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General Practice > GP > Flashcards

GP Flashcards

1
Q

Differential Diagnosis in Back Pain

A 
CVS (AAA) 
GI (Peptic ulcer disease) 
Ank Spons (<40, stiffness >3months duration) 
Shingles 
Sciata 
MSK
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2
Q

Red flags of back pain

A

Cauda equina, Cancer, Spiral fracture infection
Thoracic pain
Bladder bowel dysfunction
Previous Cancer history

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3
Q

Management of acute back pain

A

Start Back (score /9 to assess severity)
Self management: 6w duration, try and stay active
Angalgesia: NSAIDS + gastroprotection, Codeine, Diazepam if muscle spasm
Refer to exercise/CBT/Physio

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4
Q

FeverPAIN criteria

A 
Fever 
Purulent 
Ateends rapidly
Inflamed
No cough/coryza

Score of >4=immediate ABx

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5
Q

Centor Criteria

A

Tonsillar exudate, tender lymphadenopathy, <3days, no cough

score 3-4= 50% chance of Group A strep

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6
Q

Red flags for sore throat

A

Quinsy
Systemically unwell with stridor
Retropharyngeal abscess
Epiglottitis

> 7 episodes/year refer to ENT for tonsillectomy

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7
Q

Management of FLU

A

Prescribe Tamiflu if [At risk (>65, pregnant, chronic health condition) If there is a national outbreak, and within 48hrs of symptom onset]
Regular fluids, analgesia, rest 1 week off work
Safety net: SOB, Chest pain, Haemoptysis, No improvement in >1 week, or if they have a low threshold to reconsult (eg if there a carer)
Admit if: pneumonia, diabetic, other illness

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8
Q

Risk factors for AOM

A

75% of cases are in under 10s!
Passive smoking, nursery attendance, formula fed, craniofacial syndromes, and males!
-> Immediate antibiotics if <3months, very unwell, at risk of complications
-> refer if <6 months, signs of complications, repeated signs in adults could be nasopharyngeal cancer

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9
Q

Red flags of Dysuria

A

Haematuria,
Loin pain,
Rigors,
N+V, Altered mental state (all imply sepsis)

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10
Q

Risk factors for UTI

A

Neuromuscular condition, Diabetes, immunosuppression, urolithiasis and catheterisation

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11
Q

Inv UTI

A

Dipstick if: <65, no risk factors, uncomplicated

MSU if: 65, unresolved, recurrent, catheterised, haematuria

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12
Q

Management of Haematuria

A

Asymptomatic non-visible H: Dip 3x separate samples and if >2/3rd positive investigate.
Symptomatic non-visible H: [Measure BP, Creatinine, eGFR, ACR]
- If >40 refer to urology for imaging and cystoscopy if visible
- if <40 referent to nephrology for assessment

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13
Q

Management of UTI (uncomplicated)

A

1) SELF CARE (fluids, analgesia, leaflet) [no visible harm, not pregnant and not catheterised]
2) Nitro 100mg BD 3d if eGFR>45
- Trimethorpim 200mg BD for 3d (low resistance risk)
3) 2nd line: Nitro, Pivmecillinam, Fosfomycin
Delayed script if no improvement within 48hrs, and review choice of Abx when MC&S returns

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14
Q

Treating UTI associated with haematuria

A

Treat UTI

Re-test urine for blood after finishing antibiotics

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15
Q

Managing recurrent UTI

A

Manage acute UTI and send and MSU
Refer if cause unknown or suspect cancer
Behaviour hygiene: avoid douching, front to back wipe, post-coital urination, and increase water intake
Vaginal oestrogen in post-menopausal women
Consider ABx prophylaxis (eg single dose when exposed to a trigger)

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16
Q

UTI in pregnancy

A

2ary care if sepsis or ? pyelonephritis, Send MSU

Avoid Trimethorprim in 1st trimester, avoid Nitro in 3rd trimester

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17
Q

What are the serious causes of back pain?

A 
Nerve root pain
Fracture 
Malignancy 
Discitis 
Ank Spons 
Structural
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18
Q

What is the management of Sciatica

A

90% due to disc herniation (use jam doughnut analogy, and slowly over time jam gets resorbed and pain resolves)

  • conservative + physio
  • Epidural steroids
  • Refer is serious near signs or no improvement in 6wks
  • > 80% recovers in 6 weeks
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19
Q

When do you refer in febrile convulsions?

A

Common seen in 5% of kids aged 6m-6yrs due to early temp rise in viral infection (uncomplicated tonic-clonic with LOC and temp >38!)
Refer if: First seizure, unclear diagnosis, frequent and long fits, risk of epilepsy

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20
Q

Common infant rashes

A

Toxic Erythema (activation of the immune system, resolves in <2 weeks)
Milia - 15% of neonates due to blockage of sweat ducts, resolved in <4weeks
Crusted lesions - more concerning could be staph infection
Vesiculr rash - Herpes simplex
Nappy rash
Cradle cap
Umbilical Granuloma (overgrowth of healing umbilicus, treated with salt and warm water)
Conjunctivitis: GBS, Chlamydia, Gonorrheoa

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21
Q

Non-medical management of Eczema?

A

Keep nails short
Avoid triggers,
Not hot baths or hot bed clothes, cotton clothing, cool bedroom, avoid perfume and bubble baths!
-> Emollients, mild steroids, calcineurin inhibitors, bandages,
EASI score calculates severity

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22
Q

SCOFF questionnaire

A 
Sick because you feel full? 
Control over how much you eat? 
Over 1 stone weight loss in <3months 
Feel you are Fat when people say youre thing? 
Food dominates your life?

Assess: Height, weight, pulse and BP, muscle weakness and Bloods (FBC, U_E, Cr, Glu, LFTs, ECG and DEXA scan)

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23
Q

What are the most common cancers in Men?

A

Prostate - Lung - Bowel

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24
Q

What are the most common cancers in women?

A

Breast 30% - Lung - Bowel - Uterus

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25
Q

Which cancers are screened for?

A

Breast 50-70 3yrly
Cervix 25-64 3 year’s (5yrly from 50) [If HPV +ve, an abnormal cells send for colposcopy] [if HPV +ve and normal cells, recall in 12 months]
Colorectal - one off flexi-sig @ 55yrs, FIT test every 2 years from 60-74

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26
Q

NICE 2ww guidelines

A

Are designed to refer anyone with a 3% chance of having a cancer

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27
Q

2WW Breast referral:

A

> 30 with unexplained breast lump ± pain
50 with unilateral nipple disease

Consider if: skin changes of cancer, >30 with unexplained lump in axilla

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28
Q

NICE and PSA testing

A

Recommends examining prostate and consider PSA testing:

  • nocturne, frequency, poor stream, dribble
  • visible haematuria
  • erectile dysfunction
  • lower back pain and weight loss
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29
Q

2WW for bowel cancer:

A

> 40 with unexplained weight loss and Abdo pain
50 with unexplained rectal bleeding
60 with Fe anaemia / Change in bowel habit
Any age with positive FOB test

Consider: rectal or Abdo mass
Age >50 with rectal bleeding + 1 of (Abdo pain, bowel habit, weight loss, anaemia)

30
Q

Lung cancer referral if

A

Urgent CXR if > 40 with 2+ of [cough, fatigue, SOB, chest pain, weight loss, appetite loss]
(or just 1 if they’ve ever smoked)

31
Q

Management of Sinusitis

A 
Rest + Fluids 
Analgesia 
Intranasal decongestants (Max 7 days) 
Nasal irrigation with saline 
ABx [if severe with comorbidities]
Steroids [if severe and prolonged symptoms]
32
Q

Red Flags of sinusitis

A

Unilateral, persistent blockage, bloody discharge, Eye changes/neuro signs

33
Q

Differentials for back pain

A 
CVS: AAA or angina or pericarditis 
UTI (renal angle or flank pain) 
Gynae (dysmenorrhea) 
Pancreatitis / Duodenal ulcer / AAA 
Shingles (burning sensation over skin)
34
Q

What is the Rome Criteria?

A

Used to differentiate between heart burn and dyspepsia?

Heartburn: retrosternal burning with acid taste in mouth
Dyspepsia: epigastric discomfort with bloating, fullness, nausea (PUD)

35
Q

What medications can cause dyspepsia?

A

Damage mucosa: NSAIDs, Tetracyclines, Steroids, Bisphosphonates
Reduce motility: CCB, Nitrates, TCAs, Anticholinergis
[NEED to ask about Chinese supplements and steroids]

36
Q

What is the management of undiagnosed dyspepsia?

A
  1. Comprehensive drug review to remove any causes
  2. Lifestyle Advice (lower weight, lower spice, lower caffeine, lower alcohol, raise beds, alginates and antacids)
  3. 1 month trial of PPI or Test and TREAT H pylori
    Blood antigen test for diagnosis, Urea breath test for test of cure. (need to stop PPI 2 weeks before doing test)

Only refer for endoscopy if alarm symptoms (as 50% have endoscopically negative reflux)

37
Q

Differentials of acute diarrhoea

A

Gastroenteritis (if >2 weeks infection much less likely but could be giardiasis) [Stool microscopy and Metronidazole]
IBD, Coeliac, Hyperthyroidism, ETOH

38
Q

Management of Diarrhoea

A

[Send stool sample if >3days]
Hygiene and hand washing
Extra contraception needed if taking the pill
Clear fluids 2.5L/day (+200ml for each loose stool)
Loperamide
STOP: Metformin, ACEi and diuretics

39
Q

What is needed for a diagnosis of IBS?

A

> 3days a week symptoms for >3 months that improve on defamation: Abdo pain, bloating, and change in bowel habit.

Rule out red flags: weight loss, rectal bleeding, family history of bowel cancer, onset >60yrs

Initial investigations: FBC, CRP, Coeliac screen

M: soluble fibre, antispasmodics, laxatives, TCAs and SSRIs if severe

40
Q

Management of Psoriasis

A

Potent steroid am + Vit D analogue PM
Emollients (to reduce itch and scale) + salicylic acid
Steroids for 8 week (followed by 4 week steroid break)
Follow-up @ 6 weeks
Refer: if no response, extensive disease or nail involvement (for phototherapy or systemic Rx)

41
Q

Management of Acne?

A

Topical retinoids (if comedogenic) + Benzoyl peroxide (warn that bleaches clothes and hair and shows up in UV light)
Benzoyl Peroxide + Top Antibiotic (Clindamycin) (if papulopustular acne)
+ topical salicylic acid
Oral Antibiotics (Doxycycline + BPO to reduce resistance)
Hormonal Treatment if female (COCP/Cocyprindiol that carries higher VTE risk)
Isotretinoin

42
Q

Counselling someone to start Isotretinoin?

A

Its a VitA analogy that decreases sebum and decrease keratin. 9/10 see improvement with a single course: 20-80mg OD for 16-24 weeks.

SE: Dryness most common complaint of nose, lips and eyes. Increased sensitivity to sun (advise about sun cream)
Muscle and joint ache after exercising. 
Decrease night vision (warn about driving at night) 
Increased fat levels, and risk of liver inflammation (avoid alcohol) 
Contains Soya (so ask about allergies to soya and peanut)
Risk of changes in mood and behaviour

Pregnancy prevention program? all women who are able to conceive need:
2x form of contraception, give prescription after -ve test, start treatment on day 2-3 of cycle, monthly pregnancy tests until 5 weeks post-treatment, contraception continued 1month after finishing

Before starting Isotretinoin: Lipid profile, HBA1C, LFTs
Monitor: LFTs + Lipid screen (1m before, 1m after, then every 3 months)

43
Q

Treatment of Acne Rosacea

A

S/S: facial flushing, erythema, blepharitis and hinophyma (sebaceous gland hyperplasia)

R with: metronidazole gel + azelaic acid (oral ABx if more severe)

44
Q

Migraine treatment and prophylaxis:

A

Rx: Combination therapy with NSAID (900mg Aspirin), Oral triptan (5-HT agonists)
For teenager you can give nasal triptans
+ Metacloperamide if these measures dont work

Prophylaxis: given to patients with >2 attacks/month (~60% effective)
Topiramate (5-HT antagonist) - CI in CVD/IHD (as cause vasoconstriction) Taken at onset of headache not aura!
Propranolol - preferred in women of child bearing age as not teratogenic, and safe with contraception.
NICE: 10x sessions of Acupuncture
NICE: 400mg Riboflavin supplements
If women with predictable menstrual migraine, they can have short term prophylaxis (Zolmitriptan)

45
Q

What are the NICE guidelines for epilepsy?

A 
Need to be seen by Neuro in <2weeks 
2/3rds of people have recurrence in 1yr after seizure 
Infrom the DVLA 
Avoid going near water or machinery 
Infrom their employer 
[Only start AEM after 2nd seizure]
46
Q

What do you need to rule out in Secondary Amenorhea

A 
Ask about possibility of Pregnancy 
Current stress, weight loss and exercise pattern 
Normal period like, any signs of PCOS 
Hypothyroid screen 
Prolactin screen?
47
Q

Pre-conception advice

A

Always enquire about plan for pregnancy
Folic Acid + Vit D
Review Medication (no isotretinoin)
Lifestyle: diet and exercise, weight, smoking, ETOH, drugs and job
Check immunity, cervical screening and STI check
(Annual flu vaccine and whooping cough vaccine)
Diet: avoid uncooked meat, avoid soft cheese and unpasteurised meat
Continue regular exercise if doing before
Avoid saunas and hot tubs and scuba diving
Sex is safe (as long as no History of PROM)

48
Q

What is the HARKS questionnaire?

A 
Used to screen for Domestic Violence: 
Humiliated? 
Afraid of partner or anyone in your family? 
Rape (forced to have sex?) 
Kick (physically threatened or 🤕?)
Are you able to go home?
49
Q

What is the management of presentation of Angina?

A

Prescribe Aspirin, Statin and GTN spray
Obtain an ECG
Check HB (anaemia can cause angina) and lipid profile and fasting glucose
Advise that if any episodes last >15min then go to hospital
Driving must stop if symptoms occur at rest or at the wheel

50
Q

Assessment and referral of a TIA

A

Need to rule out: Migraine, hypoglycaemia, SOL, Seizure

ABCD2 score >4 needs TIA review within 24hrs.
Prescribe 300mg Aspiring (CI: bleeding disorder, anti coagulated, already on aspiring or allergic)
Refer to TIA clinic for: ECG, Carotid duplex, CT head,
Advise not to drive for 1month

(Carotid endarterectomy if stenosis is >70% in European guidelines)

51
Q

NYHA Classification

A 
Way of assessing severity of cardiac failure symptoms 
1- no limitation 
II - some limitation with exercise 
III - comfortable at rest
IV - symptoms brought on at rest
52
Q

Management of Anaphylaxis

A

0.5mls IM 1:1000 adrenaline [repeated every 5mins as necessary]
+ 200mg Hydrocortisone
+10mg Chlorphenamine

Patients should be admitted and observed for 12hours due to biphasic reaction in anaphylaxis
Serum Tryptase levels can be taken (elevated for 12hours in cases of true anaphylaxis)

53
Q

How do you investigate Phaechromocytoma?

A

Usually presents in triad of: sweating, palpitations and headaches. (usually with new onset HTN, and +ve FH of MENII)
Invx: 24hr Urinary Metanephrines (more sensitive than catecholamines)
If raised, then do a CT CAP

Mx: Initial medical management (a-blocker followed by a B-blocker) before having surgery!

54
Q

What questions do you need to ask in an asthma review?

A
  1. Have you had any difficulty sleeping because of asthma?
  2. Have you had any symptoms during the day?
  3. Has it stopped you doing your daily activities?
    - > Check: ahderence, inhaler technique + triggers
55
Q

Management of Asthma in <5yrs

A
  • SABA
  • SABA + 8 wk trial of moderate dose ICS
    (If symptoms persist, re-consider diagnosis. If symptoms resolve and recur within 4 weeks of stopping, prescribe a low dose ICS. If symptoms resolve and recur after 4 weeks of stopping, do another 8wk mod ICS trial!)
  • SABA + low dose ICS + LTRA
  • if still not controlled (stop the LTRA) and refer to specialist!
56
Q

Management of Asthma 5-16yr olds

A 
SABA 
SABA + low dose ICS 
SABA + Los ICS + LTRA 
SABA + Low ICS + LABA (stop the LTRA) 
SABA + MART 
SABA + mod ICS 
SABA + high ICS/theophylline/specialist help
57
Q

Management of Asthma in adults

A

THE SAME AS IN CHILDREN BUT YOU DO NOT STOP THE LTRA IF THEY’VE had a good response

58
Q

What is the management of PMR:

A

High dose steroids for up to 1 year reducing dose (+prevention of osteoporosis)
-> be vigilant for Giant Cell Arteritis: headache, scalp tenderness, pain on chewing, and vision loss

59
Q

What general measure advice can you give in Menopause?

A

General exercise, decrease stress, and up to date with breast and cervical screening.
- Need to cover for contraception (1 year if LMP was >50, 2 yr if LMP was <40)
Diet: soya beans, nuts and wholegrain
Can try vaginal oestrogen for atrophic vaginitis (daily for 2-3weeks then twice weekly for 6 months)

60
Q

4 Key interventions to reduce falls:

A

Strength and balance training
Rationalise medication (stop psychotropic meds)
Prescribe Calcium and VitaminD (700mg daily full glass of milk or 10mins in the sun, milk/eggs/oily fish) (Can’t take calcium with thyroxine or bisphosphonates)
Conduct an OT Home assessment

61
Q

What are the reversible causes of memory loss?

A

Pernicious anaemia, hyponatraemia (renal failure), Jaundice, Hypercalcaemia, Hypothyroidism, Diabetes

62
Q

Treating memory loss CI?

A

Anticholinergic medication (donepezil, rivostigmine) can cause bradycardia and so are CI in sick-sinus syndrome, Asthma, COPD and Peptic Ulcer Disease

Memantine (NMDA antagonist) used in advanced AD with challenging behaviour

63
Q

What is the NICE guidance on managing Alzheimer’s disease?

A

Non-Pharm: offer activities that produce wellbeing, cognitive stimulation and group therapy
Pharm: Mild to mod (AchI: donepezil, rivostigmine + galantamine)
Memantine (used as 2nd line) if CI to the above, or severe disease with challenging behaviour
NICE does not recommend antidepressants if depressed. Only offer antipsychotics in severe distress or harm.

64
Q

Management of Anxiety

A
  • Always look for potential cause: Hyperthyroidism, Cardiac disease + Medication (salbutamol, steroids, CAFFEINE)
  • Education and advice about GAD, period of watchful waiting (depending on extent)
  • Low / High intensity CBT
  • SSRI (Sertraline offered 1st line, but must warn <30 of increased suicidal thoughts/anxiety in first couple of weeks review weekly)
    Can give B blockers and Benzo’s to cover symptoms short term
65
Q

What is the management of Depression?

A

Need to rule out organic cause: LFTs, CXR, ECG, Mental state
INVx: HADS or PHQ-9 questionnaire
Med: Advise about diagnosis and suggest watchful waiting. Low intensity CBT, self help, sleep hygiene
Mod/Severe: Medication (70% effective) + high intensity CBT (SSRI SE: N+V, Abdo pain, sexual dysfunction, 4 week window to take effect, need to trial 2 SSRIs before starting another drug)
ECT reserved for drug resistant depression especially if: retardation, psychosis and easy morning waking! Normaly given bilateral 2x/week for 6 weeks.
ECT CI if: MI, arrhythmias, PE, Pneumonia, fractures, high BP during treatment.

66
Q

What is the diagnosis of mania?

A

Elated mood + 3 symptoms (self worth, inappropriate behaviour, activity, delusions and hallucinations) for > 1 week
Triggered by: lack of sleep, positive/negative events

Need to rule out organic cause: Thyroid, Neuro disorders (MS, Epilepsy, Frontal lobe) and drugs (Stimulants, steroids, anti-depressants)

67
Q

What is the treatment of acute mania

A

1st: Atypical antipsychotic (olanzaine)
2nd: Valproate, lamotrigine + Lithium

In Depression: avoid antidepressants, Clozapine can be used if rapid cycling

Maintenance: Lithium ± atypical antipsychotics ± anticonvulsants

68
Q

What are the differential diagnoses of shizophrenia?

A

Brief psychotic disorder (severe stressor <1month)
Delusional disorder (only have hallucinations and delusions without the negative symptoms)
Manic depression
ETOH Withdrawal
Drugs (cannabis, steroids, cocaine, ecstasy)

Organic causes: epilepsy, dementia, B12, hypoglycaemia, head trauma

69
Q

What investigations do you need to do if you suspect Schizophrenia?

A 
Drug Screen (cannabis and amphetamines) 
EEG (to rule out epilepsy) 
Fasting glucose 
Full neuro exam and bloods (B12, TFT, LFTs, FBC, U+E) 
CT or MRI
70
Q

How do you manage Schizophrenia?

A

Usually try and manage at home using the Crisis team. But sometimes detained under the MHA if high risk.
Acute attack: Typical/atypical antipsychotic (SE: sedation, EPSE, weight gain and diabetes)
Clozapine (after failing with 2 other meds) needs close monitoring: (1% risk of agranulocytosis, Myocarditis, severe constipaton, enzyme induction with nicotine) (Monitored after day 3 then weekly for 18 weeks!)
Psychological therapies: CBT + early warning sign interventions
Social care - give structured weekly activities
ECT if catatonic

Prognosis: 20% make full recovery, 35% LT remission, 35% have persistent, 10% have severe and unresponsive disease.

Worse prognostic factors: Pre-morbid factors, drug and ETOH abuse, slow delayed onset, current social situation

71
Q

What are different risks for developing VTE?

A

Baseline risk: 2-4/10000
On POP: 4-5/10000
On COCP: 6/10000
Pregnancy: 10/10000 (1/1000) with 60-80% being postnatal
Treated with LMWH until >6w-6m postpartum. Need to avoid spinal within 12 hours, does not pose a risk to C-Section.

General Practice (2 decks)

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