GP Flashcards
causes of back pain broadly
- mechanical
- fracture
- malignancy
- infection
- inflammatory/autoimmune
- non back pain e..g pancreatitis, AAA, pyelonephritis, pneumonia
pathologies underlying mechanical back pain
- bulging/herniated/degenerating disc
- lumbar muscle strain
- spine stenosis
- facet joint disease
types of spinal fracture/bony disease
Spondylolysis - Pars Interarticularis fracture (stress fracture)
- not particularly painful or debilitating
spondylolisthesis – vertebral body slippage secondary to spondylolysis
- likely associated with nerve root symptoms
Vertebral Fracture e.g. wedge fractures in osteoporosis
- extreme tenderness over area
back pain in malignancy
- secondaries from other cancer
- myeloma
- rarely primary tumours
especially suspect if thoracic, night pain, rest pain
cancers that are more likely to metastasise to bone are Kidney, Ovarian, Thyroid, Lung, Prostate, Testicular (only certain types), Myeloma, Breast
infectious causes of back pain
rare
- discitis
- osteomyelitis
- TB
any infective symptoms?
any immunosuppression or diabetes?
inflammatory/autoimmune causes of back pain
- Inflammatory spondyloarthopathy e.g. Ankylosing Spondylitis
- Connective tissue diseases
- Reactive arthritis
PMH and morning stiffness are indicators
what conditions associated with back pain need to be identified/ruled out using red flags
cauda equina
spinal fracture
cancer
infection
red flags back pain
- bilateral sciatica or neurological deficit
- urinary retention, incontinence or difficulty
- loss of sensation of rectal fullness –> incontinence
- saddle anaesthesia or parasthesia
- Sudden onset, severe pain, relieved by lying down
- History of trauma (this may be minor in those with osteoporosis)
- Structural spinal deformity
- Point tenderness over a vertebral body
- > 50 years old
- gradual onset, unremitting pain disturbing sleep
- worse straining
- thoracic pain
- unexplained weight loss
- any past hx of cancer
- Fever
- Tuberculosis, or recent urinary tract infection
- Diabetes
- History of intravenous drug use
- HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised
palliative care medicines for
1. Anorexia
2. Hiccups
3. Pruritis
4. nausea
anorexia - dexamethasone
hiccups - metaclopromide
pruritus - cholestyramine
nausea - cyclizine
palliative care medicines for
1. Dyspnoea
2. Excessive respiratory secretions
3. Capillary bleeding
dyspnoea - morphine
secretions - hyoscine
capillary bleeding - tranexamic acid
palliative care medicines for
1. muscle spasms
2. insomnia
3. restlessness
spasms - baclofen
insomnia - diazepam/tenazepam
restlessness - haloperidol
what is disulfiram
causes an acute reaction when consumed with alcohol thus acting as a deterrent
what is acamprosate
reduces the desire to drink alcohol
what medications should people with alcohol dependence be taking
thiamine and folic acid tablets
common side effects of metformin
Abdominal pain
Anorexia
Diarrhoea (usually transient)
Nausea
Taste disturbances
Vomiting
group 1 license; when do diabetics on non-insulin medication need to inform DVLA
if
- two episodes of severe hypoglycaemia within the last 12 months
- any impaired awareness of hypoglycaemia
- a disabling hypo is experienced while driving
- if other medical conditions may contribute to ability to drive
what non-insulin medications are most likely to cause hypos
sulphonylurea or glinide tablets
insulin treated diabetes self monitoring for driving
test no more than 2 hours before start of journey
test every 2 hours of driving
group 2 vehicles DVLA diabetes
must notify DVLA but can drive if
- full hypo awareness
- no severe hypo in last 12 months
- regularly self monitoring even when not driving
-
NICE weighted 7 point checklist suspected melanoma
Major features of the lesions (scoring 2 points each):
change in size
irregular shape
irregular colour.
Minor features of the lesions (scoring 1 point each):
largest diameter 7 mm or more
inflammation
oozing
change in sensation
refer if 3 or more points of 2ww
how quickly should a GP send a 2ww referral off
within 24 hours of seeing the pt and making the referral decision
is cholesterol measured for asymptomatic patients
yes - everyone aged 40-74 can have a CVD risk check
what does a CVD risk check include
cholesterol
diet
physical activity
smoking
alcohol
ethnicity
family hx
testing renal function on ACEi
before starting and after 2 weeks
regular testing thereafter
what is QRISK
a tool, used in primary care, to calculate a patient’s risk of suffering a cardiac event, or a stroke, over the next 10 years as a percentage. It takes into account the patient’s age, cholesterol results, family history, ethnicity, blood pressure and other existing conditions.
what is QRISK
a tool, used in primary care, to calculate a patient’s risk of suffering a cardiac event, or a stroke, over the next 10 years as a percentage. It takes into account the patient’s age, cholesterol results, family history, ethnicity, blood pressure and other existing conditions.
what should be done if QRISK over 10%
have a discussion about health behaviour modification, support to make changes and the offer to re-assess their risk again after they have tried to change some behaviours. If behavioural intervention is ineffective or inappropriate, then statin treatment should be offered.
statin recommendation if behaviour change doesn’t bring QRISK to <10%
20mg atorvastatin for the primary prevention of CVD
exercise recommendations
strength exercises on 2 or more days week, and 150 minutes of moderate activity or 75 minutes of vigorous activity (or a combination of both) and to reduce time sitting.
fever pain criteria sore throat
The FeverPAIN criteria are: score 1 point for each (maximum score of 5)
o Fever over 38°C.
o Purulence (pharyngeal/tonsillar exudate).
o Attend rapidly (3 days or less)
o Severely Inflamed tonsils
o No cough or coryza
A score of 0 or 1 is associated with a 13% to 18% likelihood of isolating streptococcus. A score of 2 or 3 is associated with a 34% to 40% likelihood of isolating streptococcus. A score of 4 or 5 is associated with a 62% to 65% likelihood of isolating streptococcus.
types of emergency contraception
Copper coil - most effective. up to 5 days
Levonorgestrel - EHC. Up to 72 hours
Ulipristal - EHC up to 5 days
when would a pregnancy test be needed after emergency contraception
irregularity in her cycle and if her next period is light or more than 3 days late, she’d need a pregnancy test.
swollen ankle/lower limb differentials
Gout
Septic arthritis
Cellulitis
Inflammatory arthritis
Osteoarthritis
Trauma
DVT
melaena
black “tarry” sticky faeces due to upper GI bleeding; the black colour is due to haemoglobin being altered by digestive chemicals and intestinal bacteria.
features of stomach upset caused by ferrous sulphate
stomach upset, cramps, dark grittiness of the stools and altered bowel habit, either towards constipation or diarrhoea
differentiating from upper GI bleed; stool are dark but gritty and pain is relieved by defection
GP medications that can lead to hyponatraemia
ACE inhibitors, diuretics, anti-depressants, and proton pump inhibitors
campylobacter
- what is it
- what treatment
- work/school
- public health?
Campylobacter are a group of bacteria that cause food poisoning, often due to eating undercooked meat
no treatment is usually required except good hydration during the illness
stay off until 48 hrs after last episode of diarrhoea
it is a notifiable disease to Public Health England
ongoing diarrhoea differentials
hyperthyroidism
IBS
IBD
anxiety
coeliac disease
colorectal cancer
investigations ongoing diarrhoea
TFTs
Faecal calprotectin - normal reduces likelihood of IBD
CRP + ESR
FBC
renal function - might put strain on kidneys
Tissue Trans-glutaminase antibodies - coeliac
medication for spasms in IBS
buscopan ( hyoscine butylbromide)
Clostridium Difficile
- what is it
- how does it occur
- treatment
most common cause of diarrhoea in hospitalised patients especially if they have received antibiotics and are elderly
bacteria which can be found in healthy people’s intestines but can cause diarrhoea when the normal gut and intestinal bacteria flora are compromised (e.g. due to antibiotics and other medications, including Proton pump inhibitors), which then lead to an overgrowth of C.difficile
in severe cases can cause pseudomembranous colitis
it is a notifiable disease
treated with other oral antibiotics, such as vancomycin/metronidazole and in the community there would need to be strict hygiene measures
common side effects of opiates
constipation
itch
nausea and vomiting
self management advice for constipation
increased consumption of fruit and vegetables
physical activity
hydration
feet on low stool when opening bowels
systems to examine/enquire about for dizziness
cardio
resp
GI - could be bleed, dehydration etc
neurological
ENT
symptomatic medications for vertigo
A vestibular sedative such as cyclizine, cinnarazine, or prochlorperazine
A vasodilator in the inner ear called Betahistine - review and stop if not helping
both should be limited courses
what is in a rescue pack for COPD exacerbation
prednisolone
doxycycline
to be started if increased breathlessness or discoloured sputum
when should a COPD exacerbation be hospitalised
Severe breathlessness.
Inability to cope at home (or living alone).
Poor or deteriorating general condition.
Acute confusion or impaired consciousness.
Cyanosis or reduced oxygen saturation esp <90%
Worsening peripheral oedema.
A new arrhythmia.
common side effects of furosemide
mild gastro-intestinal disturbances
postural hypotension
electrolyte disturbances (including hyponatraemia, hypokalaemia, hypocalcaemia,
hypochloraemia, and hypomagnesaemia)
hypersensitivity reactions (including rash, photosensitivity, and pruritus)
HARK questionnaire
screening tool for domestic abuse
H-humilation
A-afraid
R-rape
K- kick or other physical violence
1 point for each yes
sometimes S is added for is it safe to go home
starting treatment for type 2 diabetes
if HbA1C confirmed >48 after two tests then first start with lifestyle changes for 3 months
- diet
- weight
- exercise
- address other factors such as smoking and alcohol
useful if pt can see HbA1C come down
if still diabetic then metformin is first line
target HbA1C if on 2 medications
58 mmol/L
target HbA1C if one 1 medication
48 mmol/L normally
53 if medication can cause hypos such as a sulphonylurea
lower GI cancer 2WW criteria
-They are aged 40 and over with unexplained weight loss and abdominal pain or
-They are aged 50 and over with unexplained rectal bleeding or
-They are aged 60 and over with:
-Iron-deficiency anaemia or
-Changes in their bowel habit
-Tests show occult blood in their faeces
statins blood tests/monitoring
blood tests before
Repeat blood tests would be required at 3 months for total cholesterol, HDL and non-HDL cholesterol, plus liver function tests at 3 months and 12 months - small risk atorvastatin can affect liver
mechanism of action levonorgestrel
inhibiting or at least delaying ovulation by preventing follicular rupture
