive to fluids.

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5
Q

Four key x-ray changes seen in osteoarthritis:

A

LOSS

L – Loss of joint space
O – Osteophytes
S – Subchondral sclerosis (increased density of the bone along the joint line)
S – Subchondral cysts (fluid-filled holes in the bone, aka geodes)

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6
Q

Presentation of osteoarthritis:

A

Osteoarthritis presents with joint pain and stiffness. This pain and stiffness tends to be worsened by activity in contrast to inflammatory arthritis where activity improves symptoms. It also leads to deformity, instability and reduced function in the joint.

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7
Q

Commonly affected joints in osteoarthritis:

A

Hips
Knees
Sacro-iliac joints
Distal-interphalangeal joints in the hands (DIPs)
The CMC joint at the base of the thumb
Wrist
Cervical spine

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8
Q

Signs of osteoarthritis seen in the hands:

A

Heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in the PIP joints)
Squaring at the base of the thumb at the carpo-metacarpal joint
Weak grip
Reduced range of motion

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9
Q

Management of osteoarthritis:

A

Start with patient education about the condition and advise on lifestyle changes such as weight loss if overweight to reduce the load on the joint, physiotherapy to improve strength to support the joint and occupational therapy and orthotics to support activities and function.

Stepwise use of analgesia to control symptoms.

Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms.

Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.

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10
Q

Stepwise analgesia approach for osteoarthritis:

A

Oral paracetamol and topical NSAIDs or topical capsaicin (chilli pepper extract).
Add oral NSAIDs and consider also prescribing a proton pump inhibitor (PPI) to protect their stomach such as omeprazole. They are better used intermittently rather than continuously.
Consider opiates such as codeine and morphine. These should be used cautiously as they can have significant side effects and patients can develop dependence and withdrawal. They also don’t work for chronic pain and result in patients becoming depending without benefitting from pain relief.

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11
Q

Summarise rheumatoid arthritis:

Practice aloud for OSCE’s.
- What is it? Pathophysiology? Who does it affect most commonly? How does it present?

A

Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa. It is an inflammatory arthritis. Synovial inflammation is called synovitis. Rheumatoid arthritis tends to be symmetrical and affects multiple joints. Therefore it is a symmetrical polyarthritis. Inflammation of the tendons increases the risk of tendon rupture.

It is three times more common in women than men. It most often develops in middle age but can present at any age. Family history is relevant and increases the risk of rheumatoid arthritis.

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12
Q

Genetic associations with rheumatoid arthritis:

A

HLA DR4 (a gene often present in RF positive patients)
HLA DR1 (a gene occasionally present in RA patients)

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13
Q

What antibodies are associated with rheumatoid arthritis?

A

Rheumatoid Factor (RF).

Cyclic citrullinated peptide antibodies (anti-CCP antibodies).

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14
Q

Why does rheumatoid factor cause rheumatoid arthritis?

A

Rheumatoid Factor (RF) is an autoantibody presenting in around 70% of RA patients. It is an autoantibody that targets the Fc portion of the IgG antibody. All antibodies have an Fc portion on them that is used to bind to cells of the immune system. Rheumatoid factor targets this Fc portion on immunoglobin G (IgG). This causes activation of the immune system against the patients own IgG causing systemic inflammation. Rheumatoid factor is most often IgM however they can be any class of immunoglobulin.

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15
Q

Explain anti-CCP in relation to rheumatoid arthritis.

A

Cyclic citrullinated peptide antibodies (anti-CCP antibodies) are autoantibodies that are more sensitive and specific to rheumatoid arthritis than rheumatoid factor. Anti-CCP antibodies often pre-date the development of rheumatoid arthritis and give an indication that a patient will go on to develop rheumatoid arthritis at some point.

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16
Q

Presentation of rheumatoid arthritis:

A

It typically presents with a symmetrical distal polyarthropathy. The key symptoms are joint:

Pain
Swelling
Stiffness
Patients usually attend complaining of pain and stiffness in the small joints of the hands and feet, typically the wrist, ankle, MCP and PIP joints in the hands. They can also present with larger joints affected such as the knees, shoulders and elbows. The onset can be very rapid (i.e. overnight) or over months to years.

There are also associated systemic symptoms:

Fatigue
Weight loss
Flu like illness
Muscles aches and weakness

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17
Q

Presentation of RA vs OA:

A

Pain from an inflammatory arthritis is worse after rest but improves with activity. Pain from a mechanical problem such as osteoarthritis is worse with activity and improves with rest.

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18
Q

Palindromic rheumatism:

A

This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days and then completely resolve. Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full rheumatoid arthritis.

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19
Q

Common joints affected in RA:

A

Proximal Interphalangeal Joints (PIP) joints
Metacarpophalangeal (MCP) joints
Wrist and ankle
Metatarsophalangeal joints
Cervical spine
Large joints can also be affected such as the knee, hips and shoulders.

The distal interphalangeal joints are almost never affected by rheumatoid arthritis. If you come across enlarged painful distal interphalangeal joints this is most likely to be Heberden’s nodes due to osteoarthritis.

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20
Q

Atlantoaxial subluxation

A

Atlantoaxial subluxationoccurs in the cervical spine. Theaxis(C2) and theodontoid pegshift within theatlas(C1). This is caused by local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis and the atlas. Subluxation can causespinal cord compressionand is an emergency. This is particularly important if the patient is having a general anaesthetic and requires intubation. MRI scans can visualise changes in these areas as part of the pre-operative assessment.

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21
Q

Hand signs for RA:

A

Palpation of the synovium in around joints when the disease is active will give a “boggy” feeling related to the inflammation and swelling.

Key changes to look for and mention when examining someone with rheumatoid arthritis are:

Z shaped deformity to the thumb
Swan neck deformity (hyperextended PIP with flexed DIP)
Boutonnieres deformity (hyperextended DIP with flexed PIP)
Ulnar deviation of the fingers at the knuckle (MCP joints)

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22
Q

Boutonnieres deformity:

A

Boutonnieres deformity (hyperextended DIP with flexed PIP).

Boutonnieres deformity is due to a tear in the central slip of the extensor components of the fingers. This means that when the patient tries to straighten their finger, the lateral tendons that go around the PIP (called the flexor digitorum superficialis tendons) pull on the distal phalynx without any other supporting structure, causing the DIPs to extend and the PIP to flex.

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23
Q

Extra-articular manifestations of rheumatoid:

A

Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
Bronchiolitis obliterans (inflammation causing small airway destruction)
Felty’s syndrome (RA, neutropenia and splenomegaly)
Secondary Sjogren’s Syndrome (AKA sicca syndrome)
Anaemia of chronic disease
Cardiovascular disease
Episcleritis and scleritis
Rheumatoid nodules
Lymphadenopathy
Carpel tunnel syndrome
Amyloidosis

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24
Q

Investigations done for rheumatoid:

A

The diagnosis of rheumatoid arthritis is clinical in patients with features of rheumatoid arthritis (i.e. symmetrical polyarthropathy affecting small joints). A few extra investigations are required at diagnosis:

Check rheumatoid factor
If RF negative, check anti-CCP antibodies
Inflammatory markers such as CRP and ESR
X-ray of hands and feet
Ultrasound scan of the joints can be used to evaluate and confirm synovitis. It is particularly useful where the findings of the clinical examination are unclear.

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25
Q

Associated symptoms indicating a serious cause / complication in patients with palpitations:

A

Breathlessness
Chest pain
Syncope
Onset with exercise

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26
Q

Associated symptoms indicating a serious cause / complication in patients with palpitations:

A

Breathlessness
Chest pain
Syncope
Onset with exercise

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27
Q

Relevant conditions to ask about in a history for patients with palpitations.

A
  • Hypertension, diabetes, obesity, sleep apnoea, and thyrotoxicosisare associated with atrial fibrillation and flutter.
  • Anaemia is associated with tachyarrhythmias.
  • Fever isassociated with ventricular extrasystoles and atrial fibrillation, as are lack of sleep and emotional stress.
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28
Q

What type of hypersensitivity reaction is anaphylaxis?

A

Type 1 IgE-mediated hypersensitivity reaction

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29
Q

Emergency treatment for anaphylaxis:

A

0.5mg adrenaline IM
(0.5ml of 1/1000)

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30
Q

How much adrenaline is given to patient in cardiac arrest?

A

1mg (1ml of 1/1000)
Note: Not given to patients with a pulse.

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31
Q

X-ray changes for RA:

A

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

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32
Q

What diuretic can cause gynecomastia as a side effect?

A

Drugs that cause gynaecomastia include oestrogens, anti-androgens and 5-alpha reductase inhibitors. Spironolactone is an aldosterone agonist but presents with both oestrogenic and anti-androgenic properties.

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33
Q

Only appropriate contraceptive method for a women with breast cancer:

A

Copper IUD

Non-hormonal methods such as the IUD are the only acceptable form of contraception in women with active breast cancer.

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34
Q

What are the 4 types of anticipatory medications to prescribe for a palliative care patient?

A
  • Anti-emetics
  • Analgesia
  • Agitation
  • Airway secretions
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35
Q

What is the main medication used for analgesia in palliative patients?

A

Morphine
Oxycodone when morphine is contraindicated.

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36
Q

When is morphine contraindicated for palliative patients?

A

Renal failure

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37
Q

What anti-emetics are used in palliative care?

A
  • Cyclizine
  • Haliperidol
  • Levomepromazine
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38
Q

What are used for airway secretions in palliative patients?

A

Glycopyronium
Hyoscine hydrobromide

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39
Q

What medications are used for agitation in palliative patients?

A

Haloperidol
Midazolam
Levomepromazine

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40
Q

Impetigo is commonly caused by what?

A

Staphylococcal and Streptococcal bacteria

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41
Q

Pruritic =

A

Itching

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42
Q

Impetigo treatment:

A

Fusidic acid
or
1% hydrogen peroxide cream

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43
Q

What causes a hydrocele?

A

During normal development, the testes develop in the abdomen and descend into the scrotum, usually before birth. The testes descend along the path of the processus vaginalis, which should obliterate. If the processus vaginalis doesn’t completely close, fluid from the abdomen can gradually accumulate in the scrotum, causing a hydrocele.

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44
Q

How is measles diagnosed?

A

Checking for measles IgM antibodies, either from a blood or saliva sample.

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45
Q

Recurrent chest infection and raise platelets on blood tests…

A

Investigate for lung cancer.

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46
Q

Raised platelets, recurrent chest infections, weight loss.
Chest x-ray is normal.

GP management??

A

CXR pick up 80% of lung cancers and miss 20%.

In patients high risk consider 2WW referral for CT.

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47
Q

Thrombocytosis LEGO C…

A

Cancers associated with thrombocytosis:

Lung cancer
Endometrial cancer
Gastric cancer
Oesophageal cancer
Colorectal cancer

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48
Q

What medications are important to stop in AKI?

High yield

A

Suspend nephrotoxic drugs: NSAIDs, aminoglycosides e.g. gentamicin, ACE inhibitors/ARBs, and diuretics.
Suspend renally excreted drugs: metformin, lithium, digoxin.
Adjust renally excreted drugs e.g. opioids.

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49
Q

Classic nephrotoxic drugs:

A

Suspend nephrotoxic drugs: NSAIDs, aminoglycosides e.g. gentamicin, ACE inhibitors/ARBs, and diuretics.

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50
Q

What medications can increase serum potassium?

A

Note: drugs are one the commonest causes in primary care- most likely combination ACE + spiro.

ACE/ARB
Digoxin
Spironolactone, K-sparing diuretics
Beta Blockers
NSAIDs, aspirin
Potassium salts
K containing laxatives (movicol, fybogel)

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51
Q

Differentials of hyperkalaemia:

A

DKA (or any other metabolic acidosis)
AKI
Tissue cell breakdown (tumour lysis, rhabdomyolysis, haemolysis)
Addison’s Disease
Advanced CCF (chronic congestive heart failure).

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52
Q

What value of K+ results in emergency admission?

A

Emergency admission as K is over 6.5 and likely renal failure.

53
Q

Is Calcium or Adjusted Calcium most accurate and why?

A

~40% plasma calcium is bound to albumin. Total ‘calcium’ is measured but it is the unbound portion which is important and what ‘adjusted calcium” refers to. It is ‘adjusted” for the albumin.

54
Q

When to admit a patient with hyponatraemia?

A

Na</=126mmol = admit

55
Q

How to categorise patients with hyponatraemia?

A

Volume - hypovolaemic, euvolaemic, hypervolaemic.

56
Q

Hypovolaemic hyponatraemia

A
  • Burns
  • Sweating
  • Diarrhoea
  • Vomiting
  • Fistulae
  • Addison’s disease
57
Q

Euvolaemic hyponatraemia

A
  • Syndrome of inappropriate ADH release (SIADH)
  • Hypothyroidism
58
Q

Hypervolaemic hyponatraemia

A
  • Renal failure
  • Heart failure
  • Liver failure
  • Nephrotic syndrome
59
Q

What class of hyponatraemia is SIADH?

A

Euvolaemic

60
Q

What are the four different classes of causes of SIADH?

A

Hypoxia
Malignancy
Drugs
CNS Diseases

61
Q

What is the initial screen test for Hep C?

A

HCV antibody

62
Q

Why is cocp contraindicated in migraines?

A

Increased risk of stroke.

63
Q

Specific risk of aspirin:

A

GI Bleeds

64
Q

Hyoscine butylbromide often used to treat what?

A

IBS - smooth muscle relaxant
(Buscopan).

65
Q

Bleeding gums, think…

A

Scurvy

66
Q

What is deficient in scurvy?

A

Vitamin C aka ascorbic acid

Low body mass index and bleeding gums likely has scurvy due to ascorbic acid deficiency. It is also known as vitamin C. Patients with malnutrition, including those with anorexia nervosa, are at risk for a wide range of vitamin and mineral deficiencies. Other findings associated with scurvy include easy bruising, poor wound healing, coiled ‘corkscrew’ hairs with perifollicular haemorrhage, arthralgias and haemarthrosis.

67
Q

First line treatment for prolactinoma?

A

Bromocriptine

68
Q

Trauma leading to shortened, internally rotated leg could be what…?

A

Posterior hip dislocation

69
Q

What is Prehn’s sign?

A

Pain being relieved when elevating the testis (positive Prehn’s sign) makes a diagnosis of testicular torsion less likely.

70
Q
  • Unilateral testicular pain and swelling
  • Urethral discharge may be present, but urethritis is often asymptomatic
  • Dysuria
  • Positive Phren’s sign

Diagnosis?

A

Epididymo-orchitis

71
Q

Polydypsia + polyuria with high plasma osmolality and a low urine osmolality = what?

A

Cranial diabetes insipidus

72
Q

Diabetes insipidus is classified into what to groups?

A

Diabetes insipidus (DI) is a condition characterised by either a decreased secretion of antidiuretic hormone (ADH) from the pituitary (cranial DI) or an insensitivity to antidiuretic hormone (nephrogenic DI).

73
Q

Why is doxycycline contraindicated in pregnancy?

A

Doxycycline is contraindicated in pregnancy due to its teratogenic effects on foetal long bone growth and potential to cause teeth discolouration in the baby.

74
Q

Pulsus pardoxus

A

Pulsus paradoxus refers to an exaggerated fall in a patient’s blood pressure during inspiration by greater than 10 mm Hg.

75
Q

What organism causes lyme’s disease?

A

Borrelia burgdorferi

76
Q

What rash is seen in the early symptoms of lymes disease?

A

Erythema migrans

Bulls eye rash
- systemic symptoms acompany (fever, fatigue, headache).

77
Q

Smoking cessation in a pregnant women:

A

Pregnant women who smoke: nicotine replacement therapy should be offered, varenicline and bupropion are contraindicated.

78
Q

What is classed as ‘severe hyperkalaemia’?

A

Severe hyperkalaemia is defined as a potassium ≥ 6.5 mmol/L

79
Q

Acanthosis nigricans is associated with what cancer?

A

Gastric adenocarcinoma

80
Q

Narrow pulse pressure = what valvular disease?

A

Aortic stenosis

81
Q

Test for cushing’s syndrome?

A

Dexamethasone suppresion test.

82
Q

Treatment for absence seizures:

A

Ethosuximide

83
Q

First line for focal seizures?

A

First line: lamotrigine or levetiracetam

84
Q

Elbow pain, worse on resisted wrist extension/suppination whilst elbow extended.

Diagnosis?

A

Lateral epicondylitis

85
Q

1st line for angina?

A

Beta blocker

86
Q

2nd line for angina?

A

Nicorandil

87
Q

Beta blockers are contraindicated with what drug due to risk of heart block and fatal arrest?

A

Verapamil

88
Q

What antibodies are seen in Grave’s disease?

A
  • TSH receptor stimulating antibodies(90%)
  • Anti-thyroid peroxidase antibodies (75%)
89
Q

What medications are you giving to a newly diagnosed diabetic with angina?

A

Metformin + SGLT-2 inhibitor

As the patient has a history of angina i.e. established cardiovascular disease (CVD), an SGLT-2 inhibitor should be started in addition to metformin. This is for organ protection rather than glycaemic control and so is indicated regardless of glycaemic control. Metformin should be started first and the SGLT-2 inhibitor added once metformin tolerability is confirmed.

90
Q

A patient with TB wants to know why their tears and urine is bright orange. Why?

A

They’re taking rifampicin

91
Q

A patient with TB wants to know why their tears and urine is bright orange. Why?

A

They’re taking rifampicin

92
Q

A patient with TB wants to know why their tears and urine is bright orange. Why?

A

They’re taking rifampicin

93
Q

A patient with TB wants to know why their tears and urine is bright orange. Why?

A

They’re taking rifampicin

94
Q

Test to diagnose phaeochromocytoma?

A

24 hr urinary collection of metanephrines(sensitivity 97%*)

95
Q

What types of shock cause warm peripheries?

A

Neurogenic, septic, and anaphylactic shock (together are all distributive shock) will cause warm peripheries, with the others causing cool peripheries

96
Q

Vaginal pH in BV?

A

vaginal pH > 4.5

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.

97
Q

What is seen on the blood tests of a patient with Paget’s?

A

Isolated raised alkaline phosphatase (ALP)

  • Calcium and phosphate are typically normal. Hypercalcaemia may occasionally occur with prolonged immobilisation.
98
Q

Oral herpes =
Genital herpes =

A

Oral herpes = HSV1
Genital herpes = HSV2

99
Q

Weight loss + fine tremor possible

A

Hyperthyroidism

100
Q

hypothyroidism + goitre + anti-TPO

A

Hashimoto’s

101
Q

What should be given to ALL patients prescribed insulin?

A

Glucagon kit - for emergencies

102
Q

Diagnosis and screening of HIV:

A

Combination tests (HIV p24 antigen and HIV antibody) are now standard for the diagnosis and screening of HIV

103
Q

Electrolyte side effect of ppi’s

A

PPIs can cause hyponatraemia

104
Q

What does aldosterone do?

A

Aldosterone will lead to increase resorption of sodium and excretion of potassium thus resulting in hypertension.
Hypernatraemia, hypokalaemia.

105
Q

Diagnosis of ankylosing spondylitis is best supported by what?

A

Diagnosis of ankylosing spondylitis can be best supported by sacro-ilitis on a pelvic X-ray

106
Q

Fully explain rate control for AF:

A

1st line = Beta-blocker (beware asthma) or Ca2+ channel blocker
2nd line = Add digoxin

107
Q

Most common thyroid cancer:
- prognosis?

A

Papillary thyroid cancer shows excellent prognosis, despite the tendency to spread to cervical lymph nodes early

108
Q

How does glaucoma affect vision?

A

Glaucoma primarily causes visual field defects (peripheral vision loss)

109
Q

IIH is associated with what abx?

A

Tetracycline abx

110
Q

Urethritis in a male, negative for Gonorrhoea and Chlamydia →?

A

Mycoplasma genitalium

111
Q

When to use Rockall?

A

Upper GI bleed after endoscopy

112
Q

What iron study profile is seen in haematochromatosis?

A

Typical iron study profile in patient with haemochromatosis
transferrin saturation > 55% in men or > 50% in women
raised ferritin (e.g. > 500 ug/l) and iron
low TIBC

113
Q

What to replace first in B12 and folate deficiency anaemias?

A

Folate replacement is an appropriate therapy for this patient. However, folate should never be replaced before vitamin B12 due to the risk of precipitating subacute combined degeneration of the cord. (Think BeFore: B before F to help you remember).

114
Q

What medication is used to treat kidney stones and why?

A

Thiazide diuretics

Thiazides cause hypercalcemia and hypocalciuria. Low conc of Ca2+ in the urine leads to less development of kidney stones.

115
Q

PTH level primary hyperparathyroidism

A

The PTH level in primary hyperparathyroidism may be normal

116
Q

Scabies tx

A

permethrin 5% is first-line for pt and all close contacts

117
Q

Don’t give what with azathioprine?

A

Allupurinol

118
Q

Prostate cancers most commonly arise from where?

A

Over 75% of prostate adenocarcinomas arise from theperipheral zone

119
Q

Most common type of prostate cancer

A

Acinar adenocarcinoma

120
Q

How does prostate cancer present?

A

Local disease: Weak urinary stream,increased urinary frequency, andurgency.

Moreadvanced localised diseasemay also cause haematuria, dysuria, incontinence, haematospermia, suprapubic pain, loin pain, and even rectal tenesmus.

B symptoms

121
Q

What scoring system is used for prostate cancer?

A

Gleason score

122
Q

Prostate cancer differentials:

A

BPH
Prostatitis

Other causes of haematuria– these may includebladder cancer,urinary stones,urinary tract infections, and pyelonephritis.

123
Q

Normal PSA for someone over 70yrs

A

<6.5 ng/mL

124
Q

Summarise treatment options for prostate cancer:

A
  1. Low risk - watchful waiting or active surveillance (every 3 months PSA, yearly DRE).
  2. Surgery - Radical prostatectomy
  3. Radiotherapy - external beam of brachytherapy.
  4. Chemotherapy and ADT offered in metastatic disease.
125
Q

What is ADT?

A

Androgren deprivation therapy(ADT) is the mainstay of the management ofmetastatic prostate cancerand improves outcomes in patients undergoing radiotherapy, as prostate cancer cellsundergo apoptosis when deprived of testosterone.

126
Q

What class of chemo drugs is typically used in prostate cancer?

A

Taxanes

127
Q

What imaging is used for prostate cancer?

A

Multi-parametricMRI - diagnosis

Staging is accomplished withCT chest-abdomen-pelvis scanandPET-CT nuclear medicine scan.

128
Q

Investigations for prostate cancer:

A
  1. PSA and DRE
  2. Multi-parametricMRI
  3. Transperineal biopsy / Transrectal ultrasound biopsy

Year 4 Med (28 decks)

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