GP Flashcards
1
Q
Define polypharmacy
A
Concurrent use of multiple medications by one individual
2
Q
Define concordance
A
patient support in agreed medicine taking (between doctor and patient)
3
Q
Give reasons why patients may struggle sticking to medication regimes
A
- Beliefs and concerns or problems with the medicines
- Practical problems
- forgetting to take their medications
- not being able to keep track of which medicines to take
- getting confused between medicines
- having unpleasant side effects
- prescription costs might be a problem
4
Q
Give some ways concordance could be improved
A
- Address beliefs and concerns about medicines
- discuss benefits, side-effects and long-term effects of taking medicines
- get patient to record medicine taking
- simplify dosing regime
- use alternative packaging or a multi-compartment medicines system
- discuss how to deal with side-effects
- consider switching to different medicines
- explore reducing prescription costs
5
Q
What is green prescribing?
A
the practice of encouraging people to engage in nature-based interventions and activities to improve their physical and mental health
6
Q
What is blue prescribing?
A
the practice of encouraging people to engage in wetland and water-based intervention and activities to improve their physical and mental health
7
Q
Give some examples of green and blue prescribing
A
Local walking schemes
Community gardening projects
Conservation volunteering
Green gyms
Open water swimming
Arts and cultural activités taking place outdoors
8
Q
What is social prescribing?
A
a care approach that connects people to activities, groups and services in their community that meet the practical emotional and social needs affecting their health and wellbeing
9
Q
What is exercise on prescription?
A
prescribing exercise to patients to increase their physical activity levels
10
Q
What are some pros of social and green prescribing?
A
- Improves social and mental wellbeing
- Can improve physical wellbeing
- Avoids need for unnecessary medicines and side effects etc
- Social prescribers are able to spend more time with the patient than a GP is
- Could increase support for causes e.g. conservation
- Decreases GP appointments
- Improves health of local population
- Social prescribers can also help patients to access other services like housing, benefits and financial support and advice, as well as employment and training
11
Q
What are some cons of social and green prescribing?
A
- Patients might want a medicine out of their consultation instead of a referral to link worker/social prescriber
- Patient might feel that their concerns have been dismissed
- Patient might not have time or money to do the activities
- Improvements might be seen over a long time
- Requires more input from the patient
- Can be difficult to set up local services
- Might be difficult for patients with social anxiety
12
Q
What is the postnatal check?
A
A check about 6-8weeks after the birth of the baby to see how the mother is recovering and coping after the birth of the baby and adapting to life with the child (the baby check is different but can be done at the same appointment)
13
Q
What might be asked at the postnatal check?
A
- how mother is feeling physically and mentally and whether they have any worries about their health
- whether they’ve had vaginal discharge and if it is heavy
- whether they’ve had their period since the birth
- whether they’ve had incontinence
- whether she is breastfeeding and how it’s going
- whether she has resumes sex with her partner and if she needs contraception
- if she is well supported
- if she’s sleeping well
14
Q
How would you screen for postnatal depression?
A
- During the past month, how often have you been bothered by feeling down, depressed or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
If answer to either is yes, then get her to do the Edinburgh Postnatal Depression Scale questionnaire (score >13 is indicative)
15
Q
What are some symptoms of postnatal depression?
A
Depression
Guilt
Feeling unable to look after the baby
Lack of bonding to the baby
16
Q
How would you screen for domestic abuse?
A
Make sure the mother is able to speak freely and they are on their own
Ask the SAFE questions
17
Q
What are the SAFE questions for domestic abuse screening?
A
Stress/safety, afraid/abuse, friends/family, emergency
- What stresses do you experience in your relationship?
- Do you feel safe in your relationship?
- What happened when you and your partner disagree?
- Have there been situations in your relationship where you have felt afraid?
- Have you been physically hurt or threatened by your partner?
- Has your partner forced you to engage in sexual activities that you didn’t want?
- Are your friends and family aware of what is going on?
- Do you have a safe place to go in an emergency?
18
Q
Why might a new mother not need contraception?
A
Fully breastfeeding (minimum of four-hourly feeds during the day and six-hourly feeds during the night) provides good contraception for up to six months if the mother is still amenorrhoeic
19
Q
Name some forms of contraception
A
Intrauterine Contraceptive Device/Coil can be used from 6 weeks
Implants
Progesterone-only pill - oestrogen thickens blood increasing risk of DVT, particularly with surgery/C-section
Combined oral contraceptive pill
Progesterone injection - can take up to 12 months for fertility to return
Condoms - also help prevent STIs
20
Q
What is a LARC?
A
Long acting reversible contraception e.g. IUD/coil, implants etc
21
Q
Give some benefits of breastfeeding
A
- Reduces baby’s risk of infections, D&V, Sudden infant Death Syndrome, obesity, cardiovascular disease (in adulthood)
- Breastmilk adapts to baby’s needs as it grows
- Reduce’s mother’s risk of breast cancer, ovarian cancer, osteoporosis, CVD, obesity
- Is freely available without preparation
- Can be effective contraception
22
Q
Give some disadvantages of breastfeeding
A
- can be uncomfortable in public
- can’t measure how much baby is consuming
- breastmilk is usually low in vitamin D so mothers might need to take supplement
- Baby is at risk of vertical transmission of infections like HIV, Hep B, TB, H. influenzae
- Can have complications like mastitis, cracked nipples, insufficient milk production
- can be fatal for baby with Cow’s Milk Protein Allergy
23
Q
When might child’s growth cause concern?
A
- Weight drops two centile spaces
- If below 0.4th centile for weight and height
- (Evidence of Failure to Thrive)
24
Q
What is failure to thrive?
A
Poor physical growth and development as a child
Drop in weight and height/length of 2 or more centile spaces
25
What could cause Failure to Thrive
Caused by anything leading to inadequate nutrition and energy
- Inadequate nutritional intake
- Difficulty feeding
- Malabsorption
- Increased energy requirements
- Inability to process nutrition (e.g. Coeliac)
26
What could cause abnormal growth rates?
Failure to thrive
Macrocephalus (increased head circumference)
Overfeeding (increased weight of 2+ centile spaces)
Coeliac disease (weight and length decreases 2+ centile spaces)
27
What is involved in the antenatal screening programme?
Foetal Anomaly Scan
Down's syndrome screening
Sickle cell and thalassaemia screening
Infectious disease screening - Rubella, Syphilis, Hepatitis B, HIV
28
What is involved in newborn screening?
- Immediate physical external inspection
- Newborn hearing screening test
- Newborn blood spot (heel prick) at 5 days
- Physical examination of newborn given by 72 hours: cardiac exam, eyes, testes, check for developmental dysplasia of the hips and a general exam
- Matters of concern for the parents
29
what does the newborn blood spot (heel prick test) screen for?
Cystic fibrosis
sickle cell disease
congenital hypothyroidism
severe combined immunodeficiency (SCID)
Inherited metabolic diseases like phenylketonuria (PKU), Maple Syrup Urine Disease (MSUD), Medium-chain Acetyl-CoA dehydrogenase deficiency
30
What is involved in the 6-8 week baby check?
Physical exam
Review of development - growth chart and things like smiling and sounds
Immunisations
Health promotion to reduce risk of Sudden Infant Death Syndrome
31
When are immunisations given to children in the routine immunisation schedule?
8, 12, 16 weeks
12-13 months
Pre-school (3yrs 4months)
12-13 years
14 years
32
What immunisations are given at 8 weeks?
6-in-1: diptheria, tetanus, Haemophilus influenzae type B (Hib), polio, pertussis, Hepatitis B
Rotavirus
Meningitis B
33
What immunisations are given at 12 weeks?
6-in-1 (2nd dose)
PCV (pneumococcal conjugate vaccine)
Rotavirus
34
What immunisations are given at 16 weeks?
6-in-1 (3rd dose)
Meningitis B (2nd dose)
35
What immunisations are given at 12-13 months?
Hib and Meningitis type C
MMR - measles, mumps, rubella
PCV (2nd dose)
Meningitis B (3rd dose)
36
What immunisations are given at 3 years 4 months?
Booster of 4-in-1: diptheria, tetanus, pertussis, polio
MMR (2nd dose)
Nasal flu spray is also given between 2 years and end of primary school
37
What immunisations are given at 12-13 years?
HPV vaccine (2 doses, 6 months apart)
38
What immunisations are given at 14 years?
3-in-1 booster: diptheria, tetanus, polio
Meningitis ACWY
39
What are the routes of drug administration?
Oral - po
Intravenous - iv
Rectal - pr
Subcutaneous - sc
Intramuscular - im
Intranasal - in
Topical - top
Sublingual - sl
Inhaled - inh
Nebulised - neb
40
What are the routes of administration of paracetamol?
Oraly, per-rectum, intravenously
41
Give modifiable risk factors for osteoporosis
Excess alcohol consumption
Smoking
Low BMI
Calcium deficiency
Vitamin D deficiency
Reduced protein and fruit/veg intake
Sedentary lifestyle
Frequent falls
42
Give non-modifiable risk factors for osteoporosis
Age over 65 years
Female
Family history
Previous fractures
Menopause
Medications: steroids, PPIs, certain antidepressants, certain ASMs, certain chemotherapy agents
Other conditions like rheumatoid arthritis, IBD, Coeliac disease, COPD and asthmas, endocrine disorders (Cushing's syndrome, diabetes, hyperparathyroidism), CKD, HIV/AIDS, cancers, mental illnesses, eating disorders
43
What is the epidemiology of eating disorders?
Over 700 000 people in UK have one - underestimated
90% are female
affects any age, gender, ethnicity, background but most commonly affects females aged 15-19
44
Give some risk factors for developing an eating disorder
Biological:
- Having close relative with an ED or mental health condition
- Hx of dieting
- Type 1 diabetes
Psychological
- Perfectionism
- Body image dissatisfaction
- Personal history of an anxiety disorder
- Behavioural inflexibility - always following the rules as a child
- Inability to change behaviours despite changing changing environment and social demands
Social
- Weight stigma
- Teasing or bullying, particularly weight focussed
- Acculturation -> minority ethnic groups are at increased risk, especially if undergoing rapid westernisation
- Loneliness and isolation
- Historical or intergenerational trauma
45
Why might eating disorder present covertly?
- Lack of insight/awareness of illness or seriousness of illness
- Sensitive topic so the patient might not want to talk about it or it may trigger negative emotions
- Behaviours might appear healthy at first, particularly due to social stigmas
- New behaviours might appear slowly over time -> difficult to notice
- Eating alone or secretly -> might not see what or how often they are eating
- May be dishonest about how they feel or what they think
- May feel guilty or shameful about their habits so don’t want to draw attention to it
46
Describe the physical symptoms of anorexia nervosa
Weight loss
Osteoporosis
Tooth enamel damage
Irregular periods
Difficulty sleeping and tiredness
Feeling dizzy
Stomach pains
Constipation
Feeling cold
Physical weakness and lack of muscle strength
Affected hormone levels
Low blood pressure
Poor circulation
Lanugo (fine hair growth all over body)
47
Describe the mental health symptoms of anorexia nervosa
Fear of excess weight or pursuit of thinness
Excessive focus on body weight
Distorted perception of body shape or weight
Body dysmorphia
Denying/underestimating seriousness of illness
Excessive thinking about food
Anxiety about eating in front of others
Low confidence
Difficulty concentrating
Perfectionism
Other mental illnesses e.g. OCD, depression, anxiety
48
What investigations would you do for someone with anorexia?
Physical exam - BMI, core temp, cap refill, pulse, BP, sit-up test and squat test
FBC - check for anaemia, low WCC, thrombocytopenia
U&E - low Na and K, High urea and creatinine, reduced eGFR
TFTs - chec for hyperthyroidism
ESR/CRP - normal
Serum glucose - low
LFTs - low calc, vit D, Mg, Zinc
DXA - check for osteoporosis
ECG - check for abnormalities caused by electrolyte imbalances (bradycardia, long QT, T wave abnormalities)
49
Give some risk factors for diabetes
Ethnicity: African-Caribbean, Black African or South Asian
Family history
Hypertension
Higher waist circumference
Living with obesity or excess weight
Male
Smoking
Sedentary lifestyle
Drinking alcohol
History of gestational diabetes
Previous heart attack or stroke
50
Name some symptoms of diabetes
Polydipsia (excessive thirst)
Polyuria
Tiredness
Weight loss (particularly T1)
Blurred vision
Lethargy (sluggish and apathetic)
Slow wound healing
Repeated infections, particularly vaginal thrush
PCOS
Acanthosis nigricans (darkened creases)
51
How are diabetes complications categorised?
Macrovascular and Microvascular
52
What are the microvascular complications of diabetes?
Cardiovascular disease
- Increased risk of stroke/TIA, angina, myocardial infarction
Peripheral arterial disease (reduced blood supply to the feet)
- Cold feet
- Ulcers
- Hair loss on legs
53
What are the microvascular complications of diabetes?
Retinopathy
Nephropathy
Neuropathy
54
What are the components of an annual diabetic review?
Check for any lost feeling in the feet
Check for ulcers and infections on feet
Damage to blood vessels in the eyes
Blood pressure
Cholesterol level in blood
Kidney function test
Weight, BMI and waist measurement
HbA1c level is checked every 3 months
55
What is the first line treatment of type 2 diabetes?
Lifestyle advice and Metformin
56
What is metformin?
1st line treatment for type 2 diabetes
Inhibits gluconeogenesis and increases the insulin sensitivity
57
How is metformin given?
as a standard or slow-release tablet or as a liquid or sachet
58
What are some side effects of metformin?
Nausea and vomiting
Diarrhoea
Stomach ache
Loss of appetite
Metallic taste in the mouth
Vitamin B12 deficiency - fatigue, muscle weakness, mouth ulcers, vision problems
59
What is the main treatment for type 1 diabetes?
Insulin
60
Why wouldn't you give insulin as a first line treatment in T2 diabetes?
Don't want to increase insulin resistance
61
What other medications can be used in treatment of type 2 diabetes?
Sulphonylureas, SGLT-2 inhibitors, lifestyle advice
62
What are sulphonylureas?
2nd line treatment of type 2 diabetes
Stimulate insulin production in pancreas and increase insulin sensitivity
e.g. gliclazide
63
What are SGLT-2 inhibitors?
Sodium-glucose cotransporter 2 inhibitors
2nd/3rd line treatment for type 2 diabetes
Inhibition of those cotransporters, decreases glucose reabsorption in the kidneys and increase urine glucose concentration
e.g. dapagliflozin, empaglifozin
64
What lifestyle advice could be given to someone with type 2 diabetes to help with management?
Maintain a healthy weight
Eat a wide range of foods
Eat breakfast, lunch and dinner everyday
Keep sugar, fat and salt intake to a minimum
Foods to be avoided:
- Labelled as ‘diabetic’ or ‘suitable for diabetics’
- Too much red meats or processed meats
- Highly processed carbs
Keep physically active
- Do regular exercise
- Walk where possible
- Do physical chores around the house e.g. hoovering, gardening
65
What is DESMOND?
A structured food education course for people living with type 2 diabetes
66
What is the main side effect of diabetes treatments?
Hypoglycaemia
67
Give some signs and symptoms of hypoglycaemia
Hunger
Trembling/shaking
Sweating
Confusion
Difficulty concentrating
68
What are some causes of atrial fibrillation?
Lone AF - no cause
Hypertension
Other heart conditions e.g. CHD, valve problems, cardiomyopathies, pericardial disease
Hyperthyroidism
Pulmonary embolism
Pneumonia, COVID-19, lung cancer
Obesity
Drinking excess caffeine
Drinking excess alcohol
69
What are some risk factors for atrial fibrillation?
Older age
Family history
Hypertension
White ethnicity
Coronary Heart Disease
Obesity
Hyperthyroidism
Drinking alcohol
Smoking
Extreme stress (psychological)
Extreme physical activity
70
What investigations would you do for someone presenting with palpitations?
ECG - during episode if paroxysmal AF or ambulatory (24hrs)
Ultrasound/Echocardiogram - looking for cause
FBC - anaemia can cause heart failure
TFT - hyperthyroidism
U&Es - hyperkalaemia
LFTs and coagulation screening - checking clotting is good ready for AF treatment
71
What is the main complication of atrial fibrillation?
Stroke
72
What scores would you use to assess suitability of treatment for AF?
CHA2DS2-VAsc and ORBIT
73
What is the CHA2DS2-VAsc score?
Assesses whether AF patient should start anticoagulation
1 point for each or 2 for the ones with 2 after
Consider it in men with score of 1+ or women with score 2+
Congestive heart failure
Hypertension
Age>75 (2pts)
Diabetes
Stroke/TIA previously (2pts)
Vascular disease
Age 65-74
Sex = female
74
What is the ORBIT score?
Assess the risk of major bleeding in AF patients taking anticoagulation
Shouldn't use anticoagulants in higher scores
Older age (>75)
Renal impairment (GFR<60)
Bleeding previously
Iron (low iron, haemoglobin or haematocrit)
Taking antiplatelet medication e.g. aspirin, clopidogrel
75
What does atrial fibrillation look like on an ECG?
Irregularly irregular
No P waves
Tachycardia
Might have fibrillations
Paroxysmal (episodic) or persistent
76
What does atrial flutter look like on an ECG?
Irregularly irregular
Saw tooth pattern
77
What does 1st degree heart block look like on an ECG?
Prolonged but fixed PR interval >0.20s
QRS complex after each P wave
78
What does 2nd degree Mobitz Type 1 heart block look like on an ECG?
Prolonged PR interval with increasing length
Eventually misses a QRS complex
No ratio of P:QRS
Long long long drop
79
What does 2nd degree Mobitz Type 2 heart block look like on an ECG?
Fixed length normal or prolonged PR interval
Intermittently dropped QRS complexes
P:QRS ratio is usually 3:1 or 4:1 (dropped after every 3rd/4th p wave)
Same same same drop
80
What does 3rd degree/complete heart block look like on an ECG?
No relationship between P waves and QRS complex
81
What is the acute and chronic diarrhoea?
Acute is less than 2 weeks
Chronic is more than 4 weeks
82
What are the main causes of acute diarrhoea?
Infection
Medications
Anxiety
Food allergy
Appendicitis
83
What are the main causes of chronic diarrhoea?
IBS
IBD (Crohn's disease and Ulcerative Colitis)
Diet
Coeliac disease
Bowel cancer
84
What are red flags regarding diarrhoea?
Blood or pus in the stool
Severe dehydration
Vomiting
Abdominal pain or tenderness
Weight loss
Anaemia
85
What investigations would you do for someone with diarrhoea?
- Stool sample if patient is systemically unwell, blood or pus in stool, patient is immunocompromised, has taken antibiotics or PPIs, or has recently travelled abroad
- FBC, U&Es, LFTs, Calcium, Vitamin B12 and folate, Ferritin, ESR/CRP, Coeliac disease test
- Imaging: sigmoidoscopy, colonoscopy, endoscopy
- Biopsy for certain conditions
86
Describe some types of stoma bag
Colostomy - attaches to lower left iliac fossa
Ileostomy - attaches to small bowel (either side)
Loop - two holes to make a bypass for part of the bowel
J pouch - artificial rectum
Closed or open
87
How does anti motility agents work? e.g. loperamide
mu-receptor agonist
stimulating mu agonist inhibits the muscle contraction of intestinal muscles, reducing peristalsis
This slows the speed of movement through the gut and allows more water to be absorbed, producing firmer stools and lowering the frequency of passing stools
88
What are the four types of laxatives?
Bulk-forming, osmotic, stimulants and stool/faecal softeners
89
How do bulk-forming laxatives work?
Act like a fibre supplement. Absorb water from stool, increasing the bulk of the stool which stimulates peristalsis
90
How do osmotic laxatives work?
Osmotic laxatives draw fluid into the large bowel, decreasing the amount absorbed into the bloodstream. The bowels become more distended due to the fluid and the stool becomes softer. This stimulates peristalsis.
91
How do stimulant laxative work?
Stimulant laxatives stimulate the smooth muscle in the large intestine to contract with more force which squeezes the stool out
92
How do stool softeners work?
Stool softeners make the stool wetter to soften it and make it easier to push out
93
Define Acute Kidney Injury
Acute kidney injury - a sudden decrease in kidney function
It can be a minor loss or complete kidney failure
94
What is the diagnostic criteria for AKI?
One of the following:
- Rise in serum creatinine of 26 micromol/L or greater from baseline within 48 hours
- A 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days from baseline
- A fall in urine output to less than 0.5mL/kg/hour for more than 6 hours
95
How is severity of AKI classified?
KDIGO criteria
Stage 1 = creatinine > 1.5 x baseline
Stage 2 = creatinine > 2 x baseline
Stage 3 = creatinine > 3 x baseline
96
How are AKI causes classified?
Pre-renal, Renal/Intra-renal/Post-renal
97
What are the pre-renal causes of AKI?
Volume depletion -> hyovolaemia e.g. severe dehydration, diuretics
Heart issues -> decreased CO e.g. MI, heart failure
Vasodilation -> increased vessel permeability e.g. sepsis, anaphylaxis
98
What are the intra-renal causes of AKI?
- Ischaemia
- Nephrotoxic drugs
- Infections of the kidneys
- Autoimmune diseases of the kidneys
Damage (prolonged inflammation, scarring/fibrosis, necrosis) to glomerulus reduces the glomerular filtration rate
99
What are the post-renal causes of AKI?
Renal or ureteric stones
Bladder retention
Blocked catheter
Enlarged prostate
Abdominal or pelvic mass or tumour
Recurrent UTIs
Pyonephrosis
100
What investigations would you do for someone with suspected AKI?
U&Es - K+ raised is serious complication, creatinine raised in AKI
LFTs - often abnormal, high albumin
FBC - Low platelets in infection, anaemia is complication of AKI
Bicarbonate - metabolic acidosis is complication of hepatorenal syndromes
Blood cultures - sepsis
Urine dipstick - acute nephritis, infection, diabetes, ketoacidosis, hyperemesis
Urine MC&S - infection
Imaging of kidneys ureters and bladder - ultrasound for obstruction, CT for stones, Duplex ultrasound for vasculature
101
Name some nephrotoxic drugs
NSAIDs
Gentamicin/aminoglycosides
Lithium
ACE inhibitors
Thiazides and loop diuretics
Penicillins
Trimethoprim
Metformin
102
What are the two main types of dialysis?
Haemodialysis and peritoneal dialysis
103
Give some pros of haemodialysis
Up to 4 treatment free days a week
Can be done at home
Good for those who can’t do peritoneal dialysis themselves (e.g. visually impaired, dementia etc)
Can do it overnight
Can travel (with or to a machine)
104
Give some cons of haemodialysis
May need to be done at a dialysis centre each time - takes a lot of time each week
Home dialysis needs to be done more frequently
Diet and fluid intake needs to be restricted
Travelling can be difficult to organise and it may cost money if using a dialysis machine abroad
105
Give some pros of peritoneal dialysis
Can easily be done at home
Can be done overnight - leaves days free
Can still do activities whilst on CAPD
Fewer diet and fluid restrictions than hemodialysis
Catheter can be hidden with clothes
106
Give some cons of peritoneal dialysis
Needs to be done everyday
Having a permanent catheter could be upsetting
Increased risk of peritonitis
Peritoneum might become thickened and scarred so might need to switch to haemodialysis after a few years
Can cause reduced protein levels
Can cause weight gain
107
List the mains LUTS (Lower urinary tract symptoms)
Increased frequency
Increased urgency
Nocturia
Incontinence - urge, stress etc
Hesitancy
Straining
Poor/reduced flow/stream
Terminal dribble
incomplete emptying
Haematuria
Dysuria
108
Give some red flags for LUTS
Urinary retention - acute
Overflow incontinence
Hard or irregular prostate
Haematuria
Dysuria
High frequency or urgency
Pelvic pain
109
What are some risk factors for LUTS?
Older age
Increased serum dihydrotestosterone levels (promotes prostate growth)
Obesity
Raised fasting glucose
Diabetes
Fat and red meat intake
Inflammation
Enlarged prostate
Some medications e.g. antidepressants, diuretics, bronchodilators, antihistamines
110
What investigations would you do for someone with LUTS?
Urine dipstick - nitrates, leukocytes, protein, blood, glucose --> for UTIs, cancer, diabetes
Urine MC&S for UTI and STIs
FBC - low haemoglobin in haematuria, raised WCC in cancer or infection, raised platelets in cancer or inflammation, raised ESR or CRP in inflammation or infection, high HbA1c in diabetes
U&Es to check renal function
PSA to check for prostate cancer and BPH
LFTs - raised and hypercalcaemia if prostate cancer metastasised to bone
Abdo exam - distended bladder, full bladder
Digital Rectal Exam (DRE)
111
What is involved in a digital rectal exam?
External and perianal inspection for skin problems, fissures, fistulas and haemorrhoids
Size symmetry and texture of prostate gland (walnut and symmetrical)
Rectal exam for cancer and stool that hasn't passed
Anal tone exam - IBD, spinal cord pathology
Finger examination to check for melaena, fresh blood and mucus
112
What is the International Prostate Symptom Score (IPSS)?
A measure of the severity of LUTS and impact on quality of life
Seven questions relating to symptoms
Mild symptoms = 0-7
Moderate = 8-19
Severe = 20-35
113
What is a bladder diary?
A record of everything patient has eaten and drunk, when and how much urine has been passed and what they were doing at the time
Normally completed for around 4 days
114
How would you interpret a bladder diary?
Abnormal frequency?
Polyuria?
Nocturia?
Nocturnal Polyuria?
Obvious causes?
Obvious patterns?
115
What is the PSA test?
A blood test that measures the level of prostate specific antigen in blood
116
What are some pros of the PSA test?
Helps early diagnosis of prostate cancer
There's no other prostate cancer screening programme in the UK
117
What are some cons of the PSA test?
Raised PSA is normal in older age and is caused by lots of conditions and often not cancer
It can cause unnecessary worry for the patient and could even lead to unnecessary treatment
Has a high rate of false negatives (1 in 7) and false positives (3 in 4 with raised PSA don't have cancer)
It's most accurate in over 70s but isn't recommended for this age group due to their fragility
Slow-growing prostate cancer usually has a good prognosis and the fast growing ones are often untreatable anyway
118
What is the Gleason score?
A score used in staging prostate cancer from a biopsy
119
What are the main treatment options for benign prostatic hyperplasia?
Watchful waiting
Alpha blockers
5-alpha reductase inhibitors
Surgery: transurethral resection of the prostate, open prostatectomy
120
What do alpha blockers do in BPH treatment?
e.g. tamsulosin
Relax the muscle in the neck of the bladder
121
What are some side effects of tamsulosin?
1. Postural hypotension and sweating - alpha blockers cause vasodilation
2. Retrograde ejaculation - the bladder neck fails to close so seminal fluid preferentially flows into the bladder
3. Intraoperative Floppy Iris Syndrome - cataract surgery complication causing iris prolapse and pupil constriction
122
What do 5-alpha reductase inhibitors do in BPH treatment?
Block dihydrotestosterone synthesis from testosterone -> reduces symptoms and risk of acute urinary retention
e.g. finasteride
123
What are some side effects of finasteride?
Erectile dysfunction
Reduced libido
Problems ejaculating - little or no semen
124
What are some differential diagnoses for joint pain/swelling?
Osteoarthritis
Rheumatoid Arthritis
Gout
Pseudogout
Ankylosing/axial spondylitis
Psoriatic arthritis
Reactive arthritis
Septic arthritis
Enteric arthritis
Other causes e.g. injury
125
What investigations would you do for joint pain/swelling?
Rheumatoid factor - positive
Anti-CCP - positive
FBC - raised WCC and platelets in infection & inflammation, low-normal haemoglobin in anaemia of chronic disease
Raised CRP and ESR in inflammation
U&E to check renal function and CKD
LFTs - raised ALP in bone, biliary and pregnancy
Serum uric acid - raised after a flare of gout
X-ray of joints involved - SPADES
Joint aspiration for gout and pseuodgout
126
What is a shared care agreement?
A formal, local agreement enabling GPs to accept responsibility for safe prescribing and monitoring of specialist medication
Transfers care from specialist to GP where suitable and best for the patient
127
What is methotrexate?
A slowly-reversible competitive inhibitor of dihydrofolate reductase (DHFR), inhibiting nucleic acid synthesis and causing cell death
128
Why should folate supplements be given when patient is on methotrexate?
Methotrexate is a folate-antagonist so folate supplements need to counteract this action to reduce toxic effects and improve continuation of therapy
129
Give a differential diagnosis for falls
- Cardiovascular: MI, hypotension, bradycardia, arrhythmias, aortic stenosis, SOB, hypoglycaemia
- Neurological: epilepsy, stroke/TIA, Parkinson's disease, syncope, functional seizure, peripheral neuropathy (diabetes, GBS, alcohol)
- Gentiurinary: UTI
- ENT: vertigo
- excessive alcohol
- mechanical: tip, fall
- medications: ACE inhibitors, beta blockers, diabetes medications, benzodiazepines, diuretics, tamsulosin
130
What are the behavioural and mental health changes around epilepsy diagnosis?
Social anxiety
Social isolation
Depression and mood disorders
Not being able to go/stay out late
Fatigue and difficulty concentrating
Poorer memory
131
What is the mechanism of action of sodium valproate?
Inhibits GABA transaminase
GABA is an inhibitory neurotransmitter
Seizures happen when GABA concentration is too low
Sodium valproate inhibits metabolism of GABA by GABA transaminase
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What are some side effects of sodium valproate?
Highly teratogenic
Impaired concentration
Agitation
Drowsiness
Irregularities in menstrual cycle
Hepatic disorders
Nausea and vomiting
133
What are the contraindications of sodium valproate?
Pregnancy (or being female of child-bearing age) - unless there is no alternative treatment (lowest effective dose should be used and counselling of risks should then be provided) as it is highly teratogenic
Hepatic impairment and family history of hepatic dysfunction
Acute porphyrias - hereditary disease where patient is unable to produce haemoglobin
Urea cycle disorders
134
What is the mechanism of action of carbamazepine?
Binds to voltage-gated sodium ion channels and inhibits sodium channels so prevents action potentials, thereby preventing seizure
135
What are some side effects of carbamazepine?
Teratogenic
Dizziness
Drowsiness
Fatigue
Hyponatraemia
Movement disorder
Nausea and vomiting
136
What are the contraindications of carbamazepine?
Acute porphyrias
AV conduction abnormalities unless a pacemaker is fitted
Bone marrow depression
Pregnancy - teratogenic
137
How would you differentiate epilepsy and other seizure causes?
Electroencephalogram (EEG)
MRI scan to loo for cause
Inpatient or short-term EEG monitoring
Movement during seizure
Triggers
Length of seizures
Frequency of seizures
