GP Flashcards

Question

when do DOACs vs warfarin reach therapeutic levels

Answer 1

``` doacs = 3-4 hours warfarin = 3-7 days ``` BUT effects fade after 12-24 hours with DOACs vs 48-72 hours with warfarin (something to think about w poor adherence)

Answer 2

optic neuritis

Answer 3

``` ACEi, ARB diuretics stop statins if aki due to rhabdomyolsis or muscle pain metofrmin lithium digoxin - reduce dose trimethoprim and co-amox aciclovir - reduce dose morphine consider witholoding DOACs ``` should either reduce doses or stop

Answer 4

- When vomiting of diarrhoea (unless minor) should stop certain triggering medication to avoid an AKI - ACEi/ARBs, NSAIDs, diuretics - Note - not one fits all, should be stated on an individual basis

Answer 5

divide by 2

Answer 6

fybogel - ispaghula husk

Answer 7

<140/90 if >80 then <150/90 T1DM <135/85 (if accompanied by albuminuria (kidney disease) or 2+ features of metabolic syndrome then ≤130/80) CKD <140/90 (if also accompanied by CVD or diabetes or high urine creat ratio then lower than this)

Answer 8

- Stage 1 hypertension - BP in surgery/clinic is ≥140/90 mm Hg AND ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) from 135/85 mm Hg - Stage 2 hypertension - BP in surgery/clinic is ≥160/100 mm Hg AND ABPM or HBPM is ≥150/95 mm Hg - Stage 3 or severe hypertension - systolic BP in surgery/clinic is 180 mm Hg or higher or diastolic BP is 120 mm Hg or higher I.e. confirm readings with ABPM OR HBPM for stage 1 and 2!!

Answer 9

ace or arb then a + c OR a + d (then a plus c plus d)

Answer 10

CCB then c + a OR c + d (then a plus c plus d)

Answer 11

spironolactone if potassium <4.5 alpha or beta blocker if potassium >4.5

Answer 12

STAGE 1 treat if <80 AND any of following apply organ damage, established CV disease, renal disease, diabetes, QRISK >10 STAGE 2 offer regardless of age STAGE 3 investigate for end-organ damage urine dip, urine ACR, HbA1c, UE, creatiine, eGFR, opthalm, ECG if all normal, repeat BP in 7 days

Answer 13

abpm measures at least 2 per hour in persons normal waking hours - if not tolerated or declined then offer hbpm hbpm - 2 readings taken 1 min apart with person seated - at least twice daily - ideally for 7 days

Answer 14

before bed because of first dose hypotension

Answer 15

measure renal function and electrolytes before starting POTASSIUM if rises to 5 - investigate and treat other causes like stop potassium sparing drugs (amiloride, spironolactone) or nephrotoxic drugs if persists 5-5.9 - reduce dose and recheck in 5-7 days if >6 - stop and switch to amlodopine can also do ECG if raised OVERALL - refer immediately to A+E if K >6.5 or >5.5 with ECG changes EGFR AND CREATININE o If >25% reduction in eGFR or rise of >30% of creatinine - check for another cause, then stop or reduce for a week then recheck o If >15% reduce in eGFR or rise of >20% in creatinine - remeasure in 2 weeks

Answer 16

- Dry cough - High potassium - Angioedema - GI discomfort, nausea, constipation, vomiting - Renal artery stenosis - Low glucose - First dose hypotension

Answer 17

amlodipine | nifedipine

Answer 18

``` peripheral oedema flushing palpitaitons headaches constipation HF bradycardia or heart block for verapamil HF (verapamil and diltiazem can worsen HF) ```

Answer 19

non-dhps (diltiazem and verapamil) with BB - can cause brady or heart block (are both negative inotropic and chronotropic) lower dose of simvastatin - they increase dose

Answer 20

low sodium and low potassium

Answer 21

- GI - Hypokalaemia – as a result of low sodium - Hyponatraemia - Can exacerbate diabetes - Impotence may precipitate gout attakes - reduces uric acid excretion their effectiveness can be reduced by NSAIDs increases liklihood of digoxin toxicity

Answer 22

morning so not awaken to go to loo in night

Answer 23

``` fatigue cold extremities bradycardia erectile dysfunction can cause hypo or hyperglycaemia - beware in diabetics with frequent hypos ``` beware in COPD - can cause bronchospasm - not on BNF CI list CI in asthma

Answer 24

confusion nausea arrhtymias yellow vision or haloes

Answer 25

should take at 6pm every day so if their dose is changed it can be actioned on the same day (i.e. blood test in morning, then change dose for their evening time)

Answer 26

if BMI >26 or weight >70kg or if taking enzyme inducer

Answer 27

if >3 horus or >12 then take a pill asap need extra contraception for next 2 days if you have unprotected sex in the 2 days after you start taking it reliably again, you may need emergency contraception (it takes 2 days for the POP to thicken cerical mucus so sperm cannot get through)

Answer 28

only if in first week of pack and had unprotected sex in previous 7 days (if later then will just need extra contraception for 7 days

Answer 29

4 weeks before major and restart 2 weeks after due to increased VTE risk

Answer 30

if within 3 hours of taking then take another

Answer 31

- Mood swings, nausea, breast tenderness, headaches, change of periods - usually settle in a few months - May have spotting in between periods - No evidence for weight gain - Serious side effects - blood clots, cervical and breast cancer

Answer 32

levonella - immediate quick start but will need additional contraception for 7 days if COC or 2 days if POP ellaone - wait 5 days before restarting contraception then same as above

Answer 33

levelonelle has to be >48 hours before ovulation ellaone can be right up until ovulation IUD can be 5 days after ovulation

Answer 34

restricted jaw function joint noise facial pain may have locking episodes - unable to open their mouth manage by avoid yawning, singing and chewing gum, bite guards for bruxism (grinding teeth and clenching jaw), analgesia, steroid injection for some, or surgery for some

Answer 35

o Pain at night that is not relieved when person is supine  The spinal disease starts in the sacroiliac joints and may be felt as diffuse non-specific buttock pain  OE there is often tenderness of sacroiliac joints or limited range of spinal motion - later stages will get lumbar lordosis, buttock atrophy, question mark posture o Stiffness in morning that is relieved with movement/exercise - characteristic o Gradual onset of symptoms o Symptoms develop over 3 months o Usually presents before the age of 30 o Most patients have mild chronic disease or intermittent flares with periods of remission o Systemic features are common - fever, weight loss may occur in active disease o Peripheral enthesitis and peripheral arthritis each occur in about 1/3 (e.g. plantar fasciitis) o Extra-articular occur in 20-30% e.g. anterior uveitis, aortic regurgitation secondary to aortitis of ascending aorta, pulmonary fibrosis…

Answer 36

lying down | whereas pain due to cancer typically remains when supine

Answer 37

``` bilateral sciatica lower back pain neurological deficit of the legs impairment in micturition or faecal incontinence laxity of anal sphincter saddle anaesthesia sexual dysfunction ```

Answer 38

o Unilateral pain radiating below knee o Low back may also be present - if so, is less severe than leg pain (often though, is pain in legs without co-existing back pain) o Numbness, tingling and muscles weakness in the distribution is suggestive of nerve root compression

Answer 39

- De Quervain's tenosynovitis o Affects tendons that extend the thumb o The typical symptom is pain over your wrist at the base of your thumb that is made worse by activity and eased by rest - Trigger finger o This most commonly affects your ring finger. The condition prevents your finger from straightening fully - Tennis elbow (lateral epicondylitis) o It is usually due to overuse of your forearm muscles - Golfer's elbow (medial epicondylitis) - Achilles tendinopathy - Rotator cuff tendinopathy

Answer 40

``` rest ice packs ibuprofen, paracetamol, co-codamol physiotherapy steroid injection rarely - surgical release of the tendon ```

Answer 41

under surface heel pain is a misnomer as pathologyi is actually degenerative thorught to be a traction and overuse injury damage is usually in the form of micro-tears can be bilateral risk factors = spending time on feet, running, jumping, wearing worn-out trainers, obesity, flat feet reproduction of pain when pressing on plantar surface - or when patient stands on toes or passive dorsiflexion rule out referred pain from S1/s2 lesion via straight leg raise manage with weight loss, run on a softer surface, update shoes reguarly, takes 6-8w w conservative management, deep massage of sole and foot, heal and arch support may help, night splints to keep ankle dorsiflexed and toes extended to help stretch the plantar fascia limited evidence for steroid injection

Answer 42

VIRAL more likely watery discharge pre-auricular lymphadenopathy BACTERIAL purulent discharge more likely unilateral ALLERGIC itchiness more common might be redder around the eye may be swelling

Answer 43

visual acuity, fundocsopy if unsure (look for clouding of the anterior chamber), can swab for HSV if longer lasting VIRAL usually resolves within 7 days, dont share towels, cool compresses, lubricating drops, avoid contacts, avoid close contact with others (dont have to exclude from school), wash hands frequently BACTERIAL most resolve within 7 days wihtout treatment, same self care as above, if severe or needs rapid resolution then can use topical antibiotics , or can do a delayed strategy saying to take if not resolved in 3 days - chloramphenicol drops or fusidic acid second line, dont exclude from school, explain red flags of reduced visual acuity or photophobia ALLERGIC avoid allergens like pets or mould, avoid eye rubbing, cold compress, artifical tears, if non-pharmacological measures dont provide relief then topical antihistamine like antazoline drops (mast cell stabiliser second line, topical steroids if v severe)

Answer 44

90% will resolve spontaneously – the herniatied material will become dehydrated, and be reabsorbed - within a few weeks Encourage return to normal activities as soon as possible Short frequent walks Swimming is beneficial Advise analgesics and NSAIDs - 10-14 days of regular NSAIDs In more severe cases, physiotherapy may be beneficial In very severe cases, you can give local steroid injections, which will provide pain relief, but do not alter the longer term course of the illness In cases lasting longer than 12 weeks: Further investigation may be necessary X-ray is of virtually no use! MRI – is the investigation of choice. It can directly show the herniation, allowing you to assess its location, size, and view any impinged structures CT – may also be useful, but provides a lower resolution image, and has been mainly superceeded by MRI Most cases are still managed conservatively Consider some of the treatment options for chronic pain e.g. Amitriptyline 10-25mg nocte, increasing to a maximum of 75-100mg daily Operative treatment is given in some cases. The main procedure is called microdiscectomy. It is performed thrugh a small inscisional windows cut in the laminae and ligamentum flavum. In 90% of cases, patients can return to work within 6 weeks

Answer 45

low-grade fever, fatigue, headache, tired all the time, myalgia and prolonged malaise may have nausea or vomiting sore throat tonsillar enlargement (often meet in midline) - classically exudative palatal petechiae and uvular oedema bilateral cervical lymphadenopathy snoring or even sleep apnoea due to significant tonsillar enlargement neck may be swollen may seen splenomegaly (+/- abdo pain) and even hepatmegaly feverish/tired symptoms/swollen lymph glands may persist for several months after acute infection has resolveed, whereas the sore throat typically lasts 7-10 days

Answer 46

FBC - atypical lymphocytosis - i.e. a relative raised lymphocyte count within the raised WCC ESR - raised LFTs - mildly raised in around 75% monospot test is primary technique but relies on generation of non-specific heterophile IgM autoantibodies which may take a week to appear (NICE say to do this in second week of illness) repeat this a week later if negative and suspicions are high patients who remain heterophile-neg after 6 weeks with IM are considered to be heterophile-negative and should be tested for EBV specific antibodies (also useful if a false positive monospot is suspected) - via ELISA for IgM viral capsid antigen abdominal US may be required to assess for splenomegaly

Answer 47

arrange hospital admission if stridor, dehydration or difficulty swallowing, suspected splenic rupture avoid contact sports for 4 weeks because of splenic rupture risk - risk is highest 14 days after avoid alcohol for illness duration - can feel much worse than usual due to effect of glandular fever on the liver paracetamol for fever and pain bacterial superinfection is present in as many as 30% and so penicillin-based antibiotics (usually benzylpenicillin/penicillin V) are often prescribed - remember to avoid ampicillin and amoxicillin advise that symptoms usually last 2-4w tiredness is common and often last thing to resoslve dont have to exclude from work or school avoid kissing and sharing eating utensils advise to seek medical help if develop stridor, become systemicall yunwell, develop abdo pain (may indicate splenic rupture)

Answer 48

mrc dyspnoea scale

Answer 49

``` ACUTE BRONCHITIS normal cxr less unwell may or may not have temp may or may not have sputum, wheeze, breathlessness ``` PNEUMONIA fever more fatigue more productive cough

Answer 50

increase fluids, paracetamol, ibuprofen seek medical help if symptoms worsen rapidly or do not improve after 3 to 4 weeks do not routinely offer an antibiotic in people who are not systemically very unwell --> advise people that antibiotics do not make a large difference to the duration of symptoms, only shortening cough duration by about half a day on average + about adverse effects including diarrhoea and nausea offer an immediate antibiotic prescription if the person is systemically very unwell consider an immediate antibiotic prescription or a back-up antibiotic prescription for a person at higher risk of complication e.g. comorbid lung condition or something or elderly using steroids etc if CRP has been done can be a guide to abx prescribing o CRP less than 20 mg/L — do not routinely offer antibiotics o CRP 20–100 mg/L — consider a delayed antibiotic prescription o CRP greater than 100 mg/L — offer antibiotic therapy - If antibiotics are indicated, for adults 18 years of age and older: o First-line choice is oral doxycycline

Answer 51

``` - Arrhythmias o SVT, AF, bradyarrhythmias (AV block, sinus bradycardia) - Structural heart disease o Mitral valve prolapses, aortic or mitral regurgitation, cardiomegaly, HF - Psychosomatic o Anxiety, depression - Systemic causes o Hyperthyroidism, hypoglycaemia, fever, anaemia, pregnancy, menopause, hypovolaemia - Medication, recreational drugs o Beta-2 agonists, vasodilators o Withdrawal of beta blockers o Alcohol o Nicotine o Cocaine, MDMA, cannabis, speed, heroin o Caffeine - cola, coffee, tea, red bull ```

Answer 52

- Ask the patient to tap out the beat - Ask if accompanying chest pain - = more sinister - Onset associated with exercise is a red flag - Ask about family history of sudden cardiac death <40 years - General exam, BP - Gold standard is ECG taken at the time of the palpitations - Blood tests - FBC, U&Es, TFTs, LFTs and HbA1c - 24-hour or 48-hour Holter monitor (types of ambulatory ECGs) - if not can use an event monitor or self-activated recorder for less frequent symptoms - Echo if cardiomyopathy is suspected - Exercise testing: if the problem is related to exercise then a treadmill ECG or stress echocardiogram is required

Answer 53

HbA1c >48 random blood glucose >11.1 fasting blood glucose >7 should be confirmed with repeat testing - esp if asymptomatic - is prudent for symptomatic - usually taken in 2 weeks time pre-diabetes = 42-47 mmol/l

Answer 54

DESMOND programme (a group of educational programmes for diabetics) X-PERT diabetes programme (a 6w course for anyone living with a longterm health disorder inc diabetes) lifestyle - consider dietician - it is essential that these modifications continue once antidiabetic drugs are introduced o Control amount of carbohydrates and high-fat foods, increase fibre o Exercise can lower blood glucose as it increases glucose use by the muscles o Exercise daily with at least 150 minutes of moderate intensity activity over a weekly period - do strengthening activities that work all the major muscles (legs, hips, back, abdomen, chest, shoulders and arms) on at least 2 days a week o Smoking and alcohol (alcohol can exacerbate hypoglycaemia as well) 48 metofrmin - if not then DPP-4, pioglitazone, SU, SGLT-2 aim for 48, if associated with hypo then 53 58 dual therapy aim for 53 STILL NOT DECREASING add a third or consider insulin (if >58 and not if obese) STILL NOT if on triple - consider combination of metformin, SU and GLP-1 if on insulin - seek specialist advise BP management <140/90, but if kidney, eye or CV damage then <130/80 GLP1 agonist can be added w su and metformin in obese patients (or where weight loss would benefit weight related comorbidites like HTN, OA, sleep apnoea) or where insulin would lead to occupational restrictions like HGV drivers

Answer 55

starts just breakfast, then breakfast and tea etc. etc. to TDS - start at 500mg

Answer 56

sitagliptin | linagliptin

Answer 57

Vitamin B12/folic acid deficiency Iron-deficiency anaemia Splenectomy

Answer 58

in some cases, it may be indicated to differentiate between T1DM and T2DM in a newly presenting patient this involves testing for C-peptide (low in T1DM) and Autoantibodies (+ve in T1DM)

Answer 59

o Cortisol released during illness --> higher glucose levels o Increase frequency of blood glucose monitoring and consider ketone monitoring  If no ketones, then test glucose and ketones every 2-4 hours, if ketones present or glucose is high (>15) then test glucose and ketones every 2 hours o Never stop taking insulin - you may need an increased dose/additional doses of fast acting (even if not able to eat) o Try keep a normal meal pattern - meals may be replaced by carbohydrate-based drinks o Good hydration - as well as sugary drinks, also drink clear sugar free fluids to avoid dehydration o Seek urgent medical attention if unable to tolerate oral intake, drowsy or sustained vomiting, rapid breathing (sign of DKA) o If blood glucose is 10-13 then increase usually insulin by 10% o If >13 or not responded to increasing insulin then give extra dose of quick acting insulin (approximately 10% of total daily insulin) type 2 sometimes need to hold your medications - when ill still produce some insulin w type 2 so may be at risk of hypo drink a lot of fluids and montior levels seek help if vomiting

Answer 60

DAFNE - dose adjustment for normal eating educational programme

Answer 61

should perform at least 4 capillary blood glucoses per day - including one before each meal and one before bed increase monitoring if frequency of hypos increases, during periods of illness, before, during and after sport, when planning pregnancy, during pregnancy and while breastfeeding o Should be 4-7 before meals/at other times of day o 5-9 at least 90 minutes after eating o 5-7 on waking

Answer 62

- HbA1c should be 48 - measured 3-6 monthly - consider more if blood glucose control is changing rapidly

Answer 63

- DAFNE - dose adjustment for normal eating education programme - Life-long insulin is needed to prevent complications like DKA and CKD, IHD, retinopathy - 3 types of insulin regime o Basal bolus  One to offer first  Injection of rapid or short-acting before meals, with 1 or more separate daily injections of intermediate or long-acting per day  Thought to best mimic physiological function of the pancreas o Continuous subcutaneous insulin infusion (insulin pump therapy)  Patient can activate pre-meal boluses  As well as it given a regular amount of short or rapid acting  May be used in those having troubling hypoglycaemic episodes o One, two or three injections per day  These are usually injections of short acting insulin or rapid acting insulin analogue mixed with intermediate acting insulin (or injected separately)  It may be difficult to achieve optimal glycaemic control and the regimen can be complicated by hypoglycaemic episodes E.g. 4 units for small meal, 8 for large

Answer 64

lowers blood glucose levels through inhibition of hepatic gluconeogenesis whilst increasing peripheral insulin sensitivity and enhancing peripheral uptake of glucose CI in CKD and those at risk of lactic acidosis or not tolerated

Answer 65

- Patients with poor glycaemic control require measurement of the HbA1c every 3 months - Patients with stable disease can have their HbA1c measured every 6 months

Answer 66

- At least on an annual basis - During each review - BMI, smoking status, assess for any anxiety or depression - Annually … o Retinopathy: annual retinal screening and eye check o Nephropathy: renal function (eGFR) and albumin:creatinine ratio (ACR) o Neuropathy and diabetic foot: assessment for peripheral neuropathy, autonomic neuropathy, full examination including footwear, monofilament assessment of neuropathy, vascular assessment +/- dopplers o Cardiovascular risk factors: primary/secondary prevention strategy with optimisation of blood pressure and lipids

Answer 67

- Once or twice daily intermediate-acting insulin (NPH) o Often started on this in early stages - then if bad may start on mixed - Intermediate-acting insulin along-side a short-acting insulin as separate injections or a pre-mixed formula - Once daily long-acting insulin therapy (glargine, determir) o Usually reserved for when hypoglycaemia is a problem with NPH or patient relies on carers for infections - Basal-bolus regimes o Finally, patients on a pre-mixed insulin regime that still have inadequate blood glucose control should be assessed for conversion to a basal bolus regime

Answer 68

hyperthyroidism following administrating of iodine or iodide like contrast

Answer 69

- Asymptomatic with the exception of fracture | - Common fragility fractures include vertebral crush fractures and proximal wrist and proximal femur fractures

Answer 70

- All women >65 - All men >75 - All aged 50+ who have any of the following risk factors: o A previous osteoporotic fragility fracture o Current use or frequent recent use of oral corticosteroids o History of falls o Low BMI (less than 18.5 kg/m2) o Smoker o Alcohol intake of more than 14 units per week o A secondary cause of osteoporosis such as hypogonadism, DM, hyperthyroidism, hyperparathyroidism, ceoliac, MM, CKD, immobility, RA, IBD, cushings... AND<50 if taking steroids or premature menopause of histroy of fragility fractures AND <40 taking steroids or previous fractures also consider if on SSRIs, anti-epilpetics, PPIs, pioglitaozne, GnRH agonists or aromatase inhibitors

Answer 71

o Over 50 years of age with a history of fragility fractures — a DXA scan should be offered o Under 40 years of age who have a major risk factor for fragility fracture — a DXA scan should be offered o With vertebral or hip fractures — starting treatment without undertaking DXA should be considered if this is inappropriate or impractical

Answer 72

NICE recommend having a DEXA if the 10-year fracture risk is 10% or more o T score -≤2.5 = osteoporosis o -≤2.5 + previous fragility fracture = severe or established osteoporosis o -1 to-2.5 = osteopenia bloods - calcium, phosphate and PTH and ALP should be normal (low calcium could be osteomalacia, hypercalcaemia could be hyperparathyroidism) ``` can also consider doing radiographs if o ≥4cm height loss o Kyphosis o Recent or current long-term steroids o BMD ≤2.5 ```

Answer 73

treat any secondary cause offer treatment if -<2.5 T score and repeat DXA every 2 years (1 if changes to treatment) if <2.5 then dont treat but repeat DXA every 2 years lifestyle - alcohol, smoking, diet, supplementation if needed, falls assess inc med review, weight bearing exericses, balance training bisphosphonates - alendonic acid usually frst line (remember good dental hygiene and report thigh or hip pain) - others inlcude risedronate (PO) or zoledronic acid (IV injection annually) CI in low calcium and uveitis denosumab- monoclonal antibody given 6 monthly SC - SE hypocalciaemia so may have to monitor - it may be a suitable option in women who are unable to comply with instructions for alendronate raloxifene - selective oestrogen receptor modulator HRT - noramlyl reserved for younger - longterm not recommended

Answer 74

``` ET bilateral, PD unilateral PD occurs at rest PD affects arms, legs, jaw ET affects arms, head, voice ET is a postural/action tremor alcohol relieves ET tremor ``` ET can be treated with propranolol or primidone (antiepileptic)

Answer 75

- Resting tremor - usually improve with moving - Rigidity - cogwheeling and lead pipe - Bradykinesia - Postural instability - Masked facies - Shuffling gait - Hypophonia - Micrographia

Answer 76

- Diagnosis is based on clinical criteria and exclusion of other disorders - DAT scan or SPECT if unclear - CT or MRI if thinking secondary cause like stroke

Answer 77

(currently no disease-modifying treatments so key is symptom control - treatment should be initiated early following diagnosis) physiotherapy, speech and language (help with hypophonia), OT FIRST LINE TREATMENTS levodopa - usually given with a dopa decarboxylase inhibitor - is usually given in early stages of the disease when motor symptoms effect QoL - BUT only lasts for 4-6 years before longterm motor complications may arise so younger pts are often given dopamine agonists instead in earlier phases oral or transdermal dopamine agoinsts like pramipexole or ropinirole MAO-B inhibitors like selegiline - not as good for motor symptoms - so maybe good for early stages where motor not as pominent ADJUVANTS many pts will require additional therapy - this may mean combining some of the above or addigng the following COMT inhibitors like entacapone (in combo w levodopa for dyskinesia or motor fluctuations) amantadine a nicotininc antagonist (if dyskinesia not adequately controlled) sc apomorphine a dopamine agonist duodopa pump refractory to oral DBS of subthalamic nucleus if refractory to medical (via insretion of electrodes into deep nuclei of the biran then pulse generator is inserted into the chest wall) review every 6-12 m

Answer 78

constipation - increase fibre, laxatives pain n+v - avoid metoclopramide and prochlorperazine - consider low dose domperidone bladder dysfunction - catheter

Answer 79

loss of dopaminergic neurones

Answer 80

Motor ‘on-off’ fluctuations - switch from dyskinesia to immobility in a few minutes - can be helped with a dopamine agonist Dyskinesia - hyperkinetic movement due to dosing of medications - relieved by reducing dose or adding a long-acting dopamine agonist Freezing of gait - complete inability to move 'Wearing off' phenomenon - towards end of dose - can be helped by introducing other drug ontop of Levodopa Falls

Answer 81

hygeiene - avoid caffine smoking alcohol at night, regular exercise, relaxing activities, avoid heavy meals before bed, avoid screens, only use room to sleep, routine if fail - try short course 3-7 day course of z drugs - zopiclone, zaleplon, zolpidem if unlikely to reoslve soon then CBT for insomina - typically includes behavioural interventions (such as stimulus control and sleep restriction), cognitive therapy and relaxation training consider need for hypnotic medicaitions like short term z drug or melatonin if >55 for 3 weeks

Answer 82

- Symptoms o One-sided facial weakness that comes on over hours (<72 hours) o Difficulty chewing food on that side +/- drooling o Unable to close eye on affected side o Unable to wrinkle forehead o May have speech difficulties o Post-auricular/ear pain in 50% o Loss of taste on one side of tongue o Hyperacusis - loud noises may become uncomfortable - this occurs due to weakness of the strapedius muscle (strapedius nerve comes off facial nerve) - Signs o Loss of nasolabial fold o Drooping of the face on that side - corner of mouth, eyebrow, asymmetrical smile o Bell’s sign - upward movement of the eye maintained on attempt to close the eye

Answer 83

thought to be related to infalmmation and oedema of the facial nerve secondary to a viral infection or autoimmunity - most commonly due to herpes simplex of varicella zoeter most common in pregnant women and diabetics

Answer 84

- Ramsay hunt syndrome o Results from reactivation of the latent VZV within the geniculate ganglion o Facial nerve palsy that is associated with a vesicular rash at the ear, ipsilateral hard palate, and anterior 2/3 of the tongue - other than that has same symptoms as Bell’s o Treatment is with antivirals and steroids and appropriate eyecare - Stroke - Cerebral tumour - If bilateral - needs specialist input as this is very rare and often secondary to something like lyme disease, sarcoid, GBS, HIV

Answer 85

- Clinical diagnosis | - May involve routine bloods, neuroimaging or special tests like LP, lyme serology

Answer 86

prednisolone for 10 days if presenting <72 hours of symptom onset antiviral may be combined with this but only small benefit and specialist advise should be sought eye protection with eye drops, tape shut at night, wear sunglasses outdoors, avoid swimming and dusty environments if eating is affected - can use a straw for liquids and a soft diet advise that prognosis is good but may take several months to recover refer to neurology or ENT if no improvement after 3 weeks of treatment

Answer 87

- If becoming really dehydrated, may have to stop metformin - the GP or diabetic team will guide you - In general, may need to increase your medication depending on the glucose results - If on insulin - same as T1DM but increase insulin by 20% instead of 10%

Answer 88

unilateral temporal pain - occassionally diffuse and bilateral headache tenderness over scalp e.g. pain on combining hair intermittent jaw claudication +/- tongue claudication visual disturabnce in 50% - bluured vision, amaurosis fugax, transietn or permanent visual loss or diplopia - if untreated second eye is likely to be affected within 1-2 weeks systemic features like PMR - fever, fatigue, anorexia, weight loss, night sweats, anorexia, depression Thoracic aorta and aortic root involvement: occur in about 15%. This is more common in women and younger patients. Thoracic aneurysms can develop as late as 15 years after the diagnosis and successful treatment of GCA NB features of polymyalgia rheumatica – bilateral upper arm stiffness, neck and shoulder pain, aching, tenderness, pelvic girdle pain

Answer 89

examine area - temporal artereies may be prominent, beaded, tender, pulsenss listen for bruits temporal artery biopsy under LA - positive confirms but negative doesnt always run out due to skip lesions start steroids while awiting biopsy in high suspicion fbc, lfts, esr (often greater >50mm/hour), crp also typically elevated fudoscopy for eye changes = e.g. may see anterior ischaemic optic neuritis other - colour duplex US is being increasingly used but doesnt replace temporal biopsy

Answer 90

oral prednisolone - 60mg if claudication symptoms, 40mg if not - assess response in 48 hours, will be rapid once symptoms resolve then reduce dose by 10mg every 2 weeks for people w visual symptoms admit for treatment with IV methylpred course of 1-2 years of steriods is often necessary but can be longer - osteoporosis prophylaxis for longterm disease settles after 12-36m in 75% of cases aspirin 75mg to reduce thrombotic even in affected arteries - is uncertain how long for PPI for steroid and aspirin use

Answer 91

o Every 2–8 weeks during the first 6 months of diagnosis — close monitoring of BP and blood glucose (cos of steroids) o Then decrease to every 12-24 weeks monitor bloods and side effect

Answer 92

- Vision loss - Large artery complications (such as aortic aneurysm, aortic dissection, large artery stenosis, and aortic regurgitation) - Cardiovascular disease (such as MI, HF, stroke, peripheral arterial disease) - Peripheral neuropathy - Deafness - If the internal carotid arteries are affected there may be TIA or stroke

Answer 93

>15 days per month

Answer 94

consider keeping a headache diary to monitor for triggers reassure explain they are more common in sedentary people and regular exercise can benefit ibuprofen fist line - paracetamol seems to be less effective - other options = naproxen or aspirn TCAs - amitriptyline alternative

Answer 95

pain in distribution of trigeminal nerve - typically mandibular and maxillary branches (ophthalmic not so much affected) is due to vascular compression of the trigeminal nerve in most cases - other rarer causes include MS, tumours, AV malformations

Answer 96

pain in distribution of trigeminal nerve - cheek or lower jaw severe, electric shock like, unilateral, short lived (seconds-2 minutes, stopping suddenly) pain may occur infrequently - e.g. periods of remission may last years , or have a frquency of up to 100 times a day pain can be triggered by touching the face, talking, cold wind, vibration, brushing teeth atypical trigeminal nerualgia occurs when there is a persistent discomfort between pain episodes

Answer 97

50-60 rare under 40

Answer 98

diagnosis is clinical MRI if in doubt or underlying cause like a mass is supected - or occuring <40 or if surgery is being considered as a treatment

Answer 99

carbamazepine - start at 100mg up to 2x daily and titrate in steps of 100-200 until pain has resolsved once pain is in remission, dosage should be gradually reduced until maintenance level, or drug can be discontinued until a further attack occurs alternatives = gabapentin, baclofen, lamotrigine if not reponding to meds - botulinum toxin type A, deep brain stimulation surgery (decompression surgery or ablative surgery)

Answer 100

- Of a new diagnosis o 66% will have a further episode in 5 years o 77% will have a further episode in 10 years - The majority will have remission with medical therapy although 10% will not respond

Answer 101

urethral swab can diagnose urethritis (>5 polymorphonuclear cells per high power field) and gonorrhea culture and NAAT for chlamydia (or first pass urine) microscopy and cluture midstream urine for bacteria when considering mumps as a possible diagnosis - IgM/IgG serology

Answer 102

- Empirical therapy should be given to all patients with epididymo-orchitis before culture/NAAT results are available o If most likely due to STI  Ceftriaxone IM + doxycycline for 10-14 days o For epididymo-orchitis most probably due to enteric organisms  Ofloxacin 200 mg by mouth twice daily for 14 days or ciprofloxacin 500 mg by mouth twice daily for 10 days

Answer 103

IPSS to give assessment of quality of life - the score from the first 7 q’s which are about the symptoms classes the disease in mild, moderate, severe (the 8th q is about quality of life) examine abdomen for palpable bladder DRE - note tone of anal sphincter/pelvic floor as may be poor with neurogenic bladder - and assess prostate urine dipstick - MSU for microscopy and culture bloods - may be deranged in mets e.g. lfts PSA - avoid vigarous exercise and ejaculation for 48 hours prior post-void residual bladder volume via catheter or bladder scan US via abdomen or transreactal can be done to evaulate prostate size also evaluate for hydronephorisis in urinary retention MRI for malignnacy urodynamic studies - Qmax and flow pattern other = pressure studies but invasive (type of invasive urodynamic study) or cystoscopy if sticture is suspected

Answer 104

acute retention - catheter then TWOC minimal symptoms - watch and wait provided malignancy has been excluded - med and surgical therapies have comps which can be avoided MEDICAL alpha blocker reduce tone of muscle in bladder neck - tamsulosin - postural hypotension may limit use for some, and can sometimes cause ejaculatory dysfunction 5-alpha reductase inhibitos - reduce synthesis of testosteorne - can take longer to take effect (months rather than days) - finasteride - can cause reduced libido, erectile dysfunction can combine SURGERY - large prostate failed to respond TURP - can cause infection, retrograde ejaculation and may need catheter after holmium laser enucleation of prostate (HoLEP) - similar SE to TURP transurethral vaporisation of prostate transurethral incision of prostate (smaller ones) open prostaectomy for larger ones - no ejaculate can be produced and may have urinary frequency

Answer 105

- Vascular - CVD, atherosclerosis, HTN, DM, smoking, surgery or radiotherapy - Neuro - PD, stroke, MS, tumours, spinal cord disease, alcoholism, peripheral neuropathy - Hormonal - hypogonadism, high prolactin - Drugs - antihypertensives, BB, diuretics, antidepressants - Psychosexual factors - Psychiatric illness

Answer 106

avoid touching, wash hands after, avoid kissing paracetamol and ibuprofen choline salicylate gel (bonjela) (CI<16) lidocaine gel topical antiviral agents like aciclovir 5% but benefits are small and usually resolve in 7-10 days without treatment for immunocompromised - oral antiviral

Answer 107

hygiene measures - avoid touching, avoid sharing towels children should stay off school until lesions are dry and scabbed over or person has been on Abx for 48 hours LOCALISED NON-BULLOUS hydrogen peroxide cream fusidic acid 2nd line WIDESPREAD NON-BULLOUS flucloxacillin oral - plus can do topical things as above BULLOUS oral fluxclox

Answer 108

caused by varicella zoster (HHV-3) - after chickenpox it lies dormant in sensory root ganglia (if facial nerve is affected it causes ramsay hunt syndrome) presents with pre-eruptive phase - burning, itching or paraesthesia in one dermatome, may feel unwell eruptive phase - skin lesion apperas, may have neuritic pain, vesicular erythematous rash, resolves at 14-21 days chronic pain/postherpetic neuraliga - persistent pain

Answer 109

ophthalmic is a danger to sight so should see an ophthalmologist the same day for antiviral therapy rash should be kept clean to avoid secondary bacterial infection if the rash is weeping and not in a covered part of skin, then the person should stay off work or school oral aciclovir preferable within 72 hours of onset for anyone w non-truncal involvement or where moderate pain or immunocompomised and consider if >50 to reduce incidence of post-herpetic neuralgia as this is common in this age group if it is not possible to initiate treatment within 72 hours, consider starting an antiviral drug up to one week after rash onset, especially if the person is at higher risk of severe shingles or complications (e.g. continued vesicle formation, older age or severe pain) longer IV treatment may be required in elderly and the immunocompromised use of steroids is debated - must combine w aciclovir if used analgesia - can try TCAs, gabapentin or pregabalin or opiods if first line fails like NSAIDs

Answer 110

calamine lotion | non-sedating antihistmaines

Answer 111

``` age genetic predisposition increased sebum productin/oily skin medication - steroids, antiepileptics use of cosmetics - should try paraben free pcos thyroid dysfunction ```

Answer 112

abnormal follicluar differentiation sebaceous gland hyperplasia and excess sebum production propionibacterium acnes colonisation inflammation

Answer 113

patient education conservative - dont overwash face, use fragrance free products, SPF, role of diet not understood but data suggests high GI diets may exacerbate, avoid picking spots due to scarring risk MILD-MOD topical retinoid (tretinoin - skin more sensitive to light so apply at night - CI in pregnancy) alone or in combo with benzoyl peroxide (may bleech clothing - apply once daily wash off several hours after) OR topical antibiotic (clindamycin) always in comb w benzoyl peroxide OR azelaic acid OR salicyclic acid creams or lotions for dry or sensitive skin, gels for oily skin MODERATE consider adding lymecycline or doxycycline taken for at least 2m - co prescribed w topical retinoid or benzoyl peroxide OR COC ``` REFER TO DERM IF multiple treatments fail, sig distress, severe variant, diagnostic uncertainty, scarring consider isotretinoin (Roaccutane) ``` light treatments can be used but research not as good atm

Answer 114

- In primary infestation, signs and symptoms only develop after 3-4 weeks - Generalised and intense pruritus, typically worse at night and when the person is warm - Burrows - Papules, vesicles, excoriations diagnosis is clinical - magnifying lens can help identify burrows, and can do ink burrow test - skin scraping can confirm (can site mite or eggshell under micorscope)

Answer 115

treat all members of household w topical application on whole body with permethrin cream wash clothing and beeding at 50 degrees

Answer 116

combo of genetics and environment mutations in a gene that controls the skin barrier is thought to lead to impaired barrier function thus this means increased exposure and sensitisation to antigens once antigens are allowed in they trigger an inflammotory response

Answer 117

scaly, itchy and erythematous patches commonly affecting the flexures (elbow, knees, wrists) infants often present with rash affecting the cheeks those of black ethnicity may demonstrate a different distribution with rashes affecting the extensor surfaces affected skin can develop patches of both hypo and hyperpigmentation itchiness leading to scratching can be evidenced by excoriations and with time lichenification (thickening) of the skin develops

Answer 118

screening tools like POEM conservative - avoid allergens e.g. animals, soap, food, avoid tight clothing, avoid fragraces/soap, keep house cool, cut fingernails (more so for children) MILD emollients - frequent and liberal use consider mild topical steroid like hydrocortisone for areas of red angry skin MODERATIE emollients moderaly potent steroid for inflammed skin like betamethasone 0.025% severe itch then non-sedating antihistamine between flares can consider prescribing a maintenance regime of topical steroids to skin prone to flares 2nd line to topical steroids would be calcineurin inhibitor like tracrolimus SEVERE emollients potent topical steroid for inalmmed skin e.g. betamethasone 0.1% non-sedating histamine for itch severe eczema causing lots of distress then short course of oral steroid consider topical steroid between flares as above phototherapy immunosuppressants biologics can use bandages to stop scratching Local side effects of steroids are common and may include a burning sensation, thinning of skin, contact dermatitis, acne and depigmentation

Answer 119

watchful waiting, debridement w pummel stone then salicyclic acid, duct tape occlusion as an adjunct, cyrotherapy, silver nitrate solution

Answer 120

- Keep stools soft - lots of fluid, increase fibre, consider a laxative (bulk forming for adults - ispaghula husk/Fybogel) or osmotic (lactulose) for children) - Pain relief - paracetamol/ibuprofen, warm baths, GTN ointment (for adults with a fissure for over a week) - Consider a topical anaesthetic e.g. lidocaine for adults with extreme pain - Treat underlying cause - Refer adults with ongoing pain that has not resolved within 6-8 weeks - Secondary care o Topical diltiazem or nifedipine o Botulinum toxin o Surgery - sphincterotomy

Answer 121

``` internal haemorrhoids are painless cos upper anal canal has no pain fibres - only painful if strangulated external may be painful and itchy bright red bleeding with defectation feeling of rectal fullness impaired continenence ``` investigations - ask pt to sprain may become visible, protoscopy to view inside, flex sig may be done to exclude other pathology, FBC anaemia

Answer 122

increase fibre, bulk forming laxative like fibrogel analgeisa topical therapies like anaesthetics or topical steroids avoid straining non-surgical - rubber band ligation (becomes necrotic then falls off), infrared coagulation, injection sclerotheapy leads to atrophy, bipolar diathermy (heat leads to fibrosis) surgical - haemorrhoidectomy under GA, haemorrhoidal artery ligation

Answer 123

definition of CKD is the presence of either of the following for 3 months or more Marker of kidney damage: - Albuminuria (> 3 mg/mmol, i.e. A2/3) - Abnormalities (including electrolyte derangement) secondary to tubular disorders - Structural abnormalities - Abnormalities on histology - History of kidney transplant Reduced GFR: GFR < 60 ml/min/1.73 m2 (i.e. G3a-G5)

Answer 124

eGFR | ACR (degree of albuminuria)

Answer 125

RENOPROTECTION smoking cessation target bp <140/90 (<130/80 if also diabetic or ACR >70) statin 20mg antiplatelet diet - K restriction if hyperkalaemic, avoidance of high phosphate food e.g. milk, egg, cheese SECONDARY HYPERPARATHYROIDISM phosphate binders, vitamin D analogues ANAEMIA replace iron/b12/folate as necessary, consdier recombinant EPO ACIDOSIS sodium bicarb supplements OEDEMA loop diuretics RESLETSS LEGS/ CRAMPA quinine dialysis, kidney transplant at end stage <30 egfr, uncontrolled complications

Answer 126

the presence of characteristic symptoms (e.g. dysuria, frequency) and significant bacteriuria (presence of bacteria in urine). Significant bacteriuria is defined as > 105 colony forming units (CFU)/ml. In the absence of symptoms, this level of bacteriuria is termed asymptomatic bacteriuria

Answer 127

in young, non-pregnant females, typical clinical features (e.g. dysuria, suprapubic pain) in the absence of vaginal symptoms, is highly suggestive of a UTI. In this patient group, the probability of a UTI is > 90%. Further laboratory testing offers little to the diagnosis, however as a minimum, the majority of clinicians would do a urine dip In the presence of complicating factors (e.g. systemic upset, diabetes, pregnancy, recurrent UTIs), further laboratory testing is necessary. Urinalysis, involving a urine dipstick and urinary microscopy, culture & sensitivity, (MC&S), is key for complicated - can do bloods, US or CT to assess for abscess, haemorrhage, calculi, obsrtuction and emphysematous pyelonephritis consider cystoscopy if haematuria present or recurrent infections not responding to abx

Answer 128

conservative - avoid risk factors, drink lots of fluids, avoid wiping back to front, post-coital urination, avoid occlusive underwear - cranberry juice isnt recommended (benefit is limited surggestive of studies) uncomplicated UTI - trimetho or nitro for 3 days in women and childen, 7 days for men, 7 days for catheter-associated NB a delayed script can be considered instead of immediate abx if symptoms are mild and no risk factors for complicatino - 48 hours uncomplicated pylonephritis - ciprofloxacin 14 days from home complicated UTI - oral ciprofloxacin and will need MSU (complicated = occurs where anatomical, functional, or pharmacological factors predispose the person to persistent infection, recurrent infection or treatment failure - e.g. diabetes, catheter, anatomy) recurrent if associated with sex can take trimethoprim 2 hours before sex if not associated with sex then 6m course of low dose abx (nitro or trimetho) in postmenopausal women consider vaginal oestrogen Safety-netting - Tell the patient that most UTIs respond to antibiotics within 24-48 hours - seek help if not repsonding - Red flags - if pain is increasing and travelling up towards the loins, they may be developing pyelonephritis which needs treating with cephalexin +/- admission if becoming septic so they must see the GP, or call NHS 111, or 999/A&E

Answer 129

avoid trimethoprim in pregn - is a folate antagonist - esp avoid in 1st trimester avoid nitro in renal impairement -egfr <45 and avoid at term due to risk of neonatal haemolysis

Answer 130

re-test urine after antibiotic - if haematuria persists then consider possible underlying causes e.g. CKD, urological cancer, gynaecological cancer

Answer 131

peripheral/vestibular - BPPV, vestibular neuronitis, labyrinthisis, meniere's disease central - acoustic neuroma, CVA, brainstem lesion, MS NB in peripheral - if nystagmus is associaed this is NEVER vertical also can differentiate with the dix-hallpike maneouvre - in central there is no lag between it and nystagmus and nystagmus lasts <1min - whereas in peripheral - there is a 2-4 second lag and lasts <1 min And with central - neurological symptoms/signs, auditory features are uncommon, prolonged vertigo >24 hours also the vertigo provoked is more likely to be severe with peripheral after the manoeuvre

Answer 132

specific and predictable changes in head position eg getting out of bed causes vertigo that lasts 30 seconds to 1 minute nausea commonly associated is due to debris in the canal which is disturbed by head movement, then (debris could be there cos of idiopathic, infection, ageing or trauma) resettles causing vertigo due to interrpting flow of endolymph signs = nystagmus when preforming dix-hallpike is diagnostic o Turn head to 45 degrees to the horizontal. Patients are lowered quickly to a supine position with the neck extended around 30 degrees below horizontal (so hanging off the bed) – will experience vertigo and see nystagmus treat with epley manoeruvres to clear the debris - can be taught modified one to do themselves can also advise to avoid suddent head movements and to lie and sit in stages generally is self limiting - if lasting >4w then should refer as is unlikely BPPV

Answer 133

most common in 40-50 triad of vertigo, unilateral hearing loss and tinnitus (additional = aural fullness) not related to head movements like bppv abrupt onset is due to dilation of endolymphatic spaces by fluid - overproduction - causes rupture of membrane separating endolymph from perilymph vertigo attacks last >20 minutes but <24 hours (patients will have nystagmus during the attacks) - acute episodes may occur in clusters of about 6-10 a year - remission between may develop bilateral symptoms years later MRI is advised for unilateral cases to exclude acoustic neuroma should inform dvla, limit salt caffeien fatigue, consider saftey w heights, dangerous machinery acute attack treat with propchloperazine or cyclizine or antihistamines for severe may need hospital to maintain hydration prophylaxis with betahistine diuretics may be started in secondary care may also need counselling or relaxation therapy - can be distressing prognosis - vertigo may resolve if the condition 'burns out', which can happen after 5-15 years. However, tinnitus, unilateral hearing loss, and sensations of aural pressure and a sense of general imbalance may persist

Answer 134

mismatch between sensory inputs - vision, proprioception and vestibular system

Answer 135

infection of the vestibular nerve/labyrinth usually following an upper respiratory infection that leads to an inner ear infection (usually caused by viruses) hearing is not affected in vestibular neuronitis acute, isolated, spontaneous vertigo lasting several days - head movements worsen but can occur at rest, no specific position with nausea and vomiting. No deafness or tinnitus. But there may be hearing loss in labyrinthisis also have nystagmus reassure the person that symptoms will usually settle over several weeks – even if no treatment is given o Advise that factors such as alcohol, tiredness, or intercurrent illness may have a greater than usual effect on their balance o Advise that bed rest may be necessary if symptoms are particularly severe during the acute phase, but that activity should be resumed as soon as possible (even if vertigo becomes more prominent during movement) o Advise the person not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving o The person should inform their employer if their vertigo poses a risk in the workplace if severe - anthistamines or antiemetics to suppress vestibular system

Answer 136

examine ear to look for otitis, tympanic membrane perforation and cholesteatoma pure tone audiogram may help diagnose a cause although some wont have hearing loss mri for unilateral tinnitus if pulsatile, examine head and neck and check peronns bp and bruits ``` treat underlying cause if found may benefit from sound enrichment therapy - low-level background noice hearing loss w hearing aids psychological support cbt relaxation techniques ```

Answer 137

unilateral w sensorineural hearing loss = menieres disease, acoustic neuroma bilateral w sensorineural hearing loss = age releated hearing loss, noise-induced hearing loss, drug-induced ototoxicity e.g. gentamicin, aspirin, nsaidds, loop duiretics, cytotoxic drugs unilateral or bilateral w conduction hearing loss = impacted wax, otitis media, cholesteatoma, otosclerosis

Answer 138

diagnosed by presence of nasal blockage or discharge w facial pain/pressure (headache) and or reduction of sense of smell maxillofacial area swollen/tender can also do anteiror rhinoscopy (use largest speculum of an otoscope) treat in hospital if systemically unwell or has complications e.g. periorbital oedema or cellulitis analgesia for pain, anitpyretics trial of nasal saline or decongestants avoid abx - most resolve by 14 days - is usually caused by a virus and only complicated by bacteria in 2 in 100 cases only give abx if high risk ocmplications if symptoms >10 days then consider high-dose nasal steroid for 14 days or consider back-up abx prescribption with phenoxymethylpenicillin if symptoms suggest neoplasm (for example, unilateral polyp or mass, bloody nasal discharge)

Answer 139

- Symptoms for more than 10 days - Discoloured or purulent nasal discharge (with unilateral predominance) - Severe local pain (with unilateral predominance) - A fever greater than 38°C - A marked deterioration after an initial milder form of the illness (so-called 'double-sickening') - Elevated ESR/CRP (although the practicality of this criterion is limited) treat with phenoxymethylpenicillin

Answer 140

allergen avoidance intranasal antihistamines possible use of nasal irrigation w saline oral antihistamines where nasal discharge or sneezing is predominant topical intranasal steroids where predominant symptom is nasal blockage or where polyps are present nasal saline washouts surgery may be indicated e.g. polyp removal

Answer 141

``` EXTERNA erythema, oedema on otoscopy pain w movement of tragus or auricle pre-auricular lymphadneopathy more severe cases - hearing loss, discharge, fever, cellulitis spreading beyond ear ``` MEDIA middle ear fluid - red/yellow/cloudy/bulging tympanic membrane earache - if perforation occurs this will less

Answer 142

topical drops for 7 days with acetic acid for mild cases if anything more than mild then topical antibiotics with neomycin or clioquinol (avoid gent if perforated membrane) can combine with steroids if ear is inflamed e.g. otomize spray or sofradex drops (both are dex combined w an abx) if cellulitis or systemically unwell then oral fluclox if extensive swelling of ear canal then consider inserting an ear wick impregnanted with the medication changed 2-3 days NB administering the drops - remove any substantial exudate first with a cotton bud or twist of cotton wool. Then warm the drops with your hands (prevents dizziness that can occur if cold drops are given). Person should lie laterally. Remain in that position for 3-5 minutes swab if treatment failure or looks atypical

Answer 143

spread of otitis externa into the bone surrounding the ear canal (the mastoid and temporal bones) without treatment, is a fatal condition

Answer 144

advise usual course is 3 days but can be up to 1 week analgesia/antipyretic many people will not require Abx because symptoms usually resolve spontaneously within a few days usually advice that antibiotics are unlikely to make a difference can do a delayed prescribing strategy – to take after 4 days if not improving immediate abx if systemically unwell, no improvement after 4 days, <2 years with bilateral, perforation, high risk of comps like immunocomprmoseid 5-7 days of amoxicillin Take account of evidence that acute complications such as mastoiditis are rare with or without antibiotics, and the possible adverse effects of antibiotics

Answer 145

characterised by fluid in the middle ear, but is not associated with symptoms and signs of an acute ear infection AKA GLUE EAR – this is an important differential cause unknwon - but over 50% are thought to follow an episode of acute otitis media if persistent may be due to impiared eustachian tube fucntion or low-grad infection can present with significant hearing loss but can just be asymptomatic - mild intermittent ear pain w fullness or popping may occur

Answer 146

otosocpy - no signs of inflammation or discharge but will find abnormal colour of drum (yellow red or blue), loss of light reflex and may see air bublles or air/fluid level and bulging drum perform hearing test - mild conductive hearing loss pure tone audiometry nice recommends a 2nd hearing loss 3m after the first

Answer 147

spontaneous resolution of OME is common, so for most children a period of active observation over 6–12 weeks is appropriate 90% of children will have complete resolution within one year (although recurrence is common) during this period - should re-evaluate signs of the effusion and concerns regarding child's hearing or language development - 2 hearing tests with pure tone audiometry at least 3 months apart as well as tympanometry consider ENT referral depending on amount of hearing loss persistent bilateral OME or bad hearing loss may benefit from surgery with grommet insertion (SE = tympanoscerosis and infectoin)

Answer 148

- Examination is not routinely required in primary care if history suggests uncomplicated thrush - If examination is indicated - signs suggestive include erythema usually localised to vagina and vulva, vaginal fissuring and/or oedema, excoriation of the vulva investigations are not usually required but can include o pH <4.5 (>4.5 suggests bacterial vaginosis or trichomonas) o Routine vaginal swabs • High vaginal swab (HVS) but 10-20% women are asymptomatic vaginal carriers and their symptoms may not be due to the candida isolated o MSU if symptoms could be due to UTI o HbA1c to exclude DM as a cause of recurrent thrush

Answer 149

if no symptoms do not treat recommended regimen = antifungal pessary +/- cream for external areas like clotrimazole alternative = oral fluconazole or itraconazole (oral is CI in pregnancy) consider associated precipitants (e.g. soaps, shower gels, sanitary towels) or conditions like DM, steroid or abx use return if symptoms not resolved in 7-14 days for recurrent provide prescription as required or a 6m maintenance regime

Answer 150

NAAT - vulvovaginal swab in women, first catch or urethral sampling in men will see pus cells on slide

Answer 151

doxycycline 2x daily 7 days or single dose of 1g azithromycin if doxy not tolerated or ci (e.g. in pregnancy) advise that sex should be avoided until person has completed treatment NB complications = PID, reactive arthritis, perihepatitis

Answer 152

culture or NAAT - depends on setting fast pass urine for men or urethral swab, and high vaginal in women or endocervical a culture should be taken in all people who are NAAT positive to work out abx susceptibility

Answer 153

ceftriaxone 1g IM - but if antibioitc susceptibility is known then cirpofloxacin single oral dose in pregn = ceftriaxone do test of cure at least 2 weeks after treatment is finished

Answer 154

pH >4.5 thin grey/white discharge positive amine test (release of fishy odour on adding alkali/10% KOH) clue cells on microscopy

Answer 155

hay-ison score Grade 0 = epithelial cells only with no bacteria Grade 1 = normal vaginal flora (predominance of lactobacillus morphotypes) Grade 2 = intermediate vaginal flora (reduced number of lactobacilli with mixed bacterial flora) Grade 3 = mixed bacterial flora only Grade 4 = gram positive cocci only 2 and 3 = BV

Answer 156

metronidazole 400mg twice daily for 5-7 days or 2g stat (avoid single dose in pregnancy)

Answer 157

women - can be asymptomatic, or frothy yellow discharge and can have fishy odor, vulval itching, pain in sex men - usually asymptomatic but can have dysuria and discharge diagnosed via high vaginal swab w NAAT - men w culture of first void urine treat with metronidazole single dose of 5-7 days dont have alcohol on this and for 48 hours after due to possibility of disulfiram reaction

Answer 158

febrile illness prodrome for a week in first episode only - may also have a tingling sensation over the area - this is for all episodes dysuria - can be so painful that they could go into urinary retention multiple painful genital ulcers lymphadenopathy discharge untreated episode may last 3w or more future episodes may last 3-4 days - on average they have 4-5 attacks a year may have had a clinical infection for years

Answer 159

take a swab from base of lesion - pop blister if necessary - for viral culture or PCR (negative does not rule out as may have been taken too late in an attack) management - first episode treat within 5 days with oral aciclovir for 5-10 days self care - clean area w plain or saltwater, apply vaseline or topical anaesthetic, increase fluid intake to dilute urine, aovid tight clothes, analgesia, dont share towels, abstain from sex until lesions gone can have episodic antiviral thearpy for future attacks but reduction is onyl about 1-2 days can have suppressive antiviral if >6 attacks a year with aciclovir daily - then discontinue after a year to reassess attack frequency

Answer 160

predominant site of inflammation includes bursae and tendons - despite the name implying a myopathic process, the muscles are actually normal on histopathological assessment o Bursae are fluid filled sacs that counteract the friction associated with tendons cause = genetics and environemntal - the cyclical pattern of cases and peak incidence in winter months suggests an infectious trigger

Answer 161

>2 weeks duration of symptoms bilateral shoulder or pelvic girdle arching or both mornign stiffness >45 minutes in duration worse on waking may have flu like features on onset, associated with fatigue, fever, weight loss, anorexia and depression reduced ROM, synovitis and swelling, power normal peripheral symptoms like features of arthritis, swelling and carpal tunnel syndrome (10-15%) may be identified

Answer 162

raised crp and esr CK normal do autoimmune screen like ASA anti-ccp and rf screen for GCA - temporal biopsy if needed imaging like US can assess for synovitis, rotator cuff tears or joint swelling/bursitis

Answer 163

prednisolone 15mg daily review at 1 week - should have dramatic response decrease dose slowly once symptoms fully controleld (usually after 3-4 weeks) - tapering may be requried over a long period (1-2 years) due to risk fo relapse if stopped too early arrange regular reviews to assess crp, esr and glucose due to risk of steroid-induced diabetes bisphosphates, PPI +/- calcium and vitamin D saftey net about gca methotrexate occassionally used as steroid-sparing agent

Answer 164

``` high levels of uric acid in the blood foods high in purines (which are broken down into uric acid) - red meat, seafood like sardines and anchovies, alcohol, sugary drinks things that affect excretion of uric acid e.g. diuretics, ace inhibitors otehr drugs - bb, chemothearpy agents male older age genetic factors high cell turnover states e.g. lymphoma high cholesterol, DM menopause ```

Answer 165

The deposition of crystals within joints and soft tissue may occur asymptomatically such as in chronic gout with the formation of small gouty tophi on the skin. However, during acute attacks, crystals trigger an acute inflammatory reaction leading to acutely painful swollen joints typically first metatarsophalangeal joint (big toe) - can affect any joint - others inlucde knee, midfoot, fingers usually monoarticualr severe pain with swelling, redness, warmth, tenderness - max intensity within 24 hours tophi - asymmetric swellings with a chalky appearance producign firm noduels - at ear, achilles tendons and upper kimbs

Answer 166

no investigations needed if no suspicion of other conditions like septic arthritis joint micorcsopy and culture if unsure about septic arthritis - gold standard but not practial - presence of negatively birefringement needle shaped crystals do serum uric acid 4-6 weeks after an acute attack to confirm hyperuricaemia- if normal does not rule out (usual cut off is 360) Xray if suspecting other things - will be normal in gout screen for CV risk factors and renal disease e.g. lipids and glucose in meatbolic syndrome

Answer 167

conservative - rest and elevate, avoid trauma to jiont, discuss lifestyle issues, ice pack, keep exposed medical NSAID (naproxen, indometacin or diclofenac) - continue until 1-2 days after resolved w a PPI OR colchicine 2nd line = oral or injected steroid consider paracetamol as adjunct advise to return if symptoms get worse or no improvement in 1-2 days

Answer 168

medication is normally lifelong and regular monitoring is needed allopurinol is first line urate lowering agent used in all people but particuarly if 2 or more attacks in 12m, otphi present, chronic gouty arthritis, join damange, eGFR<6-, history of stones, young age, diuretic use start at low dose and titrate up every 4w until serum uric acid is <300 start 1-2w after attack settled as can actually trigger gout - so co-prescribe colchicine for 6m to prevent acute flair

Answer 169

PIP and DIP - MCP joints are spared bouchards nodes are proximal, heberdens are distal in advanced disease there may be squaring at CMC joint caused by subluxation, formation of osteophytes and bone remodelling may also be radial or ulnar deviation

Answer 170

giving way due to altered patella tracking - the patella shifts out the way when legs bends or straightends locking - suggests loose meniscal cartilage in the joint crepitus tenderness along joint line small-to-moderate effusions

Answer 171

in the spine there can be osteophyte formation and loss of disc space leading to neuro symptoms e.g. cervical spondylosis e.g. vague numbness, tingling or weakness in the upper limbs.(cervical spondylosis = cervical OA)

Answer 172

NICE say can diagnose if 45 or older, has activity related joint pain, has no morning joint-related stiffness or stiffness that lasts no longer than 30 mins can calculate BMI - weight loss if needed consider xray to exclude other conditions or diagnostic uncertainty but x ray changes do not really correlate with symptoms (NICE say can diagnose without) bloods including crp/esr to rule out inflammation check UE as a baseline before medication joint aspiration if needing to rule out gout and septic arthritis MRI good at ruling out soft tissue injuries X ray changes = joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts (look black)

Answer 173

greater trochanteric pain syndrome - a common cause of lateral hip pain due to tedinopathy of gluteal medius or minimus - this can be a differential for hip or knee OA ganglion of the hand trigger thumb sciatica spinal stenosis

Answer 174

conservative - appropriate footwear (podiatry referal), local heat or cold packs, TENS can help reduce reliance on oral analgesia and offers significant pain relief , weight loss, exercise - swimming and static bike cycling are really good options for muscle strengthening phsyiotherapy OT assesmment and help with psychological aspect of the disease paracetamol, w or without topical NSAIDs then oral NSAIDs then opiods like codeiene ot topical capsaicin intra-articualr steroid surgery - arhtroscopy w debridement, osteotomy (surgery that reshapes bones), partial or total joint replacement arthodesis is an option for base of thumb OA pain clinic referral is an option

Answer 175

usually occurs with a pushing-off motion – in contact to ankle sprain, which is often due to impact on landing Sudden onset Achilles tendon pain. Initially sharp pain, often settles within hours to days to more of a dull ache A loud “snap” or “bang” is sometimes heard when the tendon ruptures! Calf squeeze (aka Thomson’s calf squeeze test) – in a normal, intact Achilles tendon, a calf squeeze should cause plantar flexion of the ankle. In Achilles tendon rupture, there will be minimal or no plantar flexion ofter clinical diagnosis but can do US and MRI manage w no weight bearing and refer to ortho immediately then rehabiliation - may take months to get back to normal Conservative management is an option for older more sedentary patients – but decision should be made by orthopaedic specialist Plaster cast for 2 weeks Can be changed to immobilising boot from 2 weeks Weight bear as pain allows from 4-6 weeks

Answer 176

``` avoid repetitive movements consider adaptation of their workplace wrist splinting in a neutral position can help with nighttime symptoms in particular steroid injection do not prescribe NSAIDs to treat ``` refer to specialist like rheumatologist or orthopaedic surgeon if not getting better surgery - involves cutting the ligament - most people return to work after 12 days average other treatments - acupuncture has shown some benefit, or physio

Answer 177

analgeisa commonly NSAIDS or newer cox2 inhibitors like celecoxib w a PPI physiotherapy podiatry input while awaiting rheum referral to start dmards - gp's can start them on nsaids DMARD first line - methotrexate, leflunamide, sulfalazine usually in combo with bridging steroid therapy (2-3m) which allows time for DMARD to take effect failure to respond then combine dmards safteynet - report sx of infection esp sore throat w methotrexate still ongoing active disease then consider biologic therapy (either in combination w DMARD or used initialy in patietns with severely active and progressive disease) - e.g. adalimumab, infliximab... manage flairs with steroids e.g. prednisolone surgery is occasionalyl needed

Answer 178

DAS28 involves assessment of 28 joints for swelling and tenderness in combination with inflammatory markers (e.g. CRP/ESR) and global assessment of health scale

Answer 179

systemic - fevers (discitis, septic arthritis), weight change in malignany CV - chest pain (pericarditis or myocarditits) resp - dysnpoea, cough (ILD, sarcoid), pleuritic checkt pain (pleuritis) gastro - nausea, dyspepsia, abdo pain (SLE) GU - dysuria (urethritis) neuro - seizures (SLE) derm - rashes (psorosis), buterrfly rash (SLE)

Answer 180

``` mild = open and closed comedones predominate moderate= inflammatory lesions predominate - papules and pustules severe = visible scarring or risk of scarring of hyperpigmentatin ```

Answer 181

``` A – Anorexia L – Loss of weight A - Anaemia (IDA) R – Recent onset of persistent symptoms M – Melaena S – Swallowing difficulty ``` ``` other >55 years old Dysphagia/ odynophagia Persistent vomiting Palpable epigastric mass FH of upper GI malignancy 1st degree relative ```

Answer 182

dysphagia OR >55 and weight loss with any of upper abdo pain, reflux, dyspepsia non-urgent = heamatemesis, treatment resistant dyspepsia and >55, dyspepsia with nausea or vomiting...

Answer 183

* Heamaturia * Persistent UTI - UTIs can resemble bladder cancer * Constant leakage * Associated faecal incontinence * Constitutional symptoms * Poor renal function * Abnormal neurology * Saddle anaesthesia * Recent back trauma * Recent pelvic surgery

Answer 184

chadvas - consider 1, prescribe 2 hasbled - consider still anticoagulating if 2, alternatives should be found if 3 (anyone 3 or above have high risk for major bleeding)

Answer 185

ciprofloxacin | co-amox

Answer 186

teeth discolouration

Answer 187

Cephalosporins (0.17-0.7% in observational studies (10% is commonly quoted from early studies)) - cefuroxamine, ceftiaxone Carbapenems (<3%) e.g. meropenam

Answer 188

Setting - make sure is informal and appropriate Perception - assess the patients perception on their current situation, understanding of recent tests Invitation - ask if they are ready to receive their results and ask if they want anyone else to join Knowledge - Explain what results mean, let them know the results weren't what they hoped for, then break the news Emotions - recognise and respond to emotions Strategy and summarise - Organise a time to discuss next steps in treatment and referral, summarise findings for patient and answer any questions Can give details of our clinical nurse specialist if have more questions Offer assistance to tell others Point towards sources of support Offer written materials Consider asking about religious preferences

Answer 189

liraglutide exenatide note - GI upset, decreased appetiete, rare reports of pancreatitis and improved CV outcomes

Answer 190

Prisma-7 - walking aids, how much help you require time get up and go - measure time in seconds for person to rise from chair to walk 3m then walk back and sit down again - 10 seconds is normal, >20 high risks of falls and frailty rockwood frailty scale

Answer 191

SCREENING mantoux test - intradermal injection of purified tb protein - hypersntivity reaction will deevelop if they've had exposure (previous bcg can affect restuls) interferon gamma release asseay (unaffected by prev bcg vaccine - tests fot t cell interferon gamma response to tb antigens) if postiive screening then need to exclude active tb w clinical review and CXR in general patients with latent TB should be treated to prevent the development of post-primary TB DIAGNOSING ACTIVE CXR where possible 3 sputum samples should be taken for tb microscopy and culture (bronchoalveolar lavage can be taken if not) for rapid testing can use NAAT but is expensive and only advised in certian settings e.g. v young or patient has hiv can start treatment without culture results if clinical sigsns samples are analysed with ZN stain, then micorsocpy for acid fast bacillin then culture on LJ slope -takes up to 8 weeks

Answer 192

pyridoxine

Answer 193

consider lifestyle changes like increasing iron rich foods, avoid NSAIDs ask about amount of iron rich food in diet like red meat and beans

Answer 194

DRE - many men will have normal tho PSA - no UTI in last 6w, no ejaculaton for 48 hours, no vigorous exercise for 48 hours, no urological interention in past 6w (PSA can be offered to men >50 that request it) (DRE can make it raised, as can exercise, ejaculation, UTI, BPH, prostatits refer people w abnormal prostate on DRE or PSA elevated for 2ww multiparametric MRI is first line - generate a likert score from this then offer biopsy guided by US a negative biopsy does not completely exclude and should take into accont previous investigations - can have a repeat done further imaging = ct or another mri to identify spread TNM and gleason for histological grade MANAGEMENT localised = active surveillance (associated w reduce incidence of urianry incontinence and erectile dysfunction), radical prosatectomy or radical radiotherapy (radicla options reduce risk of recurrence) androgen deprivation therapy may be combined - particuarly those w high risk disease locally advanced = radical prostatectomy and radical radio - chemo may also be used metastatic = chemo and androgen deprivation may be used

Answer 195

TYPE 2 - Patients with poor glycaemic control require measurement of the HbA1c every 3 months - Patients with stable disease can have their HbA1c measured every 6 months annually for complications - eyes, nephropathy w egfr and acr, diabetic foot exam, nerve exam, cv exam and bp and lipids TYPE 1 same - should be done 3-6 monthly also screen for complications AND thyroid disease annually

GP Flashcards

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