GP Flashcards

(604 cards)

1
Q

Most common cause of painful rectal bleeding on a background of constipation

A

Anal fissure

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2
Q

What should be done if someone vomits within 3 hours of taking their combined oral contraceptive pill

A

An additional pill should be taken as soon as possible

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3
Q

Describe the tricycling method of taking the combined oral contraceptive pill

A

Take the pill everyday for 9 weeks and then take a 4-7 day free interval

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4
Q

What is the most effective form of emergency contraception?

A

the intrauterine device (IUD)

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5
Q

What is suggested if someones total cholesterol is greater tha 5mmol/L

A

20mg atrovastatin

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6
Q

What non-invasive emergency contraception can be used for up to 5 days after unprotected sex?

A

ellaOne (ulipristal acetate)

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7
Q

How do you work out units of alcohol?

A

(concentration (percent) x volume )/ 1000

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8
Q

What contraceptive is migraine with aura a contraindication for?

A

The combined oral contraceptive pill

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9
Q

First line treatment for severe depression

A

SSRI (citalopram)

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10
Q

What happens if the progesterone only pill is missed for more than 3 hours

A

Take the missed pill and wear condoms for 48 hours

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11
Q

How long after remission should an antidepressant be continued for?

A

6 months

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12
Q

Treatment of cellulitis

A

oral flucloxacillin

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13
Q

Why may creatinine be high after treatment with trimethoprim

A

competitive inhibition of creatinine secretion from the renal tubules

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14
Q

What percent of FEV1 reversibility should be achieved by bronchodilator therapy in asthma?

A

At least 12%

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15
Q

What form of contraception can be used in women with breast cancer?

A

non-hormonal methods such as the copper IUD

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16
Q

First line investigation for angina

A

CT coronary angiogram

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17
Q

Treatment of urge incontinence which is often used in frail elderly patients

A

Mirabegron

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18
Q

What medications are a risk factor for gout?

A

low dose aspirin, thiazide like diuretics and immunosuppressive medications

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19
Q

What test is used to confirm iron deficiency anaemia?

A

ferritin (below 30mcg/l)

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20
Q

What is the best contraptive method at preventing pregnancy?

A

The contraceptive implant

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20
Q

Most appropriate antibiotic for bacterial tonsilitis?

A

Oral penicillin V (phenoxymethylpenicillin)

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20
Q

Can an IUD be used in someone with active chlamydia?

A

no

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20
Q

What antibiotic is recommended to treat UTIs in elderly patients with CKD?

A

trimethoprim

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21
Q

What can topical corticosteroids cause in patients with darker skin types

A

depigmentation

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21
FEV1 of stage 2 COPD
50-80%
22
FEV1 of stage 3 COPD
30-50%
23
FEV1 of stage 4 COPD
<30%
24
25
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
26
Where do 90% or anal fissures present?
The posterior midline - If elsewhere other conditions such as crohns should be considered
27
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
28
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
29
What type of reaction is anaphylaxis
Type 1 hypersensitivity reaction
30
Common causes of anaphylaxis
Food such as nuts - most common cause in children Drugs Venom
31
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
32
Presentation of anaphylaxis
Sudden onset of: Dyspnoea Wheeze Tachycardia Urticaria Angiooedema Collapse
33
Dose of adrenaline in less than 6months
100 to 150 micrograms
34
Dose of adrenaline in 6months to 6years
150 micrograms
35
Dose of adrenaline in 6 to 12 years
300 micrograms
36
Dose of adrenaline in over 12 years
500 micrograms
37
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
38
Common causes of bacterial vaginosis
Gardnerella vaginalis Prevotells species Bacteriodes species Peptostreptococcus species
39
How does bacterial vaginosis present
Offensive fishy smelling discharge No soreness or irritation
40
Amstel criteria for bacterial vaginosis
Vaginal pH > 4.5 Typical discharge - thin, off-white, homogenous Positive whiff-amine test Clue cells on microscopy
41
Explain the whiff-amine rest
Fishy odour on adding 10% potassium hydroxide to the vaginal fluid
42
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
43
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
44
Complications of bacterial vaginosis
Can increase the risk of transmission of STIs Can cause pregnancy complications- late miscarriage, low birthweight, premature rupture of membranes
45
Pathophysiology of BPH
Hyperplasia of the stromal and epithelial cells of the prostate Usually occurs in the transitional zone of the prostate
46
Presentation of BPH
Voiding symptoms - weak intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying Storage symptoms - urgency , frequency, urinary incontinence , nocturia
47
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
48
Treatment of BPH
1. Alpha blockers such as tamsulosin 2. 5 alpha reductase inhibitors such as finasteride 3. TURP - transurethral resection of the prostate
49
What is Bell’s palsy
An acute unilateral idiopathic facial nerve paralysis
50
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
51
What additional symptoms may be present in Bell’s palsy
Post auricular pain Altered taste Dry eyes Hyperacusis
52
What is Benign Paroxysmal Positional Vertigo
A common cause of recurrent vertigo triggered by head movement
53
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
54
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
55
How is Benign Paroxysmal Positional Vertigo diagnosed
Dix- hallpike manoeuvre The manoeuvre will trigger rotational nystagmus and symptoms of vertigo in positive patients
56
How is Benign Paroxysmal Positional Vertigo treated
Epley manoeuvre Patient can do Brandt- daroff exercises at home
57
Most common causes of bronciolitis
Respiratory syncytial virus Other - rhinovirus, adenovirus
58
Most common side effect of allopurinol
Rash
59
What medication does clarithromycin interact with ?
Atrovastatin
60
What antibiotic should be used if treating a UTI in someone on methotrexate
Pivmacillinam
61
Emergency contraception in women with bmi greater than 26
Double dose of levonelle
62
What is an absolute contraindication to the combined pill?
A DVT
63
In what trimester should nitrofuratoin be avoided
Third
64
Where does impetigo rash typically start
On the face of it
65
First line prophylaxis of migraines
Propranolol, tropiramate or amitriptyline
66
Who should topiramate be avoided in?
Pregnant women
67
Who should topiramate be avoided in?
Pregnant women
68
What hormone do ovulation test strips monitor for?
LH- there is an lh surge before ovulation
69
How is diagnosis of a salivary gland stone made?
Sialogram
70
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
71
What is a contraindication to the ellaOne emergency contraception?
Severe asthma
72
What cancers are at increased risk with oral contraceptive pill
Increased risk of breast and cervical cancer Decreased risk of ovarian and endometrial cancer
73
What antibiotic is given second line in tonsilitis in the event of penicillin allergy
Clarithromycin
74
What is seen on the blood film in coeliacs
Howell jolly bodied
75
What finding on microscopy is indicative of bacterial vaginosis
clue cells
76
How does tamsulosin work?
it is a alpha 1 antagonist- it decreases smooth muscle tone of the prostate and bladder
77
What is the first line treatment of BPH in those with moderate to severe voiding symptoms
tamulosin
78
Side effects of tamulosin
dizziness, postural hypotension, dry mouth, depression
79
What is the action of finasteride
blocks the conversion of testosterone to dihydrotestosterone which is known to induce BPH
80
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
81
How long does it take for finasteride to work?
6 months
82
side effects of finasteride
erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
83
What is mastitis
inflammation of the breast tissue typically associated with breast feeding
84
How does mastitis present?
painful tender red hot breast may have fever and general malaise
85
RF for mastitis
smoking, poor breast feeding technique, nipple damage, maternal stress, previous mastitis
86
What is mastitis called when it is associated iwth breast feeding
puerperal mastitis
87
Pathophysiology of mastitis
usually occurs due to milk stasis- from inadequate milk removal or infrequent feeding Cracked sore nipples- provide entry point for bacteria
88
most common organism associated with mastitis
Staphylococcus aureus
89
What can mastitis develop into if left untreated?
breast abscess
90
first line management of mastitis
continue breast feeding
91
First line pharmacological treatment of mastitis
oral flucloxacillin (10-14 days)
92
Overview of the treatment of mastitis
continue breastfeeding analgesia warm compress oral flucloxacillin (continue breastfeeding)
93
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
94
What is a breast abscess?
a collection of pus within an area of the breast usually caused by a bacterial infection
95
what are the two types of breast abscesses?
lactation and non lactational breast abscess
96
What is the most common causative agents of breast abscesses
staphylococcus aureus
97
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
98
How are breast abscesses confirmed
USS
99
1st line treatment of a breast abscess
surgical intervention - needle aspiration or surgical incision and drainage plus antibiotics
100
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
101
Are the symptoms of parkinsons symmetrical or asymmetrical
they are characteristically asymmetrical
102
Who is most commonly affected by parkinsons
men aged 65
103
Triad of parkinsons
bradykinesia resting tremor cogwheel rigidity
104
How many bradykinesia present in parkinsons
poverty of movement short shuffling gait with reduced arm swing small handwriting reduced facial movements
105
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'
106
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
107
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
108
How is parkinsons diagnosed
clinical may use SPECT or CT/MRI scan
109
First line treatment of parkinsons if affecting quality of life?
levodopa
110
first line treatment of parkinsons if not affecting someones life
dopamine agonist (cabergoline), monamine oxidase B inhibitor or levodopa
111
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
112
pathophysiology of parkinsons disease
loss of dopaminergic neurones in the substantia nigra of the basal ganglia
113
Side effects of levodopa
dry mouth anorexia palpitations postural hypotension psychosis
114
How does levodopa work?
it breaks down into dopamine once it crosses the blood brain barrier
115
What may be combined with levodopa to prevent peripheral breakdown and release of dopamine outside of the brain
decarboxylase inhibitor (carbidopa or benserazide)
116
What is the end-of-dose wearing off phenomenon that occurs with levodopa
symptoms worsen towards the end of the levodopa interval
117
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
118
what may parkinsons patients experience when on the peak dose of levodopa
dyskinesias - chorea, dystonia and athetosis (involuntary writhing movements)
119
What may parkinsons patients experience if they stop levodopa suddently
acute dystonia
120
Which parkisnons medication is known to cause problems with impulse control
dopamine agonists (cabergoline)
121
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
122
how do monamine oxidase B inhibitors work?
inhibit the breakdown of dopamine secreted by dopaminergic neurones
123
what is an example of a MAO-B inhibitor
selegiline
124
How do COMT inhibitors work
inhibits the breakdown of dopamine- used as an adjunct to levodopa
125
Give some examples of COMT inhibitors
entacarpone, tolcapone
126
What disease is parkinsons disease commonly related to?
lewy body dementia
127
how does lewy body dementia present?
progressive cognitive impairment - typically before parkinsonisms parkinsonsism visual hallucinations
128
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
129
How is lew body dementia diagnosed?
usually clincial however SPECT scans are increasing used
130
How is lewy body dementia treated?
Acetylcholinesterase inhibitors (rivastigmine, donepezil) and memantine can be used
131
what type of drug should be avoided in lewy body dementia and why
neuroleptics - associated with irreversible parkonsonisms
132
What complications can occur with both antipsychotics and parkinsons drugs (levodopa)
neuroleptic malignant syndrome
133
how does neuroleptic malignant syndrome present?
pyrexia, muscle rigidity, autonomic lability (hypertension, tachycardia and tacypnoea) , agitated delirium
134
What might bloods show in someone with neuroleptic malignant syndrome
raised creatinine kinase is present in most may have AKI and leukocytosis in severe
135
What is the most prevalent STI in the UK
chlamydia
136
what bacteria causes chlamydia
chlamydia trachomatis
137
How common is chlamydia
affects approx 1 in 10 young women
138
what type of pathogen is chlamydia
an intracellular bacterium gram negative bacilli
139
Incubation period of chlamydia
7 to 21 days
140
what % of patients with chlamydia are asymptomatic
70% of women, 50% of men
141
How does chlamydia present in women
cervicitis- discharge, bleeding dysuria
142
how does chlamydia present in men
urethral discharge dysuria
143
how is chlamydia diagnosed
NAAT- from vulvovaginal swab in women and first void urine in men
144
treatment of chlamydia
7 days doxycycline
145
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
146
if doxycycline is contraindicated in chlamydia what may be used?
azithromycin (1g OD and then 500mg OD for 2 days)
147
what is used to treat chlamydia in pregnancy
azithromycin, erythromycin or amoxicillin
148
How long after exposure should chlamydia testing be done?
2 weeks
149
What bacteria causes gonorrhoea
gram negative diplococci neisseria gonorrhoeae
150
incubation period of gonorrhoea
2 to 5 days
151
what percentage of patients with gonorrhoea are aysmptomatic
90% of men and 50% of women
152
how does gonorrhoea present
men- urethral discharge dysuria women - vaginal discharge (yellow green thick) abdominal pain dyspareunia
153
how is gonorrhoea diagnosed?
NAAT taken from vaginal swab in women and first pass urine in men
154
treatment of gonorrhoea
IM ceftriaxone 1g
155
RF of gonorrhoea
young age new sexual contact inconsistent condom use MSM current or prior STI incareration
156
complications of gonorrhoea
pelvic inflammatory disease, pregnancy complications, development of stricture epididymitis, orchitis, prostatitis, infertility
157
What causes infectious mononucleosis
Epstein-Barr virus (EBV- also known as herpesvius 4)
158
What is a less common cause of infectious mononucleosis
cytomegalovirus and HH6
159
Triad of infectious mononucleosis
sore throat (with whitewash exudate) pyrexia lymphadenopathy (commonly in the anterior and posterior triangles of the neck )
160
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
161
presentation of EBV
triad: lymphadenopathy, pyrexia, sore throat - malaise - palatal petechiae - splenomegaly - hepatitis - lymphocytosis - haemolytic anaemia
162
How long does it usually take for EBV to resolve?
2-4 weeks
163
How is EBV diagnosed?
heterophil antibody test (monospot test) FBC- may show haemolytic anaemia and lymphocytosis LFTs may be elevated
164
Why can you get haemolytic anaemia in EBV
due to cold agglutins (IgM)
165
Differentials for EBV
strep throat, lymphoma and leukaemia, viral illnesses (e.g mumps)
166
Treatment of EBV
rest and analgesia Avoid playing contact sport - splenic rupture
167
what type of virus causes mumps
an RNA paramyxovirus
168
how is mumps spread
respiratory droplets
169
incubation period of mumps
14-21 days
170
when are patients with mumps infective
7 days before and 9 days after parotid swelling starts
171
pathophysiology of mumps
spread via respiratory droplets replicates in the upper respiratory mucosa spreads to the parotid gland
172
How does mumps present?
fever malaise parotitis (usually presents as ear ache or pain on eating)
173
how does parotitis present in mumps?
ear pain or pain on eating usually begins unilateral and then spreads to be bilateral
174
How is mumps diagnosed?
usually clinical - can be confirmed with saliva sample to detect IgM
175
differentials for mumps
viral infections- EBV acute supparative parotitis parotid duct obstruction
176
Treatment of mumps
no specific treatment- fluids, rest, analgesia notifiable disease
177
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
178
what type of pathogen is trichomonas vaginalis
a highly motile flagellated protozoan parasite
179
Presentation of trichomonas vaginalis
vaginal discharge- offensive, yellow/green frothy discharge vulval itching dysuria
180
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
181
How can the diagnosis of trichomonas vaginalis be confirmed
microscopy of a wet mount shows motile trophocytes
182
how does trichomonas vaginals present in men
usually asymptomatic- can have urethritis
183
How is trichomonas vaginalis treated?
oral metronidazole for 5-7 days
184
Complications of trichomonas vaginalis
- perinatal sepsis - PID - increased risk of cervical cancer - fascilitated HIV - infertility - increased risk of prostate cancer
185
What is conjunctivitis
inflammation of the conjunctiva if corneal involvement - keratoconjunctivitis
186
Causes of conjunctivits
bacterial viral allergic
187
how does bacterial conjunctivitis present
red eye purulent discharge eye may be stuck together in the morning
188
how does viral conjunctivitis present?
red eye serous discharge (clear) recent URTI pre-auricular lymph nodes
189
How does allergic conjunctivitis present?
red eye bilateral swollen eyelids itching is common symptom
190
treatment of infective conjunctivitis
topical antibiotic treatment- chloramphenicol or fusidic acid drops avoid wearing contact lenses avoid sharing towels clean eyes
191
Treatment of allergic conjunctivitis
1st line topical or systemic antihistamines 2nd line: topical mast-cell stabilisers
192
differentials of conunctivitis that are typically associated with increased pain
foreign body acute closed angle glaucoma anterior uveitits corneal abrasions scleritis
193
What are the two strains of the herpes simplex virus?
HSV-1 and HSV -2
194
What does HSV-1 cause
oral lesions- cold sores
195
what does HSV-2 cause
genital herpes
196
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
197
how is HSV-2 predominately spread
it is mainly an STI
198
where does HSV-1 lay dormant
trigeminal nerve ganglai
199
where does HSV-2 lay dormant
sacral nerve ganglia
200
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
201
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
202
How are genital herpes diagnosed?
NAAT
203
treatment of genital herpes
saline bathing, analgesia, topical anaesthetic (lidocaine) oral aciclovir
204
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
205
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
206
what is a severe complication of herpes?
herpes encephalitis
207
How is gingivostomatitis treated
oral aciclovir and chorhexidine mouthwash
208
how are cold sores treate
topical aciclovir
209
what is polymyalgia rheumatica?
a chronic inflammatory condition characterised by pain and stiffness in the shoulders, pelvic girdle and neck
210
who is most commonly affected by PMR
patients over the age of 60 more common in women
211
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
212
what systemic features may be present in PMR
weight loss, lethargy, low grade fever, night sweats, low mood
213
How is PMR diagnosed?
usually based on its clinical presentation and response to treatment - ESR - raised (usually >40) - creatinine kinase and EMG are normal
214
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
215
what additional medication may be given to patients treated with steroids for PMR
osteoporosis prophylaxis- bisphosphonates, calcium and vitamin D PPI for gastric protection
216
what disease is associated with PMR
giant cell arteritis
217
What is the most common type of prostate cancer?
95% are adenocarcinomas (usually in the peripheral zone of the prostate)
218
RF of prostate cancer
increasing age family history black african or caribbean origin anabolic steroid use tall stature
219
are prostate cancers androgen dependent
yes
220
How does prostate cancer present?
LUTS (hesitance, frequency, weak flow, terminal dribbling, nocturia) haematuria erectile dysfunction symptoms of metastases (bone pain most common)
221
How can prostate cancer be screened for
PSA DRE
222
how does prostate cancer present on DRE
hard, irregular, craggy
223
first line investigation for prostate cancer
mulitparametric MRI
224
gold standard investigation for prostate cancer
USS and biopsy- transrectal
225
How is prostate cancer graded?
gleason score (higher the score the worse)
226
What nodes does prostate cancer first spread to
obturator nodes
227
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)
228
complication of radiotherapy for prostate cancer
radiation proctitis and rectal malignancy
229
complication of TURP (transurethral resection of the prostate)
erectile dysfunction
230
complicationsof TRUS biopsy
sepsis pain fever haematuria and rectal bleeding
231
Why do GnRH agonists lead to lower LH levels?
they cause overstimulation which results in disruption to the endogenous hormonal feedback
232
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
233
234
What is the centor criteria
used to determine if tonsillitis is bacterial or viral
235
what features of the centor criteria suggest that tonsilitis is bacterial
tonsillar exudate tender anterior cervical lymphadenopathy fever >38 Absence of a cough
236
complications of tonsillitis
quinsy (peri-tonsillar abscess) otitis media rheumatic fever and glomerulonephritis
237
aetiology of tonsilitis
most frequently viral infection can be bacterial- group A betal haemolytic strep (strep pyogenes)
238
what two criteria can be used to determine if tonsilitis is bacterial or viral
the centor score or the feverPAIN score
239
what are the components of the feverPAIN score
fever purulence attend rapidly (within 3 days) Inflammed tonsils No cough or coryza
240
What investigation may be done to exclude a differential of tonsilitis
monospot test to exclude EBV
241
treatment of bacterial tonsilitis
phenoxymethypenicillin (penV) for 5-10 days (clarithromycin or erythromycin if allergic)
242
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
243
complications of tonsilectomy
haemorrhage and pain
244
What is urticaria
superficial swelling of the skin that is intensely red, raised and itchy
245
what defines acute urticaria
symptoms have been present for less than 6 weeks
246
What defines chronic urticaria
symptoms have been present for at least 6 weeks
247
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
248
two main causes of acute urticaria
acute viral infection allergen- food, insect bites, latex, drugs (penicillin, aspirin etc)
249
What are the two types of chronic urticaria
chronic spontaneous urticaria chronic inducible urticaria
250
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
251
what is chronic spontaneous urticaria
urticaria that occurs in response to a physical stimulus
252
give some examples of chronic inducible urticaria
aquagenic cholinergic (occurs after active or passive warming) cold delayed pressure solar
253
What feature may accompany urticaria that presents as swelling of facial features
angioedema
254
How is urticaria diagnosed?
mainly a clinical diagnosis May do: - allergy tests - inflammatory markers - skin biopsies - urinalysis
255
1st line treatment of urticaria after removing triggers
non-sedating antihistamines - e.g cetrizine consider a sedating antihistamine at night
256
2nd line treatment of urticaria
alternative/ high dose antihistamines or leukotriene receptor antagonist
257
what can be used for a short period in severe episodes of urticaria
prednisolone
258
what is vasovagal syncope
a form of reflex syncope characterised by a transient loss of consciousness in response to certain triggers
259
What can trigger vasovagal syncope
emotional events pain prolonged standing heat exposure physical exertion
260
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
261
what are the physiological mechanisms which cause the fall in BP associated with vasovagal syncope
cardioinhibitory response causing bradycardia vasodepressor response causing vasodilation
262
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
263
Management of vasovagal syncope
lifestyle changes: trigger avoidance, increased fluid and salt intake, compression stockings medical therapy to improve BP: - fludrocortisone - midodrine
264
What is the gold standard investigation for vasovagal syncope?
tilt table test - will induce cardioinhibitory and vasodepressor response and lead ot hypotension
265
RF for haemorrhoids
pregnancy obesity increased age increased intraabdominal pressure (e.g. weight lifting, chronic coughing), constipation
266
how do haemorrhoids present?
painless bright red bleeing pruritis anal mass perianal pain ( if thrombosed)
267
how are haemorrhoids classified
internal and external internal is above the dentate line while external is below
268
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
269
which type of haemorrhoid can cause pain?
external (as below the dentate line so sensate skin)
270
1st line treatment of haemorrhoids
conservative management (soften stools) and topical anaesthetic or corticosteroids
271
surgical mangament options for haemorrhoids
rubber band ligation injection sclerotherapy surgical removal
272
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
273
What are the three conditions included in peripheral arterial disease
intermittent claudication acute limb ischaemia critical limb ischaemia
274
What are RF for peripheral arterial disease?
smoking, diabetes, atherosclerosis, hypertension, physical inactivity, obesity
275
what is the most common cause of peripheral arterial disease
atherosclerosis
276
aside from atherosclerosis what else can cause peripheral arterial disease
coarctation of the aorta arterial dissection arterial embolism arterial thrombus vasospasm tumour
277
how does intermittent claudication present?
crampy pain after physical activity stopping causes the pain to go away common in the calf muscles
278
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
279
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
280
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
281
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
282
how do arterial ulcers present
small, deep, well defined borders, punched out appearance and pain
283
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
284
How can peripheral arterial disease be diagnosed
ankle-brachial pressure index
285
what value of ABPI suggests critical limb ischaemia
less than 0.3
286
what value on ABPI suggests mild arterial disease
0.6 to 0.9
287
what value of APBI suggests moderate to severe peripheral arterial disease
0.6 to 0.3
288
what does an APBI above 1.3 suggest
calcification of the arteries making them difficult to compress
289
first line treatment of peripheral arterial disease
atrovastatin and clopidogrel
290
what lifestyle changes should be recommended for patients with peripheral arterial disease?
stop smoking optimise medical treatment of comorbidities exercise training
291
what surgical options can treat peripheral arterial disease?
endarterectomy surgical bypass with autologous or prosthetic material amputation
292
endovascular techniques for peripheral arterial disease
percutaneous transluminal angioplasty +/- stent placement
293
which patients should be treated with endovascular techniques for PAD
short segment stenosis (<10cm) , aortic iliac disease and high risk patients
294
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
295
what dilatory drug may be used in severe PAD which is associated with poor QoL
naftridofuryl oxalate
296
How does trichomonas vaginalis present on light microscopy-
motile trophozoites
297
What is reactive arthritis
arthritis occurring after an infection - most commonly urogenital (chlamydia, gonorrhoea) and GI infections (salmonella, shigella)
298
What group of diseases is reactive arthritis part of?
spondyloarthropathies- associated with HLA B27
299
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)
300
what are the extra articular manifestations of reactive arthritis
cant see cant wee cant climb a tree - uveitis, conjunctivitis - circinate balanitis - enthesitis
301
What is enthesitis
inflammation of the insertion of soft tissue to bone- tendons, fascia Commonly on ankle causing archilles tendonitis and planta fascia
302
What is keratoderma blenorrhagica
Skin lesions similar to psoriasis on the palms and the soles
303
what is circinate balanitis
dermatitis on the glans penis
304
first line treatment for reactive arthritis
symptomatic control - NSAIDS
305
Treatment of reactive arthritis
NSAIDS intra-articular steroids If unresponsive DMARDS- methotrexate if chronic biologics - anti-TNF agents (e.g. infliximab)
306
Usual time course of reactive arthritis
typically arises around 4 weeks after the initial infection symptoms usually last 4-6 months
307
What types of lesions make up acne
non-inflammatory comedones (whiteheads and blackheads) inflammatory papules, pustules, nodules and cysts
308
Pathophysiology of acne
1. sebaceous gland hyperplasia and excess sebum production 2. abnormal follicular differentiation - keratinocytes usually shed however in acne they are retained due to inreased cohesiveness 3. cutibacterium acne colonisation 4. inflammation and immune response
309
What bacteria is mainly present in acne
c. acnes
310
What is acne fulminans
a severe form of acne accompanied by systemic features that require hospitalisation and corticosteroids
311
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
312
Treatment of acne if 12 week combination therapy does not work?
add in oral lymecycline or doxycycline , or add in topical azelaic acid
313
if a pregnant women experiences acne what should definitely not be involved in the treatment
tetracycines- lymecycline (erythromycin can be used instead)
314
what could be considered in the treatment of acne in women
the combined oral contraceptive pill
315
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
316
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
317
what is an anal fissure
a longitudinal or eliptical tear of the squamous lining of the distal anal canal
318
what are secondary causes of anal fissures
constipation IBD STIs colorectal cancer anal trauma adverse drug reactions pregnancy and childbirth
319
What is an acute anal fissue
one that has been present for less than 6 weeks
320
what is a chronic anal fissure
one that has been present for more than 6 weeks
321
how do anal fissures present
painful bright red rectal bleeding
322
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
323
first line treatment of anal fissures that are present for > 1 week
topical glyceryl trinitrate (GTN) twice daily for 6-8 weeks
324
If topical GTN is not effective after 8 weeks in treating anal fissures what may be considered
sphincterotomy or botulism toxin
325
what type of reaction is anaphylaxis
a type I hypersensitivty reaction
326
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
327
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
328
dose of adrenaline in under 6 months
100-150 micogram
329
dose of adrenaline in 6 months - 6 years
150 micrograms
330
dose of adrenaline in 6-12 years
300 micrograms
331
does of adrenaline in >12 years
500 micrograms
332
what blood test can confirm anaphylaxis (after treatment)
mast cell tryptase
333
when should mast cell tryptase tests be done in anaphylaxis
- immediately after treatment - 1-2 hours after - 24 hours after (gives baseline level)
334
what is refractory anaphylaxis
respiratory and/or cardiovascular problems that persist despite 2 doses of IM adrenaline
335
Management of refractory anaphylaxis
IV fluids for shock IV adrenaline infusion
336
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
337
What is folliculitis?
inflammation of the hair follicles
338
what pathogen is most commonly involved in folliculitis
staphylococcus aureus
339
what is the most common cause of septic arthritis in young adults
gonorrhoea
340
what is the first line investigation of genital herpes?
NAAT (not viral culture)
341
what might an area of rapidly worsening eczema be a sign of
eczema herperticum
342
how does primary syphilis present
painless ulceration and lymphadenopathy
343
give examples of non-sedating antihistamiens
loratadine cetirizine fexofenadine
344
what malignancies is EBV associated with
burkitt's lymphoma non-hodgkins lymphoma naso-pharyngeal carcinoma
345
How does eczema herpeticum present?
monomorphic punched out erosions usually 1-3 mm in diameter
346
how long might it take for finasteride to start working on BPH
6 months
347
if treatment of a upper respiratory tract infection with amoxicillin leads to a widespread maculopapular itchy rash what is the likely cause
EBV
348
what is presbycusis
age related sensorinerual hearing loss
349
If an anal fissure is lateral what investigation should be done
faecal calprotectin (normal anal fissures are usually in the posterior midline)
350
what are common x ray findings of psoriatic arthritis
plantar spur and pencil in cup deformitites
351
What is urge incontinence?
incontinence caused by overactivitiy of the detrusor muscle of the bladder.
352
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
353
What is stress incontinence?
incontinence due to weakness of the pelvic floor and sphincter muscles
354
How does stress incontinence present?
urinary leakage while coughing, laughing or when suprised
355
What is overflow incontinence
incontinence that occurs when there is chronic urinary retention due to an obstruction in the outflow tract.
356
How does overflow incontinence present?
overflow of urine causing incontinence without the urge to pass urine
357
What can cause overflow incontinence
anticholinergic drugs, fibroids, neuro conditions (MS, diabetes, spinal cord injury), prostate enlargement
358
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
359
investigations of urinary incontinence
1st - bladder diary for minimum of 3 days urine dipstick vaginal examination urodynamic studies
360
what are examples of urodynamic studies
cystometry uroflowmetry leak point pressure post-void residual bladder volume
361
lifestyle changes for urinary incontinence
avoid caffeine, alcohol, diuretics restrict fluid intake weight loss
362
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
363
1st line drug treatment of stress incontinence
duloxetine
364
surgical procedures for stress incontinence
tension-free vaginal tape, autologous sling procedure, coposupsension, intramural urethral bulking
365
1st line treatment of urge incontinence
bladder retraining for 6 weeks
366
1st line drug treatment for urge incontinence in young
anticholinergic medications- oxybutynin, tolterodine
367
1st line drug treatment of urge incontinence in elderly
mirabegron
368
SE of mirabegron
raised BP- hypertensive crisis increases TIA and stroke risk
369
invasive treatments of urge incontinence
botulinum toxin sacral nerve stimulation,
370
what is the most common cause of leg ulcer?
venous ulcer
371
Where do most venous ulcers occur?
the gaiter area (between the top of the foot and the bottom of the calf muscle
371
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
372
pathophysiology of venous ulcers
occurs due to sustained venous hypertension leading to chronic venous insufficiency due to venous valve incompetence or impaired calf muscles
373
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)
374
Investigation of venous ulcers
ABPI to assess for any arterial disease (normal is 0.9 to 1.2) FBC ESR and CRP
375
1st line treatment of venous ulcers
compression bandages (need to exclude arterial disease)
376
drug treatment of venous ulcers
oral pentoxyfylline- peripheral vasodilator that improves healing rate
377
What are varicose veins?
dilated superficial veins commonly found on the lower limbs
378
RF for varicose veins
age pregnancy female woman previous DVT
379
Pathophysiology of varicose veins
increased pressure in the small superficial veins due to venous insufficiency caused by valvular incompetence
380
how do varicose veins present?
can be asymptomatic May have: - pain/tenderness - pruritis - restless legs - cramps - bleeding - dilated superficial veins - venous eczema
381
Diagnosis of varicose veins
venous duplex USS - demostrates retrograde venous flow
382
conservative treatment of varicose veins
weight loss avoid prolonged standing elevate legs when possible compression stockings regular exercise
383
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
384
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
385
386
Which of episcleritis and scleritis is painful
Scleritis
387
What two causes of vaginal discharge create a pH greater than 4.5
Trichomonas vaginalis and bacterial vaginosis
388
What is the most common form of prostate cancer
Adenocarcinoma
389
What bacteria is associated with bacterial keratitis in contact lens wearers
Pseudomonas aeuginosa
390
What type of bacteria cause lyme’s disease?
Spirochetes
391
Most common bacteria associated with lymes disease
Borrelia burgdoferi
392
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
393
After how long of attachment is lymes disease usually spread from ticks
After being attached for 36-48 hours
394
If not treated, what three phases will lymes disease go through
1. Early localised disease - expanding target like rash of erythema migrans 1-36 days after tick bite 2. Early disseminated disease- weeks to months after bite, patients have multiple secondary erythema migrans, arthritis, carditis, cranial nerve palsy 3. Late disseminated disease - presents months to years after the initial infection, oligoarthritis, skin manifestations and involvement of the peripheral nervous system
395
What is post treatment Lyme disease syndrome
Persisting symptoms of lymes disease such as fatigue, pain or joint and muscle aches
396
Describe the rash associated with erythema migrans
Erythema migrans Target like rash - bulls eye Develops 1-4 weeks after bite
397
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
398
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
399
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
400
Management of confirmed/suspected Lyme disease
Doxycycline if early disease Ceftriaxone if disseminated disease
401
What reaction might occur after starting antibiotics for Lymes disease
Jarisch- Herxheimer reaction
402
What bacteria causes syphilis
Treponema pallidum
403
RF for syphilis
Unprotected sex, multiple sexual partners, transactional sex, substance misuse, social vulnerability
404
Incubation period of syphilis
21 days
405
How does primary syphilis present?
A painless ulcer (chancre) and local lymphadenopathy
406
How long after infection does secondary syphilis present?
6-10 weeks post infection
407
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
408
What is early latent syphilis
Confirmed infection without any current features
409
What classifies late syphilis
More than 2 years after infection
410
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_
411
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
412
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
413
side effect of doxycylcine
photosensitivity
414
what is the treatment of severe urticaria where antihistamines dont work
a short course of oral steroids
415
how often can adrenaline be given
every 5 mintues
416
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
417
what is the most common cause of anaphylaxis in children
food
418
419
How should utis be treated in patients on methotrexate
Nitrofurantoin- trimethoprim caused bone marrow suppression
420
Blood film findings of coeliac disease
Howell jolly bodies and targets cells
421
what is the most sensitive test for pernicious anaemia
anti-parietal cell antibodies- anti - intrinsic factor antibodies are highly specific but not very sensitive
422
how does normal pressure hydrocephalus present on neuroimaging?
ventricular enlargement with relative perservation of cortical sulci
423
How would you manage arterial stenosis in PAD of less than 10cm
endovascular revascularisation (angioplasty)
424
Causes of atrial fibrillation and how to remember?
mrs SMITH Sepsis Mitral valve pathology (stenosis or regurgitation) Ischaemic heart disease Thyrotoxicosis Hypertension
425
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
426
What are the 4 classifications of AF
paroxysmal acute persistent permanent
427
what defines paroxysmal AF
AF that spontaneously stops within 7 days
428
What defines acute AF
AF that started within 48 hours
429
What defines persistent aF
AF that lasts for more than 7 days and is not self-terminating
430
How might AF present ?
palpitations dyspnoea dizziness syncope chest pain irregularly irregular pulse
431
What 3 findings are there on ECG in AF
- absent P waves - narrow QRS complex tachycardia - irregularly irregular ventricular rhythmn
432
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
433
What is the first line rate control for AF?
beta blocker (bisoprolol) or CCB (not in HF)
434
what is second line rate control in AF
combine 2 of bisoprolol, CCB or digoxin
435
what two types of rhythmn control are there in AF
pharmacological - IV amiodarone electrical
436
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
437
describe delayed cardioversion
patient takes anticoagulants for >3 weeks and then has cardioversion
438
What invasive treatment may be used for AF if drug treatment is inadequate of not tolerated?
catheter ablation
439
What is the first line anticoagulant in AF?
DOAC - apixaban
440
what is the second line anticoagulant in AF?
warfarin
441
What scoring system can be used to determine if someone with AF needs anticoagulation?
CHA2DS2VASc score
442
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
443
What score on the CHA2DS2VASc indicates anticoagulation?
2 (1 in males)
444
What are causes of COPD
smoking causes 90% of cases alpha 1 antitrypsin deficiency occupational exposures
445
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
446
two types of patients with COPD
pink puffers (emphysema) and blue bloaters (chronic bronchitis)
447
describe chronic bronchitis
chronic cough lasting 3 months or more, occurs due to chronic inflammation of the bronchi
448
microscopic features of chronic bronchitis
goblet cell hyperplasia mucus hypersecretion chronic inflammation and narrowing of the small airways
449
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
450
How does COPD present?
chronic productive couhg breathlessness frequent infections wheeze pursed lip breathing signs of right heart failure
451
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
452
what can be seen on chest X ray of COPD (3)
hyperinflation of the lungs flattened hemidiaphragm bullae
453
What general management is used in COPD
stop smoking annual flu vaccine pneumonoccal vaccine
454
Management of COPD
1. SABA or SAMA 2. Determine if steroid response or not - if responsive add LABA and ICS - if not responsive add LABA and LAMA 3. SABA as needed then triple therapy : LABA, LAMA and ICS
455
What medications may be able to reduce risk of COPD exacerbations
prophylactic azithromycin mucolytics phosphdiesterase inhibitors (roflumilast)
456
What is the most common pathogen associated with COPD exacerbations
haemophilus influenzae
457
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
458
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
459
why does cor pulmonale occur in COPD
chronic hypoxia causes vasoconstriction of the pulmonary vessels This increases pulmonary pressure and causes right heart failure
460
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
461
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
462
Presentation of heart failure (7)
breathlessness peripheral oedema cough- pink, white frothy orthopnoea paroxysmal nocturnal dyspnoea peripheral oedema fatigue
463
signs of heart failure (8)
tachycardia tachypnoea hypertension murmurs 3rd heart sound bibasal crackles raised JVP peripheral oedema
464
first line investigation for heart failure
NT-proBNP
465
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
466
what can cause falsely raised BNP (9)
LV hypertrophy ischaemia tachycardia eGFR <60 sepsis COPD diabetes >70 liver cirrhosis
467
What can cause a falsely low BNP (6)
obesity diuretics ACEi beta blockers ARB aldosterone agonists
468
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
469
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.
470
1st line management of heart failure
ACEi and beta blocker
471
What may be added to ACEi and beta blocker if heart failure is not controlled
aldosterone antagonist (spironolactone)
472
what specialist drugs may be used to manage heart failure (5)
ivabradine SGLT-2 inhibitor ivabradine hydrazalizine with a nitrate digoxin
473
X ray findings of osteoarthritis
LOSS Loss of joint space Osteophyte formation Subchondral sclerosis subchondral cysts
474
what type of bony deformities might be seen in osteoarthritis
Herbeden's nodes - swelling of DIP Bouchard's nodes - swelling of PIP
475
1st line management of osteoarthritis
oral paracetamol and topical NSAIDs
476
2nd line management of osteoarthritis
oral NSAIDs +PPI cover
477
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
478
What are fragility fractures?
a fracture from a fall from standing height or less most commonly of the wrist spine and hip
479
What scan is used to measure bone density in osteoporosis?
DEXA scan
480
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
481
what result of a DEXA suggests osteopenia
-2.5 to -1.0
482
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
483
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
484
1st line management of osteoporosis
Bisphosphonates- taken weekly on an empty stomach (e.g. alendronate)
485
2nd line management of osteoporosis
denosumab (monoclonal antibody that targets osteoclasts)
486
pathophysiology of type 1 diabetes
autoimmune destruction of the insulin secreting beta cells in the islets of langerhans of the prancreas
487
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
488
what fasting glucose level is indicative of diabetes?
7 mmol/l
489
what result on the oral glucose tolerance test/ random plasma glucose test is indicative of diabetes?
11.1 mmol/l
490
what level HbA1c is indicative of diabetes?
>48 mmol/mol (>6.5%)
491
what level HbA1c is indicative of pre-diabetes?
42-27mmol/mol (6-6.4%)
492
how often should HbA1c be measured in diabetes?
every 3 - 6 months
493
what should be the aimed HbA1c in newly diagnosed diabetics?
48 mmol/mol
494
what should be the aimed HbA1c in diabetes treated on more than one diabetes medication?
53mmol/mol
495
give an example of a short acting insulin
actrapid
496
give and example of a long acting insulin
lantus
497
1st line treatment of type 2 diabetes?
metformin +/- SGLT-2 inhibitor
498
who is given an SGLT-2 inhibitor in diabetes?
those with an increased cardiovascular risk (QRisk > 10%) , established cardiovascular disease or heart failure
499
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
500
what should be given first line if metformin isnt tolerated due to GI side effects?
modified release metformin
501
what is given second line if diabetes is not controlled with metformin
One of the following: - DDP-4 inhibitor - pioglitazone - sulfonylurea - SGLT-2 inhibitor
502
What is given 3rd line for the treatment of T2DM
triple therapy or insulin
503
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
504
action of metformin
increase insulin sensitivity and decrease hepatic glucogenesis
505
SE of metformin
GI upset lactic acidosis due to AKI
506
what eGFR is requried for metformin ?
>30
507
action of SGLT-2 inhibitors ?
inhibit reabsorption of glucose in the kidneys by blocking the SGLT-2 channel
508
examples of SGLT-2 inhibitors (2)
empaglflozin dapagliflozin
509
SE of SGLT-2 inhibitors
UTI and thrush due to glycosuria weight loss hypoglycaemia- DKA
510
what type of drug is pioglitazone
a thiazolidinedione
511
action of pioglitazone
activates the PPAR-gamma receptor in adipocytes to promote adipogenesis and fatty acid uptake
512
SE of pioglitazone
weight gain fluid retention increase bone fractures bladder cancer
513
action of sulfonylurea
stimulates insulin release from the pancreas
514
example of a sulfonylurea
gliclazide
515
SE of sulfonylureas
weight gain hypoglycaemai
516
examples of DPP-4 inhibitors
sitagliptin alogliptin
517
action of DPP-4 inhibitors
increase incretin levels which is a hormone that inhibits glucagon secretion
518
SE of DPP-4 inhibitors
usually well tolerated by can cause headaches, acute pancreatitis
519
action of GLP-1 mimetic
mimic incretin and inhibit glucagon release
520
SE of GLP-1 mimetic
nausea and vomiting pancreatitis weight loss
521
what is acute bronchitis?
a self limiting lower respiratory tract infection caused by infection of the bronchial airways, not lung parenchyma
522
Most common cause of acute bronchitis
usually viral infections - coronavirus, rhinovirus, RSV, adenovirus
523
presentation of acute bronchitis
cough rhinorrhoea sore throat wheeze low grade fever
524
How can acute bronchitis be differentiated from pneumonia on examination?
there will be an absence of focal chest signs- consolidation, crackles
525
What test may be done in acute bronchitis if considering antibiotics?
CRP
526
What CRP cut off is used to determine if immediate antibiotics should be given in acute bronchitis?
>100
527
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
528
What is an acute stress reaction?
also known as psychological shock - a psychiatric condition that manifests after exposure to severe stress or traumatic events
529
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
530
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
531
Management of acute stress reaction
1st line - trauma focused CBT benzodiazepines may have benefit in short term
532
If an antibioitic is prescribed in acute bronchitis what is usually recommended?
doxycyline
533
what yeast infection is the most common cause of thrush?
candida albicans
534
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
535
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
536
1st line treatment of thrush ?
oral fluconazole 150mg tablet
537
what is another name for chronic fatigue syndrome?
myalgic encephalomyelitis
538
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
539
For how long should chronic fatigue be present for a diagnosis?
NICE recommends after 3 months
540
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
541
What should be involved in the management of chronic fatigue syndrome?
- CBT - energy management - sleep hygiene
542
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)
543
How can chronic kidney disease be differentiated from AKI?
renal USS- CKD usually has bilateral small kidneys
544
How can CKD present?
may be asymptomatic - fatigue - pallor - foamy urine - muscle cramps - itching (uraemia) - loss of appetite - oedema - hypertension
545
Common causes of chronic kidney disease
diabetes hypertension medications such as lithium and NSAIDS glomerulonephritis polycystic kidney disease
546
what investigations may be involved in the diagnosis of CKD?
GFR albumin creatinine urine ratio haematuria on urine dipstick USS biopsy
547
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
548
What are 4 main complications that can occur in CKD?
anaemia renal bone disease cardiovascular disease peripheral neuropathy
549
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.
550
What HLA are associated with coeliac disease?
HLA DQ2 and HLA DQ8
551
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
552
what vaccine is offered to those with coeliac disease?
5 yearly pneumococcal vaccine
553
What malignancy can be associated with coeliac diseasE?
enteropathy-associated T-cell lymphoma of small intestine
554
what three types of primary constipation are there?
normal transit (most common) slow transit dyssynergic defecation (can't relax the pelvic floor muscles)
555
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
556
What criteria is used in the diagnosis of constipation
the rome IV criteria
557
3 key features of constipation
infrequent stools (< 3 weekly) difficulty passing stool a sensation of incomplete emptying
558
First line medication for constipation in adults
bulk forming laxatives- ispaghula husk
559
second line medication for constipation in adults
osmotic laxative (e.g. macrogol, lactulose)
560
How should faecal impaction be treated?
high dose macrogol with suppositories and enemas
561
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
562
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
563
Complications of constipation
overflow diarrhoea acute urinary retention haemorrhoids
564
first line laxative in children
movicol
565
what two types of contact dermatitis are there?
irritant and allergic contact dermatitis
566
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
567
pathophysiology of allergic contact dermatitis and give an example
a delayed type IV hypersensitivity reaction Commonly cosmetics, skincare, latex, plants, nickel
568
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
569
gold standard diagnosis of contact dermatitis
patch testing
570
what causes cutaneous warts?
infection of keratinocytes with HPV
571
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
572
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
573
secondary care treatment options for resistant warts
physical ablation anitmitotic treatments immunomodulatory therapy
574
How does diverticulitis present?
abdominal pain change in bowel habit rectal bleeding fever
575
What is diverticulitis
symptomatic inflammation and infection of diverticular in the bowel (sac like protrusions of the colonic mucosa through the muscular wall)
576
Complications of diverticulitis
perforation abscess formation fistulae to adjacent organs haemorrhage
577
Gold standard investigation for diverticulitis
contrast CT of abdo pelvis
578
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
579
Which joint is most commonly affected in gout
the first metatarsophalangeal joint
580
gold standard investigation of gout
joint aspiration and microscopy- shows negatively bifringent needle shaped crystals
581
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
582
what may be seen on x ray of gout
subcortical cysts or bone erosions
583
what crystal causes gout
monosodium urate crystals
584
first line management of acute gout
NSAIDs or colchicine
585
second line management of acute gout
intra-articular or oral steroids
586
1st line treatment in chronic gout
allopurinol
587
how does allopurinol work?
xanthine oxidase inhibitor
588
what can be used if allopurinol does not work/isnt tolerated in gout prevention
febuxostat
589
what is the most common cause of tonsilitis?
group A beta haemolytic strep such as strep. pyogenes
590
What are the two broad types of lung cancer?
small cell lung cancer and non-small cell lung cancer
591
What is the most common category of lung cancer?
non-small cell lung cancer
592
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
593
What is a mesothelioma and what is it associated with?
malignancy of the mesothelial cells of the pleura Linked with asbestos exposure
594
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
595
How does superior vena cava syndrome present?
facial swelling difficulty breathing distended veins in the neck and upper chest
596
How is lung cancer diagnosed?
chest x ray CT bronchoscopy and biopsy PET scan
597
how might lung cancer present on x ray
hilar enlargement peripheral opacity pleural effusion collapse
598
How does lung cancer present?
shortness of breath cough haemoptysis finger clubbing recurrent pneumonia weight loss supraclavicular lymphadenopathy metastases - bone pain
599