GP block

Question 1

Apply the ABC approach to emergency presentations and its use in primary care

Answer 1

A- airway. is the airway patent? is there an airway obstruction?
B- is the patient breathing? what is the breathing pattern and rate?
C- circulation- capillary refill, radial pulse(rate and rhythm). blood pressure, JVP

ABC approach is used to assess wether the patient needs admitting or not

Question 2

MSK history taking

Answer 2

• Understand the severity of the person’s symptoms and the impact on day to day activities: their mobility, ability to perform ADLs, work and social roles etc.
• Distinguish inflammatory vs non-inflammatory causes of joint pain.
• Identify mechanical symptoms? (e.g. locking of the joint or giving way).
• Identify potentially significant previous problems (e.g. cancer, psoriasis; recurring conditions (e.g. gout)
• Identify family history of musculoskeletal conditions that may be inherited
• Identify occupational triggers, e.g. repetitive movements, lifting, posture

ICE

Question 3

What is GALS and what are the questions asked?

Answer 3

GALS examination (gait, arms, legs and spine), is often used as a quick screening tool to detect locomotor abnormalities and functional disability in a patient.

First question
“Do you have any pain or stiffness in your muscles, joints or back?”

This question screens for common symptoms present in most forms of joint pathology (e.g. osteoarthritis, rheumatoid arthritis, ankylosing spondylitis).

Second question
“Do you have any difficulty getting yourself dressed without any help?”

This question screens for evidence of fine motor impairment and significant restriction joint range of movement.

Third question
“Do you have any problem going up and down the stairs?”

This question screens for evidence of impaired gross motor function (e.g. muscle wasting, lower motor neuron lesions) and general mobility issues (e.g. restricted range of movement in the joints of the lower limb).

Question 4

Red flags for cauda equina syndrome

Answer 4

• Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion.
• Recent-onset urinary retention (caused by bladder distension because the sensation of fullness is lost) and/or urinary incontinence (caused by loss of sensation when passing urine).
• Recent-onset faecal incontinence (due to loss of sensation of rectal fullness).
• Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia).
• Unexpected laxity of the anal sphincter.

Question 5

Red flags for spinal fracture

Answer 5

• Sudden onset of severe central spinal pain which is relieved by lying down.
• A history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids.
• Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present.
• There may be point tenderness over a vertebral body.

Question 6

Red flags for cancer

Answer 6

• The person being 50years of age or more.
• Gradual onset of symptoms.
• Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain.
• Localised spinal tenderness.
• No symptomatic improvement after four to six weeks of conservative low back pain therapy.
• Unexplained weight loss.
• Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine.

Question 7

Red flags for spinal infection e.g. discitis, vertebral osteomyelitis, spinal epidural abscess

Answer 7

• Fever
• Tuberculosis, or recent urinary tract infection.
• Diabetes.
• History of intravenous drug use.
• HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised.

Question 8

Clinical features of OA

Answer 8

The clinical featuresof osteoarthritis arevariable, both between people and at different joint sites.Typically, there isa history of:

• Activity-related joint pain — typically only one or a few joints are affected at any one time, and pain develops over months or years,and
• No morning joint-related stiffness, or morning stiffness lasting no longer than 30 minutes.
• Functional impairment

Question 9

Clinical features of RA

Answer 9

RA typically causes symmetrical synovitis of the small joints of the hands and feet, althoughanysynovial joint may be affected.Clinical features of synovitis include:
Pain, swelling, heat and stiffness in affected joints.
- Pain — usually this is worse at rest or during periods of inactivity.
- Swelling — around the joint (not bone swelling) giving a ‘boggy’ feel on palpation.
- Stiffness — early morning stiffness usuallylast over 1hour (ahistory of prolonged morning stiffness is more helpful when forming a diagnosis than currently having morning stiffness for early RA).

Question 10

Clinical features of gout

Answer 10

• Gout typically affects the first metatarsophalangeal joint (big toe) — this is the case in 56-78% of people at first presentation. It is also common in the midfoot, ankle, knee, fingers, wrist and elbow joints although can effect any joint. Gout is usually monoarticular but can be oligoarticular or rarely polyarticular.
• Symptoms and rapidity of onset — severe pain with associated swelling, redness, warmth and tenderness usually reaches maximum intensity within 24 hours.

Question 11

What is ‘synovitis’ and what does it indicate?

Answer 11

Synovitis is inflammation (swelling, pain, and warmth) of a synovial membrane. It can be a feature of arthritis in which there is active inflammation. Common causes include rheumatoid arthritis and gout. It can sometimes occur in osteoarthritis where the degenerative process has caused some inflammation.

Question 12

Define ‘stiffness’ and explain the clinical significance of ‘early morning stiffness’?

Answer 12

Stiffness is slowness or difficulty moving one or more joints.
Early morning stiffness is used to describe stiffness on getting out of bed or staying in one position.
It is an indicator of inflammatory arthritis.
Stiffness which is generalised and lasts > 30 mins on waking is a feature of rheumatoid arthritis

Question 13

What is an acute abdomen?

Answer 13

The ‘acute abdomen’ is defined as a sudden onset of severe abdominal pain developing over a short time period

Question 14

differentials for an acute abdomen

Answer 14

abdominal aortic aneurysm
ruptured ectopic pregnancy
bleeding gastric ulcer
trauma, perforated viscus, ischaemic bowel

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Question 15

red flags for acute abdomen

Answer 15

hypovolemic shock clinical features: tachycardia and hypotension, pale and clammy on inspection, and cool to touch

Question 16

management of acute abdomen

Answer 16

arrange urgent admission to surgical assessment unit if red flags symptoms present

Question 17

assessment of acutely unwell child

Answer 17

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Question 18

management of acutely unwell child

Answer 18

if any high risk criteria admit urgently
if any moderate-high risk criteria and if impaired immunity- admit urgently (999).
if normal immunity- can a definitive diagnosis be made and treated ? if yes, treat if safe to do so and safety net clearly if not admit urgently.

Question 19

What are the likely causes of limited or painful active movement but with full, pain-free passive movement?

Answer 19

The range of passive movement of a joint (when the practitioner moves the joint with the person relaxed) is usually higher than what the person can achieve themselves through active movement.

As passive movement does not require the person to use their own nerves, muscles and tendons to produce movement, a reduction in passive range or pain on passive movement indicates a problem with the joint itself (e.g. foreign body, bony deformity, inflammation, contracture).

In active movement (when the patient moves the joint), muscles and tendons to be functioning. Therefore, a problem with the muscles and tendons would cause reduced range of active movement and/or pain on active movement only.

Question 20

What is the WHO pain ladder? What cautions are needed in applying this to chronic MSK pain?

Answer 20

The WHO pain ladder was originally developed for acute pain and advocates stepwise use of simple analgesia (e.g. paracetamol), non-steroidal drugs (e.g. ibuprofen) and stronger analgesics (e.g. opiates). It has also been used to manage cancer pain.

It can be problematic in chronic pain due to (i) risks of side-effects and habituation with prolonged regular use of analgesics; (ii) risk of addiction to opiates; (iii) risk of neglecting non-pharmacological options in treatment and rehabilitation (e.g. physiotherapy) and psychological/pain management approaches

Question 21

What are the ‘mechanical symptoms’ of the knee? What have they traditionally been thought to represent and is there any evidence to contradict this view?

Answer 21

Symptoms such as locking or catching of the knee on movement were traditionally thought to indicate a ‘mechanical’ problem with the knee such as a loose body or meniscal tear obstructing movement. More recently, this view has been challenged and it appears that these symptoms are quite common in knee disease, even without any obvious obstruction.

Question 22

What is bursitis of the knee and how would you differentiate this from a knee effusion?

Answer 22

Like other joints, the knee is surrounded by small fluid-filled sacs (called bursae) which reduce friction between moving tendons and provide cushioning for the joint.

By contrast, a knee effusion is swelling due to excess synovial fluid in the joint capsule itself. In a knee effusion, fluid can be moved across the knee (the ‘bulge’ test) and pressure over the patella causes the fluid to move (causing a ‘patellar tap’).

In bursitis, the swelling is localised to the bursa that is affected – for example, an infra-patellar swelling in prepatellar or infrapatellar bursitis

Question 23

Which causes of hip pain would tend to produce pain in the anterior, lateral and posterior hip area?

Answer 23

Certain locations of hip pain are more typically associated with particular pathology. For example:
- ‘True’ hip pain (e.g. from osteoarthritis) - anterior to the groin.
- ‘Trochanteric bursitis) – laterally in the hip.
- Posterior/posterolateral pain - lumbosacral spine or gluteal muscles.
This can be useful in guiding further questions and clinical examination to identify the anatomical source of the patient’s symptoms

Question 24

What are the clinical features of plantar fasciitis and metatarsalgia? In metatarsagia, what would make you suspect a Morton’s neuroma?

Answer 24

Plantar fasciitis typically causes pain at the insertion of the plantar fascia into the calcaneum. It tends to occur in people who spend a lot of time on their feet; often the pain is marked with the first few steps on getting out of bed and then worsens again to the end of the day.

Metatarsalgia is pain in the mid-foot and has a wide range of causes. In Morton’s neuroma, the classic finding is tenderness in the inter-digital space where the neuroma is located.

Question 25

What features on history and examination help identify ‘radicular’ back pain?

Answer 25

Radicular back pain is caused by irritation or impingement of a nerve root. It is typically felt in the dermatomal area supplied by the foot. For example, in sciatica (the commonest pattern) the pain radiates to the buttock and posterior leg; and is often worse when the sciatic nerve is stretched (e.g. in a straight leg raise test). The pain is often described as ‘shooting’ or ‘numb’ and there may be other neurological symptoms (e.g. weakness, ankle hyporeflexia).

Question 26

What is a ‘painful arc’ in the shoulder and what does this indicate?

Answer 26

Painful arc is pain in the mid-range (45 – 120 degrees) of abduction of the shoulder (I.e. movement in the scapular plane) which eases at greater range of abduction. It indicates impingement of the shoulder (catching of rotator cuff tendons or shoulder bursae) in the sub-acromial space with movement. The pain tends to be more pronounced on active than passive movement.

Question 27

Besides shoulder pathology, what other problems might present with pain in one or both shoulders?

Answer 27

A wide range of conditions including: referred pain from the neck (e.g. cervical spine radiculopathy), cardiac problems (e.g. MI, angina); lung problems (e.g. Pancoast’s tumour); diaphragmatic pain (e.g. right shoulder pain from liver enlargement); polymyalgia rheumatica (bilateral).

Question 28

How do the typical appearances of osteo- and rheumatoid arthritis in the hands differ?

Answer 28

Osteoarthritis: commonest sign in the hands is Heberden’s Nodes (on distal IP joints). Bouchard’s nodes (on proximal IP joints are less oommon).

Rheumatoid: in acute episodes, the proximal IP, metacarphalangeal and wrist are commonly affected. In chronic disease, you may see ulnar deviation of the fingers, “swan neck” and “boutonniere” deformities.

Question 29

In the elbow, when would you diagnose tennis elbow, golfer’s elbow and olecranon bursitis?

Answer 29

Tennis elbow is lateral epicondylitis. Suspect if pain in lateral elbow with tenderness over the common extensor Golfer’s elbow is medial epicondylitis. Suspect if pain in medial elbow with tenderness over the common flexor origin.
Olecranon bursitis: suspect if fluctuant (usually non-painful) swelling over the olecranon process of the elbow.

Question 30

assessment of chest pain

Answer 30

assess to exclude a serious cause such as an acute coronary syndrome
ask about: nature, onset duration, site, radiation, exacerbating and relieving factors, associated symptoms e.g breathlessness
ask about history of: chest pain and investigations, CVS risk factors, response and GI, MSK problems and previous trauma, anxiety and depression

Question 31

management of chest pain

Answer 31

admit to hospital if:

Clinical features which suggest a serious cause of chest pain, such as:
Respiratory rate > 30
HR> 130 .
Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them).
Oxygen saturation less than 92%, or central cyanosis- if no COPD
Altered level of consciousness.
temp > 38.5°C
Suspected acute coronary syndrome (ACS), who:
Have current chest pain.
Have signs of complications (such as pulmonary oedema).
Are pain-free, but have had chest pain in the last 12 hours and have an abnormal electrocardiogram (ECG) or an ECG is not available.
A recent history of ACS, who have developed further chest pain.

Question 32

assessment of acute shortness of breath

Answer 32

respiratory examinations 
pulse oximetry
ECG if possible 
peak flow if asthmatic
temperature

Question 33

management of acute shortness of breath

Answer 33

heart rate > 130
respiratory rate >30
altered level of consciousness
systolic blood pressure less than 90 mmHg or diastolic blood pressure less than 60 mmHg
oxygen saturation less than 92%, or central cyanosis
PEFR less than 33% of predicted

Question 34

symptoms of stroke vs Bell’s palsy

Answer 34

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