GP Flashcards
Most common cause of painful rectal bleeding on a background of constipation
Anal fissure
What should be done if someone vomits within 3 hours of taking their combined oral contraceptive pill
An additional pill should be taken as soon as possible
Describe the tricycling method of taking the combined oral contraceptive pill
Take the pill everyday for 9 weeks and then take a 4-7 day free interval
What is the most effective form of emergency contraception?
the intrauterine device (IUD)
What is suggested if someones total cholesterol is greater tha 5mmol/L
20mg atrovastatin
What non-invasive emergency contraception can be used for up to 5 days after unprotected sex?
ellaOne (ulipristal acetate)
How do you work out units of alcohol?
(concentration (percent) x volume )/ 1000
What contraceptive is migraine with aura a contraindication for?
The combined oral contraceptive pill
First line treatment for severe depression
SSRI (citalopram)
What happens if the progesterone only pill is missed for more than 3 hours
Take the missed pill and wear condoms for 48 hours
How long after remission should an antidepressant be continued for?
6 months
Treatment of cellulitis
oral flucloxacillin
Why may creatinine be high after treatment with trimethoprim
competitive inhibition of creatinine secretion from the renal tubules
What percent of FEV1 reversibility should be achieved by bronchodilator therapy in asthma?
At least 12%
What form of contraception can be used in women with breast cancer?
non-hormonal methods such as the copper IUD
First line investigation for angina
CT coronary angiogram
Treatment of urge incontinence which is often used in frail elderly patients
Mirabegron
What medications are a risk factor for gout?
low dose aspirin, thiazide like diuretics and immunosuppressive medications
What test is used to confirm iron deficiency anaemia?
ferritin (below 30mcg/l)
What is the best contraptive method at preventing pregnancy?
The contraceptive implant
Most appropriate antibiotic for bacterial tonsilitis?
Oral penicillin V (phenoxymethylpenicillin)
Can an IUD be used in someone with active chlamydia?
no
What antibiotic is recommended to treat UTIs in elderly patients with CKD?
trimethoprim
What can topical corticosteroids cause in patients with darker skin types
depigmentation
FEV1 of stage 2 COPD
50-80%
FEV1 of stage 3 COPD
30-50%
FEV1 of stage 4 COPD
<30%
Causes or secondary anal fissures
Constipation, IBD colorectal cancer,dermatological conditions such as psoriasis. Bacchanal, viral and fungal infections, anal trauma, pregnancy and child birth
Where do 90% or anal fissures present?
The posterior midline - If elsewhere other conditions such as crohns should be considered
Treatment of anal fissures lasting more than a week
Topical GTN applied twice a day for 6 to 8 weeks is first line
If GTN not effective consider surgery or Botox
Acute treatment of anal fissures
Soften stool- high fibre, high fluid intake, bulk forming laxatives
Lubricants such as petroleum jelly before defecation
Topical anaesthetics
Sitting in a warm bath
What type of reaction is anaphylaxis
Type 1 hypersensitivity reaction
Common causes of anaphylaxis
Food such as nuts - most common cause in children
Drugs
Venom
Resuscitation council uk definition of anaphylaxis
Sudden onset of:
Airway problems: swelling of the throat leading to hoarse voice and stridor
Breathing problems - wheeze, dyspnoea
Circulation problems - hypotension, tachycardia
Presentation of anaphylaxis
Sudden onset of:
Dyspnoea
Wheeze
Tachycardia
Urticaria
Angiooedema
Collapse
Dose of adrenaline in less than 6months
100 to 150 micrograms
Dose of adrenaline in 6months to 6years
150 micrograms
Dose of adrenaline in 6 to 12 years
300 micrograms
Dose of adrenaline in over 12 years
500 micrograms
What test can be done to confirm anaphylaxis after the event
Mast cell tryptase - collected 1-2 hours after onset but no later than 4
Common causes of bacterial vaginosis
Gardnerella vaginalis
Prevotells species
Bacteriodes species
Peptostreptococcus species
How does bacterial vaginosis present
Offensive fishy smelling discharge
No soreness or irritation
Amstel criteria for bacterial vaginosis
Vaginal pH > 4.5
Typical discharge - thin, off-white, homogenous
Positive whiff-amine test
Clue cells on microscopy
Explain the whiff-amine rest
Fishy odour on adding 10% potassium hydroxide to the vaginal fluid
Treatment of bacterial vaginosis in non-pregnant women
Oral metronidazole 400mg BD for 5 to 7 days
OR
Single dose high dose 2g metronidazole
OR
400mg intravaginal metronidazole gel OD for 5 day
Treatment of bacterial vaginosis in pregnant women
400mg oral metronidazole BD for 5 to 7 days
Or
400mg metronidazole intravaginal gel OD for 5 day
Complications of bacterial vaginosis
Can increase the risk of transmission of STIs
Can cause pregnancy complications- late miscarriage, low birthweight, premature rupture of membranes
Pathophysiology of BPH
Hyperplasia of the stromal and epithelial cells of the prostate
Usually occurs in the transitional zone of the prostate
Presentation of BPH
Voiding symptoms - weak intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
Storage symptoms - urgency , frequency, urinary incontinence , nocturia
How can BPH be diagnosed
DRE - smooth symmetrical enlarged prostate with maintenance of the central sulcus
May use PSA to screen for prostate cancer
Urine dipstick to assesss for haematuria and proteinuria
Treatment of BPH
- Alpha blockers such as tamsulosin
- 5 alpha reductase inhibitors such as finasteride
- TURP - transurethral resection of the prostate
What is Bell’s palsy
An acute unilateral idiopathic facial nerve paralysis
What happens to the forehead in Bell’s palsy
It will be included in paralysis as it is a lower motor neurone lesion - upper lesion would have forehead sparing due to bilateral inner action of the forehead
What additional symptoms may be present in Bell’s palsy
Post auricular pain
Altered taste
Dry eyes
Hyperacusis
What is Benign Paroxysmal Positional Vertigo
A common cause of recurrent vertigo triggered by head movement
Pathophysiology of Benign Paroxysmal Positional Vertigo
Caused by otoconia - loose debris of calcium carbonate
These are within the semicircular canals (most commonly the posterior canal)
Attacks are triggered by head movements causing movement of the otoconia, abnormal motion of the endolymph and feelings of vertigo
Presentation of Benign Paroxysmal Positional Vertigo
Short episodes of vertigo, usually lasting less than a minute
Episode will be triggered by head movements such as rolling over in bed
Vertigo may cause nausea and vomiting
How is Benign Paroxysmal Positional Vertigo diagnosed
Dix- hallpike manoeuvre
The manoeuvre will trigger rotational nystagmus and symptoms of vertigo in positive patients
How is Benign Paroxysmal Positional Vertigo treated
Epley manoeuvre
Patient can do Brandt- daroff exercises at home
Most common causes of bronciolitis
Respiratory syncytial virus
Other - rhinovirus, adenovirus
Most common side effect of allopurinol
Rash
What medication does clarithromycin interact with ?
Atrovastatin
What antibiotic should be used if treating a UTI in someone on methotrexate
Pivmacillinam
Emergency contraception in women with bmi greater than 26
Double dose of levonelle
What is an absolute contraindication to the combined pill?
A DVT
In what trimester should nitrofuratoin be avoided
Third
Where does impetigo rash typically start
On the face of it
First line prophylaxis of migraines
Propranolol, tropiramate or amitriptyline
Who should topiramate be avoided in?
Pregnant women
Who should topiramate be avoided in?
Pregnant women
What hormone do ovulation test strips monitor for?
LH- there is an lh surge before ovulation
How is diagnosis of a salivary gland stone made?
Sialogram
What criteria can be used to diagnose rheumatic fever
The jones criteria - evidence of recent strep infection with 2 major of 1 major plus 2 minor criteria
What is a contraindication to the ellaOne emergency contraception?
Severe asthma
What cancers are at increased risk with oral contraceptive pill
Increased risk of breast and cervical cancer
Decreased risk of ovarian and endometrial cancer
What antibiotic is given second line in tonsilitis in the event of penicillin allergy
Clarithromycin
What is seen on the blood film in coeliacs
Howell jolly bodied
What finding on microscopy is indicative of bacterial vaginosis
clue cells
How does tamsulosin work?
it is a alpha 1 antagonist- it decreases smooth muscle tone of the prostate and bladder
What is the first line treatment of BPH in those with moderate to severe voiding symptoms
tamulosin
Side effects of tamulosin
dizziness, postural hypotension, dry mouth, depression
What is the action of finasteride
blocks the conversion of testosterone to dihydrotestosterone
which is known to induce BPH
What is an indication for using finasteride in BPH
it is indicated in those with an enlarged prostate that is considered to be at high risk of progression
How long does it take for finasteride to work?
6 months
side effects of finasteride
erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
What is mastitis
inflammation of the breast tissue typically associated with breast feeding
How does mastitis present?
painful tender red hot breast
may have fever and general malaise
RF for mastitis
smoking, poor breast feeding technique, nipple damage, maternal stress, previous mastitis
What is mastitis called when it is associated iwth breast feeding
puerperal mastitis
Pathophysiology of mastitis
usually occurs due to milk stasis- from inadequate milk removal or infrequent feeding
Cracked sore nipples- provide entry point for bacteria
most common organism associated with mastitis
Staphylococcus aureus
What can mastitis develop into if left untreated?
breast abscess
first line management of mastitis
continue breast feeding
First line pharmacological treatment of mastitis
oral flucloxacillin (10-14 days)
Overview of the treatment of mastitis
continue breastfeeding
analgesia
warm compress
oral flucloxacillin (continue breastfeeding)
When should someone be treated for mastitis
if systemically unwell, if a nipple fissure is present, if symptoms do not improve after 12-24 hours of effective milk removal or if culture indicates infection
What is a breast abscess?
a collection of pus within an area of the breast usually caused by a bacterial infection
what are the two types of breast abscesses?
lactation and non lactational breast abscess
What is the most common causative agents of breast abscesses
staphylococcus aureus
Presentation of a breast abscess
a swollen, fluctuant lump within the breast
(fluctuant means the fluid can be moved around within the lump using pressure on palpation)
If active infection the abscess may be hardened
May also have features of mastitis- tender, swollen red breast
How are breast abscesses confirmed
USS
1st line treatment of a breast abscess
surgical intervention - needle aspiration or surgical incision and drainage
plus antibiotics
What are causes of parkinsonisms (not just parkinsons)
parkinsons disease
drug induced (antipsychotics, metoclopramide)
progressive supranuclear palsy
multiple system atrophy
wilsons disease
post encephalitis
dementia with lewy bodies
Are the symptoms of parkinsons symmetrical or asymmetrical
they are characteristically asymmetrical
Who is most commonly affected by parkinsons
men aged 65
Triad of parkinsons
bradykinesia
resting tremor
cogwheel rigidity
How many bradykinesia present in parkinsons
poverty of movement
short shuffling gait with reduced arm swing
small handwriting
reduced facial movements
Describe the tremor associated with parkinsons
resting tremor
usually 3-5 Hz
worse when tired or stressed
improves with voluntary movement
described as ‘pill-rolling’
Features of parkinsons (apart from the classic triad)
mask like face
flexed posture
soft voice
drooling saliva
Depression (affects about 40%)
postural instability
loss of sense of smell
sleep disorder
How does drug induced parkinsons differ from parkinsons disease in its presentation
drug induced is mroe likely to have a rapid onset and bilateral symptoms
it is less likely to have rigidity and resting tremour
How is parkinsons diagnosed
clinical
may use SPECT or CT/MRI scan
First line treatment of parkinsons if affecting quality of life?
levodopa
first line treatment of parkinsons if not affecting someones life
dopamine agonist (cabergoline), monamine oxidase B inhibitor or levodopa
If a patient with Parkinson’s is on the optimal dose of levodopa but still has symptoms what medication may be added?
MAO-B or COMT inhibitor
pathophysiology of parkinsons disease
loss of dopaminergic neurones in the substantia nigra of the basal ganglia
Side effects of levodopa
dry mouth
anorexia
palpitations
postural hypotension
psychosis
How does levodopa work?
it breaks down into dopamine once it crosses the blood brain barrier
What may be combined with levodopa to prevent peripheral breakdown and release of dopamine outside of the brain
decarboxylase inhibitor (carbidopa or benserazide)
What is the end-of-dose wearing off phenomenon that occurs with levodopa
symptoms worsen towards the end of the levodopa interval
What is the on-off phenomenon associated with levodopa
there are large variations in motor performance with normal function during an on period and weakness and restricted mobility during a off
what may parkinsons patients experience when on the peak dose of levodopa
dyskinesias - chorea, dystonia and athetosis (involuntary writhing movements)
What may parkinsons patients experience if they stop levodopa suddently
acute dystonia
Which parkisnons medication is known to cause problems with impulse control
dopamine agonists (cabergoline)
What complications is associated with dopamine agonists that requires monitoring investigations before beginning?
pulmonary and cardiac fibrosis
Patients should have an ECHO, ESR, creatinine and chest ray before starting
how do monamine oxidase B inhibitors work?
inhibit the breakdown of dopamine secreted by dopaminergic neurones
what is an example of a MAO-B inhibitor
selegiline
How do COMT inhibitors work
inhibits the breakdown of dopamine- used as an adjunct to levodopa
Give some examples of COMT inhibitors
entacarpone, tolcapone
What disease is parkinsons disease commonly related to?
lewy body dementia
how does lewy body dementia present?
progressive cognitive impairment - typically before parkinsonisms
parkinsonsism
visual hallucinations
How can you differentiate between parkinsons disease and lewy body dementia
in parkinsons motor symptoms are usually present for a year before cognitive impairment whereas in lewy body dementia cognitive impairment usually comes first
How is lew body dementia diagnosed?
usually clincial however SPECT scans are increasing used
How is lewy body dementia treated?
Acetylcholinesterase inhibitors (rivastigmine, donepezil) and memantine can be used
what type of drug should be avoided in lewy body dementia and why
neuroleptics - associated with irreversible parkonsonisms
What complications can occur with both antipsychotics and parkinsons drugs (levodopa)
neuroleptic malignant syndrome
how does neuroleptic malignant syndrome present?
pyrexia, muscle rigidity, autonomic lability (hypertension, tachycardia and tacypnoea) , agitated delirium
What might bloods show in someone with neuroleptic malignant syndrome
raised creatinine kinase is present in most
may have AKI and leukocytosis in severe
What is the most prevalent STI in the UK
chlamydia
what bacteria causes chlamydia
chlamydia trachomatis
How common is chlamydia
affects approx 1 in 10 young women
what type of pathogen is chlamydia
an intracellular bacterium
gram negative bacilli
Incubation period of chlamydia
7 to 21 days
what % of patients with chlamydia are asymptomatic
70% of women, 50% of men
How does chlamydia present in women
cervicitis- discharge, bleeding
dysuria
how does chlamydia present in men
urethral discharge
dysuria
how is chlamydia diagnosed
NAAT- from vulvovaginal swab in women and first void urine in men
treatment of chlamydia
7 days doxycycline
complications of chlamydia
pelvic inflammatory disease
epididymitis
reactive arthritis
conjunctivits and pneumonia in neonates if infected mother
perihepatitis (Fitz-Hugh-Curtis syndrome)
infertility
increased ectopics
if doxycycline is contraindicated in chlamydia what may be used?
azithromycin (1g OD and then 500mg OD for 2 days)
what is used to treat chlamydia in pregnancy
azithromycin, erythromycin or amoxicillin
How long after exposure should chlamydia testing be done?
2 weeks
What bacteria causes gonorrhoea
gram negative diplococci neisseria gonorrhoeae
incubation period of gonorrhoea
2 to 5 days
what percentage of patients with gonorrhoea are aysmptomatic
90% of men and 50% of women
how does gonorrhoea present
men- urethral discharge
dysuria
women - vaginal discharge (yellow green thick)
abdominal pain
dyspareunia
how is gonorrhoea diagnosed?
NAAT taken from vaginal swab in women and first pass urine in men
treatment of gonorrhoea
IM ceftriaxone 1g
RF of gonorrhoea
young age
new sexual contact
inconsistent condom use
MSM
current or prior STI
incareration
complications of gonorrhoea
pelvic inflammatory disease, pregnancy complications, development of stricture
epididymitis, orchitis, prostatitis, infertility
What causes infectious mononucleosis
Epstein-Barr virus (EBV- also known as herpesvius 4)
What is a less common cause of infectious mononucleosis
cytomegalovirus and HH6
Triad of infectious mononucleosis
sore throat (with whitewash exudate)
pyrexia
lymphadenopathy (commonly in the anterior and posterior triangles of the neck )
how does lymphadenopathy differ in EBV and tonsilitis
EBV more likely to be in the anterior and posterior triangles of the neck
Tonsilitis more likely to be in the upper anterior cervical chain
presentation of EBV
triad: lymphadenopathy, pyrexia, sore throat
- malaise
- palatal petechiae
- splenomegaly
- hepatitis
- lymphocytosis
- haemolytic anaemia
How long does it usually take for EBV to resolve?
2-4 weeks
How is EBV diagnosed?
heterophil antibody test (monospot test)
FBC- may show haemolytic anaemia and lymphocytosis
LFTs may be elevated
Why can you get haemolytic anaemia in EBV
due to cold agglutins (IgM)
Differentials for EBV
strep throat, lymphoma and leukaemia, viral illnesses (e.g mumps)
Treatment of EBV
rest and analgesia
Avoid playing contact sport - splenic rupture
what type of virus causes mumps
an RNA paramyxovirus
how is mumps spread
respiratory droplets
incubation period of mumps
14-21 days
when are patients with mumps infective
7 days before and 9 days after parotid swelling starts
pathophysiology of mumps
spread via respiratory droplets
replicates in the upper respiratory mucosa
spreads to the parotid gland
How does mumps present?
fever
malaise
parotitis (usually presents as ear ache or pain on eating)
how does parotitis present in mumps?
ear pain or pain on eating
usually begins unilateral and then spreads to be bilateral
How is mumps diagnosed?
usually clinical - can be confirmed with saliva sample to detect IgM
differentials for mumps
viral infections- EBV
acute supparative parotitis
parotid duct obstruction
Treatment of mumps
no specific treatment- fluids, rest, analgesia
notifiable disease
complications of mumps
parotitis
orchitis- occurs in post-pubertal men and can lead to impairments in fertility. May present as pain and swelling of the testicals
hearing loss- usually transient
meningoencephalitis
pancreatitis
what type of pathogen is trichomonas vaginalis
a highly motile flagellated protozoan parasite
Presentation of trichomonas vaginalis
vaginal discharge- offensive, yellow/green frothy discharge
vulval itching
dysuria
Examination findings of trichomonas vaginalis
strawberry cervix
pH greater than 4.5
yellow-green frothy discharge with a fishy odour
inflammation of the vulva and vagina
How can the diagnosis of trichomonas vaginalis be confirmed
microscopy of a wet mount shows motile trophocytes
how does trichomonas vaginals present in men
usually asymptomatic- can have urethritis
How is trichomonas vaginalis treated?
oral metronidazole for 5-7 days
Complications of trichomonas vaginalis
- perinatal sepsis
- PID
- increased risk of cervical cancer
- fascilitated HIV
- infertility
- increased risk of prostate cancer
What is conjunctivitis
inflammation of the conjunctiva
if corneal involvement - keratoconjunctivitis
Causes of conjunctivits
bacterial
viral
allergic
how does bacterial conjunctivitis present
red eye
purulent discharge
eye may be stuck together in the morning
how does viral conjunctivitis present?
red eye
serous discharge (clear)
recent URTI
pre-auricular lymph nodes
How does allergic conjunctivitis present?
red eye
bilateral
swollen eyelids
itching is common symptom
treatment of infective conjunctivitis
topical antibiotic treatment- chloramphenicol or fusidic acid drops
avoid wearing contact lenses
avoid sharing towels
clean eyes
Treatment of allergic conjunctivitis
1st line topical or systemic antihistamines
2nd line: topical mast-cell stabilisers
differentials of conunctivitis that are typically associated with increased pain
foreign body
acute closed angle glaucoma
anterior uveitits
corneal abrasions
scleritis
What are the two strains of the herpes simplex virus?
HSV-1 and HSV -2
What does HSV-1 cause
oral lesions- cold sores
what does HSV-2 cause
genital herpes
pathophysiology of HSV-1
it is commonly contracted in childhood and remains dormant until at times of stress it can reactivate in the trigeminal nerve and cause cold sores
how is HSV-2 predominately spread
it is mainly an STI
where does HSV-1 lay dormant
trigeminal nerve ganglai
where does HSV-2 lay dormant
sacral nerve ganglia
symptoms of genital herpes
painful genital ulceration
dysuria
pruritis
may have systemic illness (particularly in the primary infection) - headache, fever, malaise
Tender inguinal lymphadenopathy
urinary retention
neuropathic like pain
How does oral herpes (cold sores) present?
prodromal pain, burning and tingling for 6-48 hours
crops of vesicles that rupture and lead to superficial ulcers before crusting over and healing
How are genital herpes diagnosed?
NAAT
treatment of genital herpes
saline bathing, analgesia, topical anaesthetic (lidocaine)
oral aciclovir
If a pregnant women has a gential herpes infection during pregnancy how is it treated?
she should have an elective caesarean if primary attack occurs during a pregnancy at greater than 28 weeks
what is gingivostomatitis
a common presentation of herpes in young children where they present with vesicles and ulcers on the tongue, lips, gums and buccal mucosa
what is a severe complication of herpes?
herpes encephalitis
How is gingivostomatitis treated
oral aciclovir and chorhexidine mouthwash
how are cold sores treate
topical aciclovir
what is polymyalgia rheumatica?
a chronic inflammatory condition characterised by pain and stiffness in the shoulders, pelvic girdle and neck
who is most commonly affected by PMR
patients over the age of 60
more common in women
What does NICE describe as the core features of PMR
symptoms present for at least 2 weeks:
- bilateral shoulder pain that radiates to the elbow
- bilateral pelvic girdle pain
- worse on movement
- interferes with sleep
- stiffness for at least 45 minutes in the morning
what systemic features may be present in PMR
weight loss, lethargy, low grade fever, night sweats, low mood
How is PMR diagnosed?
usually based on its clinical presentation and response to treatment
- ESR - raised (usually >40)
- creatinine kinase and EMG are normal
treatment of PMR
initially 15mg of prednisolone a day
assess after 3-4 weeks (should have 70% improvement in symptoms and inflammatory markers should be normal)
Steroid reducing regime:
- 15mg until fully controlled
- 12.5mg for 3 weeks
- 10mg for 4-6 weeks
- reduce by 1mg every 4,8 weeks
what additional medication may be given to patients treated with steroids for PMR
osteoporosis prophylaxis- bisphosphonates, calcium and vitamin D
PPI for gastric protection
what disease is associated with PMR
giant cell arteritis
What is the most common type of prostate cancer?
95% are adenocarcinomas (usually in the peripheral zone of the prostate)
RF of prostate cancer
increasing age
family history
black african or caribbean origin
anabolic steroid use
tall stature
are prostate cancers androgen dependent
yes
How does prostate cancer present?
LUTS (hesitance, frequency, weak flow, terminal dribbling, nocturia)
haematuria
erectile dysfunction
symptoms of metastases (bone pain most common)
How can prostate cancer be screened for
PSA
DRE
how does prostate cancer present on DRE
hard, irregular, craggy
first line investigation for prostate cancer
mulitparametric MRI
gold standard investigation for prostate cancer
USS and biopsy- transrectal
How is prostate cancer graded?
gleason score (higher the score the worse)
What nodes does prostate cancer first spread to
obturator nodes
Treatment options for prostate cancer
external beam radiotherapy
brachytherapy- radioactive seed implanted into the prostate
radical prostatectomy
hormonal therapy- androgen receptor blocker, GnRH agonist, orchidectomy (stop testosterone production)
complication of radiotherapy for prostate cancer
radiation proctitis and rectal malignancy
complication of TURP (transurethral resection of the prostate)
erectile dysfunction
complicationsof TRUS biopsy
sepsis
pain
fever
haematuria and rectal bleeding
Why do GnRH agonists lead to lower LH levels?
they cause overstimulation which results in disruption to the endogenous hormonal feedback
what is a side effect of GnRH agonists in treatment of prostate cancer
an initial tumour flare as there may be an initial rise in testosterone
often given with an anti-androggen
What is the centor criteria
used to determine if tonsillitis is bacterial or viral
what features of the centor criteria suggest that tonsilitis is bacterial
tonsillar exudate
tender anterior cervical lymphadenopathy
fever >38
Absence of a cough
complications of tonsillitis
quinsy (peri-tonsillar abscess)
otitis media
rheumatic fever and glomerulonephritis
aetiology of tonsilitis
most frequently viral infection
can be bacterial- group A betal haemolytic strep (strep pyogenes)
what two criteria can be used to determine if tonsilitis is bacterial or viral
the centor score or the feverPAIN score
what are the components of the feverPAIN score
fever
purulence
attend rapidly (within 3 days)
Inflammed tonsils
No cough or coryza
What investigation may be done to exclude a differential of tonsilitis
monospot test to exclude EBV
treatment of bacterial tonsilitis
phenoxymethypenicillin (penV) for 5-10 days (clarithromycin or erythromycin if allergic)
who is offered tonsilectomy
those who have had:
- 7 or more episodes in the past year
- 5 per year or more in the past 2 years
- 3 or more in the preceding three years
or if there has been one epsiode of quincy or airway obstruction
Other: febrile convulsions, obstructive sleep apnoeaco
complications of tonsilectomy
haemorrhage and pain
What is urticaria
superficial swelling of the skin that is intensely red, raised and itchy
what defines acute urticaria
symptoms have been present for less than 6 weeks
What defines chronic urticaria
symptoms have been present for at least 6 weeks
pathophysiology of urticaria
there is a release of histamine and other inflammatory mediators from mast cells which leads to increased vascular permeability and the production of wheals
two main causes of acute urticaria
acute viral infection
allergen- food, insect bites, latex, drugs (penicillin, aspirin etc)
What are the two types of chronic urticaria
chronic spontaneous urticaria
chronic inducible urticaria
describe chronic spontaneous uritcaria
where urticaria has occured with no known identifiable cause, however symptoms may be aggravated by heat, stress, drugs.
Autoimmune urticaria is part of this group
what is chronic spontaneous urticaria
urticaria that occurs in response to a physical stimulus
give some examples of chronic inducible urticaria
aquagenic
cholinergic (occurs after active or passive warming)
cold
delayed pressure
solar
What feature may accompany urticaria that presents as swelling of facial features
angioedema
How is urticaria diagnosed?
mainly a clinical diagnosis
May do:
- allergy tests
- inflammatory markers
- skin biopsies
- urinalysis
1st line treatment of urticaria after removing triggers
non-sedating antihistamines - e.g cetrizine
consider a sedating antihistamine at night
2nd line treatment of urticaria
alternative/ high dose antihistamines or leukotriene receptor antagonist
what can be used for a short period in severe episodes of urticaria
prednisolone
what is vasovagal syncope
a form of reflex syncope characterised by a transient loss of consciousness in response to certain triggers
What can trigger vasovagal syncope
emotional events
pain
prolonged standing
heat exposure
physical exertion
pathophysiology of vasovagal syncope
there is a brief loss of cerebral perfusion due to an abrupt fall in blood pressure
This occurs due to changes in the activation of the autonomic nervous system:
- cardoinhibitory response: there is increased parasympathetic activity causing bradycardia
- vasodepressor response: there is decreased sympathetic activity leading to systemic vasodilation and hypotension
what are the physiological mechanisms which cause the fall in BP associated with vasovagal syncope
cardioinhibitory response causing bradycardia
vasodepressor response causing vasodilation
how does vasovagal syncope present ?
a prodrome of nausea, pallor, sweating, light-headedness, palpitations, visual alterations and reduced hearing
loss of consciousness (usually brief lasting 8-12 seconds)
may have some residual fatigue after
Management of vasovagal syncope
lifestyle changes: trigger avoidance, increased fluid and salt intake, compression stockings
medical therapy to improve BP:
- fludrocortisone
- midodrine
What is the gold standard investigation for vasovagal syncope?
tilt table test - will induce cardioinhibitory and vasodepressor response and lead ot hypotension
RF for haemorrhoids
pregnancy
obesity
increased age
increased intraabdominal pressure (e.g. weight lifting, chronic coughing), constipation
how do haemorrhoids present?
painless bright red bleeing
pruritis
anal mass
perianal pain ( if thrombosed)
how are haemorrhoids classified
internal and external
internal is above the dentate line while external is below
what are the 4 grades of internal haemorrhoids
1- no protrusion into the anal canal
2- protrusion on straining
3- protrusion that is manually reducible
4- permanent protrusion
which type of haemorrhoid can cause pain?
external (as below the dentate line so sensate skin)
1st line treatment of haemorrhoids
conservative management (soften stools) and topical anaesthetic or corticosteroids
surgical mangament options for haemorrhoids
rubber band ligation
injection sclerotherapy
surgical removal
what is peripheral arterial disease?
a range of arterial syndromes characterised by reduced blood flow to the extremities - most commonly the aortic-ileac and infra-inguinal arteries
What are the three conditions included in peripheral arterial disease
intermittent claudication
acute limb ischaemia
critical limb ischaemia
What are RF for peripheral arterial disease?
smoking, diabetes, atherosclerosis, hypertension, physical inactivity, obesity
what is the most common cause of peripheral arterial disease
atherosclerosis
aside from atherosclerosis what else can cause peripheral arterial disease
coarctation of the aorta
arterial dissection
arterial embolism
arterial thrombus
vasospasm
tumour
how does intermittent claudication present?
crampy pain after physical activity
stopping causes the pain to go away
common in the calf muscles
how does acute limb ischaemia present
rapid onset of limb ischaemia occuring due to a blockage of the arterial supply
presents with:
- pain
- pallor
- pulselessness
- perishingly cold
- paraesthesia
How will acute limb ischaemia caused by a thrombus and an embolus differ
if caused by a thrombus there will be pre-existing claudication with sudden deterioration
if caused by an embolus there will be no pre-existing claudication with sudden onset of painful leg
What is critical limb ischaemia
end stage peripheral arterial disease
there will be pain at rest, ulcers and gangrene
typical presentation is burning pain that is worse at night as the leg is raised
What is Leriche syndrome
occlusion of the distal aorta or proximal iliac artery leading to a triad of
- thigh/buttock claudication
- absent femoral pulses
- male impotence
how do arterial ulcers present
small, deep, well defined borders, punched out appearance and pain
What is Buerger’s test
a test to identify peripheral arterial disease
- patient lays down and lifts legs to 45 degrees for 1-2 mins
- pallor suggest there is insufficient arterial supply to overcome gravity
- then get patient to sit up and hang legs over the edge of the bed
- in healthy legs they will go pink however in peripheral arterial disease they will go blue first and then dark red
How can peripheral arterial disease be diagnosed
ankle-brachial pressure index
what value of ABPI suggests critical limb ischaemia
less than 0.3
what value on ABPI suggests mild arterial disease
0.6 to 0.9
what value of APBI suggests moderate to severe peripheral arterial disease
0.6 to 0.3
what does an APBI above 1.3 suggest
calcification of the arteries making them difficult to compress
first line treatment of peripheral arterial disease
atrovastatin and clopidogrel
what lifestyle changes should be recommended for patients with peripheral arterial disease?
stop smoking
optimise medical treatment of comorbidities
exercise training
what surgical options can treat peripheral arterial disease?
endarterectomy
surgical bypass with autologous or prosthetic material
amputation
endovascular techniques for peripheral arterial disease
percutaneous transluminal angioplasty +/- stent placement
which patients should be treated with endovascular techniques for PAD
short segment stenosis (<10cm) , aortic iliac disease and high risk patients
which patients should be treated with surgical techniques for PAD
those with long segment stenosis (>10cm), multifocal lesions, lesions of the common femoral and purely popliteal disease
what dilatory drug may be used in severe PAD which is associated with poor QoL
naftridofuryl oxalate
How does trichomonas vaginalis present on light microscopy-
motile trophozoites
What is reactive arthritis
arthritis occurring after an infection - most commonly urogenital (chlamydia, gonorrhoea) and GI infections (salmonella, shigella)
What group of diseases is reactive arthritis part of?
spondyloarthropathies- associated with HLA B27
How does reactive arthritis present?
asymmetrical oligoarthritis, usually of the lower limb (painful red swollen knee)
inflammatory back pain
dactylitis
enthesitis
extra-articular manifestations ( keratoderma blenorrhagica, circinate balnitis, uveitis)
what are the extra articular manifestations of reactive arthritis
cant see cant wee cant climb a tree
- uveitis, conjunctivitis
- circinate balanitis
- enthesitis
What is enthesitis
inflammation of the insertion of soft tissue to bone- tendons, fascia
Commonly on ankle causing archilles tendonitis and planta fascia
What is keratoderma blenorrhagica
Skin lesions similar to psoriasis on the palms and the soles
what is circinate balanitis
dermatitis on the glans penis
first line treatment for reactive arthritis
symptomatic control - NSAIDS
Treatment of reactive arthritis
NSAIDS
intra-articular steroids
If unresponsive DMARDS- methotrexate
if chronic biologics - anti-TNF agents (e.g. infliximab)
Usual time course of reactive arthritis
typically arises around 4 weeks after the initial infection
symptoms usually last 4-6 months
What types of lesions make up acne
non-inflammatory comedones (whiteheads and blackheads)
inflammatory papules, pustules, nodules and cysts
Pathophysiology of acne
- sebaceous gland hyperplasia and excess sebum production
- abnormal follicular differentiation - keratinocytes usually shed however in acne they are retained due to inreased cohesiveness
- cutibacterium acne colonisation
- inflammation and immune response
What bacteria is mainly present in acne
c. acnes
What is acne fulminans
a severe form of acne accompanied by systemic features that require hospitalisation and corticosteroids
First line treatment of mild - moderate acne
12 week course of topical combination therapy (one of the below combinations)
topical adapalene + topical benzy peroxide
Topical tretinoin and topical clindamycin
Topical benzy peroxide and topical clindamycin
Treatment of acne if 12 week combination therapy does not work?
add in oral lymecycline or doxycycline , or add in topical azelaic acid
if a pregnant women experiences acne what should definitely not be involved in the treatment
tetracycines- lymecycline
(erythromycin can be used instead)
what could be considered in the treatment of acne in women
the combined oral contraceptive pill
what COCP has antiandrogen properties and why is it not used first line in acne treatment
dianette (co-cyprindiol)
has a higher risk of DVT
Which patients with acne should be referred to dermatology
acne that hasnt responded to treatment
acne with scarring
acne with persistent pigmentary changes
patients with nodulo-cystic acne
acne causing severe psychological distress
patients with conglobate acne
what is an anal fissure
a longitudinal or eliptical tear of the squamous lining of the distal anal canal
what are secondary causes of anal fissures
constipation
IBD
STIs
colorectal cancer
anal trauma
adverse drug reactions
pregnancy and childbirth
What is an acute anal fissue
one that has been present for less than 6 weeks
what is a chronic anal fissure
one that has been present for more than 6 weeks
how do anal fissures present
painful bright red rectal bleeding
what is the treatment of acute anal fissures
soften stool- high fibre diet, high fluid intake, bulk forming laxatives
lubricants before passing stool - petroleum jelly
topical anaesthetics
analgesia
first line treatment of anal fissures that are present for > 1 week
topical glyceryl trinitrate (GTN) twice daily for 6-8 weeks
If topical GTN is not effective after 8 weeks in treating anal fissures what may be considered
sphincterotomy or botulism toxin
what type of reaction is anaphylaxis
a type I hypersensitivty reaction
pathophysiology of anaphylaxis
SENSITISATION:
- an allergen enters the body and is taken up by an antigen presenting cell
- this interacts with a T helper 2 cell
- this stimulates B cells to produce specific IgE to the allergen
- the IgE binds to mast cells and basophils
RE-EXPOSURE:
- when the allergen enters the body again mast cells with the specific IgE will bind to it
- this leads to activation and degranulation causing the release of pro-inflammatory mediators (histamine, tryptase, cytokines)
- the mediators cause local inflammation, vessel dilation, loss of vascular integrity and fluid extravasation causing oedema
- the oedema and vasodilation causes airway obstruction, bronchoconstriction and reduced cardiac output
Presentation of anaphylaxis
sudden onset of :
- airway problems: swelling of the throat and tongue
- breathing problems: resp wheeze, SOB
- circulation problems: hypotension, tachycardia
And skin symptoms: urticaria, itching, angiooedma
dose of adrenaline in under 6 months
100-150 micogram
dose of adrenaline in 6 months - 6 years
150 micrograms
dose of adrenaline in 6-12 years
300 micrograms
does of adrenaline in >12 years
500 micrograms
what blood test can confirm anaphylaxis (after treatment)
mast cell tryptase
when should mast cell tryptase tests be done in anaphylaxis
- immediately after treatment
- 1-2 hours after
- 24 hours after (gives baseline level)
what is refractory anaphylaxis
respiratory and/or cardiovascular problems that persist despite 2 doses of IM adrenaline
Management of refractory anaphylaxis
IV fluids for shock
IV adrenaline infusion
management of anaphylaxis after stabilisation
non-sedating oral antihistamines (e.g. chlorphenamine) if remaining skin reaction
referral to a specialist allergy clinic if first time
2 adrenaline autoinjectors
What is folliculitis?
inflammation of the hair follicles
what pathogen is most commonly involved in folliculitis
staphylococcus aureus
what is the most common cause of septic arthritis in young adults
gonorrhoea
what is the first line investigation of genital herpes?
NAAT (not viral culture)
what might an area of rapidly worsening eczema be a sign of
eczema herperticum
how does primary syphilis present
painless ulceration and lymphadenopathy
give examples of non-sedating antihistamiens
loratadine
cetirizine
fexofenadine
what malignancies is EBV associated with
burkitt’s lymphoma
non-hodgkins lymphoma
naso-pharyngeal carcinoma
How does eczema herpeticum present?
monomorphic punched out erosions usually 1-3 mm in diameter
how long might it take for finasteride to start working on BPH
6 months
if treatment of a upper respiratory tract infection with amoxicillin leads to a widespread maculopapular itchy rash what is the likely cause
EBV
what is presbycusis
age related sensorinerual hearing loss
If an anal fissure is lateral what investigation should be done
faecal calprotectin (normal anal fissures are usually in the posterior midline)
what are common x ray findings of psoriatic arthritis
plantar spur and pencil in cup deformitites
What is urge incontinence?
incontinence caused by overactivitiy of the detrusor muscle of the bladder.
How does urge incontinence present?
sudden urges to pass urine, having to rush to the bathroom and then not arriving before urination occurs.
People may avoid activities where a toilet isnt easily accessible
What is stress incontinence?
incontinence due to weakness of the pelvic floor and sphincter muscles
How does stress incontinence present?
urinary leakage while coughing, laughing or when suprised
What is overflow incontinence
incontinence that occurs when there is chronic urinary retention due to an obstruction in the outflow tract.
How does overflow incontinence present?
overflow of urine causing incontinence without the urge to pass urine
What can cause overflow incontinence
anticholinergic drugs, fibroids, neuro conditions (MS, diabetes, spinal cord injury), prostate enlargement
What is functional incontinence
when a comorbid physical condition impairs someones ability to get to the bathroom in time - may be caused by dementia, sedating medication, injury
investigations of urinary incontinence
1st - bladder diary for minimum of 3 days
urine dipstick
vaginal examination
urodynamic studies
what are examples of urodynamic studies
cystometry
uroflowmetry
leak point pressure
post-void residual bladder volume
lifestyle changes for urinary incontinence
avoid caffeine, alcohol, diuretics
restrict fluid intake
weight loss
1st line treatment of stress incontinence
pelvic floor exercises - at least 8 contractions performed at least 3 times a day for a minimum of 3 months
1st line drug treatment of stress incontinence
duloxetine
surgical procedures for stress incontinence
tension-free vaginal tape, autologous sling procedure, coposupsension, intramural urethral bulking
1st line treatment of urge incontinence
bladder retraining for 6 weeks
1st line drug treatment for urge incontinence in young
anticholinergic medications- oxybutynin, tolterodine
1st line drug treatment of urge incontinence in elderly
mirabegron
SE of mirabegron
raised BP- hypertensive crisis
increases TIA and stroke risk
invasive treatments of urge incontinence
botulinum toxin
sacral nerve stimulation,
what is the most common cause of leg ulcer?
venous ulcer
Where do most venous ulcers occur?
the gaiter area (between the top of the foot and the bottom of the calf muscle
RF for venous ulcers
increasing age
obesity
immobility
limited ankle motion
previous ulcer
family or personal history of varicose veins
history of DVT
female sex
multiple pregnancies
history of leg trauma
pathophysiology of venous ulcers
occurs due to sustained venous hypertension leading to chronic venous insufficiency due to venous valve incompetence or impaired calf muscles
how do venous ulcers present?
- gaiter area
- large, superficial ulcers
- gently sloping edges
- symptoms worse at end of the day and relieved by raising leg
- chronic venous skin changes (hyperpigmentation, venous eczema, lipdermatosclerosis)
Investigation of venous ulcers
ABPI to assess for any arterial disease (normal is 0.9 to 1.2)
FBC
ESR and CRP
1st line treatment of venous ulcers
compression bandages (need to exclude arterial disease)
drug treatment of venous ulcers
oral pentoxyfylline- peripheral vasodilator that improves healing rate
What are varicose veins?
dilated superficial veins commonly found on the lower limbs
RF for varicose veins
age
pregnancy
female
woman
previous DVT
Pathophysiology of varicose veins
increased pressure in the small superficial veins due to venous insufficiency caused by valvular incompetence
how do varicose veins present?
can be asymptomatic
May have:
- pain/tenderness
- pruritis
- restless legs
- cramps
- bleeding
- dilated superficial veins
- venous eczema
Diagnosis of varicose veins
venous duplex USS - demostrates retrograde venous flow
conservative treatment of varicose veins
weight loss
avoid prolonged standing
elevate legs when possible
compression stockings
regular exercise
What indications are there to refer someone with varicose veins to vascular surgery
symptomatic primary or recurrent varicose veins
skin changes
superficial vein thrombosis and suspected venous incompetence
active venous ulcer
healed venous ulcer
What are potential invasive treatments for varicose veins
sclerotherapy - irritant foam is injected into a vessel and causes closure of the vein
Endothermal ablation
phlebectomy
high ligation and vein stripping
Which of episcleritis and scleritis is painful
Scleritis
What two causes of vaginal discharge create a pH greater than 4.5
Trichomonas vaginalis and bacterial vaginosis
What is the most common form of prostate cancer
Adenocarcinoma
What bacteria is associated with bacterial keratitis in contact lens wearers
Pseudomonas aeuginosa
What type of bacteria cause lyme’s disease?
Spirochetes
Most common bacteria associated with lymes disease
Borrelia burgdoferi
How is lymes disease spread?
The bacteria is transmitted to humans via ticks
Ticks attach onto humans to have a ‘blood meal’
The longer they are attached the increased likelihood of transmission
After how long of attachment is lymes disease usually spread from ticks
After being attached for 36-48 hours
If not treated, what three phases will lymes disease go through
- Early localised disease - expanding target like rash of erythema migrans 1-36 days after tick bite
- Early disseminated disease- weeks to months after bite, patients have multiple secondary erythema migrans, arthritis, carditis, cranial nerve palsy
- Late disseminated disease - presents months to years after the initial infection, oligoarthritis, skin manifestations and involvement of the peripheral nervous system
What is post treatment Lyme disease syndrome
Persisting symptoms of lymes disease such as fatigue, pain or joint and muscle aches
Describe the rash associated with erythema migrans
Erythema migrans
Target like rash - bulls eye
Develops 1-4 weeks after bite
How is lymes disease diagnosed
If erythema migrans is present it can be diagnosed clinically
If not then ELISA test for antibodies to Borrelia burgdorferi is 1st line test
If the ELISA test is negative for Lymes disease what should be done
If tested within 4 weeks of symptom onset it should be repeated after another 4-6 weeks
If still negative after 12 weeks the immunoblot test should be done
How are asymptomatic tick bites treated
Remove the tick if still present- fine tipped tweezers, grasp as close to skin as possible and then wash skin
Management of confirmed/suspected Lyme disease
Doxycycline if early disease
Ceftriaxone if disseminated disease
What reaction might occur after starting antibiotics for Lymes disease
Jarisch- Herxheimer reaction
What bacteria causes syphilis
Treponema pallidum
RF for syphilis
Unprotected sex, multiple sexual partners, transactional sex, substance misuse, social vulnerability
Incubation period of syphilis
21 days
How does primary syphilis present?
A painless ulcer (chancre) and local lymphadenopathy
How long after infection does secondary syphilis present?
6-10 weeks post infection
How does secondary syphilis present?
Systemic involvement including skin and hair changes, maculopapular rash on trunk palms and soles, condylomata lata (moist wart like lesion on the genitalia), patchy alopecia, oral lesions (snail tract lesions), generalised lymphadenopathy and low grade fever
What is early latent syphilis
Confirmed infection without any current features
What classifies late syphilis
More than 2 years after infection
What two phases of latent syphilis are there?
Late latent syphilis where there is confirmed disease but no current features
Tertiary syphilis- granulomatous lesions on the skin and bone (Gummas), cardiac disease (aortic aneurysms), and/or neurological disease (general paralysis of the insane, tabes dorsalis, Argyll - Robertson pupil_
Features of tertiary syphilis
Gummas (granulomatous lesions of the skin and bone)
Ascending aortic aneurysms
General paralysis of the insane
Tabes dorsalis
Argyll Robertson pupil
What two types of serological tests can be used to test for syphilis
Non-treponemal tests - not specific to syphilis but looks at the reactivity of serum to cardiolipin-cholesterol-lecithin antigen
side effect of doxycylcine
photosensitivity
what is the treatment of severe urticaria where antihistamines dont work
a short course of oral steroids
how often can adrenaline be given
every 5 mintues
How can you differentiate spinal stenosis and peripheral arterial disease
Spinal stenosis is more likely to have:
- pain the improves with sitting down or crouching
- weakness in the leg
- lack of smoking history
- lack of cardiovascular history
what is the most common cause of anaphylaxis in children
food
How should utis be treated in patients on methotrexate
Nitrofurantoin- trimethoprim caused bone marrow suppression
Blood film findings of coeliac disease
Howell jolly bodies and targets cells
what is the most sensitive test for pernicious anaemia
anti-parietal cell antibodies-
anti - intrinsic factor antibodies are highly specific but not very sensitive
how does normal pressure hydrocephalus present on neuroimaging?
ventricular enlargement with relative perservation of cortical sulci
How would you manage arterial stenosis in PAD of less than 10cm
endovascular revascularisation (angioplasty)
Causes of atrial fibrillation and how to remember?
mrs SMITH
Sepsis
Mitral valve pathology (stenosis or regurgitation)
Ischaemic heart disease
Thyrotoxicosis
Hypertension
Overall features of the pathology of AF (4)
- irregularly irregular ventricular contractions
- tachycardia
- heart failure due to poor filling of the ventricles during diastole
- increased stroke risk due to pooling of the blood in the heart
What are the 4 classifications of AF
paroxysmal
acute
persistent
permanent
what defines paroxysmal AF
AF that spontaneously stops within 7 days
What defines acute AF
AF that started within 48 hours
What defines persistent aF
AF that lasts for more than 7 days and is not self-terminating
How might AF present ?
palpitations
dyspnoea
dizziness
syncope
chest pain
irregularly irregular pulse
What 3 findings are there on ECG in AF
- absent P waves
- narrow QRS complex tachycardia
- irregularly irregular ventricular rhythmn
When would you do rhythm control in AF
- patient has heart failure due to AF
- patient has new onset AF within the past 48 hours
- patient has a reversible cause of their AF
What is the first line rate control for AF?
beta blocker (bisoprolol) or CCB (not in HF)
what is second line rate control in AF
combine 2 of bisoprolol, CCB or digoxin
what two types of rhythmn control are there in AF
pharmacological - IV amiodarone
electrical
when would you do immediate and when would you do delayed cardioversion
immediate if AF onset was within 48 hours or if the patient is haemodynamically unstable
delayed if over 48 hours since onset and patient is table
describe delayed cardioversion
patient takes anticoagulants for >3 weeks and then has cardioversion
What invasive treatment may be used for AF if drug treatment is inadequate of not tolerated?
catheter ablation
What is the first line anticoagulant in AF?
DOAC - apixaban
what is the second line anticoagulant in AF?
warfarin
What scoring system can be used to determine if someone with AF needs anticoagulation?
CHA2DS2VASc score
What makes up the CHA2DS2VASC ?
Congestive HF = 1
Hypertension= 1
Age >75 =2
Diabetes
Stroke or TIA history =2
Vascular disease= 1
Age 65-74= 1
Sex- female= 1
What score on the CHA2DS2VASc indicates anticoagulation?
2 (1 in males)
What are causes of COPD
smoking causes 90% of cases
alpha 1 antitrypsin deficiency
occupational exposures
how does alpha-1-antitrypsin cause COPD?
alpha-1-antirypsin is a protease inhibitor that opposes the action of elastase in the lungs
If decreased elastase can break down elastin in the wall of the alveoli
two types of patients with COPD
pink puffers (emphysema) and blue bloaters (chronic bronchitis)
describe chronic bronchitis
chronic cough lasting 3 months or more, occurs due to chronic inflammation of the bronchi
microscopic features of chronic bronchitis
goblet cell hyperplasia
mucus hypersecretion
chronic inflammation and narrowing of the small airways
describe emphysema
damage and dilation of the alveoli decreasing the surface area for gas exchange to occur in the lungs
Occurs as inflammatory cells produce proteases that break down elastin in the walls of the alveoli
How does COPD present?
chronic productive couhg
breathlessness
frequent infections
wheeze
pursed lip breathing
signs of right heart failure
How is COPD diagnosed?
spirometry shows FEV1/FVC < 70% with no/little reversibility
Chest X ray
FBC - may show secondary polycythaemia in response to chronic hypoxia
what can be seen on chest X ray of COPD (3)
hyperinflation of the lungs
flattened hemidiaphragm
bullae
What general management is used in COPD
stop smoking
annual flu vaccine
pneumonoccal vaccine
Management of COPD
- SABA or SAMA
- Determine if steroid response or not
- if responsive add LABA and ICS
- if not responsive add LABA and LAMA - SABA as needed then triple therapy : LABA, LAMA and ICS
What medications may be able to reduce risk of COPD exacerbations
prophylactic azithromycin
mucolytics
phosphdiesterase inhibitors (roflumilast)
What is the most common pathogen associated with COPD exacerbations
haemophilus influenzae
What features suggest that COPD is steroid responsive (4) ?
atopy or asthma diagnosis
variation in FEV1 of more than 400ml
raised blood eosinophils
diurinal variability in PEF
criteria for having long term oxygen therapy in COPD
NO SMOKING
A pO2 < 7.3kPa or 7.3-8 if one of the following features is present:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
why does cor pulmonale occur in COPD
chronic hypoxia causes vasoconstriction of the pulmonary vessels
This increases pulmonary pressure and causes right heart failure
Explain heart failure with a reduced ejection fraction, including some specific causes
heart failure with an ejection fraction less than 50%
Usually due to systolic dysfunction
Causes include:
- IHD
- arrhythmias
- dilated cardiomyopathy
- myocarditis
Explain heart failure with a preserved ejection fraction and give some causes
heart failure with an ejection fraction more than 50% , usually due to diastolic dysfunction during filling
causes include:
- hypertrophic obstructive cardiomyopathy
- restricted cardiomyopathy
- cardiac tamponade
Presentation of heart failure (7)
breathlessness
peripheral oedema
cough- pink, white frothy
orthopnoea
paroxysmal nocturnal dyspnoea
peripheral oedema
fatigue
signs of heart failure (8)
tachycardia
tachypnoea
hypertension
murmurs
3rd heart sound
bibasal crackles
raised JVP
peripheral oedema
first line investigation for heart failure
NT-proBNP
investigation of heart failure after BNP (and how quickly should it be done)
if BNP is between 400-2000 then echo within 6 weeks
if BNP is over 2000 then echo in 2 weeks
what can cause falsely raised BNP (9)
LV hypertrophy
ischaemia
tachycardia
eGFR <60
sepsis
COPD
diabetes
>70
liver cirrhosis
What can cause a falsely low BNP (6)
obesity
diuretics
ACEi
beta blockers
ARB
aldosterone agonists
what may be seen on chest x ray of someone with heart failure
Alveolar oedema
Kerly B lines
Cardiomegaly
Dilated upper lobe veins
pleural Effusion
what classification system is used in heart failure
the NYHA classification
1- no symptoms
2- mild symptoms on activity
3- moderate symptoms on any activity
4- symptoms at rest.
1st line management of heart failure
ACEi and beta blocker
What may be added to ACEi and beta blocker if heart failure is not controlled
aldosterone antagonist (spironolactone)
what specialist drugs may be used to manage heart failure (5)
ivabradine
SGLT-2 inhibitor
ivabradine
hydrazalizine with a nitrate
digoxin
X ray findings of osteoarthritis
LOSS
Loss of joint space
Osteophyte formation
Subchondral sclerosis
subchondral cysts
what type of bony deformities might be seen in osteoarthritis
Herbeden’s nodes - swelling of DIP
Bouchard’s nodes - swelling of PIP
1st line management of osteoarthritis
oral paracetamol and topical NSAIDs
2nd line management of osteoarthritis
oral NSAIDs +PPI cover
RF for osteoporosis
SHATTERED
steroid use
hyperthyroidism/hyperparathyroidism
Alcohol and tobacco
thin (BMI <22)
testosterone reduced
Early menopause
Renal/liver disease
Erosive/inflammatory disease
Decreased dietary calcium and diabetes
What are fragility fractures?
a fracture from a fall from standing height or less
most commonly of the wrist spine and hip
What scan is used to measure bone density in osteoporosis?
DEXA scan
What defines osteoporosis on a DEXA scan
a bone mineral density 2.5 standard deviations away from peak mass (of an average young person)- shown by a T score of -2.5 or less
what result of a DEXA suggests osteopenia
-2.5 to -1.0
what risk score can be used to assess for osteoporosis?
FRAX - measures the risk of a patient having an osteoporotic fracture in the next 10 years.
If > 10% should DEXA
Who should be offered a DEXA scan?
- Those over 50 with a history of a fragility fracture
- those less than 40 if they have a major risk factor
1st line management of osteoporosis
Bisphosphonates- taken weekly on an empty stomach (e.g. alendronate)
2nd line management of osteoporosis
denosumab (monoclonal antibody that targets osteoclasts)
pathophysiology of type 1 diabetes
autoimmune destruction of the insulin secreting beta cells in the islets of langerhans of the prancreas
pathophysiology of type 2 diabetes
repeated insulin and glucose exposure causes cells to become resistant to insulin
This means that more insulin is needed to have the desired effect
Overtime the pancreas becomes tired and starts to reduce insulin production
what fasting glucose level is indicative of diabetes?
7 mmol/l
what result on the oral glucose tolerance test/ random plasma glucose test is indicative of diabetes?
11.1 mmol/l
what level HbA1c is indicative of diabetes?
> 48 mmol/mol (>6.5%)
what level HbA1c is indicative of pre-diabetes?
42-27mmol/mol (6-6.4%)
how often should HbA1c be measured in diabetes?
every 3 - 6 months
what should be the aimed HbA1c in newly diagnosed diabetics?
48 mmol/mol
what should be the aimed HbA1c in diabetes treated on more than one diabetes medication?
53mmol/mol
give an example of a short acting insulin
actrapid
give and example of a long acting insulin
lantus
1st line treatment of type 2 diabetes?
metformin +/- SGLT-2 inhibitor
who is given an SGLT-2 inhibitor in diabetes?
those with an increased cardiovascular risk (QRisk > 10%) , established cardiovascular disease or heart failure
what should be given first line if metformin is contraindicated ?
if CVD risk - SGLT-2 inihibitor
If no CVD risk - piolglitazone, sulfonylurea or DPP-4 inhibitor
what should be given first line if metformin isnt tolerated due to GI side effects?
modified release metformin
what is given second line if diabetes is not controlled with metformin
One of the following:
- DDP-4 inhibitor
- pioglitazone
- sulfonylurea
- SGLT-2 inhibitor
What is given 3rd line for the treatment of T2DM
triple therapy or insulin
what can be given if T2DM is not controlled on triple therapy, or if insulin isn’t suitable
one of the medications can be swaped to a GLP-1 mimetic
action of metformin
increase insulin sensitivity and decrease hepatic glucogenesis
SE of metformin
GI upset
lactic acidosis due to AKI
what eGFR is requried for metformin ?
> 30
action of SGLT-2 inhibitors ?
inhibit reabsorption of glucose in the kidneys by blocking the SGLT-2 channel
examples of SGLT-2 inhibitors (2)
empaglflozin
dapagliflozin
SE of SGLT-2 inhibitors
UTI and thrush due to glycosuria
weight loss
hypoglycaemia- DKA
what type of drug is pioglitazone
a thiazolidinedione
action of pioglitazone
activates the PPAR-gamma receptor in adipocytes to promote adipogenesis and fatty acid uptake
SE of pioglitazone
weight gain
fluid retention
increase bone fractures
bladder cancer
action of sulfonylurea
stimulates insulin release from the pancreas
example of a sulfonylurea
gliclazide
SE of sulfonylureas
weight gain
hypoglycaemai
examples of DPP-4 inhibitors
sitagliptin
alogliptin
action of DPP-4 inhibitors
increase incretin levels which is a hormone that inhibits glucagon secretion
SE of DPP-4 inhibitors
usually well tolerated by can cause headaches, acute pancreatitis
action of GLP-1 mimetic
mimic incretin and inhibit glucagon release
SE of GLP-1 mimetic
nausea and vomiting
pancreatitis
weight loss
what is acute bronchitis?
a self limiting lower respiratory tract infection caused by infection of the bronchial airways, not lung parenchyma
Most common cause of acute bronchitis
usually viral infections - coronavirus, rhinovirus, RSV, adenovirus
presentation of acute bronchitis
cough
rhinorrhoea
sore throat
wheeze
low grade fever
How can acute bronchitis be differentiated from pneumonia on examination?
there will be an absence of focal chest signs- consolidation, crackles
What test may be done in acute bronchitis if considering antibiotics?
CRP
What CRP cut off is used to determine if immediate antibiotics should be given in acute bronchitis?
> 100
Management of acute bronchitis (4)
analgesia
fluid intake
antibiotics may be considered- if CRP 20-100 consider delayed Abx, if > 100 give immediately
May consider giving a SABA
What is an acute stress reaction?
also known as psychological shock - a psychiatric condition that manifests after exposure to severe stress or traumatic events
How might an acute stress reaction present?
cognitive symptoms:
- confusion
- disorientation
- intrusive thoughts
- derealisation and depersonalisation
Behavioural symptoms:
- avoidance behaviour
- hypervigilance
Physiological symptoms:
- tachycardia and hypertension
-sweating and trembling
how is acute stress reaction be differentiated from panic disorder and PTSD?
ASR is more situational than panic disorder
PTSD is when ASR has occurs from over 4 weeks
Management of acute stress reaction
1st line - trauma focused CBT
benzodiazepines may have benefit in short term
If an antibioitic is prescribed in acute bronchitis what is usually recommended?
doxycyline
what yeast infection is the most common cause of thrush?
candida albicans
RF for thrush
- increased oestrogen (higher in pregnancy, lower post menopause and pre-puberty)
- poorly controlled diabetes
- immunosuppression
- broad spectrum antibiotic use
- local irritants
- sexual activity
- HRT
How can thrush be differentiated from BV on swab?
in thrush the vaginal pH is < 4.5 whereas in BV it is likely > 4.5
1st line treatment of thrush ?
oral fluconazole 150mg tablet
what is another name for chronic fatigue syndrome?
myalgic encephalomyelitis
what is chronic fatigue syndrome ?
a sudden or gradual onset of persistent disabling fatigue, post-exertional malaise, unrefreshing sleep, cognitive and autonomic dysfunction and pain
For how long should chronic fatigue be present for a diagnosis?
NICE recommends after 3 months
What investigations may be used to rule out other diagnosis in chronic fatigue syndrome?
FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening and also urinalysis
What should be involved in the management of chronic fatigue syndrome?
- CBT
- energy management
- sleep hygiene
What are the four key symptoms that build the NICE criteria for chronic fatigue syndrme
disabling fatigue without a cause and not relieved by rest
post-exertional malaise
unrefreshing sleep
cognitive difficulties (brain fog)
How can chronic kidney disease be differentiated from AKI?
renal USS- CKD usually has bilateral small kidneys
How can CKD present?
may be asymptomatic
- fatigue
- pallor
- foamy urine
- muscle cramps
- itching (uraemia)
- loss of appetite
- oedema
- hypertension
Common causes of chronic kidney disease
diabetes
hypertension
medications such as lithium and NSAIDS
glomerulonephritis
polycystic kidney disease
what investigations may be involved in the diagnosis of CKD?
GFR
albumin creatinine urine ratio
haematuria on urine dipstick
USS
biopsy
How can CKD be staged with GFR (give the values for each stage)
G1- >90
G2- 60 to 89
G3a - 45-59
G3b - 30-44
G4- 15-29
G5- < 15
What are 4 main complications that can occur in CKD?
anaemia
renal bone disease
cardiovascular disease
peripheral neuropathy
why does anaemia occur in CKD and how is it treated?
kidney cells produce EPO which stimulates the production of RBC
Can be treated with erythropoeisis stimulating agents such as erythropoietin and darbepoetin.
What HLA are associated with coeliac disease?
HLA DQ2 and HLA DQ8
what is the gold standard investigation for coeliac disease and what findings are there?
endoscopy and biopsy- shows crypt hyperplasia, villous atrophy and lymphocyte infiltration
what vaccine is offered to those with coeliac disease?
5 yearly pneumococcal vaccine
What malignancy can be associated with coeliac diseasE?
enteropathy-associated T-cell lymphoma of small intestine
what three types of primary constipation are there?
normal transit (most common)
slow transit
dyssynergic defecation (can’t relax the pelvic floor muscles)
list some causes of secondary constipation
Neuro- parkinsons, spinal cord injury, hirschprungs
Metabolic- hypercalcaemia
Endocrine - hypothyroidism
Medications- iron supplements, antispasmodics, calcium channel blockers, opiates
GI - IBD, strictures
What criteria is used in the diagnosis of constipation
the rome IV criteria
3 key features of constipation
infrequent stools (< 3 weekly)
difficulty passing stool
a sensation of incomplete emptying
First line medication for constipation in adults
bulk forming laxatives- ispaghula husk
second line medication for constipation in adults
osmotic laxative (e.g. macrogol, lactulose)
How should faecal impaction be treated?
high dose macrogol with suppositories and enemas
how do stimulant laxatives work and give and example
stimulate the local nervous system in the gut wall to increase contractility and secretions
example is senna
Give some examples of newer therapies that may be given to those with ongoing constipation
prokinetics
secretagogues
opioid antagonists (naloxegol) - blocks opioid receptor in bowel to reduce constipation in those one opioids
Complications of constipation
overflow diarrhoea
acute urinary retention
haemorrhoids
first line laxative in children
movicol
what two types of contact dermatitis are there?
irritant and allergic contact dermatitis
what is contact dermatitis
an inflammatory skin condition that effects the epidermis and dermis and occurs as a result of exposure to an external irritant or allergen
pathophysiology of allergic contact dermatitis and give an example
a delayed type IV hypersensitivity reaction
Commonly cosmetics, skincare, latex, plants, nickel
difference in the presentation of irritant and allergic contact dermatitis
irritant can be quicker onset but is often less severe with localised area of erythema
allergic can develop over 24-72 hours and presents as acute weeping, blistering eczema
gold standard diagnosis of contact dermatitis
patch testing
what causes cutaneous warts?
infection of keratinocytes with HPV
What types of warts are there?
- common warts: firm raised papules resembling a cauliflower
- plane warts- round, flat-topped wards
- palmar and plantar warts (veruccae)
- mosaic warts
- filiform warts
treatment of cutaneous warts
usually do not treat but may be done if painful, unsightly or on patients request.
- topical salicylic acid
- cryotherapy with liquid nitrogen
secondary care treatment options for resistant warts
physical ablation
anitmitotic treatments
immunomodulatory therapy
How does diverticulitis present?
abdominal pain
change in bowel habit
rectal bleeding
fever
What is diverticulitis
symptomatic inflammation and infection of diverticular in the bowel (sac like protrusions of the colonic mucosa through the muscular wall)
Complications of diverticulitis
perforation
abscess formation
fistulae to adjacent organs
haemorrhage
Gold standard investigation for diverticulitis
contrast CT of abdo pelvis
factors that contribute to the development of gout
purine overproduction- increased cell turnover or lysis (e.g. myeloproliferative disorders, psoriasis, chemotherapy )
increased purine intake- seafood, red meat
decreased uric acid excretion - diuretics, AKI, CKD
Which joint is most commonly affected in gout
the first metatarsophalangeal joint
gold standard investigation of gout
joint aspiration and microscopy- shows negatively bifringent needle shaped crystals
why shouldn’t uric acid levels me measured in an acute attack of gout?
as levels often fall during an acute attack - instead should be measured 4-6 weeks after an attack
what may be seen on x ray of gout
subcortical cysts or bone erosions
what crystal causes gout
monosodium urate crystals
first line management of acute gout
NSAIDs or colchicine
second line management of acute gout
intra-articular or oral steroids
1st line treatment in chronic gout
allopurinol
how does allopurinol work?
xanthine oxidase inhibitor
what can be used if allopurinol does not work/isnt tolerated in gout prevention
febuxostat
what is the most common cause of tonsilitis?
group A beta haemolytic strep such as strep. pyogenes
What are the two broad types of lung cancer?
small cell lung cancer and non-small cell lung cancer
What is the most common category of lung cancer?
non-small cell lung cancer
list some types of non-small cell lung cancer, which is most common?
adenocarcinoma (most common)
squamous cell (most associated with smoking)
large cell
alveolar cell
bronchial adenoma
What is a mesothelioma and what is it associated with?
malignancy of the mesothelial cells of the pleura
Linked with asbestos exposure
What extrapulmonary manifestions of lung cancer might be present?
- hoarse voice- occurs due to compression of recurrent laryngeal nerve, most common in pancoast tumours
- phrenic nerve palsy (leads to diaphragm weakness)
- superior vena cava syndrome
- horners syndrome
- syndrome of inappropriate ADH
- cushings (ectopic ACTH from small cell)
- ectopic PTH -> hypercalcaemia
- hypercal
How does superior vena cava syndrome present?
facial swelling
difficulty breathing
distended veins in the neck and upper chest
How is lung cancer diagnosed?
chest x ray
CT
bronchoscopy and biopsy
PET scan
how might lung cancer present on x ray
hilar enlargement
peripheral opacity
pleural effusion
collapse
How does lung cancer present?
shortness of breath
cough
haemoptysis
finger clubbing
recurrent pneumonia
weight loss
supraclavicular lymphadenopathy
metastases - bone pain
