GP 2 Flashcards
What is otitis externa?
inflammation of the skin in the external ear canal
also known as swimmer’s ear
What are some potential causes of otitis externa?
bacterial infection
fungal infection (aspergillus or candida)
eczema
seborrhoeic dermatitis
contact dermatitis
What are the 2 most common bacterial causes of otitis externa?
pseudomonas aeruginosa
staphylococcus aureus
What are the typical symptoms of otitis externa?
ear pain
discharge
itchiness
conductive hearing loss
What signs of otitis externa can be seen on examination of the ear>
erythema and swelling of the ear canal
tenderness of the ear canal
pus or discharge in the ear canal
lymphadenopathy in the neck or around the ear
What is the management for otitis externa? mild/moderate
mild - acetic acid (can also be used prophylactically before and after swimming)
moderate - topical antibiotic and steroid e.g. neomycin, dexamethasone and acetic acid
What is malignant otitis externa?
severe and potentially life-threatening form of otitis externa where the infection spreads to the bones surrounding the ear and progresses to osteomyelitis of the temporal bone
What is psoriasis?
a chronic autoimmune condition which causes recurrent symptoms of psoriatic skin lesions with a large variety in severity of presentation
Briefly describe what patches of psoriasis look like
dry, flaky, scaly and faintly erythematous skin lesions which appear in raised and rough plaques
commonly occur over the extensor surfaces of the elbows and knees and on the scalp
What are the 4 types of psoriasis?
plaque psoriasis - MC form in adults, features thickened erythematous plaques with silver scales
guttate psoriasis - commonly occurs in children, small raised papules across the trunk and limbs which can turn into plaques, often triggered by a strep throat
pustular psoriasis - rare, severe form of psoriasis where pustules form under areas of erythematous skin, pus is non-infectious, MEDICAL EMERGENCY
erythrodermic psoriasis - rare severe form of psoriasis with extensive erythematous inflamed areas covering most of the surface area of the skin, MEDICAL EMERGENCY
WHat are 3 specific signs which suggest psoriasis?
auspitz sign - small points of bleeding when plaques are scraped off
koebner phenomenon - development of psoriatic lesions to areas of skin affected by trauma
residual pigmentation of the skin after the lesions resolve
What is the management for psoriasis?
Topical steroids
Topical vitamin D analogues (calcipotriol)
Topical dithranol
Topical calcineurin inhibitors (tacrolimus) are usually only used in adults
Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis
What is pelvic inflammatory disease/
inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix
what is salpingitis?
inflammation of the fallopian tubes
What are the causes of PID?
PID is usually associated an STI
neisseria gonorrhoea
chlamydia trachomatis
mycoplasma genitalium
less-commonly:
gardenerella vaginalis
haemophilus influenzae
E. coli
What are some risk factors for PID? x6
Not using barrier contraception
Multiple sexual partners
Younger age
Existing sexually transmitted infections
Previous pelvic inflammatory disease
Intrauterine device (e.g. copper coil)
How does PID usually present? x6
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
What are some possible findings on examination in PID? x4
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
What is the management for PID?
antibiotics depending on local and national guidelines
ceftriaxone (gonorrhoea)
doxycycline (chlamydia and mycoplasma)
metronidazole (gardnerella)
What is Fitx-hugh-curtis syndrome?
a complication of PID caused by inflammation and infection of the liver capsule (Glisson’s capsule) leading to adhesions between the liver and peritoneum
What is the definition of hypertension?
Blood pressure ≥140/90mmHg
What are the initiating factors for hypertension? (8)
DRIED ICE
- Disturbance of autoregulation
- Renal sodium retention
- Insulin resistance/hyperinsulinaemia
- Excess sodium intake
- Dysregulation of RAAS with elevated plasma renin activity
- Increased sympathetic drive
- Cell membrane transporter changes
- Endothelial dysfunction
Which medications increase blood pressure?
- NSAIDs
- SNRIs (serotonin and norepinephrine reuptake inhibitors)
- Corticosteroids
- Oral contraceptives (oestrogen containing)
- Stimulants
- Anti-anxiety drugs
- Anti-TNFs
What are the risk factors for hypertension?
- age >65yrs
- moderate/high alcohol intake
- sedentary lifestyle
- FH of hypertension of CAD
- obesity
- metabolic syndrome
- diabetes mellitus
- black ancestry
- hyperuricemia
- obstructive sleep apnoea
** Smoking is NOT a risk factor
What is the equation for BP?
BP = CO x TPR
What factors affect blood pressure?
- Preload
- Contractility
- Vessel hypertrophy
- Peripheral constriction
What are the common symptoms of hypertension?
Most often symptomless.
- headache
- visual changes
- dyspnoea
- chest pain
- sensory of motor deficit
What is the gold standard screening for hypertension?
ECG
What is the management for hypertension?
- Lifestyle modification and monitoring (increase exercise, reduce sodium intake, lose weight)
Medical treatment thresholds: low CDV risk = 160/100mmHg, high CDV risk = 140/90mmHg
- calcium channel blockers, ACEis, ARBs, diuretics, B-blockers
What is peripheral vascular disease?
A range of symptoms caused by atherosclerotic obstruction of the lower extremity arteries.
What is the most common cause of PVD?
Atherosclerosis
What are the risk factors for PVD?
- Smoking
- diabetes mellitus
- hypertension
- hyperlipidaemia
- age >40yrs
- history of CAD, CVD, sedentary lifestyle, CKD, T2DM
What are the key presentations of PVD?
Most often asymptomatic, intermittent claudication, diminished/absent pulse
What is the 1st line investigation for PVD?
Ankle-brachial index </= 0.90
What is the management for PVD?
Intermittent claudication: RF management
Chronic limb ischaemia: revascularization surgery (PCI if small, bypass if larger)
Acute limb threatening ischaemia: surgical emergency - revascularization within 4-6 hours other very high amputation risk
What are the 3 presentations of PVD?
Intermittent claudication (least severe)
Chronic critical limb ischaemia
Acute limb ischaemia
What are the 6 Ps that indicate limb-threatening ischaemia?
Pulselessness, Pallor, Pain, Persisting cold, Paralysis, Paraesthesia (the more that are present, the more limb threatening)
What are the causes of secondary hypertension?
Renal disease (MC cause)
Obesity
Pregnancy or pre-eclampsia
Endocrine (T2DM, Conn’s, Cushing’s diseases)
Drugs (alcohol, steroids, NSAIDs, oestrogen)
What is trichomoniasis
an STI with the parasite trichomonas vaginalis which lives in the urethra of men and women and the vagina
What conditions does trichomonas infection increase the risk of?
HIV
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications
What are the symptoms of trichomoniasis?
up to 50% of cases are asymptomatic
non-specific symptoms;
Vaginal discharge (frothy and yellow-green)
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
What is the characteristic appearance of the cervix in trichomonas vaginalis?
strawberry cervix where there are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry
What investigations are used to diagnosis trichomoniasis?
charcoal swab with microscopy
vaginal pH (>4.5)
urethral swab in men
What is the treatment for trichomoniasis?
metronidazole
What is tonsillitis?
inflammation of the tonsils (typically the palatine tonsils) which can occur due to viral or bacterial infection
What are the most common bacterial causes of tonsillitis?
group A streptococcus (MC)
streptococcus pneumoniae
haemophilus influenzae
moraxella catarrhalis
staphylococcus aureus
What are the symptoms of tonsillitis? x3
sore throat
fever >38
pain on swallowing
What is seen on examination of patients with tonsillitis>
red, inflamed and enlarged tonsils
+/- exudates
anterior cervical lymphadenopathy (swollen, tender lymph nodes in the anterior triangle of the neck)
What are the centor criteria for bacterial tonsillitis?
Fever >38
tonsillar exudates
absence of cough
tendor anterior cervical lymph nodes
3+ score = 40-60 % probability of bacterial tonsillitis and its appropriate to offer antibiotics
What is the treatment for tonsillitis?
viral is self-resolving
bacterial - 10 day course of penicillin V with relatively narrow spectrum of activity, effective against strep myogenes
What are some potential complications of tonsillitis? x6
peritonsillar abscess (quinsy)
otitis media
scarlet fever
rheumatic fever
post-strep glomerulonephritis
post-strep reactive arthritis
What is lyme disease?
a disease caused by infection with borrelia burgdorferi and the body’s immune response to this infection
How is lyme disease transmitted?
The b.burgdorferi spirochaete bacteria which causes lyme disease is carried by deer ticks which can attach to humans resulting in lyme disease
What are the stages of Lyme disease infection?
- Early/localised Lyme disease
- circular, target-like rash which radiates from the site of the tick bite, known as erythema migrans
- usually appears within 3-36 days - Disseminated Lyme disease
- flu-like illness which can include symptoms like joint and muscle pains, headache, fever, tiredness, nausea or vomiting
- neurological disorders e.g. meningism, facial nerve palsies, mild encephalitis
- occurs days to months later - Late manifestations of Lyme disease
- arthritis
- acrodermatitis chronica atrophicans
- late neurological disorders e.g. polyneuropathy, chronic encephalomyelitis, vertigo and psychosis
- chronic Lyme disease and ‘post-Lyme syndrome’ (similar to CFS or fibromyalgia)
What are the investigations for Lyme disease?
It is difficult to make a diagnosis clinically
Patients with erythema migrans should be diagnosed and treated for Lyme disease based on clinical assessment without lab testing (at this point there is a high chance that the antibody test will be negative due to the time that it takes for the antibody response to develop)
If Lyme disease is suspected in people without erythema migrans, offer an enzyme-linked immunosorbent assay (ELISA) test for Lyme disease
IF the ELISA test is positive or equivocal, perform an immunoblot test for Lyme disease
What is the management for Lyme disease?
Treat with oral antibiotic for 2-3 weeks:
Doxycycline or amoxicillin
to treat later complications:
High dose IV benzylpenicillin, ceftriaxone
What is the definition of menopause? what is the average age at which it occurs?
a permanent end to menstruation which is confirmed after a woman has has no periods for 12 months
usually occurs around the age of 51
What is the perimenopausal period
the time around the menopause where the woman may be experiencing vasomotor symptoms and irregular periods
this includes the time leading up to the last menstrual period and the 12 months afterwards
typically in women older than 45 yrs
What is the definition of premature menopause and what causes it?
menopause before the age of 40 years which results from premature ovarian insufficiency
Briefly describe the physiology of menopause
menopause is caused by a decline in the development of the ovarian follicles which results in reduced oestrogen production
oestrogen has a negative feedback effect on the pituitary gland, suppressing the quantity of LH and FSH produced
as the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH
the failing follicular development means that ovulation does not occur, resulting in irregular menstrual cycles
without oestrogen, the endometrium does not develop, leading to a lack of menstruation
lower levels of oestrogen also cause the perimenopausal symptoms
What are the perimenopausal symptoms x8
hot flushes
emotional lability or low mood
premenstrual syndrome
irregular periods
joint pains
heavier or lighter periods
vaginal dryness and atrophy
reduce libido
Which conditions do women have an increased risk of following menopause due to lack of oestrogen ?
cardiovascular disease and stroke
osteoporosis
pelvic organ prolapse
urinary incontinence
How long do women need to use effective contraception for following their last menstrual period?
2 years after in women under 50
1 year after in women over 50
What are the management options for perimenopausal symptoms?
vasomotor symptoms are likely to resolve after 2-5 years without any treatment
options:
- no treatment
- HRT (most effective in treating hot flushes/night sweats, mood swings and vaginal/bladder symptoms)
- Tibolone (synthetic steroid hormone which acts as continuous combined HRT)
- Clonidine
- CBT
- SSRI antidepressants
- Testosterone to treat reduced libido
- Vaginal oestrogen cream or tablets to treat dryness and atrophy
- Vaginal moisturisers (Sylk, replens, YES)
What is mumps?
a viral infection which is spread by respiratory droplets and usually resolves without treatment after around a week
What are the symptoms and signs of mumps?
initial period of flu-like symptoms followed by painful parotid swelling which is associated with:
fever
muscle aches
lethargy
reduced appetite
headache
dry mouth
What are some potential complications of mumps and their symptoms x4
pancreatitis
orchitis
meningitis or encephalitis
sensorineural hearing loss
What are the investigations/management options for mumps
diagnosis can be confirmed using PCR saliva testing
antibody testing of blood or saliva can also be used to confirm diagnosis
NOTIFIABLE DISEASE
self-limiting condition so management is supportive with rest, fluids and analgesia
What is influenza and what are the types?
an RNA virus which has 3 variants: A, B and C which affect humans
Type A has different H and N subtypes and examples of the strains are H1N1 which caused the spanish flu pandemic
What are the typical presenting features of influenza? x8
fever
lethargy and fatigue
anorexia
muscle and joint aches
headache
dry cough
sore throat
coryzal symptoms
What are 3 things which help distinguish flu from the common cold?
flu tends to have an abrupt onset, whereas common cold is more gradual
fever is a typical feature of the flu but rare with a common cold
people with flu are wiped out with muscle aches and lethargy which is uncommon with a cold
WHat tests can be used to confirm influenza infection?
POC swab tests which detect viral antigens
Viral nasal or throat swabs for PCR testing
What is the management for influenza
usually self-resolving with supportive care measures (rest and fluid intake)
for people at risk of complications:
oral oseltamivir
inhaled zanamivir
What are some potential complications of influenza? x6
Otitis media, sinusitis and bronchitis
Viral pneumonia
Secondary bacteria pneumonia
Worsening chronic health conditions, such as COPD and heart failure
Febrile convulsions (young children)
Encephalitis
What is infectious mononucleosis/glandular fever?
a condition caused by infection with Epstein Barr virus (EBV)
commonly known as the kissing disease or mono
What are the key symptoms of glandular fever?
fever
sore throat
fatigue
lymphadenopathy
tonsillar enlargement
splenomegaly and in rare cases splenic rupture
What tests are used to diagnose glandular fever
Test for heterophile antibodies (multipurpose antibodies produced in response to but not specific to EBV antigens), almost 100% specific for IM but only 70-80% sensitive
- Monospot test - introduces pt’s blood to horse’s RBCs
- Paul-Bunnell test - like the monospot but uses sheep RBCs
Can also test for specific EBV antibodies which target viral capsid antigen:
- IgM antibody rises early and suggests acute infection
- IgG persists after the condition and suggests immunity
What is the management for glandular fever
usually self-limiting and lasts around 2-3 months
fatigue can last for several months once infection is cleared
avoid alcohol and sports (risk of splenic rupture)
WHat are the potential complications of glandular fever? x5
splenic rupture
glomerulonephritis
haemolytic anaemia
thrombocytopenia
chronic fatigue
What are the key symptoms of UTIs?
dysuria
suprapubic pain or discomfort
frequency
urgency
incontinence
haematuria
cloudy or foul-smelling urine
confusion (in old/frail patients)
What is the additional triad symptoms seen in pyelonephritis?
fever
loin or back pain
nausea or vomiting
may also have:
systemic illness
loss of appetite
haematuria
renal angle tenderness on examination
What are the bacteria which commonly cause UTIs?
Escherichia coli (gram-negative, anaerobic, rod-shaped bacteria)
Klebsiella pneumoniae (gram-negative, anaerobic, rod-shaped)
enterococcus
pseudomonas aeruginosa
staph saprophyticus
What are the important factors on MSU and what do they indicate?
Nitrites - suggestive of bacteria in the urine as they break down nitrates to nitrites
Leukocytes - significant rise can indicate infection or other cause of inflammation
Nitrites are a better indication of infection than leukocuytes
If both are present or nitrites are present the patient should be treated as a UTI but not if only leukocytes are present
What are some signs which indicate an atypical UTI?
- seriously ill or septicaemia
- poor urine flow
- abdominal or bladder mass
- raised creatinine
- failure to respond to suitable antibiotics within 48
hours - infection with atypical (non-E. coli) organisms.
Which antibiotics are used to treat UTIs?
nitrofurantoin
trimethoprim
How is pyelonephritis managed?
referral to hospital is required if there are features of sepsis
cefalexin, co-amox, trimethoprim or ciprofloxacin antibiotics
What are the antibiotic options for treating UTIs in pregnant women?
nitrofurantoin (avoid in the 3rd trimester due to risk of neonatal haemolysis)
amoxicillin (only after sensitivities are known)
cefalexin (typical choice)
trimethoprim should be avoided due to folate antagonistic properties
what is urticaria? what causes it and what is it associated with?
Urticaria is hives i.e. small itchy lumps that appear on the skin.
They may be associated with angioedema (swelling of the deeper layers of the skin, caused by a build-up of fluid.) and flushing of the skin
Urticaria are caused by the release of histamine and other pro-inflammatory chemicals by mast cells in the skin.
Most common form is spontaneous urticaria which can be acute (<6 weeks) or chronic (>6 weeks)
What are varicose veins?
distended superficial veins which measure >3mm in diameter usually affecting the legs
How do varicose veins develop?
when the valves in veins become incompetent they can’t carry out their function of preventing blood being drawn downwards by gravity and pooling in the veins
the deep and superficial veins are connected by vessels called the perforating veins which allow blood to flow from the superficial veins to the deep veins
when the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them
this leads to dilatation and engorgement of the superficial veins, forming varicose veins
What happens in chronic venous insufficiency?
blood pools in the distal veins and pressure builds up causing the veins to leak small amounts of blood into the tissues nearby
the haemoglobin in this leaked blood breaks down to haemosiderin which is deposited around the shins in the legs giving them a brown discolouration
pooling of blood in the distal tissues results in inflammation and the skin becoming dry and inflamed –> venous eczema
the skin and soft tissues become fibrotic and tight, causing the lower legs to become narrow and hard, referred to as lipdermatosclerosis
What are the risk factors for varicose veins? x7
increasing age
family history
female
pregnancy
obesity
prolonged standing
deep vein thrombosis
What are some symptoms of varicose veins? x7
heavy or dragging sensation in the legs
aching
itching
burning
oedema
muscle cramps
restless legs
What are the special tests for varicose veins?
tap test (apply pressure at the SFJ and tap the distal varicose vein –> thrill?)
cough test (apply pressure to the SFJ while patient coughs –> thrill?)
trendelenburg’s test - lift affected leg to drain the veins then apply a tourniquet to thigh and get the patient to stand - the tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve, reassess at different levels to identify the location of the incompetent valves
perthes test
What is the management for varicose veins?
weight loss
staying physically active
keeping the leg elevated when possible to help drainage
compression stockings
surgical options:
endothermal ablation (catheter insertion and radiofrequency ablation)
sclerotherapy (irritant foam injection to close the vein)
stripping (veins are ligated and pulled out of the leg)
What happens in a vasovagal episode?
the vagus nerve receives a strong stimulus e.g. an emotional event, painful sensation or change in temperature and stimulates the parasympathetic nervous system
parasympathetic activation counteracts the sympathetic nervous system which keeps the smooth muscle in blood vessels constricted
as the blood vessels delivering blood to the brain relax, the blood pressure in the cerebral circulation drops, leading to hypoperfusion of the brain tissue
this causes the patient to lose consciousness and ‘faint’
What are venous ulcers?
wounds or breaks in the skin which occur due to the pooling of blood and waste products in the kin secondary to venous insufficiency
What are the typical features of venous ulcers which differentiate them from arterial ulcers?
occur in the gaiter area (between the top of the foot and bottom of the calf muscle)
are associated with chronic venous changes, e.g. hyperpigmentation, venous eczema and lipodermatosclerosis
occur after a minor injury to the leg
are larger and more superficial than arterial ulcers
have irregular, gently sloping borders
high chance of bleeding
pain relieved by elevation and worse on lowering the leg
How are venous ulcers managed?
wound care (cleaning, debridement, dressing)
compression therapy
antibiotics for infection
analgesia for pain
What is peripheral arterial disease?
the narrowing of arteries supplying the limbs and peripheries, reducing blood flow to these areas
What is intermittent claudication?
a symptom of ischaemia in a limb, occurring during exertion and relieved by rest
typically a crampy, achy pain in the calf, thigh or buttock muscles associated with muscle fatigue when walking beyond a certain intensity
What are the features of acute limb ischaemia? 6P’s
Pain
Pallor
Pulseless
Paralysis
Paraesthesia
Perishing cold
What is Leriche syndrome?
occlusion in the distal aorta or proximal common iliac artery which presents with a clinical triad of:
- thigh/buttock claudication
- absent femoral pulses
- male impotence
What are some signs of arterial disease seen on inspection?
skin pallor
cyanosis
dependent rubor (deep red colour when the limb is lower than the rest of the body)
muscle wasting
hair loss
ulcers
poor wound healing
gangrene
What is Buerger’s test?
with patient lying supine, lift their legs to 45 degree angle and hold them for 1-2 mins, looking for pallor
then gt the patient to sit up with their legs hanging over the edge of the bed
in PAD the legs, rather than turning pink, will go initially blue and then dark red (rubor)
What are the investigations for peripheral arterial disease?
Ankle-brachial pressure index (ABPI)
Duplex USS
Angiography
What is the ankle-brachial pressure index?
the ratio of systolic blood pressure in the ankle compared with the systolic blood pressure in the arm
0.9-1.3 is normal
0.6 – 0.9 indicates mild peripheral arterial disease
0.3 – 0.6 indicates moderate to severe peripheral arterial disease
Less than 0.3 indicates severe disease to critical ischaemic
How is intermittent claudication managed?
lifestyle changes
exercise training (programme of regularly walking to the point of near-maximal claudication and pain, then resting and repeating)
atorvastatin, clopidogrel, naftidrofuryl oxalate (peripheral vasodilator)
endovascular angioplasty and stenting, endarterectomy, bypass surgery
What is critical limb ischaemia and how is it managed?
the end-stage of PAD, where there is an inadequate supply of blood to a limb to allow it to function normally at rest
medical emergency requiring urgent referral to the vascular team
urgent revascularisation is needed via:
Endovascular angioplasty and stenting
Endarterectomy
Bypass surgery
Amputation of the limb if it is not possible to restore the blood supply
What is acute limb ischaemia and how is it managed?
refers to a rapid onset of ischaemia in a limb, typically due to a thrombus
management options:
Endovascular thrombolysis or thrombectomy
surgical thrombectomy
endarterectomy
bypass surgery
amputation of the limb if impossible to restore the blood supply
What are the risk factors for atherosclerosis/PAD?
Non-modifiable
- older age
- family history
- male
Modifiable
- smoking
- alcohol consumption
- poor diet
- low exercise/sedentary lifestyle
- obesity
- poor sleep
- stress
What is rhinosinusitis
inflammation of the paranasal sinuses in the face (sinusitis) combined with inflammation of the nasal cavity (rhinitis)
can be acute (<12 wks) or chronic (>12 wks)
What are some potential causes of rhinosinusitis? x4
infection
allergies
obstruction of drainage e.g. foreign body, trauma or polyps
smoking
What are the symptoms associated with rhinosinusitis? x6
nasal congestion
nasal discharge
facial pain or headache
facial pressure
facial swelling over the affected areas
loss of smell
What is the management for rhinosinusitis>
Patients with systemic infection or sepsis require admission to hospital for emergency management.
NICE recommend not offering antibiotics to patients with symptoms for up to 10 days. Most cases are caused by a viral infection and resolve within 2-3 weeks.
NICE recommend for patients with symptoms that are not improving after 10 days, the options of:
High dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily)
A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line)
What are viral exanthema?
eruptive widespread rashes
originally there were 6 viral exanthema which have now been renamed:
First disease: Measles
Second disease: Scarlet Fever
Third disease: Rubella (AKA German Measles)
Fourth disease: Dukes’ Disease
Fifth disease: Parvovirus B19
Sixth disease: Roseola Infantum
What are warts>
non-cancerous viral skin growths which affect the squamous epithelium and usually occur on the hands and feet but can also affect the genitals or face
they are caused by the human papillomavirus
What is the treatment for warts?
salicyclic acid, or cryotherapy
What are dermatophytosis infections? how are they classified
also known as ringworm/tinea infections, they are fungal infections caused by dermatophytes - a group of fungi which invade and grow in dead keratin
they tend to grow outwards on skin, producing a ring-like pattern which gave them the name ringworm
classified according to site:
scalp - tinea capitis
feet - tinea pedis
nail - onychomycosis
groin - tinea cruris
body - tinea corporis
How does ringworm/dermatophysis present?
itchy rash which is erythematous, scaly and well-demarcated
tinea capitis - hair loss in a demarcated region plus itching dryness and scalp erythema
tinea pedis (athlete’s foot) - white or red, flaky, cracked, itchy patches between the toes
onychomycosis - thickened, discoloured and deformed nails
What is the management for ringworm/dermatophysis>
usually clinical supported by good response to antifungal meds
antifungal creams e.g. clotrimazole and miconazole
antifungal shampoo eg. ketoconazole
antifungal oral meds e.g. fluconazole, griseofulvin and itraconazole
What is contact dermatitis?
an inflammatory process of the skin that occurs in response to contact with exogenous substances and involves pruritic and erythematous patches
What are the 2 types of contact dermatitis/
Allergic contact dermatitis - a type IV delayed hypersensitivity reaction. It occurs after sensitisation and subsequent re-exposure to an allergen.
Irritant contact dermatitis - an inflammatory response that occurs after damage to the skin, usually by chemicals. This is not an allergy and can occur in any individual significantly exposed to an irritant. This may be acute or chronic/cumulative.
What are the signs/symptoms of contact dermatitis?
skin redness
vesicles or papules over the affected area
crusting and scaling of skin
itching of an affected area
fissures
hyperpigmentation
pain or burning sensation from an affected area
What is the treatment for contact dermatitis?
identify and avoid the irritant
protect skin with protective equipment and creams
more severe or chronic forms can benefit from topical corticosteroid cream
What is herpes simplex virus?
a virus causing cold sores and genital herpes which can become latent after initial infection in the associated sensory nerve ganglia
2 main strains, HSV-1 (most associated with cold sores) and HSV-2 (typically causes genital herpes)
it is spread through direct contact with affected mucous membranes or viral shedding in mucous secretions
What is the usual disease pathway of HSV-1?
often contracted initially in childhood (before 5 years) and remains dormant in the trigeminal nerve ganglion and reactivates as cold sores, particularly in times of stress
genital herpes caused by HSV-1 is usually contracted through oro-genital sex, where the virus spreads from a person with an oral infection to the person that develops a genital infection `
What are the signs and symptoms of genital herpes?
can be asymptomatic
ulcers or blistering lesions
neuropathic type pain
flu-like symptoms
dysuria
inguinal lymphadenopathy
What is the management for genital herpes?
aciclovir + supportive measures e.g. analgesia, fluids, loose clothing
What is folliculitis?
inflammation of the hair follicles of the skin which can occur for a variety of reasons
can be acute or chronic
What are the specific types of folliculitis?
sycosis barbae - chronic folliculitis in the beard area of the face where the skin is painful and crusted with burning and itching on shaving, numerous pustules develop in the hair follicles
hot tub folliculitis - caused by pseudomonas aeruginosa
gram-negative folliculitis - can occur after acne has been treated with long-term antibiotics
pseudo-folliculitis - razor bumps caused by inflammation from shaving and ingrown hairs
what are the most common causes of CKD?
diabetes (mc)
hypertension
What are the signs of CKD?
hypertension
fluid overload
uraemic sallow: yellow or pale brown colour of skin
uraemic frost: urea crystals can deposit in the skin
pallor
evidence of underlying cause
What are the symptoms of CKD?
pruritis
loss of appetite
nausea
oedema
muscle cramps
What are the investigations for CKD?
- estimated GFR - can be checked with U+E bloods, 2 tests required 3 months apart
- proteinuria, checked using a urine albumin:creatinine ration
- haematuria - checked using a urine dipstick
- renal USS
What is the G score in CKD staging?
G1: eGFR>90
G2: eGFR: 60-89
G3a: eGFR: 45-59
G3b: eGFR: 30-44
G4: eGFR: 15-29
G5: eGFR<15 known as end-stage renal failure
What is the A score in CKD staging?
Based off the albumin:creatinine ratio:
A1: <3
A2: 3-30
A3: >30
What is the management for CKD?
Slowing the progression of the disease
Optimise diabetic control
Optimise hypertensive control
Treat glomerulonephritis
Reducing the risk of complications
Exercise, maintain a healthy weight and stop smoking
Special dietary advice about phosphate, sodium, potassium and water intake
Offer atorvastatin 20mg for primary prevention of cardiovascular disease
What are some potential complications of CKD?
Renal bone disease
Anaemia
Cardiovascular- hypertension, hypercholesterolemia , heart failure due to fluid overload and anaemia
Define what a Supraventricular Tachycardia is. What are the 4 types? What is the most common?
Any tachycardia which arises from the atrium or AV junction
Atrial fibrillation
Atrial flutter
AV nodal re-entry tachycardia (AVNRT) (MC)
AV reciprocating tachycardia (AVRT)
Supraventricular Tachycardias - What is atrial flutter? What things characterise it?
It is irregular ORGANSIED atrial firing, around 250 - 300BPM (conduction pathway typically from around opening of tricuspid valve)
Often associated with AF
Atrial HR = 300 BPM
Ventricular rate = 150/100/75 BPM (due to AV node conducting every 2nd/3rd/4th beat “flutter beat” , so see at least 2 P waves for every QRS complex - but QRS complexes will be regular
ECG - see flutter waves, which are a saw-tooth pattern of atrial activation, most prominent in leads II, III, aVF, and V1
Supraventricular Tachycardias - Name some causes of atrial flutter
- Idiopathic (30%)
- Coronary heart disease
- Thyrotoxicosis
- COPD
- Pericarditis
- Acute excess alcohol intoxication
Supraventricular Tachycardias - Outline the pathophysiology behind atrial flutter.
It is caused by the electrical signal re-entering/ re-circulating back into the atrium, due to an extra electrical pathway
It goes round and round, without interruption, so Atrial contraction is at 300bpm
The signal makes its way into the ventricles every second lap due to the long refractory period to the AV node, causing 150 bpm ventricular contraction.
Can be sudden and brief in episodes, or on going
Supraventricular Tachycardias - what would you see on an ECG that would indicate Atrial flutter?
ECG: regular sawtooth-like atrial flutter waves (F waves) with P-wave after P-wave
Supraventricular Tachycardias - what is the management of atrial flutter?
- Treat the reversible underlying condition (e.g. hypertension or thyrotoxicosis)
- Rate/rhythm controlwith beta blockers or cardioversion (use of electric shock to put heart back into rhythm)
- Radiofrequency ablationof the re-entrant rhythm (Uses heat generated by radio waves to destroy tissue)
- Anticoagulationbased on CHA2DS2VASc score
Supraventricular Tachycardias - What characterises AV nodal re-entry tachycardia (AVNRT)?
Most common type of SVT - AV nodal re-entry tachycardia (AVNRT)
Twice as common in women than men
The electrical conduction of the atrium re enters back through the AV node, Due to the presence of a “ring” of conducting pathways in the AV node, of which the “limbs” have different conduction times and refractory periods
This allows a re-entry circuit and an impulse to produce a circus movement tachycardia
Supraventricular Tachycardias - what is the are the key presentations of someone with AV nodal re-entry tachycardia/AV reciprocating Tachycardia?
(What’s the slightly rogue one)
Presentation
Regular rapid palpitations – abrupt onset and sudden termination
Neck pulsation – JV pulsations
Polyuria – due to release of ANP in response to increased atrial pressure during tachycardia
Chest pain and SOB
Symptoms
Palpitations
Dizziness
Dyspnoea
Central chest pain
Syncope
Supraventricular Tachycardias - What is AV reciprocating tachycardia? What is the best known type of this?
The eletrical signals goes back in the atria via an accessory pathway.
The best known type of this is Wolff-Parkinson-White Syndrome, there is an accessory pathway (bundle of kent) between atria and ventricles
Supraventricular Tachycardias - What would you see on an ECG of someone with AV Nodal re-entry tachycardia?
P waves are either not visible, or are seen immediately before or after the QRS complex (short PR interval)
QRS complex is a normal shape because the ventricles are activated in the normal way (down bundle of His)
Supraventricular Tachycardias - what would you see on an ECG for AV Nodal Reciprocating Tachycardia? (WPW syndrome)
The early depolarisation of part of the ventricle leads:
- shortened PR interval
- slurred start to the QRS (delta wave)
- QRS is narrow
Patients are also prone to atrial and occasionally ventricular fibrillation
Supraventricular Tachycardias - What is the initial management of AV Nodal re-entry tachycardia and AV Reciprocating tachycardia?
Breath-holding
Carotid massage - massage the carotid on one side gently with two fingers.
Valsalva manoeuvre - Pt blows hard into resistance
Supraventricular Tachycardias - if carotid massage and Valsalva manoeuvre are unsuccessful, what can you give to treat AVNRT and AVRT?
If manoeuvres unsuccessful, IV adenosine
Causes a complete heart block for a fraction of a second
Effective at terminating AVNRT and AVRT
Supraventricular Tachycardias - What is Atrial fibrilation?
Atrial fibrillation is where the contraction of the atria is uncoordinated, rapid and irregular. This is due to disorganised electrical activity that overrides the normal, organised activity from the sinoatrial node.
This disorganised electrical activity in the atria also leads to irregular conduction of electrical impulses to the ventricles.
What does atrial fibrillation lead to?
- Irregularly irregularventricular contractions
- Tachycardia
- Heart failuredue topoor fillingof the ventricles duringdiastole
- Risk ofstroke
What are some common causes of atrial fibrillation?
PE/COPD
IHD, Heart failure
Rheumatic heart disease, Valve abnormalities
Alcohol intake
Thyroid issues - Hyperthyroidism
Sleep Apnoea
Electrolyte disturbances - Hyper/Hypo Kalaemia, Hypo magnesia
PIRATE
What are some signs and symptoms of AF?
- Irregular irregular pulse
- Hypotension:red flag; suggest haemodynamic instability
- Evidence of heart failure: red flag; such as pulmonary oedema
- Palpitations
- Dyspnoea
- Chest pain: red flag
- Syncope: red flag
Can also be asymptomatic!
What investigations would you carry out for AF
ECG
Tests to look for causes of AF:
Serum Electrolytes
Thyroid Function Tests
Cardiac biomarker - eg Troponin
Chest x-ray look for heart failure
Transthorasic Echo - look for functional heart disease
What is the management for someone who is haemodynamically unstable with AF? What signs could indicate that this is the case?
Emergency electrical synchronised DC cardioversion
- Shock: hypotension (systolic blood pressure <90 mm Hg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
- Syncope
- Myocardial ischaemia
- Heart failure:
What is the first line management for someone who is haemodynamically stable with AF? What signs could indicate that this is the case? What Rate control would you do?
Start by controlling either rate of rhythm
Rate control:
- First line: beta-blocker (e.g. bisoprolol) or arate-limiting calcium-channel blocker (e.g. verapamil)
- Digoxin: may be considered first-line in patients with AF and heart failure
OF HAEMODYNAICALLY STABLE, DO RATE CONTROL BEFORE RHYTHM CONTROL
What Further management might be necessary for persistent AF/ or AF that has not been treated with meds
Left atrial ablation - small burns/freezes to scar heart tissue to break up electrical signals that cause irregular heartbeats
Electrical DC cardioversion
Anticoagulants - DOACS - Apixaban to reduce risk of strokes, or Warafarin if DOACs are CI, (aka in Metal heart valves)
Anticoagulants are often given to patient with AF to reduced their likelihood of developing clots that can cause strokes.
What scoring system is used to calculate stroke risk in AF? What types of factors are included on it?
CHADS2VASc score used to calculate stroke risk in AF
0 = no anticoagulation
1 = consider oral anticoagulation or aspirin
2 = Anticoagulants - DOACS - Apixaban to reduce risk of strokes
Congestive Heart failure = 1
Hypertension = 1
Age > 75 = 2
Age 65-74 = 1
Diabetes Mellitus = 1
Stroke or TIA = 2
Vascular disease = 1
Female sex = 1
What would you see on an ECG for someone in AF?
Irregularly irregular
F (Fibrillatory) waves
No clear P waves
Rapid QRS complex
absence of [isoelectric]
baseline
variable ventricular rate
What Rhythm control would you do in AF?
Rhythm control: - either pharmacological or electrical cardioversion
- Pharmacological: - anti-arrhythmics
- Flecainide or amiodarone: if no evidence of structural/ischaemic heart disease
- Amiodarone: if structural/ischaemic heart disease is present
- Electrical cardioversion:rapidly shock the heart back into sinus rhythm
IF HAEMODYNAICALLY UNSTABLE, DO RHYTHM CONTROL BEFORE RATE CONTROL (aka Cardioveresion)
What is a Delta wave? Why does it occur?
“ A delta wave is slurring of the upstroke of the QRS complex.
Occurs because the action potential from the SA node is able to conduct to the ventricles very quickly through the accessory pathway
=> QRS occurs immediately after the P wave, making the delta wave.
Define obesity
Abnormal or excessive fat accumulation which poses a risk to health.
BMI > 30.
What are some potential consequences of obesity ?
- Type II Diabetes
- Hypertension
- Coronary artery disease
- Stroke
- Osteoarthritis
- Gout
- Obstructive sleep apnoea
- Carcinoma (breast, endometrium, colon, prostate)
What are 5 risk factors for obesity
- Hypothyroidism
- Hypercortisolism
- Corticosteroid therapy
- Diet high in sugar and fats
- High alcohol intake
What is leptin and its action?
A hormone released by adipocytes which switches off appetite and stimulates the immune system. Leptin levels in the blood increase after eating and decrease after fasting.
What is ghrelin and its action?
A hormone released by endocrine cells of the stomach which stimulates growth hormone release and appetite. Blood levels are high when fasting and fall after eating.
What is the action of insulin?
- suppresses hepatic glucose output (decreases glycogenolysis and gluconeogenesis)
- increases glucose uptake into muscle and fat
- suppresses lipolysis and muscle breakdown
What is the action of glucagon?
- increases hepatic glucose output (increases glycogenolysis and gluconeogenesis)
- reduce peripheral glucose uptake
- stimulate peripheral release of gluconeogenic precursors (glycerol, AAs) - increases lipolysis and muscle breakdown
What is Type I diabetes?
An insulin deficiency disease characterised by loss of beta cells due to autoimmune destruction.
What are the risk factors for T1 Diabetes?
- HLA DR3 and DR4 and islet cell antibodies
- Other autoimmune diseases
- Environmental infections (e.g. viruses)
What is diabetes mellitus?
A disorder of carbohydrate metabolism characterised by hyperglycaemia.
How does DM cause morbidity and mortality?
- Acute hyperglycaemia (leads to diabetic ketoacidosis and hyperosmolar hyperglycaemic state if untreated)
- Chronic hyperglycaemia leading to tissue complications
- Side effects of treatment - hypoglycaemia
What random plasma glucose level with symptoms indicates diabetes mellitus?
> 11mmol/l
What fasting plasma glucose value indicates diabetes mellitus?
> 7mmol/l
What is GTT and what are the fasting and 2hr values that indicate diabetes mellitus?
GTT = Glucose tolerance test
GTT (75g glucose) fasting > 7mmol/l
or 2hr value >11mmol/l (repeated on 2 occasions)
What is HbA1c and what value is associated with diabetes mellitus?
HbA1c = glycated haemoglobin, a form of haemoglobin used to measure the average haemoglobin-associated glucose in blood over the last three months, HbA1c >48mmol/mol (6.5%) is seen in patients with diabetes mellitus
What is the cause of Type I diabetes?
Beta cells express HLA (human leukocyte antigen) which activates a chronic cell mediated immune process leading to chronic ‘insulitis’ and consequently insulin insufficiency
What is the typical presentation/symptoms of Type I DM?
Young lean pt
- polydipsia
- nocturia/polyuria
- glycosuria
- polyphagia (excessive eating) + weight loss
- excessive tiredness
What is the treatment for T1DM?
Basal Bolus Insulin
- basal = longer acting to maintain stable insulin levels throughout day
- bolus = faster acting, 30 mins preprandial to give “insulin spike”
What are the risk factors for T2DM?
genetic link, smoking, obesity, sedentary lifestyle
What is the pathophysiology of T2DM?
Peripheral insulin resistance (e.g. malfunctional insulin intracellular activation pathway) leads to decrease GLUT4 receptor expression + minor destruction of pancreatic islets.
This results in hyperglycaemia with increased insulin demand from depleted beta cell population.
What is the typical presentation and symptoms of T2DM?
Obese, hypertensive, older patient
- persistant hyperglycaemia
- polydypsia
- nocturia + polyuria
- glycosuria
- blurred vision
- recurrent infections
- tiredness
- acanthosis nigiricans (dark pigmentation of skin folds) suggesting insulin resistance
What are IGT and IFG?
IGT = Impaired Glucose Tolerance
IFG = Impaired Fasting Glycaemia
Conditions of slightly elevated blood glucose but not high enough to be classed as diabetic so are called prediabetic states
What is the treatment for T2DM?
- Lifestyle changes (weight loss, exercise, diet changes)
- medications to control BP, blood glucose + lipids
- Metformin (1st line)
- DPP-IV inhibitors (vildagliptin, sitagliptin)
- GLP analogues (exenatide, liraglutide)
- SGLT-2 inhibitors (empagliflozin, canagliflozin)
- Sulphonylureas (gliclazide, glibenclamide)
- Thiazolidinediones (pioglitazone)
What are the actions of sulphonylureas?
- Stimulate insulin release by binding to beta-cell receptors
- improve glycaemic control at the expense of significant weight gain
*risk of hypoglycaemia
What are the actions of thiazolinediones?
- Bind to the nuclear receptor PPARy and activate genes concerned with glucose uptake and utilisation and lipid metabolism
- improve insulin sensitivity
- need insulin for therapeutic effect
What is the action of metformin?
improves action of insulin in reducing blood glucose
What is the action of GLP-1 analogues?
They extend the duration of GLP-1 which is a gut hormone that stimulates insulin release and reduces appetite. GLP-1 analogues extend the duration of GLP-1 action and so lower blood glucose and help to reduce weight and cardiovascular disease.
What is the action of DPP-IV inhibitors?
DPP-IV is an enzyme which destroys incretin, a hormone which helps the body reduce blood glucose. DPP-IV inhibitors stop the destruction of incretin and so help lower blood glucose however the effect is not highly significant and has no effect on CVD or weight.
What is the action of SGLT2 inhibitors?
They inhibit the sodium glucose transporters in the renal proximal tubules, blocking the reabsorption of glucose and so increasing glucose excretion and lowering blood glucose levels.
Define hypothyroidism
Abnormally low thyroid hormone levels
What is the physiological cause of primary hypothyroidism?
Absence/dysfunction of thyroid gland
What condition is the cause of most cases of primary hypothyroidism?
Hashimoto’s thyroiditis
What are the physiological causes of secondary and tertiary hypothyroidism?
Secondary - pituitary disfunction
Tertiary - hypothalamic dysfunction
What are the causes of primary hypothyroidism?
- Hashimoto’s thyroiditis
- ^(131)I therapy
- Thyroidectomy
- Postpartum thyroiditis
- Thyroiditis
- Drugs
- Iodine deficiency
- Thyroid hormone resistance
Which drugs can cause hypothyroidism?
- Iodine (inorganic or organic)
- Iodide
- Iodinated contrast agents
- Amiodarone
- Lithium
- Thionamides
- Interferon-a
What are the causes of hypothyroidism in children/neonates?
- Thyroid agenesis
- Thyroid ectopia
- Thyroid dishormonogenesis
- Resistance to thyroid hormone
- Isolated TSH deficiency
What are the clinical features of hypothyroidism?
- Fatigue
- Weight gain
- cold intolerance
- Constipation
- Menstrual disturbance
- muscle cramps
- Slow cerebration (thinking)
- Dry, rough skin
- Periorbital oedema
- Carotenaemia
- Oedema
What are the investigations for primary hypothyroidism?
Elevated TSH and usually low free T4 and T3
What are the investigations for secondary/tertiary hypothyroidism?
TSH inappropriately low for reduced free T4/T3 levels
What is the treatment of choice for hypothyroidism?
Synthetic Levothyroxine (T4)
- in primary dose is titrated until TSH normalises
- in secondary T4 is monitored as TSH will remain low
What are the stages of hypertension?
1 - Clinic blood pressure from 140/90 to 159/99 mmHg or average HBPM from 135/85 to 149/95 mmHg
2 - Clinic BP ≥160/100 but <180/120 mmHg and HBPM average ≥150/95
3 - Clinic systolic BP ≥180 mmHg or clinic diastolic BP ≥120 mmHg
What are some potential causes of otitis externa?
bacterial infection
fungal infection (aspergillus or candida)
eczema
seborrhoeic dermatitis
contact dermatitis
What are the 2 most common bacterial causes of otitis externa?
pseudomonas aeruginosa
staphylococcus aureus
What are the typical symptoms of otitis externa?
ear pain
discharge
itchiness
conductive hearing loss
What signs of otitis externa can be seen on examination of the ear>
erythema and swelling of the ear canal
tenderness of the ear canal
pus or discharge in the ear canal
lymphadenopathy in the neck or around the ear
What is the management for otitis externa? mild/moderate
mild - acetic acid (can also be used prophylactically before and after swimming)
moderate - topical antibiotic and steroid e.g. neomycin, dexamethasone and acetic acid
What is malignant otitis externa?
severe and potentially life-threatening form of otitis externa where the infection spreads to the bones surrounding the ear and progresses to osteomyelitis of the temporal bone
What is psoriasis?
a chronic autoimmune condition which causes recurrent symptoms of psoriatic skin lesions with a large variety in severity of presentation
Briefly describe what patches of psoriasis look like
dry, flaky, scaly and faintly erythematous skin lesions which appear in raised and rough plaques
commonly occur over the extensor surfaces of the elbows and knees and on the scalp
What are the 4 types of psoriasis?
plaque psoriasis - MC form in adults, features thickened erythematous plaques with silver scales
guttate psoriasis - commonly occurs in children, small raised papules across the trunk and limbs which can turn into plaques, often triggered by a strep throat
pustular psoriasis - rare, severe form of psoriasis where pustules form under areas of erythematous skin, pus is non-infectious, MEDICAL EMERGENCY
erythrodermic psoriasis - rare severe form of psoriasis with extensive erythematous inflamed areas covering most of the surface area of the skin, MEDICAL EMERGENCY
WHat are 3 specific signs which suggest psoriasis?
auspitz sign - small points of bleeding when plaques are scraped off
koebner phenomenon - development of psoriatic lesions to areas of skin affected by trauma
residual pigmentation of the skin after the lesions resolve
What is the management for psoriasis?
Topical steroids
Topical vitamin D analogues (calcipotriol)
Topical dithranol
Topical calcineurin inhibitors (tacrolimus) are usually only used in adults
Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis
What is pelvic inflammatory disease/
inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix
what is salpingitis?
inflammation of the fallopian tubes
What are the causes of PID?
PID is usually associated an STI
neisseria gonorrhoea
chlamydia trachomatis
mycoplasma genitalium
less-commonly:
gardenerella vaginalis
haemophilus influenzae
E. coli
What are some risk factors for PID? x6
Not using barrier contraception
Multiple sexual partners
Younger age
Existing sexually transmitted infections
Previous pelvic inflammatory disease
Intrauterine device (e.g. copper coil)
How does PID usually present? x6
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
What are some possible findings on examination in PID? x4
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
What is the management for PID?
antibiotics depending on local and national guidelines
ceftriaxone (gonorrhoea)
doxycycline (chlamydia and mycoplasma)
metronidazole (gardnerella)
What is Fitx-hugh-curtis syndrome?
a complication of PID caused by inflammation and infection of the liver capsule (Glisson’s capsule) leading to adhesions between the liver and peritoneum
What is the definition of hypertension?
Blood pressure ≥140/90mmHg
What are the initiating factors for hypertension? (8)
DRIED ICE
- Disturbance of autoregulation
- Renal sodium retention
- Insulin resistance/hyperinsulinaemia
- Excess sodium intake
- Dysregulation of RAAS with elevated plasma renin activity
- Increased sympathetic drive
- Cell membrane transporter changes
- Endothelial dysfunction
Which medications increase blood pressure?
- NSAIDs
- SNRIs (serotonin and norepinephrine reuptake inhibitors)
- Corticosteroids
- Oral contraceptives (oestrogen containing)
- Stimulants
- Anti-anxiety drugs
- Anti-TNFs
What are the risk factors for hypertension?
- age >65yrs
- moderate/high alcohol intake
- sedentary lifestyle
- FH of hypertension of CAD
- obesity
- metabolic syndrome
- diabetes mellitus
- black ancestry
- hyperuricemia
- obstructive sleep apnoea
** Smoking is NOT a risk factor
What is the equation for BP?
BP = CO x TPR
What factors affect blood pressure?
- Preload
- Contractility
- Vessel hypertrophy
- Peripheral constriction
What are the common symptoms of hypertension?
Most often symptomless.
- headache
- visual changes
- dyspnoea
- chest pain
- sensory of motor deficit
What are the causes of secondary hypertension?
Renal disease (MC cause)
Obesity
Pregnancy or pre-eclampsia
Endocrine (T2DM, Conn’s, Cushing’s diseases)
Drugs (alcohol, steroids, NSAIDs, oestrogen)
What is diabetic ketoacidosis?
Result of too much gluconeogenesis so that glucose is converted to ketone bodies which are acidic. Caused by poorly managed T1 DM or from infection/illness
What are the signs of diabetic ketoacidosis?
T1DM symptoms +…
- Kussmaul breathing (deep laboured breaths to compensate for increased CO2)
- Pear drop breath (breath smells fruity due to ketones)
- Reduced tissue turgor, hypotension + tachcardia
What are the diagnostic blood concentrations of ketones, glucose and acid in DKA?
Ketones >3mmol/l
Random plasma glucoe >11.1mmol/l
pH<7.3 or <15mmol HCO3-
What is the treatment for DKA?
- in an emergency ABCDE
- 1st line always fluid (dehydration is most likely cause of death)
- then insulin (+ glucose and postassium)
What are the FPG and OGTT values in IGT?
FPG >/= 6mmol/l
2hr OGTT 7.8-11mmol/l
What are the FPG and OGTT in IFG?
FPG 6.1-6.9mmol/L
2hr OGTT <7.8mmol/l
What are the potential complications of DKA?
- cerebral oedema
- adult respiratory distress syndrome
- thromboembolism
- aspiration pneumonia (drowsy/comatose patients)
- death
What is Hashimoto’s thyroiditis?
An autoimmune disease which causes the immune system to attack the thyroid gland resulting in permanent hypothyroidism
What are the symptoms of Hashimoto’s thyroiditis?
- goitre
- tiredness
- weight gain
- muscle weakness
Why can insulin treatment for DKA cause hypokalaemia and why is this dangerous?
insulin decreases potassium levels in the blood by redistributing K+ into the cells via increased Na/K pump activity causing low serum K+ levels –> hypokalaemia
low levels of K+ can cause arrhythmia, weakness (as the heart and muscles can struggle to contract)
What is balanitis?
inflammation of the glans penis
sometimes extends to the underside of the foreskin which is known as balanoposthitis
What is the treatment for balanitis?
gentle saline washes and ensuring washing under the foreskin
1% hydrocortisone
if caused by candidiasis, treat with topical clotrimazole for 2 weeks
oral flucloxacillin for bacterial balanitis
circumcision can help in cases of lichen sclerosus associated balanitis
lichen sclerosus and plasma cell balanitis of Zoon are managed with high potency topical steroids like clobetasol
dermatitis and circinate balanitis are managed with mild potency topical corticosteroids e.g. hydrocortisone
What are the common causes of balanitis?
candidiasis - white non-urethral discharge
dermatitis (contact or allergic) - clear non-urethral discharge
dermatitis (eczema or psoriasis)
bacterial (most commonly staph spp.) - yellow non-urethral discharge
lichen planus - Wickam’s striae and violaceous papules
lichen sclerosus (rare)
plasma cell balanitis of Zoon (rare)
circinate balanitis (can be associated with reactive arthritis)
What is chancroid? what are the ulcers like?
a tropical STD caused by haemophilus ducreyi which presents with painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement
the ulcers typically have a sharply defined, ragged, undermined border
What is the treatment for chancroid?
macrolide antibiotics - azithromycin, ceftriaxone or erythromycin
aminoglycosides e.g. gentamycin second line
What is lymphogranuloma venereum?
STI caused by chlamydia trachomatis serotypes L1, L2 and L3
What are 3 risk factors for lymphogranuloma venereum?
men who have sex with men
HIV
historically seen more in the tropics
What are the 3 stages of lymphogranuloma venereum infection?
1: small painless pustule which later forms an ulcer
2: painful inguinal lymphadenopathy which can form fistulating buboes
3: proctocolitis (inflammation of the rectum and colon)
What is the treatment for lymphogranuloma venereum?
doxycycline
What are genital warts and what causes them?
also known as condylomata accuminata
small, slightly pigmented fleshy protuberances which may bleed or itch
caused by the many varieties of the human papillomavirus HOV, especially types 6 & 11
What is the management for genital warts?
1st line: topical podophyllum or cryotherapy
2nd line: imiquimod cream
often resistant to treatment
What are the routes of transmission of HIV?
- Sexual
- Vertical (in the womb, breast-feeding)
- Blood or bodily fluids
What are 5 scenarios when HIV testing takes place?
- Clinician indicated diagnostic testing
- Routine screening in high prevalence locations
- Antenatal screening
- Screening in high risk groups
- Patient initiated requests for testing
What symptoms indicate risk of HIV infection?
With any recurrent, severe or unexplained medical condition HIV should be considered.
Common examples:
- multi-dermatomal shingles
- unexplained lymphadenopathy
- unexplained weight loss or diarrhoea, night sweats, pyrexia
- oral/oesophageal candidasis or hairy leukoplakia
- flu-like illness, rash, meningitis
- unexplained blood dyscrasias (disorders)
What is a normal CD4 count?
500-1200 cells/mm3
What is HIV?
Human Immunodeficiency virus, a lentivirus which uses reverse transcriptase to replicate. (retrovirus) Decimates the CD4 cell population over time causing immunodeficiency and viral load increases over time.
When is the viral load counted as undetectable?
<50 copies/mL
What are some examples of AIDS-defining illnesses associated with end-stage HIV infection? x6
Kaposi’s sarcoma (disease in which cancer cells are found throughout the GI tract and presents with purple patches on the skin)
Pneumocystis jivorecii pneumonia (PCP)
Cytomegalovirus infection
Candidiasis (oesophageal or bronchial)
Lymphomas
Tuberculosis
What are the treatment options for HIV? what is the aim of treatment?
antiretroviral therapy medications e.g. protease inhibitors, integrase inhibitors, nucleoside reverse transcriptase inhibitors, entry inhibitors
usual starting regime = 2 NRTIs (e.g. tenofovir plus emtricitabine) plus a third agent e.g. bictegravir
aim of treatment is to achieve a normal CD4 count and undetectable viral load
What are some additional management options for HIV patients?
prophylactic co-trimoxazole (for PCP)
close monitoring for cardiovascular risk factors due to increased risk
yearly cervical smears due to increased risk of HPV and cervical cancer
vaccinations
condom use to prevent spread
What are the recommended guidelines for delivery in HIV positive patients according to viral load?
under 50 copies –> normal vaginal birth
over 50 copies –> consider pre-labour c-section
over 400 copies –> pre-labour c-section recommended
unknown viral load or >1000 copies –> IV zidovudine infusion during labour
What are the usual choices of PEP and PrEP medications?
PEP is a combination of ART therapy: emtricitabine/tenofovir and raltegravir for 28 days
PrEP: emtricitabine/tenofovir
What causes pubic lice?
pediculosis pubis is caused by Phthirus pubis, an obligate, blood-sucking ectoparasite found on pubic and perianal hairs and transmitted through sexual contact or occasionally contact with infected towels, clothing or bedding
What is the presentation of pubic lice?
genital itching, usually worse at night
small blue macules or red papules may be seen at feeding sites
rust-coloured flecks of the lice’s faecal material may be seen on skin and underwear
what is the management for pubic lice?
insecticides such as permethrin or malathion
decontamination of clothing and bedding and avoidance of close bodily contact until treatment is completed
What is erectile dysfunction?
the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
it is a symptom and not a disease
What factors favour an organic cause of erectile dysfunction? x3
gradual symptoms onset
lack of tumescence (swelling)
normal libido
What features of erectile dysfunction favour a psychogenic cause x6
sudden symptoms onset
decreased libido
good quality spontaneous or self-stimulated erections
major life events
problems or changes in a relationship
previous psychological problems
history of premature ejaculation
What are some risk factors for erectile dysfunction?
increasing age
cardiovascular disease risk factors e.g. obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking
alcohol use
drugs - SSRIs, beta-blockers
What are the investigations for erectile dysfunction?
free testosterone (measured in the morning between 9-11am) - low or borderline it should be repeated with FSH, LH and prolactin and if any are abnormal referral to endo is indicated
What is the management for erectile dysfunction?
Treat the cause
Lifestyle changes - stop smoking, lose weight, reduce alcohol consumption
What are the medications used to treat erectile dysfunction?
phosphodiesterase inhibitors e.g. sildenafil improve relaxation of smooth muscle
vacuum erection devices
prostaglandins are used as second line drug therapy
penile prosthesis
What are the management options for premature ejaculation?
selective serotonin reuptake inhibitor (SSRI)
Sertraline, Paroxetine and fluoxetine
topical anesthetic to reduce penile sensitivity, eg. lidocaine-prilocaine cream (5%) applied 20-30 minutes before sexual activity
behavioural techniques - . ‘Stop-start’ techniques, thicker condoms
taking breaks during sex
Couples therapy advice
What are some causes of dyspareunia in women?
infection - especially, trichomonas, vaginal candidiasis
vaginal atrophy - postmenopausal shrinkage; infrequent intercourse
psychological - vaginismus, fear, ignorance, previous painful intercourse
poor sexual stimulation
pelvic inflammatory disease
endometriosis
What is the treatment for dypareunia in females?
Management typically focuses on treating underlying causes where appropriate
A penetration desensitisation programme is useful in dyspareunia and vaginismus
Fenton’s procedure - increase the dimensions of the introitus
intramuscular injection of botulinum toxin
Psychological therapy may be useful in some patients.
if psychosexual problems persist refer her to a psychosexual therapist
What is retrograde ejaculation? what can cause it?
semen passes into the bladder rather than the urethra - complication of TURP or bladder neck incision
may also occur as a result of spinal injury or DM
the patient can usually achieve an orgasm but there is no ejaculate or the volume of the ejaculate is decreased
urine may be cloudy after having sex
What is vaginismus, and what are some common causes?
vaginismus is usually apparent at vaginal examination - severe spasm of the vaginal muscles and adduction of the thighs
Common causes:
- fear of intercourse
- local pain
- past history of rape, abuse or severe emotional trauma
- defence mechanism against growing up
What is the management of vaginismus?
progressive relaxation to manage anxiety
densensitisation - vaginal trainers and encouraging the woman to examine herself
physiotherapy hypnotherapy
topical lidocaine applied within the vagina
antidepressants
What are the stages of hypertension?
1 - Clinic blood pressure from 140/90 to 159/99 mmHg or average HBPM from 135/85 to 149/95 mmHg
2 - Clinic BP ≥160/100 but <180/120 mmHg and HBPM average ≥150/95
3 - Clinic systolic BP ≥180 mmHg or clinic diastolic BP ≥120 mmHg
What are the 3 categories of health behaviours? Give an example of each
Health behaviour = behaviour aimed at preventing disease e.g. eating healthily
Illness behaviour = behaviour aimed at seeking remedy e.g. going to the doctor
Sick role behaviour = any activity aimed
at getting well e.g. taking prescribed medications, resting
What are the determinants of health?
environment (physical, social and economic)
genes
lifestyle
healthcare access
Define equity and equality
equity = recognises each person has different circumstances and allocates the exact resources and opportunities needed to reach an equal outcome
equality = each individual or group of people is given the same resources or opportunities regardless of circumstance
Give an example of equality but inequity
Flat government subsidy for travel to work of £5 per day
Some people’s travel costs more than others e.g.
£7 - £5 = £2 to pay
£14 - £5 = £9 to pay
Define horizontal and vertical equity
Horizontal equity is equal treatment for equal need e.g. all individuals with pneumonia (assuming all other things equal) should be treated equally
Vertical equity is unequal treatment for unequal need e.g. individuals with common cold vs pneumonia need unequal treatment
What are the 3 domains of public health practice?
Health improvement
= societal interventions aimed at preventing disease, promoting health and reducing inequalities
Health protection
= measures to control infectious disease risks and environmental hazards
Health care
= organisation and delivery of safe, high quality services for prevention, treatment, and care
What are the 3 levels of public health interventions?
Ecological (population) level
e.g. clean air act
Community level e.g. creating playground for local community
Individual level e.g. childhood immunisations
Define primordial and quaternary preventions
Primordial prevention is action to prevent risk developing in healthy people who are currently not at risk
e.g. laws/health promotion put in place to discourage and prevent substance misuse
Quaternary prevention is action to prevent over treatment of patients with a condition or disease
e.g. empowering individuals to seek own outcome and avoid over-treatment and medication dependence
What is the difference between secondary and tertiary prevention? Give an example of each
Secondary is focussed on early detection of illness and either curing or preventing progression/ long-term effects
e.g. mammograms to detect breast cancer early
Tertiary is centred on preventing worse outcomes or complications of a
condition or disease
e.g. reducing or controlling the symptoms and morbidity of established cancer or the morbidity caused by cancer therapy.
Define primary prevention and give an example
Preventing development of a health problem when risk exists
e.g. targeted education, health promotion against recreational substance misuse
What are the 4 stages of the planning cycle?
Needs assessment
Planning
Implementation
Evaluation
What are the 5 levels in Maslow’s triangle?
Self-actualisation (achieving one’s full potential, including creative activities)
Esteem needs (prestige and feeling of accomplishment)
Belongingness and love needs (intimate relationships, friends)
Safety needs (security, safety)
Physiological needs (food, water, warmth, rest)
What are the 4 categories in Bradshaw’s taxonomy of social need?
Felt (individual perceptions of variation from normal health)
Expressed (individual seeks help to overcome variation in normal health (demand))
Normative (professional defines intervention appropriate for the expressed need)
Comparative (comparison between severity, range of interventions and cost)
What are the 3 approaches to health needs assessment?
epidemiological
corporate
comparative
What are the leading causes of death in the UK? x5
Dementia and Alzheimer’s disease
Ischaemic heart disease
Chronic lower respiratory diseases
Cerebrovascular diseases
Malignant neoplasm of trachea, bronchus and lung
What are the 4 factors which influence perceptions of risk?
- Lack of personal experience with the problem
- Belief that the problem is preventable by personal action
- Belief that if the problem has not happened by now, it’s not likely to
- Belief that problem is infrequent
What are the reasons for change stated in the health belief model (Becker 1974)?
individuals will change if they:
- Believe they are susceptible to the condition in question (e.g. heart disease)
- Believe that it has serious consequences
- Believe that taking action reduces susceptibility
- Believe that the benefits of taking action outweigh the costs
What is intention determined by in the theory of planned behaviour (Ajzen 1988)?
- A person’s ATTITUDE to the behaviour e.g. I don’t think smoking is a good thing
- The perceived social pressure to undertake the behaviour, or SUBJECTIVE NORM e.g. important people in my life want me to give up smoking
- A persons appraisal of their ability to perform the behaviour, or their PERCEIVED BEHAVIOURAL CONTROL e.g. I believe I have the ability to give up smoking
What are some limitations of the theory of planned behaviour?
Lack of a temporal element and direction or causality
Doesn’t take into account emotions such as fear, threat, positive affect
Doesn’t explain how attitudes, intentions and perceived behavioural control interact
What are the stages in the transtheoretical model of behaviour change?
Pre-contemplation (not ready yet)
Contemplation (thinking about it)
Preparation (getting ready)
Action (doing it)
Maintenance (sticking with it)
[Relapse]
What are some limitations of the transtheoretical model of behaviour change?
not all people move through every stage or in that order
change might operate on a continuum rather than in discrete stages
doesn’t take into account values, habits, emotions, culture, social and economic factors
people often change their behaviour in the absence of planning/intentions can change over a very short time period
What is the motivational interviewing model?
a counselling approach for initiating behaviour change by resolving ambivalence
clinical impact shown in problem drinkers
What is the nudge theory of behaviour change?
“nudge’ the environment to make the best option the easiest e.g. opt out schemes such as pensions, fruit next to checkouts
weak evidence to support efficacy of nudging in improving population health
What is malnutrition?
deficiencies , excess or imbalances in a person’s intake of energy and/or nutrients. Includes undernutrition and weight excess, obesity and diet-related non-communicable disease like heart disease, stroke, diabetes,
What chronic medical conditions require nutritional support?
Cancer
Cystic fibrosis
Coeliac disease
Inflammatory bowel diseases
Types 1 and 2 Diabetes Mellitus
Faltering growth
Eating disorders
Overweight, obesity
Management of sarcopenic obesity in elderly patients
What are the 4 dimensions of food insecurity?
Availability
Access
Utilisation
Stability
