GP Flashcards
Define acne vulgaris?
Acne vulgaris is a common skin disorder which usually occurs in adolescence.
Typically affects the face, neck and upper trunk and is characterised by the obstruction of the pilosebaceous follicles with keratin plugs which results in comedones, inflammation and pustules
What bacteria usually colonises in acne vulgaris?
Propionibacterium acnes
What is mild acne vulgaris?
Open and closed comedones with or without sparse inflammatory lesions
What is moderate acne vulgaris?
Widespread non-inflammatory lesions and numerous papules and pustules
What is severe acne vulgaris?
Extensive inflammatory lesions, which may include nodules, pitting, and scarring
What is the management for mild-to-moderate acne?
12 week course of:
Topical adapalene with topical benzoyl peroxide
Topical tretinoin with topical clindamycin
Topical benzoyl peroxide with topical clindamycin
What is the management for severe acne?
12 week course of:
Topical adapalene with topical benzoyl peroxide
+ oral lymecycline or oral doxycycline
Topical tretinoin with topical clindamycin
Topical azelaic acid
+ oral lymecycline or oral doxycycline
What pharmacological agents used in acne management should be avoided in pregnancy and what is the alternative?
Tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age.
Erythromycin
When is the typical presentation of eczema and when does it usually clear?
It typically presents before 2 years
Clears in around 50% of children by 5 years of age Clears in around 75% of children by 10 years of age
What are the features of eczema younger children?
Itchy, erythematous rash on the extensor surfaces
The face and the trunk are most affected
What are the features of eczema in older children?
Itchy, erythematous rash on the flexor surfaces and the creases of the neck and face
What is the general management for eczema?
Avoid irritants
Steroid creams and emollients - increased in stepwise manner from weakest to strongest
What is the mild topical steroid used in eczema?
Hydrocortisone 0.5-2.5%
What is the moderate topical steroid used in eczema?
Betamethasone valerate 0.025% (Betnovate RD)
Clobetasone butyrate 0.05% (Eumovate)
What is the potent topical steroid used in eczema?
Fluticasone propionate 0.05% (Cutivate)
Betamethasone valerate 0.1% (Betnovate)
What is the very potent tropical steroid used in eczema?
Clobetasol propionate 0.05% (Dermovate)
What is the mnemonic used for stepwise management of topical steroids in eczema?
Help Every Budding Dermatologist
- Hydrocortisone (mild)
- Eumovate (moderate)
- Betnovate 0.1 (potent)
- Dermovate (very potent)
What is the causative organism of bacterial vaginosis?
Gardnerella vaginalis
What disease can gardnerella vaginalis cause?
Bacterial vaginosis
Describe the pathophysiology behind bacterial vaginosis?
An overgrowth of predominately anaerobic organisms leading to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
What are the classical features of bacterial vaginosis?
Vaginal discharge: ‘fishy’, offensive
Asymptomatic in 50% of patients
What criteria is used for the diagnosis of bacterial vaginosis?
Amsel’s criteria (3/4):
Thin, white homogenous discharge
Clue cells on microscopy: stippled vaginal epithelial cells
Vaginal pH > 4.5
Positive whiff test (addition of potassium hydroxide results in fishy odour)
What is the management of bacterial vaginosis in an asymptomatic patient?
If the woman is asymptomatic, treatment is not usually required
Exceptions include if the patient is undergoing termination of pregnancy
What is the first line management of bacterial vaginosis in a symptomatic patient?
Oral metronidazole for 5-7 days
Single oral dose of 2g may be used if adherence is an issue
What are the alternative management options for bacterial vaginosis?
Topical metronidazole or topical clindamycin
Define tinea capitis?
Dermatophyte fungal infection of the scalp
Define tinea pedis?
Dermatophyte fungal infection of the foot
Define tinea crurus?
Dermatophyte fungal infection of the groin
Define tinea corporis?
Dermatophyte fungal infection of the trunk, legs or arms
What is the management for trichophyton tonsurans tinea capitis?
Oral antifungal - terbinafine
Topical ketoconazole shampoo for first two weeks to reduce transmission
What is the management for microsporum tinea capitis?
Oral antifungal - griseofulvin
Topical ketoconazole shampoo for first two weeks to reduce transmission
What is the management for tinea corporis?
Oral fluconazole
What is the management for fungal nail infections?
Oral terbinafine
Define molluscum contagiosum?
Molluscum contagiosum is a common skin infection caused by molluscum contagiosum virus (MCV), a member of the Poxviridae family
How is molluscum contagiosum spread?
Transmission occurs directly by close personal contact, or indirectly via fomites (contaminated surfaces) such as shared towels and flannels
What are the classic features of molluscum contagiosum?
Pinkish or pearly white papules with a central umbilication
5mm in diameter
Children - typically trunk and flexures
Adults - Genitalia, pubis, thighs, and lower abdomen
What is the management for molluscum contagiosum?
Treatment is not usually recommended
Cryotherapy can be used or simple trauma
What HPV strains cause genital warts?
Types 6 and 11
What is the first line management for genital warts?
Topical podophyllum - when multiple and non-keratinised
Cryotherapy - when solitary and keratinised
What is the second line management for genital warts?
Imiquimod which is a topical cream
Define folliculitis?
An inflammatory process involving any part of the hair follicle; it is most commonly secondary to infection
What is the most common cause of folliculitis?
Staphylococcus aureus
What is the management for staph folliculitis?
Clindamycin or Flucloxacillin
What is the management for gram negative folliculitis?
Topical benzoyl peroxide
Define psoriasis?
A chronic skin disorder defined by red, scaly patches on the skin
Define plaque psoriasis?
The most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp
Define flexural psoriasis?
The same as plaque psoriasis but the skin is smooth
Define guttate psoriasis?
Transient psoriatic rash frequently triggered by a streptococcal infection.
Define pustular psoriasis?
Commonly occurs on the palms and soles
What may exacerbate psoriasis?
Trauma
Alcohol
Drugs: beta blockers, antimalarials, NSAIDs, ACEi and infliximab
Withdrawal of systemic steroids
What is the first line management for chronic plaque psoriasis?
Potent topical corticosteroid OD + vitamin D analogue OD
What is the second line management for chronic plaque psoriasis?
Potent topical corticosteroid OD + vitamin D analogue BD
If no improvement after 8 weeks
What is the third line management for chronic plaque psoriasis?
Potent topical corticosteroid BD + vitamin D analogue BD
If no improvement after 8-12 weeks
What is the secondary care management for chronic plaque psoriasis?
Ultraviolet B light
Ultraviolet A light + psoralen
Oral methotrexate
What is the management for scalp psoriasis?
Potent topical corticosteroids used once daily for 4 weeks
What is the management for face, flexural, and genital psoriasis?
Mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks
Due to pronity of steroid atrophy of skin
What are some examples of vitamin D analogues?
Calcipotriol (Dovonex)
Calcitriol
Tacalcitol
How do vitamin D analogues work in psoriasis management?
Decrease cell division and differentiation, therefore there is decreased epidermal proliferation
Define acute bronchitis?
Acute bronchitis is a type of chest infection a result of inflammation of the trachea and major bronchi
What are the classical features of acute bronchitis?
Cough: may or may not be productive
Sore throat
Rhinorrhoea
Wheeze
What is the difference between acute bronchitis and pneumonia?
No other focal chest signs in acute bronchitis other than wheeze.
No systemic symptoms
What is the management of acute bronchitis?
Analgesia
Fluid intake
CRP 20-100 = delayed prescription antibiotics
CRP >100 = immediate antibiotics
What antibiotics are given in acute bronchitis when indicated?
Doxycycline if first-line
Amoxicillin if pregnant or child
What criteria used used to diagnose acute bronchitis?
MacFarlane Criteria:
An acute illness of <21 days
Cough as the predominant symptom
At least 1 other lower respiratory tract symptom, such as sputum production, wheezing, chest pain
No alternative explanation for the symptoms
What is the MacFarlane criteria used for?
A diagnosis of acute bronchitis
What type of hypersensitivity reaction is asthma?
Type 1 hypersensitivity
Why is diagnosis of asthma in children difficult?
It is common for young children to wheeze when they develop a virus (‘viral-induced wheeze’)
Patient with asthma may also suffer from what conditions?
Other IgE-mediated atopic conditions such as:
Atopic dermatitis (eczema)
Allergic rhinitis (hay fever)
What are asthma patients most likely allergic to? What else will they have?
Aspirin
Will most likely have nasal polyps if this is the case
What are the features of asthma?
Cough - worse at night
Dyspnoea
Expiratory wheeze
Reduced peak expiratory flow rate
What is FEV1?
Forced expiratory volume - volume that has been exhaled at the end of the first second of forced expiration
What is FCV?
Forced vital capacity - volume that has been exhaled after a maximal expiration following a full inspiration
What are the typical spirometry results in asthma?
FEV1 - significantly reduced
FVC - normal
FEV1% (FEV1/FVC) < 70%
What are the investigations for asthma?
Spirometry - First line
Fractional exhaled Nitric Oxide
Chest X-ray (in smokers)
What is the first line management for asthma? What is the side effect?
Salbutamol
Tremor
What type of drug is salbutamol, what is the mechanism of action?
Short-acting-beta agonist (SABA). Relaxing the smooth muscle of airways
What is the additional second line management for asthma?
Inhaled corticosteroids
What is the additional third line management for asthma?
Leukotriene receptor antagonist (LTRA) - Montelukast
Give some examples of inhaled corticosteroids in asthma? What are the side effects?
Beclometasone dipropionate
Fluticasone propionate
Oral candidiasis
Stunted growth in children
What is the fourth-line management for asthma?
Salmetrol
What type of drug is salmetrol, what is the mechanism of action?
Long-acting beta-agonist
They work by relaxing the smooth muscle of airways
What would the assessment of a severe asthma attack show in children?
SpO2 < 92%
PEF - 33-50%
Too breathless to talk or feed
Use of accessory neck muscles
HR - >125 (>5 years), >140 (1-5 years)
RR - >30 (>5 years), >40 (1/5 years)
What is the fourth-line management for asthma?
Monteleukast - Leukotriene receptor antagonist
What would the assessment of a life-threatening asthma attack show in children?
SpO2 <92%
PEF - <33%
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
What is the management for mild-moderate acute asthma in children?
Beta-2-agonist via a spacer (>3 years use close fitting mask)
1 puff every 30-60 seconds. Max 10 puffs
If no symptom control refer to hospital
Steroid therapy for 3-5 days
2-5 years - 20mg prednisolone OD
>5 years - 30-40mg prednisolone OD
Define bronchiolitis?
Bronchiolitis is a condition characterised by acute bronchiolar inflammation
What is the pathogen which causes bronchiolitis?
Respiratory syncytial virus (80%)
Rhinovirus (20%)
What is the investigation of choice for bronchiolitis?
Immunofluorescence of nasopharyngeal secretions may show RSV
What is the management for bronchiolitis?
If SpO2 persistently >92% - humidified oxygen
Accessory:
NG feeding
Suction of secretions
What would classify a patient as high-risk in bronchiolitis?
Bronchopulmonary dysplasia (e.g. Premature)
Congenital heart disease
Cystic fibrosis
Define COPD?
COPD is an umbrella term encompassing the older terms chronic bronchitis and emphysema
What are the features of COPD?
Cough: often productive
Dyspnoea
Wheeze
RSHF -> peripheral oedema
What would spirometry show for COPD?
Post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
What would a chest X-ray show for COPD?
Hyperinflation
Bullae: if large, may sometimes mimic a pneumothorax
Flat hemidiaphragm
What are the investigations for COPD?
Post-bronchodilator spirometry
Chest X-ray
FBC - exclude secondary polycythaemia
BMI calculation
What would mild COPD be using FEV1?
FEV1/FVC < 0.7
FEV1 of predicted >80%
What would moderate COPD be using FEV1?
FEV1/FVC < 0.7
FEV1 of predicted 50-79%
What would severe COPD be using FEV1?
FEV1/FVC < 0.7
FEV1 of predicted 30-49%
What would very severe COPD be using FEV1?
FEV1/FVC < 0.7
FEV1 of predicted <30%
What are the causes of COPD?
C4-GAS:
Cadmium
Coal
Cotton
Cement
Grain
Alpha-1 antitrypsin deficiency
Smoking - biggest risk factor
What is the general advice for COPD?
Smoking cessation
Annual influenza vaccination
One-off pneumococcal vaccination
Pulmonary rehabilitation
What is the first-line management for COPD?
SABA or SAMA
How do you determine whether a patient with COPD has asthmatic/steroid responsive features?
Previous diagnosis of asthma / atopy
Higher blood eosinophil count
Substantial FEV1 variation over time (>400ml)
Substantial diurnal variation in PEF (20%)
What is second-line management of CODD if a patient has no asthma/steroid response features?
LABA + LAMA
What is second-line management of CODD if a patient has asthma/steroid response features?
LABA + ICS
+ LAMA if no response
What pharmacological agent should be considered in patients with chronic productive cough in COPD?
Mucolytics
What pharmacological agent is given to patients with severe (+very severe) COPD to reduce the risk of exacerbations?
Phosphodiesterase-4 (PDE-4) inhibitors - roflumilast
When should you assess patients considered for LTOT in COPD?
Very severe airflow obstruction (FEV1 >30%)
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
O2 sats <=92% OA
What is the investigation for assessment of LTOT in COPD?
ABG - 2 weeks apart
pO2 <7.3 kPA
OR
pO2 <7.3-8 kPA AND one of the following:
Secondary polycythaemia
Peripheral oedema
Pulmonary hypertension
When should LTOT not be offered to patients?
Those who continue to smoke despite being offered smoking cessation advice and treatment
What pathogens may cause a COPD exacerbation?
Haemophilus influenzae (most common cause)
Rhinovirus - most common virus
What is the management for a COPD exacerbation?
Increase the frequency of bronchodilator use and consider giving via a nebuliser
30mg prednisolone for 5 days
When should antibiotics be given in a COPD exacerbation?
If sputum is purulent or there are clinical signs of pneumonia
Amoxicillin or clarithromycin or doxycycline
What are the classical features of croup?
Cough which is barking and seal-like, with symptoms worse at night.
A cough which is barking and seal-like, with symptoms worse at night would indicate what?
Croup
What is the management for croup?
Single dose of oral dexamethasone regardless of severity.
Second line - Prednisolone
What is the emergency management for croup?
High-flow oxygen and nebulised adrenaline
Why would you never perform a throat examination on a child with suspected croup?
Never perform a throat examination on a patient with croup due to risk of airway obstruction
What sign would be seen on a posterior-anterior chest X-ray of a child with croup?
Subglottic narrowing, commonly called the ‘steeple sign’
What sign would be seen on a lateral chest X-ray of a child with croup?
Swelling of the epiglottis - the ‘thumb sign’
What is the main organism that causes croup?
Parainfluenza virus accounts for the majority of cases of croup
When is croup more common in the year?
Autumn
What type of influenza virus accounts for the majority of clinical disease?
A and B
What is the difference between the children and adult influenza vaccine?
Children - Live
Adult - Inactivated
Define rhino-sinusitis?
An inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.
What are the features of rhino-sinusitis?
Facial pain - pressure when bending forward
Nasal discharge
Nasal obstruction - mouth breathing
Post-nasal drip
What is the management for rhino-sinusitis?
Avoid allergen
Intranasal corticosteroids
Nasal irrigation with saline solution
What are the red flag symptoms of rhino-sinusitis?
Unilateral symptoms
Persistent symptoms despite 3 months treatment
Epistaxis - nose bleed
What is pertussis and what is the causative pathogen?
Whooping cough (pertussis) is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis
What are the features of pertussis in the catarrhal phase?
URTI symptoms
What are the features of pertussis in the paroxysmal phase?
Cough increases in severity
Worse at night or after feeding
Inspiratory whoop
Infants may have spells of apnoea
What are the features of the convalescent phase in pertussis infection?
Cough will subside over weeks to months
What is the diagnostic criteria for whooping cough?
Acute cough >14 days AND one of following:
Paroxysmal cough
Inspiratory whoop
Post-tussive vomiting
undiagnosed apnoeic attacks in children
What is the management for pertussis?
An oral macrolide (e.g. clarithromycin, azithromycin or erythromycin)
Notify public health
What is atrial flutter?
Atrial flutter is a form of supraventricular tachycardia characterised by a succession of rapid atrial depolarisation waves
What would ECG changes be for atrial flutter?
Sawtooth appearance (flutter waves / f wave)
What is the immediate management for atrial flutter?
Synchronised cardioversion with anticoagulant
What are the different types of AF?
First detected episode
Recurrent episodes
Permanent AF
What are the types of recurrent AF?
Paroxysmal AF - Terminates spontaneously
Persistent AF - Non-self terminating (>7 days)
What are the features of AF?
Palpitations
Dyspnoea
Chest pain
Irregularly irregular pulse
What is the role of rate control on AF management?
Accept that the pulse will be irregular, but slow the rate down to avoid negative effects on cardiac function
What is the role of rhythm control in AF management?
Try to get the patient back into, and maintain, normal sinus rhythm. This is termed cardioversion.
What pharmacological management is used for rate control in AF?
A beta-blocker or a rate-limiting calcium channel blocker (e.g. diltiazem) is used first-line
What happens if one drug does not control rate adequately in AF?
combination therapy with any 2 of the following:
Betablocker
Diltiazem
Digoxin
When is there the highest risk of embolism leading to stroke in AF?
The moment a patient switches from AF to sinus rhythm
What is the criteria to use rhythm control first in AF management?
Short duration of symptoms (less than 48 hours) OR
Be anticoagulated for a period of time prior to attempting cardioversion - 3 weeks.
What is the CHA2DS2-VSAc score used for?
Calculates stroke risk for patients with atrial fibrillation
What score calculates stroke risk for patients with atrial fibrillation?
CHA2DS2-VSAc
What are the individual scores in the CHA2DS2-VSAc scoring system?
C - congestive heart failure - 1
H - hypertension - 1
A2 - Age - Age >= 75 - 2, Age 65-74 - 1
D - diabetes - 1
S2 - Prior Stroke, TIA or thromboembolism - 2
V - Vascular disease (IHD, PAD) - 1
S - sex (female) - 1
What is the anticoagulation strategy based on CHA2DS2-VSAc score?
0 - No treatment
1 - Male - consider coagulation, Female - no treatment
2 or more - Offer anticoagulation
What pharmacological agents are used for cardioversion in AF?
Amiodarone
Flecainide (if no structural heart disease)
What pharmacological agents are used first-line for anticoagulation in AF?
DOACs:
Apixaban
Dabigatran
Edoxaban
Rivaroxaban
What pharmacological agent is used second-line for anticoagulation in AF?
Warfarin due to requiring regular blood tests to check the INR
What is Wolff-Parkinson White syndrome?
Caused by a congenital accessory conducting pathway between the atria and ventricles leading to atrioventricular re-entry tachycardia (AVRT)
What is a common contraindication for beta-blockers for rate control in patients with AF?
Asthma
What would an ECG show for right-sided accessory pathway Wolff-Parkinson-White syndrome?
Short PR interval
Wide QRS complex with slurred upstroke - Delta wave
Left axis deviation - majority of cases
What would an ECG show for left-sided accessory pathway Wolff-Parkinson-White syndrome?
Short PR interval
Wide QRS complex with slurred upstroke - Delta wave
Right axis deviation
Dominant R wave in V1
What is the management for supra-ventricular tachycardias?
Definitive treatment: radiofrequency ablation of the accessory pathway
Medical: amiodarone, flecainide
What is the most common type of supra-ventricular tachycardia?
Atrioventricular nodal reentrant tachycardia (AVNRT)
What is the first line acute management for supra-ventricular tachncardia?
Valsalva manoeuvre: e.g. trying to blow into an empty plastic syringe
carotid sinus massage
What is the second line acute management for supra-ventricular tachycardia?
Adenosine Rapid IV 6g bolus -> 12mg -> 18mg
Verapamil if asthmatic
What is would ventricular fibrillation show on an ECG?
No QRS complex can be identified, ECG completely disorganised
Patient is likely to be unconsious
What is the management for ventricular fibrillation?
Immediate Dc cardioversion
What are the two types of ventricular tachycardia?
Monomorphic VT: most commonly caused by myocardial infarction
Polymorphic VT: A subtype of polymorphic VT is torsades de pointes
What is the management for ventricular tachycardia?
Immediate cardioversion
IV amioderone
Define ventricular ectopic?
Ventricular ectopics are premature ventricular beats
What is the management for ventricular ectopic?
Reassurance in otherwise healthy people
Beta blockers and Ca channel blockers for palpitations
What is the management for torsades de pointes?
IV magnesium sulphate
Define peripheral vascular disease?
A major circulatory disorder characterised by arterial obstruction, leading to reduced blood supply and ischaemia in the lower limbs
What is the primary investigation for peripheral vascular disease?
Ankle-brachial pressure index
What does an ABPI of >1.4 indicate?
Abnormally calcified vessels
What does an ABPI of 0.9-1.2 indicate?
Normal - does not exclude diagnosis if clinically indicated
What does an ABPI of 0.5-0.9 indicate?
Intermittent claudication - mild-to-moderate arterial disease
What does an ABPI of <0.5 indicate?
Critical limb ischaemia - rest pain, ulceration, gangrene
What does an absent of pulse in the lower extremity indicate on doppler ultrasound?
Suspect acute limb ischaemia
What is the first-line investigation for confirmed peripheral vascular disease?
Duplex ultrasound
What is the management for PVD?
Exercise + management of risk factors
3 month no improvement = surgery - ballon dilation, stent, arthrectomy
Define varicose veins?
Dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart
Where do varicose veins usually occur?
Commonly occur in the legs due to reflux in the great saphenous vein and small saphenous vein
What are the risk factors for varicose veins?
Increasing age
Female
Pregnancy - uterus compression on pelvic vein
Obesity
What is the investigation of choice for varicose veins?
Venous duplex ultrasound: this will demonstrate retrograde venous flow
What are the conservative management options for varicose veins?
Leg elevation
Weight loss
Regular exercise
Graduated compression stockings
What are the reasons for varicose vein referral to secondary care?
Significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
Previous bleeding from varicose veins
Skin changes secondary to chronic venous insufficiency
Active or healed leg ulcer
What are the possible treatments for varicose veins?
Endothermal ablation
Foam sclerotherapy
Surgery - stripping or ligation
Where are venous ulcers typically seen?
Medial malleolus
What is the management for venous ulcers?
Compression bandaging, four layer
Oral pentoxifylline, a peripheral vasodilator, improves healing rate
Define acute stress reaction?
A stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event
What is the difference between acute stress reaction and PTSD?
Acute stress reaction - <4 weeks
PTSD - >4 weeks
What are the features of an acute stress reaction?
Intrusive thoughts e.g. flashbacks,
nightmares
Dissociation e.g. ‘being in a daze’, time slowing
Negative mood
Avoidance
Arousal e.g. hypervigilance, sleep disturbance
What is the management for an acute stress reaction?
First line - trauma-focused cognitive-behavioural therapy (CBT)
Benzodiazepines
What is OCD?
Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both.
Define obsession?
An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
Define compulsion?
Compulsions are repetitive behaviours or mental acts that the person feels driven to perform.
A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.
What would be defined as severe OCD?
Someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance
What would the management be for an individual with mild functional impairment for OCD?
Low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
If this is insufficient or can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)
What would the management be for an individual with moderate functional impairment for OCD?
Offer a choice of either a course of an SSRI or more intensive CBT (including ERP)
Consider clomipramine (as an alternative first-line drug treatment to an SSRI)
In what case would you specifically given fluoxetine for a moderate functional impairement of OCD?
Fluoxetine is specifically given for body dysmorphic disorder
In what case would you give clomipramide for a moderate functional impairment of OCD?
Can be considered as an alternative first-line drug treatment to SSRIs if the person has had a previous good response to it.
What would the management be for an individual with severe functional impairment for OCD?
Refer to secondary care mental health team for assessment.
Whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider Clomipramine
What is exposure and response prevention (ERP)?
ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
What timeframe would you review a patient who is starting a sertraline and is under the age of 30?
1 week
Define anxiety?
Excessive worry about a number of different events associated with heightened tension.
List some medications that may trigger anxiety?
Salbutamol
Theophylline
Corticosteroids
Antidepression
Caffeine
What is step 1 of GAD management?
Education about GAD + active monitoring
What is step 2 of GAD management?
Low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
What is step 3 of GAD management?
High-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.
What is step 4 of GAD management?
Highly specialist input e.g. Multi agency teams
What is the first line pharmacological management of GAD?
Sertraline is first-line
What would second-line pharmacological management for GAD?
If sertraline is ineffective, an alternative SSRI or SNRI can be used.
Duloxetine or Venlafaxine (SNRI examples)
What would the pharmacological management be for an individual with GAD who cannot tolerate SSRIs or SNRIs?
f the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
What must you warn patients of who are under the age of 30, before commencing SSRIs and SNRIs?
For patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm.
Weekly follow-up is recommended for the first month
What is the first-line treatment of panic disorder in primary care?
Cognitive behavioural therapy or drug treatment
If there is no response to SSRIs for panic disorder in primary care, what can be offered?
If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
What are some risk factors for developing GAD?
Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent
What are some protective factors against GAD?
Aged 16 - 24
Being married or cohabiting
Define pseudodementia?
Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss - this is called pseudodementia
What is normal pressure hydrocephalus? What is it thought to be caused by?
Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. It is thought to be secondary to reduced CSF absorption at the arachnoid villi.
What is the classic triad of features seen in normal pressure hydrocephalus?
Urinary incontinence
Dementia and bradyphrenia
Gait abnormality (may be similar to Parkinson’s disease)
What would the triad of urinary incontinence, dementia and bradyphrenia, gait abnormality (may be similar to Parkinson’s disease) suggest?
Normal pressure hydrocephalus
What would normal pressure hydrocephalus present with on imaging?
Hydrocephalus with ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement
Ventriculomegaly without sulcal enlargement on imaging of the brain would indicate what?
Normal pressure hydrocephalus
What is the management of normal pressure hydrocephalus?
Ventriculoperitoneal shunting
What are the complications of ventriculoperitoneal shunting?
Around 10% of patients who have shunts experience significant complications such as seizures, infection and intracerebral haemorrhages
What are some non-pharmacological managements of Alzheimer’s disease?
A range of activities to promote wellbeing that are tailored to the person’s preference
Group cognitive stimulation therapy for patients with mild and moderate dementia
Group reminiscence therapy and cognitive rehabilitation
What types of drugs are donepezil, galantamine and rivastigmine?
Acetylcholinesterase inhibitors
What pharmacological management can be given for mild to moderate Alzheimer’s disease?
Donepezil, Galantamine and Rivastigmine
What second line pharmacological management can be given for Alzheimer’s disease?
Memantine
What type of drug is memantine?
NMDA receptor antagonist
Under what conditions can the second line pharmacological management be used for Alzheimer’s disease?
- For moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors.
- As an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s.
- Monotherapy in severe Alzheimer’s
What feature would contraindicate use of donepezil?
Bradycardia
What is an adverse effect of donepezil?
Insomnia
What is the characteristic pathological feature of lewy-body dementia?
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas would suggest what?
Lewy-body dementia
What are the features of lewy-body dementia?
Progressive cognitive impairment which typically occurs before parkinsonism, but usually both features occur within a year of each other.
Cognition may be fluctuating (different to other dementias)
Parkinsonism
Visual hallucinations + dementia = lewy -body dementia
Visual hallucinations + dementia would indicate what?
Lewy body dementia
What pharmacological management can be given for mild to moderate lewy body dementia?
Donepezil and Rivastigmine
What second line pharmacological management can be given for Lewy body dementia?
Memantine
What class of drugs should be avoided in lewy body dementia and why?
Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism.
E.g, Risperidone and Haloperidol.
What is frontotemporal lobular degeneration?
Frontotemporal lobar degeneration (FTLD) is the third most common type of cortical dementia after Alzheimer’s and Lewy body dementia.
What are the three recognised types of FTLD?
Frontotemporal dementia (Pick’s disease)
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
Semantic dementia
What are the common features of FTLD?
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
What are the most common features of Frontotemporal dementia (Pick’s disease)?
Characterised by personality change and impaired social conduct.
What axillary features ‘may’ be present in Frontotemporal dementia (Pick’s disease)?
Hyperorality
Disinhibition
Increased appetite
Perseveration behaviours
What would you see on imaging for frontotemporal dementia (Pick’s disease)?
Focal gyral atrophy with a knife-blade appearance.
Macroscopic - Atrophy of the frontal and temporal lobes
Microscopic: Pick bodies - spherical aggregations of tau protein (silver-staining)
Gliosis
Neurofibrillary tangles
Senile plaques
What is the most common feature of chronic progressive aphasia (CPA)?
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
What is the most common feature of semantic dementia?
A fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.
Define Alzheimer’s disease?
Alzheimer’s disease (AD) is a progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK
What are the risk factors for Alzheimer’s disease?
Increasing age
Family history
Inherited autosomal trait
Apoprotein E allele E4
Caucasian ethnicity
Down syndrome
What autosomal dominant traits are associated with an increased risk of Alzheimer’s disease?
Mutations in:
- The amyloid precursor protein (chromosome 21)
- Presenilin 1 (chromosome 14)
- Presenilin 2 (chromosome 1) genes
What genetic condition is associated with an increased risk of Alzheimer’s disease?
Down syndrome
What macroscopic pathological changes are seen in Alzheimer’s disease?
Widespread cerebral atrophy, particularly involving the cortex and hippocampus
What microscopic pathological changes are seen in Alzheimer’s disease?
Cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
Hyperphosphorylation of the tau protein has been linked to AD
What biochemical pathological changes are seen in Alzheimer’s disease?
There is a deficit of acetylcholine from damage to an ascending forebrain projection
What is the difference between Parkinson’s disease dementia and Lewy-body dementia?
Motor symptoms will be present before dementia symptoms for PDD.
PDD is diagnosed if a patient had a Parkinson’s disease diagnosis for at least 1 year.
What is Creutzfeldt-Jakob disease?
Creutzfeldt-Jakob disease (CJD) is rapidly progressive neurological condition caused by prion proteins.
What is the pathophysiology of Creutzfeldt-Jakob disease?
Prion proteins induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases.
What are the features of Creutzfeld-Jakob disease?
Dementia with rapid onset
Myoclonus
What would you see on imaging with an individual with Creutzfeldt-Jakob disease?
MRI - hyperintense signals in the basal ganglia and thalamus.
Hyperintense signals in the basal ganglia and thalamus of an MRI would indicate what?
Creutzfeldt-Jakob disease
What is vascular dementia?
It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease.
What is the second most common form of dementia?
Vascular dementia
What are the subtypes of vascular dementia?
Stroke-related VD
Subcortical VD
Mixed dementia
What is stroke-related VD?
Vascular dementia caused by a multi-infarct or single-infarct dementia
What is subcortical VD?
Vascular dementia caused by small vessel disease.
What is mixed dementia?
The presence of both VD and Alzheimer’s disease
What are the risk factors for vascular dementia?
History of stroke or transient ischaemic attack (TIA)
Atrial fibrillation
Hypertension
Diabetes mellitus
Hyperlipidaemia
Smoking
Obesity
Coronary heart disease
A family history of stroke or cardiovascular
In what disease would vascular dementia be inherited?
CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopath)
What is the typical presentation of vascular dementia?
Several months or several years of a history of a sudden or STEPWISE DETERIORATION of cognitive function.
What may some features of vascualr dementia be?
Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
The difficulty with attention and concentration
Seizures
Memory disturbance
Gait disturbance
Speech disturbance
Emotional disturbance
What criteria is used to diagnose vascular dementia?
NINDS-AIREN criteria
The NINDS-AIREN criteria is used for what?
For a diagnosis of vascular dementia
Outline the NINDS-AIREN criteria?
Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event
Cerebrovascular disease defined by neurological signs and/or brain imaging
A relationship between the above two disorders inferred by:
- The onset of dementia within three months following a recognised stroke
- An abrupt deterioration in cognitive functions
fluctuating, stepwise
- Progression of cognitive deficits
What is the management for for vascular dementia?
Include: cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy
What would be less severe depression according to the PHQ-9 score?
A PHQ-9 score of < 16
What would be more severe depression according to the PHQ-9 score?
A PHQ-9 score of ≥ 16
A PHQ-9 score of < 16 would indicate what?
Less severe depression
A PHQ-9 score of ≥ 16 would indicate what?
More severe depression
List the treatment options for less severe depression in order of preference by NICE?
- Guided self-help
- Group cognitive behavioural therapy (CBT)
- Group behavioural activation (BA)
- Individual CBT
- Individual BA
- Group exercise
- Group mindfulness and meditation
- Interpersonal psychotherapy (IPT)
- Selective serotonin reuptake inhibitors (SSRIs)
- Counselling
- Short-term psychodynamic psychotherapy (STPP)
List the treatment options for less severe depression in order of preference by NICE?
- A combination of individual cognitive behavioural therapy (CBT) and an antidepressant
- Individual CBT
- Individual behavioural activation (BA)
- Antidepressant medication
- Selective serotonin reuptake inhibitor (SSRI), or
- Serotonin-norepinephrine reuptake inhibitor (SNRI), or
- Another antidepressant if indicated based on previous clinical and treatment history
- Individual problem-solving
- Counselling
- Short-term psychodynamic psychotherapy (STPP)
- Interpersonal psychotherapy (IPT)
- Guided self-help
- Group exercise
Define depression?
Five (or more) of the DSM-5 symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
In which antidepressants is a direct switch possible?
Citalopram
Escitalopram
Sertraline
Paroxetine
(only when to another SSRI)
What are the rules when switching from fluoxetine to another SSRI?
Withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low dose of the alternative SSRI
In which antidepressants is a direct switch to Venlafaxine possible?
Citalopram
Escitalopram
Sertraline
Paroxetine
What are the rules when switching from an SSRI to a tricyclic antidepressant?
Cross-tapering is recommended (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
List some SSRIs?
- Citalopram (Cipramil)
- Dapoxetine (Priligy)
- Escitalopram (Cipralex)
- Fluoxetine (Prozac or Oxactin)
- Fluvoxamine (Faverin)
- Paroxetine (Seroxat)
- Sertraline (Lustral)
- Vortioxetine (Brintellix)
List some SNRIs?
- Desvenlafaxine (Pristiq, Khedezla)
- Duloxetine (Cymbalta, Irenka)
- Levomilnacipran (Fetzima)
- Milnacipran (Savella)
- Venlafaxine (Effexor XR)
What is the mechanism of action of benzodiazepines?
They enhance the activity of the inhibitory neurotransmitter GABA in the CNS.
What are the common benzodiazepines?
Diazepam (Valium) and Lorazepam, and Alprazolam (Xanax)
What is the overdose management for benzodiazepines?
Flumazenil IV
What is the mechanism of action of barbiturates?
Barbiturates act on GABA-A receptors by increasing the amount of time the chloride ion channel is opened, which increases the affinity of the receptor for GABA.
What are the common barbiturates?
Pentobarbitone and Phenobarbitone
What is the mechanism of action of opioids?
Opioids work via the endogenous opioid system by acting as a potent agonist to the μ receptor. This results in a complex cascade of intracellular signals resulting in dopamine release, blockade of pain signals, and a resulting sensation of euphoria.
What is the triad of an opioid overdose?
Pinpoint pupils
Respiratory depression
Decreased level of consciousness
What is the immediate management of an opioid overdose?
IV or IM Naloxone
Activated charcoal can be given in 3 hour window instead of 1 hour due to slowing of gastric motility by opiates
What is the mechanism of action of naloxone?
Naloxone is a competitive opioid receptor antagonist
What is the mechanism of action of amphetamines?
Amphetamines increase neurotransmission of dopamine (DA), serotonin (5-HT), and norepinephrine (NE) by entering neurons via the 5-HT and DA transporters and displacing storage vesicles.
What is the overdose management for amphetamines?
Benzodiazepines for sedation and to control seizures
Activated charcoal if within 1 hour of amphetamine ingestion
What is the overdose management for cocaine?
Benzodiazepines - These are CNS depressants and thus will counteract the effects of cocaine
What is the overdose management of paracetamol?
N-acetylcysteine
What is the overdose management for tri-cyclic antidepressants?
Sodium bicarbonate
What is the overdose management for organophosphates?
Atropine
What is the management for opioid detoxification?
Methadone or buprenorphine
What is chronic fatigue syndrome (myalgic encephalomyelitis)?
Diagnosed after at least 3 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease which may explain symptoms
What is the classical presentation of a tension headache?
Often described as a ‘tight band’ around the head or a pressure sensation.
Symptoms tend to be bilateral
What is the management for tension type headaches?
Aspirin, paracetamol or an NSAID are first-line
What type of hypersensitivity reactions are allergies?
IgE mediated therefore type 1 hypersensitivity
What are some common allergens?
House dust mite
Pollen
Mold
Foods
Drugs
Latex
Household chemicals
What are the investigations for allergies?
Clinical diagnosis first line
Skin prick testing in children - wheal >2mm is positive result
RAST testing - measures total and allergen specific IgE in blood