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DPD > GP clinic > Flashcards

GP clinic Flashcards

1
Q

what exams and Ix

A
  • Urine dip
  • Abdo exam
  • Pregnancy test
  • Basic set of obs
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2
Q

ddx?

A
  • HR borderline high
  • BO normal
  • Apyrexic, rr and sats normal
  • High HR because struggling to lie still

Renal colic – loin to groin pain, in waves – as move into ureter = colicky type pain. N and V because so painful (can also be caused by infection) Blood in urine

UTI/pyelonephritis – no evidence of infection in urine or fever = less likely. Pain more constant

Ectopic pregnancy – want negative test

Biliary colic – would be more on R

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3
Q

Mx of renal colic

A

are there complications – complete urinary tract obstruction, infection, unable to keep fluids in – vomit = shock/dehydrate = a and e, eg fever or infection in urine

Risk of AKI because one kidney obstructed – normally other can compensate. If CKD, bilateral stones or one kidney – risk of AKI = A and E

no sign of infection, obs normal, no PMH – still need urgent ix - CT KUB in 24hr – ambulatory care

Analgesia – paracetamol and an anti-inflammatory

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4
Q

safety netting for renal colic

A

Complications = a and e

  • fever
  • If not passing urine/intermittent urine flow
  • If persistently vomit, or cant tolerate oral fluids
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5
Q

qns in Hx

A

Other urinary sx – dysuria, anything suggest UTI but leukocytes and nitrites -ve

Freq dribbling, LUTs

Systemic – FLAWS

Is it renal colic – loin to groin pain

Urethral discharge

Any medications

FH

Social hx – RF for urological malignancy – smoke, and have they been in contact with aromatic amines – dyes, rubbers and textiles

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6
Q

ddx

A
  • Bladder cancer
  • Cancer in urinary tract – renal/prostate
  • BPH
  • Prostatitis
  • Urinary tract infection
  • Pyelonephritis but no sign of infection
  • Transient – if exercised/sexual intercourse cause haematuria
  • If female and on period might be transient cause of blood in sample
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7
Q

next steps

A

Repeat dipstick – see if persistent or transient cause –

need to be 2 out of 3 samples taken a couple of weeks apart

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8
Q

causes of macroscopic haematuria

A

malignancy - prostate, bladder or kidney

stones

infection

trauma

renal disease

BPGH

transient - vigorous exercise, menstrual blood

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9
Q

Ix for haematuria

A

depend on pt demographic, Hx and Ex

repeat dip

check BP

urine MCS

urine ACR

blood - eGFR

specialist - cystoscopy, imaging, biopsy

bp, ACR and eGFR are for glomerulonephritis

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10
Q

when would you consider 2ww for haematuria

A

age >/=45 with unexplained visible haematuria

age >/=60 with unexplained non-visible haematuria and raised WCC or dysuria

If had really high index of suspicion of malignancy – could still make a 2ww based on suspicion

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11
Q

what would you do now

A
  • Examine throat
  • Obs
  • Check for cervical LN
  • Listen to chest – because URTI
  • Wouldn’t go straight to swab – might do further down line if struggling with mx
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12
Q

ddx

A
  • Tonsilitis – more common
    • Bacterial or viral
    • Majority are viral
  • Glandular fever

just tachy because of temp

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13
Q

Mx

A

Centor criteria or FeverPain score

Centor:

  • age 3-14 = +1, 15-44 = 0, >=45 = -1
  • exudate or swelling in tonsils = 1
  • tender/swollen anterior cervical LN = 1
  • temp >38 = 1
  • no cough = 1

3 or 4 = AB - penicillin V or erythromycin for 7-10days

0-2 = likely viral - watch and wait/delayed prescription

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14
Q

after amoxicillin for sore throat:

what has happened

A

Glandular fever – caused by EBV – if give amoxicillin to pt with EBV – cross reactivity between Ab on EBV and AB = rash

Only happens with amoxicillin not other penicillins

Could be drug allergy but had amoxicillin before

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15
Q

signs of glandular fever

A

enlarged spleen

axillary lymphadenopathy

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16
Q

ix for glandular fever

A
  • Monospot test same as heterophile Ab test
  • In some cases might do serology
  • Wouldn’t do swab unless monospot -ve and think you need other AB
  • FBC – haemolytic anaemia, thrombocytopenia, reactive lymphocytosis
17
Q

advice for glandular fever

A

Avoid close contact with people

Avoid contact sport for 8weeks because risk of splenic ruture

Make sure well hydrated analgesia

Sx can linger for weeks to months

18
Q

ddx

A
  • Gallstone – biliary colic, cholecystitis
  • Pancreatitis
  • Gord
  • Peptic ulcer
  • Lower lobe pneumonia
  • Liver – hepatitis

Most likely is biliary colic – worse after eating, last 1hr, sick and vomiting

19
Q

what Ix would you do

A
  • Not tender and no mass in RUQ*
  • If think gallstone is it biliary colic or is it cholecystitis – when stuck in tree = inflammation: constant pain, tachy, tender, temp*
  • LFT
  • US
  • Lipid profile – if cholesterol stones
  • Not XR – cant see biliary stones
  • Amylase and lipase
20
Q

mx of biliary colic

A
  • Diet advice – avoid fatty foods
  • Safety net
  • Analgesia
  • Refer to upper GI surgeons

Risk could get stuck somewhere = refer for laparoscopic cholecystectomy

asymptomatic and tree normal – don’t need referral

asymptomatic but stones in tree – need referral because high risk of complication

Acute cholecystitis/cholangitis need urgent referral

21
Q

ddx

A
  • PVD
    • Intermittent claudication – vasculopathy, and relived by rest
    • Chronic limb ischemia
  • Diabetic neuropathy
  • SE of statin – myopathy – typically wouldn’t just be in leg when walked – ask how long ago started statin
  • Spinal stenosis – narrow of spinal canal mimic claudication sx – typically other neuro sx – better when bend over, sit, in foetal position – stretch the spinal canal and release pressure
  • MSK
22
Q

Ex

A
  • Peripheral vascular exam
  • Pulse
  • Temp
  • Beurgeur’s test
  • Loss of hair
  • Check skin for ulcers – arterial and venous
  • Temp
  • Muscle atrophy
  • Skin change
  • Cap refill in both legs
  • Look for signs of acute limb ischemia
  • CVS exam because of CV risk
23
Q

signs of peripheral arterial disease

A
  • Weak pulse, legs can look normal
  • Think skin, tissue loss near heal and around toes, hair loss
  • Beugeur’s test – arterial insufficiency – when elevate leg goes pale, when hang over bed it is more red
24
Q

Mx

A
  • ABPI – ankle brachial pressure index – make dx and determine mx based on this
  • Overall cardio risk
    • Smoking cessation
    • Exercise
  • Supervised exercise program
  • Safety net for acute ischemic sx
  • Make sure on med needs to be on for PVD – statin (maybe higher dose), antiplt
25
Q

what is peripheral arterial disease

A

umbrella term for intermittent claudication, critical limb ischemia and acute limb ischemia

chronic limb ischemia encompasses intermittent claudication and critical limb ischemia

26
Q

intermittent claudication

A
27
Q

critical limb ischemia

A

blood flow is more impaired - more risk of losing limb so need surgery

28
Q

acute limb ischemia

A

sx come on more quickly – thrombosis from atherosclerotic plaque rupture – complete blockage of peripheral arteries. This is a vascular emergency – need to go straight to A and E

29
Q

what else would you like to ask

A
  • Cough
  • Dysphagia – red flag
  • Is it worse when lie down
  • RF - Smoking, large meals, alcohol, stress
  • Tried anything to help already
  • Any med – any OTC, what on regularly
30
Q

ddx

A
  • GORD
  • Peptic ulcer

Sx high up in throat with acid taste and no stomach pain – GORD is top dx

Worse after eating so peptic ulcer back in mind

Oesophageal cancer – rule out with hx and ex

31
Q

Ix

A
  • Don’t need endoscopy unless initial treatments don’t work
  • Given young age and no systemic sx mx in primary care
  • Either 4wk trial of omeprazole and lifestyle and sx might respond
  • Test and treat – test for H pylori and if +ve give rx
  • If either don’t work try the other
  • Each time you see assess for red flags and think if need referral
  • Need to be off PPI for 2wk and AB for 4wks before test for H pylori – so do it before start PPI
32
Q

Mx for H pylori

A
  • Triple therapy – amoxicillin, PPI twice a day (normally once a day if not H p) clarithromycin or metronidazole
33
Q

ddx and ex

A
  • Stoke
  • Bell’s palsy - idiopathic acute facial nerve palsu
  • Facial nerve palsy – need to know if UMN or LMN
    • CN exam
    • Upper and lower limb
    • Look in ear, at scalp, mastoid region, oral cavity
    • Parotid gland exam
    • Need to see if forehead affected – if effected suggest LMN
    • If forehead spared – UMN – because forehead is bilaterally innervated
34
Q

Mx of Bell’s palsy

A
  • Reassurance – recover in 3-4mo
  • Eye care – particularly when sleeping – eye might not shut = corneal scratch, and get dry – need eye lubricant and tape eye shut
  • If eye get painful, itch, red – refer
  • if present within 72hr Steroids – pred 50mg for 10days?
  • If no improvement refer to neurology in a few weeks
35
Q

causes of facial nerve palsy

A

can give acyclovir for Ramsay hunt

DPD (38 decks)

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