GP and primary healthcare Flashcards
Acne vulgaris
Acne vulgaris is a chronic inflammatory skin conditions affecting the face, back and chest.
Characterised by the blockage and inflammation of pilosebaceous unit (hair follicle)
Presents with non-inflammatory, inflammatory lesions (or a mixture)
Clinical features of acne vulgaris
- Non-inflammatory lesions (comedones) must be present for a diagnosis
- Papules and pustules (< 5mm)
- Nodules or cysts (> 5mm)
Huge variety in clinical features depending on person and severity
Conservative management of acne vulgaris
Advice:
- Avoid over-cleaning the skin
- Use non-alkaline synthetic detergent cleansing product
- Avoid oil-based comedogenic products
- Treatment might irritate the skin at the start
Medical management for mild to moderate acne
1st line: 12 week course of any 2 of the following in combination:
- Topical benzoyl
- Topical antibiotics (clindamycin)
- Topical retinoids (tretinoin adapalene)
Medical management for moderate to severe acne
- 1st line: 12 week course of same medicines as above but different doses (NICE CKS)
- Sometimes the combo topical creams combined with oral tetracycline and doxycycline
- COCP as alternative to systemic abx for women
Acute stress reaction
Immediate and intense psychological response following exposure to traumatic event.
Appear within minutes of exposure and lasts from 3 days - 4 weeks after traumatic event.
If >1 month = PTSD
ICD10: https://icd.who.int/browse10/2019/en#/F43.0
Clinical features of Acute Stress Reaction
ICD10 criteria:
- Patient must have been exposed to an exceptional mental/physical stressor
- Exposure followed by immediate symptom onset (<1hr):
- Social withdrawal
- Dissociation
- Anger
- Despair/hopelessness
- Inappropriate overactivity
- Overwhelming anxiety/grief
- Autonomic sypmtoms: tachycardia, sweating, flushing)
ICD10 book from Sheffield uni library and quesmed
Mangement of Acute Stress Reaction
1st line: trauma focused CBT, medications e.g. benozodiazepines for symptomatic relief
Consider differentials such as PTSD and adjustment disorder
Iron deficiency anaemia
Low Hb concentration in blood
Causes:
- Dietary insufficiency, common in children
- Loss of iron, e.g. heavy menstruation
Inadequate iron absorption, e.g. IBD/Coeliac
Anaemia: Hb and Mean Cell Volume (MCV)
MCV = size of RBC
Women:
- Hb: 120 – 165 g/L
- MCV: 80-100 femtolitres (fL)
Men:
- Hb: 130 -180 g/L
- MCV: 80 - 100 fL
-
Causes of anaemia
- Microcytic anaemia (low MCV)
- Normocytic anaemia (normal MCV)
- Macrocytic anaemia (large MCV)
Mmemonic for microcytotic anaemia
TAILS
T – Thalassaemia
A – Anaemia of chronic disease
I – Iron deficiency anaemia
L – Lead poisoning
S – Sideroblastic anaemia
Causes of normocytic anaemia
AAAHH
A – Acute blood loss
A – Anaemia of chronic disease
A – Aplastic anaemia
H – Haemolytic anaemia
H – Hypothyroidism
Anaemia of chronic disease often in CKD due to reduced erythropoietin production. Tx = erythropoietin
Causes of macrocytic anaemia
- Megablastic (impaired DNA synthesis > large, abnormal cells): B12, folate deficiency
- Normoblastic macrocytic anaemia: alcohol, reticulocytosis (usually from haemolytic anaemia or blood loss), hypothyroidism, liver disease, drugs (e.g. azathioprine)
Clinical features of anaemia
- Tiredness
- SOB
- Headache
- Dizziness
- Palpitations
- Worsening of angina, HF, PAD
- IDA: pica, hair loss
Anaemia: signs on examination
- Pale skin
- Conjunctival pallor
- Tachycardia
- Increased RR
- IDA: koilonychia, angular cheilitis, atrophic glossitis (smooth tongue), brittle hair + nails
- Haemolytic anaemia: jaundice
Terms in iron-deficiency anaemia blood tests
- Iron = ferric ions (Fe3+) in blood
- Transferrin = carrier
- Total iron binding capacity (TIBC) = available space on transferrin
- Serum Ferritin = form of iron stored in cells, raised in inflammation
Normal ranges
Serum Ferritin: 41 - 400 ug/L
Serum Iron (variable throughout the day): 12 - 30 μmol/L
TIBC: 54 – 45 - 80 μmol/L
Transferrin sat: 15 - 50%
Transferrin sat (%) = serum iron/TIBC
Transferrin & TIBC = increase in IDA
Investigations for anaemia
Depends on suspected cause
- FBC for Hb and MCV
- Reticulocyte count (indicates red blood cell production)
- Blood film
- Renal profile for CKD
- LFT for liver disease and bilirubin (raised in haemolysis)
- Ferritin (iron)
- B12 and folate
- Intrinsic factor antibodies for pernicious anaemia
- TFT for hypothyroidism
- Coeliac disease serology (anti-TTG)
- Myeloma screening (e.g., serum protein electrophoresis)
- Haemoglobin electrophoresis for thalassaemia and sickle cell disease
- Direct Coombs test for autoimmune haemolytic anaemia
Unexplained anaemia = bone marrow biopsy for leukaemia or myeloma
Management for iron deficiency anaemia
Unexplained IDA = colonscopy and oesophagogastroduodenoscopy (OGD) for malignancy
Tx:
- Oral iron (e.g., ferrous sulphate or ferrous fumarate)
- Iron infusion (e.g., IV CosmoFer)
- Blood transfusion (in severe anaemia)
Management of iron-deficiency anaemia in children
- Tx underlying cause e.g. dietician for dietary deficiency
- Supplements: ferrous sulphate or fumarate (not suitable for malabsorption IDA)
- Rarely, blood transfusiion
Haemorrhoids
- Enlarged anal vascular cushions
- Associated with constipation and straining, pregnancy, obesity and increased intra-abdo pressure (e.g. weightlifting)
Anal cushion are specialised submucosal tissues that help control anal continence alongside internal and external anal sphincters.
Classification of haemorrhoids
- 1st degree: no prolapse
- 2nd degree: prolapse when straining and return on relaxing
- 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
- 4th degree: prolapsed permanently
Clinical features of haemorrhoids
- Asymptomatic
- Painless, bright red bleeding, not mixed with stool (think ddx)
- Sore, itchy anus
- Lump around/inside anus
Examinations for haemorrhoids
- External (prolapsed) haemorrhoids - swellings covered in mucosa
- Internal - PR exam but difficult or not possible usually
- Prolapse might be visible if pt asked to “bear down”
- Proctoscopy needed to confirm dx
Differentials for rectal bleeding
- Anal fissures
- Haemorroids
- Diverticulosis
- Inflammatory bowel disease
- Colorectal cancer
Management of haemorrhoids
Topical
- Anusol/Anusol HC (+hydrocortisone)+
- Germoloid (contains lidocaine)
- Proctosedyl ointment (cinchocine + HC)+
Non-surgical tx:
- Rubber band ligation
- Injection sclerotherapy (phenol oil to cause sclerosis and atropy)
- Infrared coagulation
- Bipolar diathermy (electrical current)
+ Short-term use only
Surgical tx for haemorrhoids
- Haemorrhoidal artery ligation - cutting off blood supply to haemorroid
- Haemorrhoidectomy - excision
Thrombosed haemorrhoids - caused by strangulation at base, resolve within a few weeks or admission + surgery if presents <72hrs with extreme pain.
Tx for psoriasis
Main one in GP
Dovobet gel
Eczema (atopic dermatitis)
Inflammatory skin condition characterised by dry, pruritic skin
Chronic and replasing
Usually dx < 5yo
Acute = flare-up
Chronic = chronic inflammation e.g. lichenification
Presentation of eczema
Usually in childhood
- Sore, itchy skin in flexor surfaces, face, neck
- Caused by defects in skin barrier that allow irritants, microbes and allergens to trigger immune response
- Part of atopy (asthma, hayfever)
Management of ezcema
- Maintenance and management of flares
Maintenance: artifical skin barrier
- Emollients to apply and in shower
Avoid triggers: e.g. cold weather, washing powders, cleaning products, stress
Flares: thicker emollients, topical steroids, “wet wraps”1
Very severe flare require: IV abx, oral steroids, zinc impregnanted bandages, phototherapy, systemic immunosuppressant e.g. methothrexate
1 applying thick emollient and coering in wrap to lock moisture
Emollients available for eczema
Use as thick as tolerated
Thin: E45, diprobase cream, cetraben, oilatum
Thick,greasy: 50:50 ointment (50% liquid paraffin), diprobase or centraben ointment
Topical steroid ladder
Better to use stronger steroids for shortest time than weak steroids for a long time
Thin skin e.g. eyelids/face = weak
Thick skin e.g. palms = potent
- Mild: Hydrocortisone 0.5%, 1% and 2.5%
- Moderate: Eumovate (clobetasone butyrate 0.05%)
- Potent: Betnovate (betamethasone 0.1%)
- Very potent: Dermovate (clobetasol propionate 0.05%)
Infections of the skin in eczema
- Staphylococcus aureus = admission and IV abx
- Eczema herpeticum1 = HSV/VZV. Viral swabs and aciclovir
1 Patients are very unwell with widespread, painful, vesicular rash and fever/lethargy.
Atrophic Vaginitis
- Dryness, atrophy and loss of elasticity of vaginal mucosa due to lack of oestrogen
- More prone to inflammation
- Change in vaginal pH and microbial flora = infection
- Oestrogen = thicker vaginal and urinary tract epithelial lining, more secretions, elastic
Presentation of atrophic vaginitis
Postmenopausal women:
- Itching
- Dryness
- Dyspareunia
- Bleeding (inflammation)
- Recurrent UTIs
- Stress incontinence
- Pelvic organ prolapse
Signs on examination in atrophic vaginitis
Examine the labia and vagina
- Pale mucosa
- Thin skin
- Reduced skin folds
- Erythema and inflammation
- Dryness
- Thinning pubic hair
Management of atrophic vaginitis
Vaginal lubricants e.g. Sylk, YES
Topical oestrogen = significant symptom improvements!
- Estriol cream (applicator at night), pessaries (inserted at night), tablets, rings (3 monthly replacement)
- CI in breast cancer, angina, VTE, monitor at least annually, stop tx if possible
Bell’s palsy
Acute, sudden-onset, unilateral facial palsy, single episode, no constitutional symptoms, keratoconjunctibitis sicca (dry eye)
Cause: maybe HSV-1
Clinical dx of exclusion
Tx is high-dose corticosteroid e.g. prednisolone, eye protection (glasses, artifical tears)
Exclude Lyme’s disease-associated facial paralysis before tx as worsen outcome
Eyelid disorders: blepharitis
- Inflammation of eyelid margins
- Gritty, itchy and dry sensation
- Associated with dysfunction of Meibomian glands (secrets meibum (oil) onto eye surface)
- Can lead to styes and chalazions
- Mx = warm compress and gentle cleaning
Eyelid disorder: stye
Hordeolum externum: infection of gland of Zeis and Moll, sebaceous and sweat glands at base of eyelashes
Hordeolum internum: infection of the Meibomian glands, deeper, more painful
Mx: hot compresses, analgesia, topical abx (e.g. chloramphenicol) if conjuctivitis or persistent
Eyelid disorder: chalazion (Meibomian cyst)
Meibomian gland becomes blocked and swells. Swelling in eyelid, can be tender and red but usually not!
Mx: warm compresses, massage towards eyelashes to help drainage, surgical drainage might be needed
Eyelid disorders: entropion
When eyelids turn inwards and lashes press against the eye
Pain, coneal damage and ulceration
Mx: tape eyelid to prevent inward turn, then refer to ophhalmology for surgery, same-day if risk to sight
Eyelid disorder: ectropion
Eyelid turns outwards, exposing inner membrane
Usually bottom eyelids = exposure keratopathy as eyeball not lubricated and protected
Mx: mild cases = lubricating eye drops, severe cases = surgery, same-day referral to opthalmology if risk to sight
Eyelid disorders: trichiasis
Inward growth of eyelashes, pain, corneal damage and ulceration
Mx: remove affected eyelashes, if recurrent then electrolysis, cryotherapy or laser tx to stop regrowth. Same-day ophthalmology referral if risk to sight
Eyelid disorders: periorbital cellulitis
Infection of the eyelid and skin in front of the orbital septum (in front of the eye)
Swollen, red, hot skin around eyelid and eye
Tx with systemic (oral or IV) abx, can develop into orbital cellulitis so children etc. need admission and monitoring
Key ddx is orbital cellulitis = sight and life-threatening emergency
Eyelid disorders: orbital cellulitis
Infection around eyelid of the tissue behind orbital septum
Pain on eye movement, reduced eye movement, vision changes, proptosis, abnormal pupil reactions
Emergency admission to opthalmology and IV abx per local policy, surgical drainage if abscess
Benign paroxymal positional vertigo (BPPV)
- Causes recurrent episodes of vertigo triggered by head movement
- Variety of head movements trigger vertigo, e.g. turning over in bed, lasts 20 to 60s
- Episodes over several weeks, then resolves, then reoccurs weeks or months later
- Peripheral cause of veritgo = inner ear cause, not the brain
- Does not cause hearing loss or tinnitus
Pathophysiology of BPPV
Calcium carbonate crystals called otoconia that become displaced in the semicircular canals.
Causes: viral infection, head trauma, aging
Distruption of the endolymph flow through canals, confusing the vestibular system. Head movement = endolymph flow = vertigo
Diagnosis of BPPV
Dix-Hallpike Manoeuvre
Dix for Dx
Triggers endolymph flow through semicicular canals
Positive signs = rotational nystagmus towards affected ear and vertigo
BPPV treatment
Epley Manoeuvre to move crystals in semicircular canal to a position that does not disrupt endolymph flow.
Benign Prostatic Hyperplasia (BPH)
- Common in men > 50
- Hyperplasia of stromal and epithelial cells of the prostate
Presentation of BPH
Lower urinary tract symptoms (LUTS), typically:
FUNI: frequency, urgency, nocturia, intermittency (flow starts/stops)
SHID: (poor) stream, hesitancy, incomplete empyting, dribbling (terminal)
International prostate symptom score (IPSS) - socre to assess LUTS severity
Assessment in BPH
- Digital rectal exam (prostate exam)
- Abdo exam for bladder
- Urinary frequenct volume chart
- Urine dipstick
- PSA (unreliable)
Benign vs cancerous prostate on examination
Benign prostate: smooth, symmetrical and soft, central sulcus
Cancerous:firm/hard, asymmetrical, craggy, irregular, loss of central sulcus
Management of BPH
- Mild = conservative
Medical:
- Alpha-blockers1 (e.g. tamsulosin) relax smooth muscle for symptoms
- 5-alpha reductase inhibtor2 (finasteride) for tx of BPH
Surgery:
- MC is transurethral resection of the prostate (TURP) - remove parts of prostate from inside of urethra
1 Key SE: postural hypotension, consider tamsulosin as cause of dizziness on standing/falls in older man
2 Key SE is erectile dysfunction
Peripheral arterial (vascular) disease (PAD)
Narrowing of arteries supplying limbs and peripheries
Most common in lower limbs > intermittent claudication (ischaemia in a limb during exertion, better on rest)
Chronic limb-threatening ischaemia - end-stage of PAD, inadquate blood supply to limb even at rest.
Presentation of PAD
Intermittent claudication - crampy achy pain in calf, thigh or buttock muscles when walking beyond a certain distance
Chronic limb threatening ischaemia - burning pain at rest, worse at night, non-healing ulcers and gangrene
PAD: signs on examination
Generally, peripheral arterial disease:
- Skin pallor
- Cyanosis
- Depedent rubor (deep red when limb is lower than body)
- Muscle wasting
- Hair loss
- Ulcer
- Poor woundhealing
- Reduced skin temp
- Reduced sensation
- CRT > 2s
- Positive Buerger’s test
Atherosclerosis is the underlying cause of PAD, what are the risk factors of atherosclerosis?
Non-modifiable risk factors: older age, FHx, male
Modifiable risk factors:
- Smoking
- Alcohol consumption
- Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s)
- Low exercise / sedentary lifestyle
- Obesity
- Poor sleep
- Stress
Medical co-morbidities that increase the risk:
- Diabetes
- HTN
- CKD
- Inflammatory conditions e.g. RA
- Atypical antipsychotics
Tom tip: make sure to think and ask about RFs when taking a hx from someone with atherosclerotic disease: exercise, diet, PMH, FHx, occupation, smoking, alcohol, meds
Acute limb ischaemia
Occurs when a thrombus blocks the arterial supply of a distal limb.
6Ps
- Pain
- Pallor
- Pulseless
- Paralysis
- Paraesthesia (abnormal sensation or “pins and needles”)
- Perishing cold
Leriche syndrome
Occlusion in distal aorta or proximal common iliac artery
- Thigh/buttock claudication
- Absent femoral pulses
- Male impotence
PAD: Buerger’s Test
Assesses for PAD in legs
Part one: patient lies supine, straight leg lift 45 degrees for 1 - 2 mins, PAD = pallor
Part two: patient sits up with legs dangling, in PAD:
- Blue initially as ischaemic tissue deoxygenates blood
- Dark red (rubor) after due to vasodilation from waste products from anaerobic respiration
Investigations for PAD
- Ankle-bracgial pressure index
