GP community and public health Flashcards
What are the 4 main determinants of health?
- Lifestyle.
- Access to healthcare.
- Genes.
- Environment.
Define equity and equality.
Equity = what is fair and just
Equality = concerned with equal shares
Define horizontal equity
Equal treatment for equal need
e.g. individuals with pneumonia (with all other things being equal) should be treated equally
Define vertical equity.
Unequal treatment for unequal needs
e.g. individuals with common cold vs pneumonia need unequal treatment
e.g. areas with poorer health may need higher expenditure on health services
Give 2 factors that affect equity
- Spatial
- geography - Social
- age
- gender
- socioeconomic
- ethnicity
What are the 3 domains of public health?
- health improvement - social interventions aimed at preventing disease through promoting health
- health protection - concerned with measures to control infectious disease risks
- health care - organisation and delivery for healthcare services
Define health psychology
Emphasises the role of psychological factors in the cause, progression and consequences of health and illness.
Promotes healthy behaviours
What are the 3 main categories of health categories?
- health behaviour
- illness behaviour
- sick role behaviour
Define health behaviour
a behaviour aimed to prevent disease e.g. eating healthy
Define illness behaviour
a behaviour aimed to seek remedy (e.g. going to the doctor)
Define sick role behaviour
Sick role Behaviour: any activity aimed at getting well (e.g. taking prescribed medications; resting)
What are health damaging behaviours?
Health damaging behaviours are often related to mortality e.g. smoking, alcohol, high risk sexual behaviours.
What are health promoting behaviours?
Behaviours that seek and maintain health e.g. exercise, eating healthily, having vaccines.
What factors affect medication adherence?
- not knowing what the medication does
- poly pharmacy
- side effects
- they feel well
- don’t take it properly
What sort of health behaviour interventions are there?
Population level
- health promotion
- enabling people to exert control over the determinants of health (screening, vaccines)
Individual level
- patient centred approach
- care responsive to individuals needs
What are the 3 3lv3ls of intervention of behaviour change?
individual behaviour
Local community
Population level
What is unrealistic optimism?
Individuals continue to practise health damaging behaviour sue to inaccurate perception go risk and susceptibility
What are the perceptions of risk influenced by?
- Lack of personal experience with problem
- Belief that preventable by personal action
- Belief that if not happened by now, it’s not likely to
- Belief that problem is infrequent
- situational variability (seemed a good idea at the time)
- cultural variability
What did Davison’s study of patients perception of risk show?
- People had their own ideas of the cause of (heart) disease
- people who thought they were low risk were associated with reduced attendance to cardiac rehab & reduced medication adherence
What is a cross-sectional study?
Observations made at a specific point in time (now)
What are the pros and cons of a cross sectional study?
Strengths
Fast, inexpensive
who currently has exposure and outcome
no follow up
Weaknesses
not suitable for rare diseases
difficult to establish order of events
Can’t find causes
What is a case control study?
(Past) select participants with and without outcome and look back to see who had exposure
Strengths and weaknesses of case control study?
Strengths
suitable for rare diseases
multiple exposures can be studied
quick
Weaknesses
only a single disease can be studied
difficult to establish order of events
affected by selection bias & confounding factors
What is a cohort study?
(future)
collect participants info on a sample (some have exposure, others don’t)
Follow up over time, see who gets outcome
Strengths and weaknesses of cohort study?
Strengths
useful for demonstrating causal effect
multiple diseases & exposure can be studied
less chance of bias
weaknesses
time consuming and expensive
not suitable for rare diseases
people drop out
What is an RCT? Pros and cons?
Participants randomised to groups and followed up to compare outcomes
Strengths
- ‘gold standard’
- prevents bias - can be double blinded
- shows cause and effect
Weaknesses
- expensive
- not suitable for long term effects
- not always ethical
can be effected by non-compliance
What is a crossover trial? pros and cons?
Everyone in the study has all arms of the trial at some point
order of each arm randomised
everyone is their own comparison
Cons
more technical analysis
not always suitable (if drug/ surgery has carry over effects)
What is ‘Health Needs Assessment’?
A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities.
Health Needs Assessment: define need.
The ability to benefit from an intervention.
Health Needs Assessment: briefly describe the planning cycle.
(is the need met)
Needs assessment -> planning -> implementation -> evaluation -> needs assessment etc…
What is felt need?
Individual internalised perception of variation from normal health
What is expressed need?
Individual seeks help to overcome variation in normal health (demand)
What is normative need?
Professional defines intervention appropriate for the expressed need
What is comparative need?
Comparison between severity, range of interventions and cost
Health needs assessment: define demand.
what people ask for
Health needs assessment: define supply.
What is provided
What is the inverse care law?
The availability of good medical care can vary inversely with the need for it
(greater unmet need for disadvantaged people)
Name 3 different types of health needs assessment.
Epidemiological.
Comparative.
Corporate.
Give 3 negative points for epidemiological health needs assessments.
- Required date may not be available.
- Variable data quality.
- Ignores felt needs.
Who might be involved with corporate health needs assessment?
Politicians.
Press.
Providers.
Professionals.
Patients.
Give 3 negative points for corporate health needs assessments.
- Difficult to distinguish need from demand.
- Groups may have vested interests.
- May be influenced by political agendas.
Briefly describe a comparative health needs assessment.
Compares services received by one population with other populations.
Give 3 negative points for comparative health needs assessments.
- Required date may not be available.
- Variable data quality.
- It is hard to find comparable populations.
What are the challenges and benefits of a health needs assessment?
Benefits:
- strengthen community involvement in decision making
- public participation
- improved patient care
Challenges
- lack of commitment from top down
- problems accessing target population
- lack of info sharing
Define Acne vulgaris and its cause.
Acne caused by chronic inflammation with or without localised infection
Increased production of sebum (natural skin oils), trapping of keratin (dead skin cells) and blockage of the pilosebaceous unit (contain hair follicles and glands) –> swelling & inflammation
Androgenic hormones increase production of sebum so acne can increase in puberty
Describe the appearance of acne vulgaris
Macules = flat marks
Papules = small lumps
Pustules = small lumps containing yellow pus
Comedomes = skin coloured papule representing blocked pilosebaceous units
Blackheads = open comedones with black pigmentations in centre
Ice pick scars = small indentations after acne lesions heal
Hypertrophic scars = small lumps after acne lesions heal
Rolling scars = irregular wave-like irregularities of the skin after acne lesions heal
What is the aim of acne vulgarise treatment?
- reduce symptoms
- reduce risk of scarring
- minimise psychosocial impact of condition
(explore anxiety and depression)
Management of acne vulgaris.
- No treatment if mild
- Topical Benzoyl peroxide = reduce inflammation & toxic to Propionibacterium acnes bacteria
- Topical retinoids = slow production of sebum
- Topical antibiotics = e.g. clindamycin with benzoyl peroxide to reduce bacterial resistance
- Oral antibiotics = lymecycline
- Oral contraceptive pill = help stabilise female hormones & reduce production of sebum
- Oral retinoids = severe, last line, tetragenic so with contraceptives
What is the Oral retinoid used for treating acne vulgaris and its mechanism?
Isotretinoin (Roaccutane)
- reduces production of sebum
- reduce inflammation
- reduce bacterial growth
Only prescribed by dermatologist
What are the side effects of isotretinoin?
- tetragenic so must be on contraceptives
- dry skin and lips
- photosensitivity of the skin
- depression, anxiety, aggression & suicidal ideation
- rarely Stevens-Johnson syndrome & toxic epidermal necrolysis
Define: Acute bronchitis
Lower respiratory tract infection which causes inflammation in the bronchial airways
Define: pneumonia
an infection of the lung tissue in which the air sacs in the lungs become filled with micro-organisms, fluid and inflammatory cells affecting the function of the lungs
(consolidation on a CXR)
What are the symptoms of acute bronchitis?
- cough
- may have sputum, wheeze, breathlessness
- chest pain present from cough
- may have raised temp
Investigations: Acute Bronchitis
- listen to chest = wheeze
- check temp & ops
- refer to get CXR if severe
Management: Acute Bronchitis
- self limiting, cough for 3-4 weeks
- fluid, paracetamol or ibuprofen, cough medicine
- smoking cessation
- antibiotics = only if systemically unwell
Define: Acute Stress Reaction
Follows a sudden severe stressor and lasts for only a few days
Occurs in an individual without previous psychological disorder
What are common causes of Acute Stress Reaction?
- rape or other assault
- war or natural disaster
- breakup of intimate relationship
What are features of an Acute Stress Reaction?
- fear, anxiety, depression
- palpitations, sweats, restlessness, insomnia
- avoidance
- denial and repression
Management: Acute Stress Reaction
- sympathetic listening
- short term anxiolytics
- encouragement to recall event and to express emotion
- Improve coping strategies
- Help with long term consequences of stressful reaction such as disability
What are the types of allergies seen by GPs?
- allergic rhinitis
- angio-odema + anaphylaxis
- Asthma
- conjunctivitis
- Cow’s milk allergy in children
- Food allergy
Insect bites and stings - Tiredness/fatigue in adults
- Urticaria
Define: Allergic rhinitis
IgE mediated inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitised to allergens
Can be allergic, non-allergic, infective or mixed
Cause: Allergic Rhinitis
- house dust mites
- pollens
- moulds
- animal hair
- occupation
Management: Allergic rhinitis
- nasal spray
- anit-histamines
- avoid trigger
- allergy testing
Management: milk or food allergy
- allergy testing
- send to A&E if severe
- paediatric dietician
Define: anaemia
Low red blood cell production due to low iron stores in the body
What are the causes of anaemia?
- dietary deficiency
- malabsorption e.g. coeliac, H.pylori, gastrectomy
- increased loss e.g. chronic blood loss
- Increased requirement = pregnant
Symptoms: Anaemia
Symptoms
- dyspnoea
- fatigue
- headache
- cognitive dysfunction
- restless leg syndrome
- weak
- pruritus
Signs
- pallor
- atrophic glossitis
- damaged hair
- alopecia
- angular cheilosis
- koilonychia
Investigations: Anaemia
- FBC (low Hb and MCV)
men = below 130
women over 15 yrs = below 120
children = below 120 - Ferritin level
If MCV <95 - check B12 and folate
Management: Anaemia
Refer if:
- suspected cancer and over 60 yrs
- suspected cancer, rectal bleeding, over 50 yrs
- to GI if rectal bleeding
Treatment:
1. lifestyle advice = increase in iron in diet
2. Oral ferrous sulfate/fumarate/gluconate = one daily for 3 months
3. recheck FBC within 4 weeks
Define: Anal Fissure
Tear or ulcer in lining of the anal canal which causes pain on defecation
What are the causes of anal fissures?
- constipation
- IBD
- Colorectal cancer
- Anal surgery or sex
Management: Anal Fissure
- Ensure stools are soft = laxatives
- manage pain = paracetamol or ibuprofen, steroid cream
- Topical antibiotics
- Surgery if fails to heal
Refer if rectal cancer suspected
Define: anaphylaxis
Severe, life threatening generalised hypersensitivity reaction with rapid airway/breathing/circulation problems
Management: Anaphylaxis
- A+E
- 500mg intramuscular
- allergy info
- advice on biphasic reaction
Define: Generalised anxiety disorder
Characterised by excessive worry about every issue that is disproportionate to any inherent risk
What are the symptoms for Generalised anxiety disorder?
3 of symptoms present at all times:
- restlessness
- nervousness
- fatigue easily
- poor concentration
- irritability
- muscle tension
- sleep disturbance
What assessment is used for generalised anxiety disorder?
GAD-7 anxiety questionnaire
- helps establish the severity of the diagnosis
Management: Generalised anxiety disorder
- communicate the diagnosis early, provide info
- refer for counselling, guided self help, groups
- High intensity CBT
- Medication = sertraline SSRI
Define: OCD
Obsessive- compulsive disorder = recurrent obsessional thoughts or compulsive acts/ both may cause functional impairment +/ distress
Obsession = unwanted, intrusive thought, image or urge that repeatedly enters the person’s mind and that causes anxiety/ distress
compulsions = repetitive behaviours or rituals that the person feels driven to perform by their obsession that must be applied rigidly or to achieve a sense of ‘completeness’
What are the screening questions for OCD?
Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you that you would like to get rid of, but cannot?
Do your daily activities take a long time to finish?
Are you concerned about putting things in a special order, or are you upset by mess?
Do these problems trouble you?
ICD-11 and DSM- 5 criteria
Management: obsessive-compulsive disorder
- referral to CAMHS
- patient and carer education
1. CBT = exposure and response prevention - SSRIs medications
- TCA = clomipramine
- severe = antipsychotics e.g. aripiprazole or risperidone
Define: arrhythmias
Abnormal heart rhythms
- interruption to the normal electrical signals that coordinate the contraction of the heart muscles
What are the different types of arrhythmias?
- Cardiac arrest rhythms
shockable:
- ventricular tachycardia
- ventricular fibrillation
Unshockable:
- pulseless electrical activity
- asystole - Narrow Complex Tachycardia (QRS<0.12s)
- sinus tachycardia
- supraventricualr
tachycardia
- atrial fibrillation
- atrial flutter - Broad complex tachycardia (QRS >0.12s)
- ventricular tachycardia
- AF with bundle branch block
- supra ventricular tachycardia with BBB
Management: Arrhythmias
Emergency admission
- Ventricular tachycardia
- haemodynamic instability
- IHD
- Chest pain
- significant breathlessness
- syncope
Refer to cardiology
- Atrial flutter
- SVT
- Wolff-parkinson White syndrome
Non-urgent
- bloods
- lifestyle advice
- cease driving if likely to cause incapacity
What are the causes of AF?
SMITH
Sepsis
Mitral valve pathology
Ischaemic heart disease
Thyrotoxicosis
Hypertension
structural heart disease
electrical abnormalities
systemic causes = hyperthyroidism, obesity, diabetes
lifestyle factors = caffeine
genetic
idiopathic
Investigations: AF
- ECG
(Absent P waves
narrow QRS
irregularly irregular ventricular rhythm) - 24 hr ECG
- Echo
Management: atrial fibrillation
- CHADVASC
high risk >2
- anticoagulation = DOAC then warfarin/aspirin
(HAS-BLED score for bleed on anticoagulation) - Rate control (1st line for symptom control)
- BB e.g. bisoprolol
- CCB e.g. verapamil
- Digoxin
- Rhythm control (severe symptoms or HF)
- antiarrhymthmic drugs
- amiodarone, flecainide - electrical cardio version
- catheter ablation
Anticogulation (persistent AF) e.g. DOAC or warfarin
Define: Asthma
Chronic respiratory condition associated with airway inflammation and hyper-responsiveness
How to diagnose asthma?
- presence of more than one symptoms = wheeze, cough, breathlessness and chest tightness
- diurnal = worse at night/ early morning - FH of atopic conditions
- Fractional exhaled nitric oxide testing = positive >40
- Spirometry = FEV1/FVC <70%
- Bronchodilator reversibility = improvement of FEV1 of 12% or more
- Variable peak expiratory flow readings = >20 % variability
What is the aim of asthma management?
- no daytime symptoms
- no night time waking
- no need for rescue medication
- no asthma attacks
- no limitations on activity including exercise
- normal lung function
Management: Asthma
- SABA - short acting beta agonist
- Add low ICS
(if deliver inhaler used 3 or more times a week) - Add Leukotriene receptor antagonist LTRA
- Add LABA
- Change to MART (ICS + LABA )
- Increase ICS dose
- Add muscarinic receptor antagonist, theophylline or high ICS dose
What should be checked before increasing asthma medication?
- recheck adherence
- check inhaler technique
- check elimination of trigger factors
What should be monitored at an asthma a review?
- monitor number of asthma attacks
- nocturnal symptoms
- adherence
- lung function
- bronchodilator overuse
- smoking status
- possibility of occupational asthma
What are the different risk stages of future asthma attacks?
Greatly increased risk
- history of previous asthma attacks
Moderately increased risk
- poor control
- inappropriate or excessive use of SABAs
Slightly increased risk
- older age, female, reduced lung function, obesity, smoking, depression
What are the features for moderate asthma exacerbation?
- PEFR > 50-75%
- normal speech
What are the features for acute severe asthma exacerbation?
- PEFR 33-50%
OR resp rate >25/min
OR pulse rate >110
OR inability to complete sentence in one breath
OR accessory muscle use
OR inability to feed
with O2 sats at least 92%
What are the features for life threatening asthma exacerbation?
- PEFR <33%
OR O2 sats <92%
OR altered consciousness
OR exhaustion
OR cardiac arrhythmia
OR hypotension
OR cyanosis
OR poor resp effort
OR silent chest
OR confusion
Treatment: Moderate asthma exacerbation
- oxygen face mask
- pressurised meter-dose inhaler with a large volume spacer
Treatment: life threatening + severe asthma exacerbation
- oxygen mask
- nebulised salbutamol
- add nebulised ipratopium bromide
- first dose of prednisolone
Define: Domestic Abuse
Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality.
What are the types of domestic abuse?
- psychological
- physical
- sexual
- financial
- emotional
How can domestic abuse impact on health?
- Traumatic injuries following assault e.g. fractures, miscarriage.
- Somatic problems or chronic illness e.g. chronic pain, headaches.
- Psychological problems e.g. PTSD, depression, anxiety.
Give 3 potential indications of domestic abuse.
- Unwitnessed by anyone else.
- Repeat attendances to GP or A+E.
- Delay in seeking help.
- Multiple minor injuries.
What assessment tool can be used to determine someones risk of domestic abuse?
DASH assessment
What action would you take if someone was at high risk of domestic abuse?
Refer to MARAC or IDVAS.
What are the 4 features of the Health Belief Model?
- Believe they are susceptible to the condition in question
- believe it has serious consequences
- Believe that taking action reduces susceptibility
- Believe that the benefits of taking action outweighs the costs
‘Cues to action’ are another important aspect of the health belief model. What is meant by this?
- Internal cues e.g. worsening pain or breathlessness may trigger someone to want to change their behaviour.
- External cues e.g. reminder letters or phone calls from GP.
Give 3 disadvantages of the health belief model.
- Health beliefs may be affected by alternative factors e.g. outcome expectancy and self efficacy.
- The model does not consider the influence of emotions on behaviour.
- Cues to action are often missing in research.
- It does not differentiate between first time and repeat behaviours.
Define: Theory of Planned behaviour
Proposes the best predictor of behaviour is intention
What does the Theory of Planned Behaviour say intention is determined by?
- a person’s ATTITUDE to the behaviour
- the perceived social pressure to undertake the behaviour, or SUBJECTIVE NORM
- A person’s appraisal of their ability to perform the behaviour or their PERCEIVED BEHAVIOURAL CONTROL
How do we help people to act on their intentions?
- Perceived control = recall own success
- Anticipated regret = link to sustained intentions
- Preparatory actions = dividing a task into sub-goals increases self-efficacy
- Implementation intentions = ‘if then’ plans facilitates the translation of intention in to action
- Relevance to self
What are some criticisms of the Theory of Planned Behaviour model?
- lack of direction or causality
- doesn’t consider emotion
- doesn’t explain how attitudes, intentions and behaviour interact
- some things are not planned but just habits and routine
- relied on self-reported behaviour
What are the 5 stages of change in the transtheoretical model?
- precontemplation
- contemplation
- preparation
- action
- maintenance
(Relapse - at any point with in stages)
What are the pros and cons of the Transtheoretical model?
Pros:
- acknowledges different stages
- accounts for relapse
- temporal element
Cons:
- not all people move through every stages
people may move backwards
- progress may not be in a continuous steps
- doesn’t take into account values, habits, emotions, culture etc.
Give 3 external factors that are important when thinking about behaviour change.
- Impact of personality traits.
- Assessment of risk perception.
- Impact of past behaviour/habit.
- Social environment.
Define: atopic dermatitis/eczema
A chronic inflammatory skin condition that affects people of all ages
What are the symptoms/appearance of eczema?
Itchy skin +3:
- dry skin in last 12 months
- visible flexural eczema (in skin creases e.g. elbows)
- history of asthma or allergic rhinitis
- onset of symptoms before 2 yrs old
How to classify eczema?
Clear = normal skin with no active ezcema
Mild = areas of dry skin = infrequent itching
Moderate = areas of dry skin, frequent itching, redness
Severe = widespread areas of dry skin, incessant itching, and redness
Infected = weeping, crusted or pustules present with fever
How to categorise the impact of eczema on quality of life?
None = no impact on QoL
Mild = little impact on everyday activities, sleep, and psychosocial well-being
Moderate = moderate impact on everyday activities and psychological well-being and frequently disturbed sleep
Severe = severe limitation on everyday activity, psychosocial functioning, loss of sleep every night
Management: Mild eczema
- prescribe lots of emollients
- consider mild topical corticosteroid
Refer to dermatology if diagnosis uncertain or eczema uncontrolled
Management: Moderate eczema
- consider trigger factors or infection
- emollients
- if inflamed skin = moderately potent topical corticosteroid (max 5 days)
Preventative
- maintenance regime of topical corticosteroids
Management: severe eczema
- emollients frequently
- skin inflamed = potent topical corticosteroid
- severe itch = one month non-sedating antihistamine
- if affects sleep = sedating anti-histamine
- causes psychological distress = short course of an oral corticosteroid
preventative
- topical corticosteroids intermittent treatment for flare ups
Management: infected eczema
1st: flucloxacillin
penicillin allergy = clarithromycin
Localised areas of infection = topical fusidic acid
New emollients and corticosteroids (discard old products incase infected)
If recurs = send swab for micro testing
Define: Atrophic vaginitis
Refers to dryness and atrophy of the vaginal mucosa due to a lack of oestrogen
- occurs in women entering menopause
What is the pathophysiology of atrophic vaginitis?
Epithelial lining of vagina and urinary tract responds to oestrogen becoming thicker, more elastic and producing secretions
- in menopause Oestrogen levels drops so mucosa becomes thinner, less elastic and more dry
Tissue more prone to inflammation and changes in vaginal PH
What are the symptoms of atrophic vaginitis?
- itching
- dryness
- dyspareunia
- bleeding sue to localised inflammation
can present with
- recurrent UTIs
- stress incontinence
- pelvic organ prolapse
What is seen on examination for atrophic vaginitis?
- pale mucosa
- thin skin
- reduced skin folds
- erythema and inflammation
- dryness
- sparse pubic hair
Management: Atrophic vaginitis?
- vaginal lubricants = fro dryness
- topical oestrogen
- estriol cream
- estriol pessaries
- estradiol tablets
- estradiol ring
(HRT SE = breast cancer, angina, venous thromboembolism)
Define: bacterial vaginosis
An overgrowth of bacteria in the vagina specifically anaerobic bacteria due to loss of lactobacilli (friendly bacteria)
What are the risk factors for bacterial vaginosis?
- multiple sexual partners
- excessive vaginal clearing
- recent antibiotics
- smoking
- copper coil
What are the symptoms for bacterial vaginosis?
- fishy smelling watery grey or white vaginal discharge
Investigations: bacterial vaginosis
- speculum examination = view typical discharge
- vaginal pH = swab + pH paper >4.5
- Charcoal vaginal swab for micro (clue cells = gardnerella vaginalis)
Management: bacterial vaginosis
Can resolve without treatment
- antibiotic = metronidazole
oral or vaginal gel - check for chlamydia and gonorrhoea
What should be avoided when taking metronidazole?
Alcohol
- cause ‘disulfirman-like reaction’ with nausea and vomiting, flushing and sometimes hock and angioedema
What are the complications of bacterial vaginosis?
- miscarriage
- preterm delivery
- premature rupture of membranes
- chorioamnionitis
- low birth weight
- postpartum endometritis
Define: Bell’s palsy
An acute unilateral facial nerve weakness or paralysis of rapid onset and unknown cause
What are the symptoms for Bell’s palsy?
- rapid onset <72hrs
- facial muscle weakness or paralysis = upper and lower face unilateral
- ear pain
- difficulty chewing, dry mouth and changes in taste
- poor to incomplete eye closure, dry eye, eye pain
- hyperacusis
- numbness or tingling of cheek/mouth
- speech articulation problems
Management: Bell’s palsy
Prednisolone within 72 hrs
- 50 mg for 10 days or 60mg for 5 days
What are the types of eyelid disorders?
- blepharitis
- Stye
- Chalazion
- Entropion
- Ectropion
- trichiasis
- periorbital cellulitis
- orbital cellulitis
What is Blepharitis? Cause and management?
- inflammation of the eyelid margins
- cause gritty, itchy, dry sensation in the eyes
- dysfunction of meibomian glands = secrete meibum
Management = warm compress and gentle cleaning
What is a Stye?
Hordeolum external = infection of the glands of Zeis or glands of Moll.
Hordeoulum internum = infection of meibomian glands
Cause tender red lump along eyelid that may contain pus
What is the treatment for Stye’s?
Hot compress
Analgesia
Antibiotics if conjunctivitis or symptoms remain
What is an chalazion and treatment?
Meibomian gland becomes blocker and swells
- swelling in eyelid non tender
Treat: warm compress and gentle massage towards eyelashes to drain
What is entropion vs ectropion?
Entropion = Eyelid turn inward with the lashes pressed against the eye
- cause corneal damage and ulceration
Ectropion = eyelid turns outwards exposing inner aspect
- exposure keratopathy as eyeball exposed
What is the treatment for entropion and ectropion?
Entropion
- tape eyelid down + lubricate
- surgical
Ectropion
- lubricate drops
- significant cases = surgical
What is trichiasis?
Inward growth of eyelashes
- results in pain and can cause corneal damage and ulceration
Treat:
- remove affected eyelashes
- electrolysis or cryotherapy
- refer to ophthalmology if risk to sight
What is periorbital cellulitis?
AN eyelid and skin infection in front of the orbital septum
- hot, woollen, red skin around the eyelid and eye
Management: Periorbital cellulitis
- CT scan = Must differentiate from orbital cellulitis
- systemic antibiotics
What is orbital cellulitis?
An infection around the eyeball involving the tissues behind the orbital septum
- eye pain
- reduced eye movements
- vision changes
- abnormal pupil reactions
- proptosis
Management: orbital cellulitis
- Emergency admission
- IV antibiotics
- surgical drainage if abscess forms
Define: Benign paroxysmal postural vertigo
A disorder of the inner ear characterised by repeated episode of positional vertigo
Loose calcium carbonate debris in the semi-circular canals of the inner ear.
Movement of head causes movement of debris leading to vertigo
Management: postural vertigo BPPV
- most people recover over several weeks without treatment
- repositioning manoeuvre can alleviate symptoms
- advice not to drive
Define: benign prostatic hyperplasia
Hyperplasia of the stroll and epithelial cells of the prostate
What are the symptoms of BPH?
- hesitancy
- weak flow
- urgency
- frequency
- intermittency
- straining
- terminal driblling
- incomplete emptying
- nocturia
Investigations: BPH
- digital rectal exam = BPH feel smooth, symmetrical, soft
- abdominal exam = palpable bladder
- urianry frequency volume chart
- urine dipstick = infection, haematuria
- Prostate specific antigen = unreliable
What are reasons for a high PSA?
- prostate cancer
- BPH
- prostatitis
- UTI
- vigorous exercise
- recent ejaculation
Management: BPH
- alpha blockers e.g. tamsulosin
- relax smooth muscle - 5-alpha reductase inhibitors e.g. finasteride
- gradually reduce size of prostate - surgical
- TURP, TEVAP, open prostatectomy
Define breast abscess + mastitis
A collection of pus within an area of the breast usually caused by a bacterial infection
Mastitis = inflammation of breast tissue mainly due to breastfeeding or can be infection
What is the presentation of mastitis?
- nipple changes
- purulent nipple discharge
- localised pain
- tenderness
- warmth
- erythema
- hardening of the skin
- swelling
Management: Mastitis
lactational mastitis
- continue breastfeeding, breast massage, heat packs and warm showers
- analgesia
- antibiotics if infection suspected
Non-lactating
- analgesia
- antibiotics
- treatment of underlying cause e.g. eczema or candid infection
Management: breast abscess
- referral to surgical team
- antibiotics
- ultrasound
- drainage = needle aspiration or surgical incision ans drainage
- micro culture and sensitivities of the drained fluid
Define: bronchiolitis
Inflammation and infection in the bronchioles, the small airways of the lungs
Usually caused by respiratory syncytial virus (RSV)
What is the presentation for bronchiolitis?
MC in children under 1 yrs
- Coryzal symptoms = running nose, sneezing, mucus in throat, watery eyes
- signs of resp distress
- dyspnoea
- tachypnoea
- poor feeding
- mild fever
- apnoeas
- wheeze and crackles on auscultation
What are the signs of resp distress in paediatrics?
- raised resp rate
- use of accessory muscles
- intercostal and subcostal recessions
- nasal flaring
- head bobbing
- tracheal tugging
- cyanosis
- abnormal airway noises = wheezing, grunting, stridor
Management: bronchiolitis
- ensuring adequate intake
- don’t overfeed as a full stomach will restrict breathing - saline nasal drops and nasal suctioning
- supplementary oxygen <92%
- ventilatory support
Prevention
- Palivizumab injection given monthly
(ex-premature and congenital heart disease)
- provides passive protection
Define: bursitis
Trochanteric = inflammation fo bursa over the greater trochanter on the outer hip
Olecranon = inflammation and swelling of bursa over the elbow
(Bursae are sacs of synovial fluid to reduce friction at joints)
What is the cause of bursitis?
- Friction from repetitive movements
- Trauma
- Inflammatory conditions (e.g., rheumatoid arthritis)
- Infection – referred to as septic bursitis
Management: bursitis
- rest
- ice
- analgesia
- physio = hip
- aspirate going = elbow
- steroid injections
infected elbow = aspirate for micro and antibiotics
What is presentation and tests for trochanteric bursitis?
- aching or burning pain
- worse with activity
- tenderness on examination
Hip exam
- trendelenburg test
- resisted abduction of hip
- resisted internal rotation
- resisted external rotation
What does aspirate appearance indicate in olecranon bursitis?
Pus = indicates infection
Straw-coloured fluid = infection is less likely
Blood-stained fluid = may indicate trauma, infection or inflammatory causes
Milky fluid = indicates gout or pseudogout
Define: vaginal candidiasis/ thrush
Vaginal infection with a yeast of the candida family
(Candida albicans)
What are the risk factors for candidiasis?
- Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids)
- Broad-spectrum antibiotics
What is the presentation of candidiasis?
- Thick, white discharge = does not typically smell
- Vulval and vaginal itching, irritation or discomfort
Investigations: Candidiasis
- vaginal pH <4.5)
(distinguish between bacterial vaginosis + trichomonad pH >4.5) - charcoal swab with micro
Management: candidiasis
- vaginal
topical antifungal agents:
- clotrimazole cream
- miconazole cream/vaginal suppositories
- oral fluconazole single dose
recurrent = fluconazole once a week for 6 months
pregnant = cream or pessaries (no oral as too systemic)
- oral
- mild = nystatin oral suspensions or miconazole oral gel
- severe = oral fluconazole - neonates
- oral = nystatin oral suspension
- severe = oral fluconazole (monitor)
(Canesten duo - over the counter)
(anti fungal cream can damage latex condoms)
Define: chlamydia
Chlamydia trachomatis = gram negative bacteria causes STI
What is the presentation for chlamydia?
In women that are sexually active:
Abnormal vaginal discharge
Pelvic pain
Abnormal vaginal bleeding (intermenstrual or postcoital)
Painful sex (dyspareunia)
Painful urination (dysuria)
men that are sexually active and present with:
Urethral discharge or discomfort
Painful urination (dysuria)
Epididymo-orchitis
Reactive arthritis
Investigations: chlamydia
Nucleic acid amplification tests (NAAT)
- swab checking the DNA/RNA of organism
- swab endocervical, vulvovaginal and then urine
Management: chlamydia
- Doxycycline 100mg twice a day for 7 days
- abstain from sex for 7 days
- inform all partners + refer for testing
- advice on future prevention
What are some consequences of chlamydia?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Ectopic pregnancy
Epididymo-orchitis
Conjunctivitis
Lymphogranuloma venereum
Reactive arthritis
How to diagnose chronic fatigue syndrome?
- sleepiness = indicate sleep apnoea or another sleep disorder
- weakness = neuromuscular cause
- persistent fatigue for a min of 6 weeks
- debilitating fatigue worsened by activity
- post-exertional malaise = onset delayed by hours of days, disproportionate to activity
- unrefreshing sleep or sleep disturbance
- cognitive difficulties = struggling to remember words
Investigations: chronic fatigue syndrome
Tests to rule out other pathology
- FBC + serum ferritin = anaemia, polycythaemia, haematological malignancy
- ESR and CRP = infection
- liver function tests = underlying liver disease
- renal function tests
- thyroid function tests
- HBA1c
- IgA tissue transglutaminase = coeliac
- urinalysis = protein, blood, glucose
- creatine kinase = muscle tenderness –> neuromuscular cause
- bone biochem + myeloma screen
Management: chronic fatigue
- refer if underlying cause
- refer to chronic fatigue specialist
What is the presentation of chronic kidney disease?
Fatigue
Pallor (due to anaemia)
Foamy urine (proteinuria)
Nausea
Loss of appetite
Pruritus (itching)
Oedema
Hypertension
Peripheral neuropathy
Investigations: CKD
- eGFR
- Proteinuria = urine albumin:creatinine ratio
- Urine dipstick = haematruia
- renal USS
- BP
- HbA1c
- Lipid profile
What are the classifications for CKD?
G1 Over 90
G2 = 60-89
G3a = 45-59
G3b = 30-44
G4 = 15-29
G5 = Under 15
What are the complications of CKD?
Anaemia
Renal bone disease
Cardiovascular disease
Peripheral neuropathy
End-stage kidney disease
Dialysis-related complications
Management: CKD
- Optimising diabetic control
Optimising hypertension control
Reducing or avoiding nephrotoxic drugs (where appropriate)
Treating glomerulonephritis (where this is the cause) - Slow progression
- ACEi
- SGLT - 2 inhibitors e.g. dapagliflozin - Manage complications:
- Oral sodium bicarbonate = metabolic acidosis
- Iron and erythropoietin = anaemia
- Vitamin D, low phosphate diet and phosphate binders = renal bone disease - Dialysis
- Renal transplant
What is the presentation of COPD?
Shortness of breath
Cough
Sputum production
Wheeze
Recurrent respiratory infections, particularly in winter
NO CLUBBING, HAEMOPTYSIS OR CHEST PAIN
What are the grades of the MRC dyspnoea scale?
Grade 1: Breathless on strenuous exercise
Grade 2: Breathless on walking uphill
Grade 3: Breathlessness that slows walking on the flat
Grade 4: Breathlessness stops them from walking more than 100 meters on the flat
Grade 5: Unable to leave the house due to breathlessness
How to diagnose COPD?
Spirometry
- FEV1/FVC ration <70%
- No bronchodilator reversibility with salbutamol
What are the grades of severity for COPD?
Stage 1 (mild): FEV1 more than 80% of predicted
Stage 2 (moderate): FEV1 50-79% of predicted
Stage 3 (severe): FEV1 30-49% of predicted
Stage 4 (very severe): FEV1 less than 30% of predicted
Management: COPD
- stop smoking
- flu vaccine
1. SABA + SAMA
(short acting muscarinic antagonists = ipratropium bromide )
2. No asthmatic features:
LABA + LAMA
OR
asthmatic features:
LABA + ICS
- LABA, LAMA + ICS
- pulmonary rehab
- Long term oxygen therapy
Define: conjunctivitis
Inflammation of the conjunctiva - the thin layer fo tissue that covers the inside of the eyelids and sclera
Bacterial, viral or allergic
Unilateral or bilateral
How does conjunctivitis present?
Red, bloodshot eye
Itchy or gritty sensation
Discharge
Bacterial
- purulent discharge
- worse in morning
- highly contagious
viral
- clear discharge
- comes with dry cough, sore throat and blocked nose
- tender pr-auricular lymph nodes
- contagious
(no pain, photophobia ore reduced visual acuity)
What are the causes of an acute painful red eye?
Acute angle-closure glaucoma
Anterior uveitis
Scleritis
Corneal abrasions or ulceration
Keratitis
Foreign body
Traumatic or chemical injury
What are the causes of an acute painless red eye?
Conjunctivitis
Episcleritis
Subconjunctival haemorrhage
Management: conjunctivitis
resolves within 1-2 weeks
- clean eyes with cooled boiled water and cotton water to clear discharge
- chloramphenicol or fusidic acid eye drops (bacterial if necessary)
Management: constipation
- lifestyle changes
- healthy diet with fibre
- increased fluid intake
- increased activity
- regular toilet routine - Bulk forming laxatives
- ispaghula - Osmotic laxative e.g. macrogol
- Stimulant laxative
(stools soft but difficult to pass)
Ask person to gradually reduced and stop laxative once soft stool formed 3 times a week
What are secondary causes of constipation?
- medications
- diabetes
- IBD
- neurological conditions
- anal problems (fissures, structures, haemorrhoids)
Define: Contact dermatitis
Inflammatory skin condition which occurs as a result of exposure to an external irritant or allergen
How to diagnose contact dermatitis?
irritant
- dryness, tightness, burning
- skin Chanes in one area
- avoidance of irritant resolves symptoms
allergic
- develop within 24-72hrs
- itching
- blistering, weeping, oedema
- resolution can take many days
- may affect areas not directly in contact from fingers spreading it
Management: contact dermatitis
- avoid trigger
- emollient and soap substitutes
- topical corticosteroids
Define: Croup
Acute infective respiratory disease affecting young children (6months to 2 yrs)
- upper resp tract
- oedema in the larynx
What is the cause of croup?
MC = Parainfluenza virus
Influenza
Adenovirus
Respiratory Syncytial Virus (RSV)
What is the presentation of croup?
Increased work of breathing
“Barking” cough, occurring in clusters of coughing episodes
Hoarse voice
Stridor
Low grade fever
Management: croup
- Oral dexamethasone (usually single dose of 150mcg/kg)
- Oxygen
- Nebulised budesonide
- Nebulised adrenalin
- Intubation and ventilation
Define: Gout
Crystal arthropathy
- high blood uric acid levels
- urate crystals deposited in joint
- single acute, hot swollen, painful joint (big toe, base of thumb)
Investigations: gout
- raised urate blood test
- Joint aspiration = monosodium urate crystals with needle shaped negatively birefringent of polarised light
- X-ray
- maintained joint space
- lytic lesions in bone
- punched out erosions
- erosions have sclerotic borders
Management: Gout
Acute
1. NSAIDs (naproxen) with PPI
2. colchicine
3. oral steroids e.g. prednisolone
Prophylaxis
(xanthine oxidase inhibitors = lower uric acid level)
- allopurinol
- febuxostat
Define: Pseudogout
crystal arthropathy caused by calcium pyrophosphate crystals collecting in the joints.
It is formally known as calcium pyrophosphate deposition disease (CPPD) or chondrocalcinosis.
What is the presentation of pseudogout?
- many patients asymptomatic
- some present with chronic pain and stiffness in multiple joints
Typical = rapid onset hot, swollen, stiff, painful knee
(also affects shoulders, hip, wrists)
Investigation: Pseudogout
- Joint aspiration = calcium pyrophosphate crystals with rhomboid shaped positively birefringent of polarised light
- X-ray
- calcium deposits in joint cartilage
- similar to OA with LOSS
Management: pseudogout
Symptoms usually resolve on their own over several weeks
- NSAIDs (e.g., naproxen) with PPI
- Colchicine
- Intra-articular steroid injections (septic arthritis must be excluded first)
- Oral steroids
Define: Ringworm
A fungal infection of the skin
Tinea capitis = scalp
Tinea pedis = feet, athletes foot
Tinea cruris = groin
Tinea corporis = body
Onychomycosis = fungal nail infection
What is the presentation of ringworm?
Itchy rash that is erythematous, scaly and well demarcated edge
- hair loss
- deformed nails
Mangement: ringworm
- Anti-fungal creams e.g. clotrimazole and miconazole
- Anti-fungal shampoo e.g. ketoconazole for tinea capitis
- Oral anti-fungal medications e.g. fluconazole, griseofulvin and itraconazole
Management: Cutaneous warts
- Cause no symptoms and usually resolve
- cryotherapy
- topical salicylic acid
Mangement in GP: Dementia
- provide person and family with info
- ask person with consent to share info with services
- discuss care
- treat symptoms
- review medication
What routine screening is offered in the UK?
- Diabetic eye screening = people with diabetes aged 12 every 2 yrs
- Cervical screening for women 25-64yrs every 3-5 yrs
- Breast screening for women aged 50 yrs (until 71yrs)
- Bowel cancer screening for men + women ages 60-74yrs every 2 years
- Abdominal aortic aneurysm for men aged 65 yrs
What neonatal/newborn screening is offered?
- Fetal anomaly screen (FASP) = Down’s, Edward’s, Patau, spine bifida etc.
- Infectious diseases in pregnancy screening
- Sickle cell and Thalassaemia = pregnant women
- Newborn blood post test = CF, sickle cell etc.
- Newborn infant and physical examination (NIPE)
- Newborn hearing screening programme (NHSP)
Define: diverticular disease
Diverticulum = pocket in bowel wall
Diverticulosis = presence of diverticula without inflammation or infection
Diverticular disease = when patient experiences symptoms
Diverticulitis = inflammation and infection of diverticula
What is the presentation for acute diverticulitis?
- pain and tenderness in lower left abdomen
- fever
- diarrhoea
- nausea and vomiting
- rectal bleeding
- palpable abdominal mass
- raised inflammatory markers
Investigations: diverticulosis
Colonoscopy or CT scans
Management: Acute diverticulitis
- oral co-amoxiclav
- analgesia
- only taking clear liquids (avoid solid food)
- follow up within 2 days to review symptoms
acute abdomen/sepsis
- IV fluids, antibiotics, analgesia
- urgent investigations and surgery
How to diagnose hypertension?
above 140/90 in clinical settings
above 135/85 at home
What are the causes of secondary hypertension?
ROPED
Renal, disease
Obesity
Pregnancy or pre-eclampsia
Endocrine
Drugs
What are the stages for hypertension?
Stage 1 = above 140/90 in clinic and >135/85 at home
Stage 2 = above 160/100 in clinic and >150/95 at home
Stage 3 = above 180/120
What should be checked in a newly diagnosed hypertension patient?
- urine albumin:creatinine ratio = proteinuria, dipstick for haematuria
- bloods = Hb1Ac, renal function, lipids
- Fundus examination = hypertensive retinopathy
- ECG = cardiac abnormalities eg. left ventricular hypertrophy
Management: hypertension
- Under 55/type 2 diabetic = ACEi (e.g. ramipril)
Aged over 55/black African = CCB (e.g. amlodipine) - Add ACEi/CCB
- Add Thiazide like diuretic e.g. candesartan
- <4.5 potassium = spironolactone
>4.5 potassium = alpha blocker (e.g. doxazosin) or beta blocker (e.g. atenolol)
Define: Malignant hypertension
High BP over 180/120
with retinal haemorrhages or papilloedema
Management: malignant hypertension
- Fundoscopy = check for retinal haemorrhages or papilloedema
- same day referral
- IV sodium nitroprusside, labetalol, glyceryl trinitrate, nicardipine
Define: fibromyalgia
Presence of chronic widespread pain, fatigue, cognitive symptoms, IBS
With no known cause
Management: Fibromyalgia
- investigations to rule out other causes
- lifestyle changes = increased exercise
- talking therapies
- medication = antidepressants
- pain clinic
Define: folliculitis
Infection and inflammation of one or more hair follicles
What are the causes of folliculitis?
- infection
- physical irritation e.g. shaving
- chemical irritation
- blockage of hair follicle
- excessive sweating
- steroid creams
- inflammatory skin conditions
Management: folliculitis
- avoiding things that aggravate it
- stop with hair removal
- avoid wearing tight clothes
- keeping cool, expose to fresh air
- not sharing towels, flannels or razors
- applying an antibacterial moisturiser and soap substitute
Define: GORD
Acid from the stomach flows through the lower oesophageal sphincter and into the oesophagus, where it irritates the lining and causes symptoms
What are the causes/triggers of GORD?
- greasy, spicy foods
- coffee and tea
- alcohol
- NSAIDs
- stress
- smoking
- obesity
- hiatus hernia
What is the presentation of GORD?
Dyspepsia (indigestion
- heart burn
- acid reflux
- retrosternal or epigastric pain
- bloating
- nocturnal cough
- hoarse voice
What are the red flag features of GORD?
- dysphagia (difficulty swallowing)= urgent 2 week referral
- aged over 55 yrs
- weight loss
- upper abdominal pain
- reflux
- nausea and vomiting
- upper abdominal mass
- anaemia
- raised platelet count
Investigations: GORD
- oesophagi-gastro-duodenoscopy (OGD)
- CXR/ CT scan for hiatus hernia
- H.pylori stool test or urea breath test
Management:
- Lifestyle changes = reduce tea, coffee, alcohol, avoid smoking
- Reviewing medications (e.g., stop NSAIDs)
- Antacids (e.g., Gaviscon, Pepto-Bismol and Rennie) – short term only
- Proton pump inhibitors (e.g., omeprazole and lansoprazole)
- Histamine H2-receptor antagonists (e.g., famotidine)
- Surgery = laparoscopic fundoplication
Define: gonorrhoea
Gram negative diplococcus bacteria
- it infects mucous membranes with a columnar epithelium
- spreads via contact with mucous secretions
What is the presentation for gonorrhoea?
- odourless purulent discharge = green or yellow
- dysuria
- pelvic pain or testicular pain for men
Management: Gonorrhoea
- Nucleic acid amplification testing = detect RNA or DNA present
- Single dose of IM ceftriaxone (sensitivities not known)
Single dose of oral ciprofloxacin (sensitivities KNOWN)
What is disseminated goncoccal infection?
A complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints.
It causes:
Various non-specific skin lesions
Polyarthralgia (joint aches and pains)
Migratory polyarthritis (arthritis that moves between joints)
Tenosynovitis
Systemic symptoms such as fever and fatigue
Define: haemorrhoids
Enlarged anal vascular cushions
- often caused by constipation and straining
- MC in pregnancy, obesity, increased age and increased intra abdominal pressure
What are the classifications 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
Symptoms: haemorrhoids
- painless, bright red bleeding
- sore
- itchy
- feeling a lump around or inside anus
What are the 2 types of haemorrhoids?
- External (prolapsed) haemorrhoids = are visible on inspection as swellings covered in mucosa
- Internal haemorrhoids = may be felt on a PR exam (although this is generally difficult or not possible)
Management: haemorrhoids
- proctoscopy
- test fo anaemia if prolonged bleeding
- rule out other red flags
- Increase fibre and laxatives
- topical treatment to reduced swelling e.g. anusol
- Surgical = ligation, haemorrhoidectomy, staples
Define: Herpes simplex virus
Infection of genitals, ocular or oral
How to diagnose herpes simplex virus?
- multiple painful crops of blisters
- dysuria, vaginal or urethral discharge
- headache
Management: herpes simplex virus
- advice on self-care measures
- advice on informing sexual partners
- swab for micro
- Aciclovir 400mg three times a day for 5 days
Define + types: hiatus hernia
Refers to the herniation of the stomach up through the diaphragm
types
1. sliding = stomach slides up though the diaphragm
2. rolling = separate portion of stomach folds around and enters through diaphragm alongside oesophagus
3. combination of sliding and rolling
4. large opening with additional abdominal organs entering the thorax
Investigations: Hiatus hernia
CXR
Ct scan
endoscopy
barium swallow testing
Management: hiatus hernia
- Conservation
- treat GORD symptoms - surgical repair = laparoscopic fundoplication
Define: hypothyroidism
Insufficient thyroid hormones = T3 (triiodothyronine) and T4 (thyroxine)
Primary = high TSH and low T3+T4 (thyroid behaves abnormally)
Secondary = low TSH and low T3+T4 (pituitary behaves abnormally)
What are the causes of hypothyroidism?
- Hashimoto’s thyroiditis = autoimmune condition causing inflammation of the thyroid gland due to anti-thyroid peroxidase antibodies and anti-thyroglobulin antibodies
- iodine deficiency
- Medication for hyperthyroidism
- lithium
- amiodarone
Secondary
- tumours
- surgery to pituitary
- radiotherapy
- trauma
What is the presentation for hypothyroidism?
SLOW
Weight gain
Fatigue
Dry skin
Coarse hair and hair loss
Fluid retention (including oedema, pleural effusions and ascites)
Heavy or irregular periods
Constipation
Goitre
Management: hypothyroidism
- oral levothyroxine (synthetic version of T4)
Causes: hyperthyroidism
- graves disease = antibodies stimulate thyroid gland
- toxic multi nodular goitre = nodules produce excess
- thyroiditis = inflammation of thyroid
- excessive iodine intake
- thyroid cancer = rare
Presentation: hyperthyroidism
fast
- weight loss
- palpitations, tachycardia, AF
- tremors
- heat intolerance
- sweating
- diarrhoea
- enlarged thyroid gland
Investiagtions: hyperthyroidism
- serum thyroid function tests
- low TSH , high T4 + T3 - thyroid antibodies
- TSH receptor antibodies = graves
- thyroids peroxidase antibodies = graves / thyroiditis - thyroid imaging
- USS
- radioactive iodine uptake - ECG
- to assess for arrhythmias
Management: hyperthyroidism
- carbimazole
- beta blockers e.g. propanolol = for palpitations and tremors
- radioactive iodine therapy
- taken orally
- contraindicated in pregnant women - thyroidectomy
- if large goitre causing issues
- tolerant to medication
Define: Impetigo
A superficial bacterial skin infection
- caused by Staph aureus bacteria
- contagious
- enters through a break in the skin e.g. eczema, dermatitis
What is the presentation of the 2 types of impetigo?
Golden crust
Non - Bullous
- around nose and mouth
- exudate from lesions dries to form crust
Bullous
- grown in vesicles that then burst
Define: infectious mononucleosis
Condition caused by Epstein Barr Virus
(glandular fever)
- virus is found in the saliva of infected individuals
Adolescent with a sore throat, itchy rash after taking amoxicillin
Presentation: EBV
Fever
Sore throat
Fatigue
Lymphadenopathy (swollen lymph nodes)
Tonsillar enlargement
Splenomegaly and in rare cases splenic rupture
Investigations + management: EBV
- monospot test = EBV anitbodies
- EBV specific serology (when monospot test negative) = IgM+IgG
IgM antibody - rises early, acute
IgG antibody - suggests immunity - liver function testes = mild elevations in ALT and AST
Management:
- self limiting 2-3 weeks = painreflied, NSAIDs, sorethroat sweets, rest
- severe = short course of corticosteroids (rare)
- avoid alcohol
- avoid sports to avoid splenic rupture for 4 weeks
Define + presentation: influenza
- RNA virus
- 3 types = A, B, C
Fever
Lethargy and fatigue
Anorexia (loss of appetite)
Muscle and joint aches
Headache
Dry cough
Sore throat
Coryzal symptoms
(Flu has abrupt onset whereas cold is more gradual)
Mangement: Influenza
healthy patients don’t need treatment
- oral oseltamivir OR
inhaled zanamivir
How to diagnose IBS?
- Full blood count = anaemia
- Inflammatory markers (e.g., ESR and CRP)
- Coeliac serology (e.g., anti-TTG antibodies)
- Faecal calprotectin = inflammatory bowel disease
- CA125 = ovarian cance
Management: IBS
Drinking enough fluids
Regular small meals
Adjusting fibre intake according to symptoms (more fibre if predominantly constipated, less with diarrhoea/bloating)
Limit caffeine, alcohol and fatty foods
Low FODMAP diet, guided by a dietician
Probiotic supplements may be considered over-the-counter (discontinuing after 12 weeks if there is no benefit)
Reduce stress where possible
Regular exercise
medical:
1. diarrhoea = loperamide
2. bulk-forming laxatives e.g. lactulose
3. Antispasmodics for cramps e.g. mebeverine, alverine
4. SSRI
5. CBT
Management: soft tissue injury
- RICE
Sprain = bracing, physical therapy
Strains = rest, slowly increase mobility
Contusions = bruises
Define: Lyme disease
An infection caused by a tick bite
Present with erythema migraines
- bull’s eye
- spreading redness with well-defined edge
Management: Lyme disease
- offer ELISA test
- Doxycycline
- amoxicillin
- Azithromycin
Define and presentation: measles
Highly contagious infection caused by a morbillivirus of the paramyxovirus family
- contact with someone with measles
- recent travel
- fever
- maculopapular rash
- cough
- coryza symptoms
- conjunctivitis
Management: measles
Usually self-limiting
- stay away from school or work
fully vaccinated
Define: menopause
Menopause diagnosed = no periods for 12 months
menopause = the point at which menstruation stops
postmenopause = period from 12 months after the final period onwards
perimenopause = time around the menopause where women may be experiencing vasomotor symptoms and irregular periods includes lead up to last menstrual period and 12 months after
premature menopause = <40 yrs old, result of premature ovarian insufficiency
What are hormones levels in menopause?
Oestrogen and progesterone = low
LH and FSH = high (in response to absence of negative feedback from oestrogen)
What are perimenopausal symptoms?
A lack of oestrogen causes:
Hot flushes
Emotional lability or low mood
Premenstrual syndrome
Irregular periods
Joint pains
Heavier or lighter periods
Vaginal dryness and atrophy
Reduced libido
Management: perimenopausal symptoms
- No treatment
- Hormone replacement therapy (HRT)
- Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea)
- Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors
- Cognitive behavioural therapy (CBT)
- SSRI antidepressants, such as fluoxetine or citalopram
- Testosterone = treat reduced libido (usually as a gel or cream)
- Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT)
- Vaginal moisturisers, such as Sylk, Replens and YES
What are the 4 main types of migraines?
- Migraine without aura
- Migraine with aura
- Silent migraine (migraine with aura but without a headache)
- Hemiplegic migraine = unilateral limb weakness
what are the 5 stages of migraine?
- Premonitory or prodromal stage (can begin several days before the headache)
- Aura (lasting up to 60 minutes)
- Headache stage (lasts 4 to 72 hours)
- Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
- Postdromal or recovery phase
Presentation: migraine
Unilateral pounding or throbbing headache
- Moderate-severe intensity
- Pounding or throbbing in nature
- Photophobia (discomfort with lights)
- Phonophobia (discomfort with loud noises)
- Osmophobia (discomfort with strong smells)
- Aura (visual changes)
- Nausea and vomiting
management: migraines
Acute
- NSAIDS
- paracetamol
- triptans e.g. sumatriptan
- antiemetics
Prophylaxis
- propanolol
- amitriptyline
- topiramate
Define + presentation: Mumps
Viral infection spread by resp droplets
- prodrome
- fever
- muscle aches
- lethargy
- reduced appetite
- headache
- dry mouth - Parotid gland swelling
- abdominal pain
- testicular pain + swelling
- confusion
Management: Mumps
- PCR testing - antibodies
- notify public health
- supportive with fluids and analgesia
Presentation: Osteoarthritis
Unilateral weight bearing joints e.g. hip, knee, DIP in hands, CMC at base of thumb, lumbar spine, cervical spine
- Heberden’s nodes (distal)
- Bouchard’s nodes (proximal)
- bulky nony enlargement of the joint
- restricted range of motion
- crepitus on movement
- worse as day goes on
- no morning stiffness <30 mins
Investigations: OA
X-ray:
L – Loss of joint space
O – Osteophytes (bone spurs)
S – Subarticular sclerosis (increased density of the bone along the joint line)
S – Subchondral cysts (fluid-filled holes in the bone)
Management: OA
- lifestyle = exercise, weight loss, OT
- topical NSAIDs
- oral NSAIDs with PPI
- weak opioids + paracetamol for short term
- steroid injections
- joint replacement
Define: Osteoporosis + osteopenia
osteoporosis = reduction in bone density <-2.5
osteopenia = less severe decrease in bone density -1 to -2.5
Investigations: osteoporosis
assess:
- anyone on long term corticosteroids
- anyone >50 with risk factors
- all women >65 yrs
- all men >75 yrs
- QFracture tool
- FRAX score
- > 10% for DEXA scan
Management: osteoporosis
- lifestyle = exercise, reduce weight, stop smoking, reduce alcohol
- check / increase calcium dn vitamin D intake
- bisphosphonates e.g. alendronate, risedronate, zoledronic acid
- MAB , HRT
Define: Otitis Externa
Inflammation of the skin in the external ear canal
- swimming
- trauma to ear canal
- removal of ear wax
Presentation: otitis externa
Ear pain
Discharge
Itchiness
Conductive hearing loss (if the ear becomes blocked)
Examination
- Erythema and swelling in the ear canal
- Tenderness of the ear canal
- Pus or discharge in the ear canal
- Lymphadenopathy (swollen lymph nodes) in the neck or around the ear
- tympanic membrane = obstructed by wax or discharge
Management: Otitis externa
Otoscopy = examination of ear
- mild = acetic acid 2%
- Moderate = topical antibiotics + steroids e.g. neomycin + betamethasone
- severe = oral antibiotics OR discussion with ENT for admission
Fungal infection = clotrimazole ear drops (likely after multiple courses of antibiotics)
Define: otitis media
infection in the middle ear
(between the tympanic membrane and the inner ear)
- contains cochlea, vestibular apparatus and nerves
- bacteria enter through the Eustachian tube
What bacteria is likely to cause otitis media?
- step pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
What is the presentation of otitis media?
- ear pain
- reduced hearing
- malaise
- fever
- cough
- sore throat
- balance issues and vertigo
Management: Otitis media
otoscope = tympanic membrane looks red, bulging and inflamed
resolve within 3 days
if unresolved >4 days
1. amoxicillin
2. Clarithromycin
Define + presentation : Parkinson’s disease
progressive reduction in dopamine in the basal ganglia
- asymmetrical
- resting tremor (improves on movement)
- cogwheel rigidity
- bradykinesia –> shuffling gait
- reduced facial expression
Management: Parkinson’s disease
Diagnosis = history + examination
- Levodopa (with peripheral decarboxylase inhibitors) e.g. carbidopa
- COMT inhibitors e.g. entacapone
- Dopamine agonists e.g. pergolide, cabergoline
- Monoamine oxidase-B inhibitors e.g. selegiline
Define: pelvic inflammatory disease
Inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix
Endometritis
Salpingitis (Fallopian tubes)
Oophoritis (ovaries)
Parametritis (connective tissue around uterus)
Peritonitis
What are the causes and risk factors of pelvic inflammatory disease?
Usually by an STI
- neisseria gonorrhoea
- chlamydia trachomatis
- mycoplasma genitalium
or bacterial vaginosis
RF
- not using barrier contraception
- multiple sexual partners
- IUDs
- STD
What is the presentation of pelvic inflammatory disease?
Pelvic or lower abdominal pain
Abnormal, purulent vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
Management: pelvic inflammatory disease
NAAT swab, HIV swab
- IM ceftriaxone –> gonorrhoea
- Doxycycline –> chlamydia + mycoplasma genitalium
- metronidazole –> Gardnerella vaginalis
Define: peripheral vascular arterial disease
Narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas
- claudication
What are the types of claudication?
Intermittent claudication = cramps pain, during exertion, relived at rest
Critical limb ischaemia = inadequate supply, painful at rest, non-healing ulcers, gangrene, worse at night when leg raised
Acute limb ischaemia = blocked artery, rapid onset, 6Ps (pulseless, pallor, paraesthesia, painfully cold, pain, paralysis)
What are the differences between an arterial and venous ulcer?
Arterial
- smaller
- deeper
- well defined borders
- punched out appearance
- peripheral (toes)
- reduced bleeding
- painful
Venous
- occur after minor injury
- larger
- superficial
- irregular
- less painful
- calf to ankle area
Investigations: Peripheral vascular disease
- ankle brachial pressure index (>1.3 = calcification)
- duplex USS
- angiography CT or MRI
Management: peripheral vascular disease
Intermittent claudication
1. lifestyle changes + exercise training
2. atorvastatin
2. clopidogrel
3. naftidrofuryl oxalate
4. Surgical options - end-vascular angioplasty + stenting
Critical limb ischaemia
1. surgery - endovascular angioplasty, stent, bypass, amputation
Acute limb ischaemia
1. surgery - thrombolysis, thrombectomy
Opioid misuse: name a drug that can be used for detoxification.
Buprenorphine
Opioid misuse: in what type of people would maintenance therapy be indicated?
Stabilisation/maintenance is needed for the following:
- Those who have been addicted for a long time.
- IVDU
Give 3 signs of addiction.
- Cravings.
- Tolerance.
- Compulsive drug-seeking behaviour.
- Physiological withdrawal state.
What formula is used to work out how many units of alcohol there are in a drink?
Strength of drink (%ABV) X Volume (ml) / 1000
How effective are opioids for acute and chronic pain?
- opioids very effective for acute pain
- chronic pain longer than 3 months
What are the negative effects of chronic pain?
- central sensitisation
- allodynia = pain from non-painful stimulus
- deconditioning
- biomechanics problems
- depression
- cognitive impairment
- dysfunctional relationships
- suicide risk
What opioid is given in renal failure?
Fentanyl
What are the negative effects of opioids?
- addiction
- tolerance
- withdrawal symptoms
- dependence
- may not be able to drive if drowsy
- constipation (slow down peristalsis) –> give Senna
- respiratory depression esp when sleeping
- overdose
- reduce immune system
- death
What are the signs of an opioid overdose?
- not moving- tiny pupils
- slow or no breathing
- choking, gurgling, snoring sounds
- blue lips and nails
- clammy or cold skins
What is given to treat an opioid overdose?
Naloxone = opioids
Acetylcysteine — paracetamol.
Digoxin-specific antibody fragments — digoxin.
Flumazenil injection = benzodiazepine
- take bloods
- ECG
What guidance is given on treating chronic pain?
- group exercise weight loss
- acceptance and commitment therapy (ACT) or CBT
- psychological: counselling
- occupational: work place based review
Pharmological
- antidepressant
- amitriptyline, citalopram, duloxetine, fluoxetine, sertraline
DO NOT OFFER = gabapentinoids, antipsychotic drugs
Define: malnutrition and triple burden
Malnutrition = deficiencies, excesses or imbalances in a person intake of energy and/or nutrients
- Undernutrition or
- overweight/obesity
- triple burden = micronutrient deficiencies (hidden hunger)
Name 2 early influences on feeding behaviour.
- Human foetuses swallow amniotic fluid = maternal diet
- Breast feeding.
- parenting practices
Give 3 advantages of breast feeding on feeding behaviour.
- More likely to accept novel foods in weaning.
- Less fussy eaters in childhood.
- More likely to have a diet rich in fruit and vegetables.
Give 3 ways in which parents can tackle fussy eating.
- Modelling healthy eating behaviours and eating as a family.
- Provide a variety of food.
- Avoid pressure to eat.
- Restriction.
- Authoritative parenting.
- Not using food as a reward.
What is the public health issue for breastfeeding?
Breastfeeding low in:
- young mothers
- disadvantaged socio-economic groups
What are the 4 dimensions of food insecurity?
- Availability of food
- Access - economic and physical
- Utilisation - opportunity to prepare food
- Stability - of the 3 dimensions over time
What are the challenges of weight loss?
- maintaining the weight loss is hard
- weight cycling = leads to overshooting gaining more weight
- loss of lean body mass = after diet so reduced metabolic rate
- dieting disrupts ‘normal’ appetite responses
- body defends the highest weight
Define: polymyalgia rheumatica
Chronic, systemic rheumatic inflammatory disease
- aching, morning stiffness in neck, shoulders pelvic girdle
- over 50 yrs old
Investigations + management: polymyalgia rheumatica
- ESR and CRP bloods = both raised
- exclude giant cell arteritis
- Trial of oral prednisolone 1 week
- start reducing prednisolone when symptoms controlled
typically treatment is required between 1-2 years
Presentation: prostate cancer
Can be asymptomatic
- LUTS
- haematuria
- erectile dysfunction
- weight loss
- bone pain
Investigations: prostate cancer
- PSA antibody test - very unreliable
- prostate examination - cancer feel hard, craggy, asymmetrical
- Multiparametric MRI
- Prostate biopsy - MRI scale 3 or above
- Gleason grading system
- TNM staging - Isotope bone scan - look for bone metastasis
Management: prostate cancer
- surveillance
- external beam radiotherapy
- brachytherapy - implanting radioactive seeds in prostate
- hormone therapy - reduce levels of androgens
- surgery - radical prostatectomy
Define + presentation: psoriasis
Chronic autoimmune condition with psoriatic skin lesions
- dry
- flaky
- scaly
- erythematous
- raised
- elbows and knees and scalp
What are the signs suggestive of psoriasis?
- Auspitz sign = small points of bleeding when plaques are scraped off
- Koebner phenomenon = the development of psoriatic lesions to areas of skin affected by trauma
- Residual pigmentation = of skin after the lesions resolve
Management: psoriasis
1, topical steroids
2. topical vitamin D analogues
3. topical dithranol
4. topical calcineurin inhibitors
5. phototherapy
Define + presentation: back pain + sciatica
Mechanical back pain = no specific disease causing it
sciatica = irritation of sciatic nerve at L4-S3
Chronic lower back pain
What are the causes and red flags of back pain?
Mechanical
- muscle or ligament sprain
- facet joint dysfunction
- sacroiliac joint dysfunction
- herniated disc
- scoliosis
neck = whiplash, cervical spondylosis
Red flags
- spinal fracture
- cauda equina = bilateral sciatica
- spinal stenosis
- ankylosing spondylitis
- spinal infection
Presentation: sciatica
- unilateral pain from buttock radiating down the back of the thigh to below the knee
- paraesthesia
- numbness
- motor weakness
ask about
- trauma
- stiffness in morning
- gradual onset = ankylosing
- weight loss
- bilateral, saddle anaesthesia, incontinence, urinary retention = caudal equina
- fever = spinal infection
Investigations: sciatica
- X-ray spine
- Emergency MRI = caudal equina
- raised inflammatory markers = ankylosing
Management: sciatica
- amitriptyline or duloxetine
- epidural corticosteroid or local anaesthetic injections
- spinal decompression
Define: reactive arthritis
Synovitis in joints after an infection
- single swollen, warm, painful joint
- STIs or gastroenteritis
- HLA B27 gene
Can’t see, pee or climb a tree
- conjunctivitis
- urethritis
- anterior uveitis
Management: reactive arthritis
- rule out septic joint = joint aspiration + micro
- Antibiotics for infection
- NSAIDs
- steroid injections into joint
- systemic steroids if multiple joints
Define + causes: sinusitis
Inflammation of the parasternal sinuses in the face
- Viral URTI
- allergies
- obstruction of drainage
- smoking
Presentation: sinusitis
Nasal congestion
Nasal discharge
Facial pain or headache
Facial pressure
Facial swelling over the affected areas
Loss of smell
tenderness on palpation
fever
Management: sinusitis
usually self-limiting
> 10 days
1. antibiotics = Pen V then clarithromycin
2. high dose steroid nasal spray
Define + causes: syphilis
STI caused by Treponema palladium
- sex
- vertical transmission
- IV drugs
- blood transfusion
Presentation: syphilis
Primary
- painless genital ulcer = chancre
- local lymphadenopathy
Secondary
- maculopapular rash
- wart lesions
- fever
- alopecia
- oral lesions
Tertiary
- gummatous lesions
- aortic aneurysms
- neurosyphilis
Neurosyphilis
- headache
- altered behaviour
- dementia
- paralysis
Management: syphilis
Antibody testing = PCR or dark field microscopy
- IM benzathine benzylpenicillin
Presentation + management: tension headache
Pressure band around the head
- caused by stress, depression, alcohol, dehydration
- Stress managing techniques
- simple analgesia
- frequent headaches = amitriptyline
Define + presentation: Tonsillitis
Inflammation of tonsils
- MC viral infection
- sore throat
- fever
- pain on swallowing
What is the criteria for giving antibiotics for tonsillitis?
Centor criteria
1. fever
2. tonsillar exudates
3. absence of cough
4. tender cervical lymph nodes
>3 = bacteria so give antibiotics
FeverPAIN score
1. fever
2. Purulence
3. Attended within 3 days of the onset of symptoms
4. Inflamed tonsils
5. No cough or coryza
> 4 give antibiotics
Management: tonsillitis
- Penicillin V (phenocymethylpenicllin)
- clarithromycin
Define + Increase risk of: trichomonad vaginalis
Parasite spread through sexual intercourse
Increase risk of:
- contracting HIV
- bacterial vaginosis
- cervical cancer
- pelvic inflammatory disease
- pregnancy related complications
Presentation: trichomoniasis
- vaginal discharge = frothy, yellow, green
- itching
- dysuria
- dyspareunia (painful sex)
- balanitis (inflammation to glans penis)
Management: trichomoniasis
Women:
Charcoal swab with microscopy –> from posterior fornix of vagina
Men:
urethral swab or first catch urine
- metronidazole
Presentation + management: trigeminal neuralgia
Intense facial pain in distribution of nerve: ophthalmic, maxillary, mandibular
- unilateral
- carbamazepine
- surgical
What are the types of urinary incontinence?
- Urge = caused by overactivity of detrusor muscle of the bladder
- stress = pelvic flaw muscles weak so urine leaks through at increased pressures
- mixed
- overflow = obstruction to the outflow of the urine
What is the grading system for urinary incontinence?
Modified Oxford grading system:
0: No contraction
1: Faint contraction
2: Weak contraction
3: Moderate contraction with some resistance
4: Good contraction with resistance
5: Strong contraction, a firm squeeze and drawing inwards
Investigation: urinary incontinence
- bladder diary
- urine dipstick testing
- post-void residual bladder volume
- urodynamic testing = catheter inserted and measure pressure in bladder + rectum
Management: Stress incontinence
- avoid caffeine, overfilling bladder, weight loss
- supervised pelvic floor exercises
- surgery = tension-free vaginal tape, sling procedures
- Duloxetine
Management: urge incontinence
- bladder retraining
- anticholinergic medication = oxybutynin
- Mirabegnon
- invasive = botulin toxin injection, sacral nerve stimulation, augmentation cytoplasty
Define: lower urinary tract infection
Infection in the bladder causing cystitis (inflammation of the bladder)
- usually caused by E.coli
Presentation: Lower urinary tract infection
- dysuria
- suprapubic pain
- frequency
- incontinence
- haematuria
- cloudy or foul smelling urine
- confusion in older patients
(pyelonephritis = fever, back pain, nausea, renal angle tenderness)
Investigations: lower urinary tract infection
Urine dipstick
- nitrites = bacteria present (best sign)
- leukocytes (if only present without nitrites then need more evidence to treat as UTI)
- RBCs
Midstream urine = sent for micro + culture
Management: lower urinary tract infection
- trimethoprim
- nitrofurantoin
3 days = in women
5-10days = immunosuppressed women, abnormal anatomy or impaired kidney function
7 days = men, pregnant women, catheter
What antibiotics are used in lower urinary tract infection in pregnancy?
- Nitrofurantoin = avoided in 3rd trimester
Trimethoprim = avoided in 1st trimester (folate antagonist) - Amoxicillin
- Cefalexin
Define + presentation: urticaria
Hives
- small itchy lumps appear on the skin
- patchy erythematous rash
- angioedema
- flushing
What are the causes of urticaria?
acute
- allergies
- contact with chemicals
- medictaions
- viral infections
- insect bites
Chronic
- chronic idiopathic = no clear cause
- chronic inducible = episodes triggered by sunlight, temp change, exercise, strong emotions
- autoimmune = SLE
Management: urticaria
- antihistamines
- fexofenadine - oral steroids = short term for flares
- Anti-leukotrienes such as montelukast
- Omalizumab, which targets IgE
- Cyclosporin
Why do varicose veins develop?
- deep and superficial veins are connected by vessels
- valves incompetent = blood flows from the deep veins back into the superficial veins and overloads them
- leads to dilatation of superficial veins
Presentation: varicose veins
Heavy or dragging sensation in the legs
Aching
Itching
Burning
Oedema
Muscle cramps
Restless legs
chronic venous insufficiency = e.g., skin changes and ulcers
What are the special tests for varicose veins?
Tap test = apply pressure to saphenofemoral junction and tap distal varicose vein, feel thrill
Cough test = apply pressure to SFJ and cough, feel thrills
Trendelenburg’s test = lift affect leg lying down, apply tourniquet, then stand up, if varicose veins reappear then valve below is incompetent, if don’t reappear than above
Perthes test = apply tourniquets, heel raises, if superficial veins disappear then deep veins functioning
Duplex USS
Management: varicose veins
- weight loss, exercise, elevate leg, compression stockings
- surgical
- Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation
- Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
- Stripping – the veins are ligated and pulled out of the leg
Define + physiology: vasovagal syncope
Temporarily losing consciousness
1. problem with autonomic nervous system regulating blood flow to brain
2. strong stimulus to vagus nerve stimulates parasympathetic nervous system
3. relaxes smooth muscle in blood vessels
4. BP in cerebral circulation drops
5. hypo perfusion of brain tissue
6. patient faints
Presentation + things to rule out: syncope
- can remember how they felt prior
- dizzy, sweaty, vision going blurry, headache
- lasts a few seconds
Epilepsy
- prolonged periods of confusion, disorientation
- incontinence in both
- aura
- tongue biting
- jerking
- cyanosis
- lasts more than 5 mins
Investigations: syncope
ECG = arrhythmia, QT interval
24 hr ECG
ECHO
Bloods = FBC (anaemia), electrolytes (arrhythmias + seizures), blood glucose (diabetes)
Management: syncope
normal in children and teenage girls
rule out other causes
- Avoid dehydration
- Avoid missing meals
- Avoid standing still for long periods
- When experiencing prodromal symptoms such as sweating and dizziness, sit or lie down, have some water or something to eat and wait until feeling better
Define + 6 types: viral exanthemas
eruptive widespread rash
- Measles = kopek grey spots on buccal mucosa, rash starts on face, behind ears
- Scarlet Fever = red blotchy, macula rash, sandpaper skin, starts on trunk
- Rubella (AKA German Measles) = starts on face, lasts 3 days, mild fever, sore throat
- Dukes’ Disease = no organism found, non-specific
- Parvovirus B19 = bright red rash on both cheeks
- Roseola Infantum = fever first, then rash appears across arms, legs, trunks, not itchy
Define + presentation: gastroenteritis
inflammation of stomach and bowels
- abdo pain
- nausea
- vomiting
- diarrhoea
What are the causes of gastroenteritis?
- E.coli
- campylobacter jejuni
- shigella
- salmonella
- bacillus cereus
- yersinia enterocolitica
- staph enterotoxins
- giardiasis
Management: gastroenteritis
- faeces sample for micro
- ensure hydrated
- antidiarrhoeal drugs (loperamide) + antiemetics (metoclopramide)
- antibiotics = only when organism confirmed
Define: whooping cough
Upper resp tract infection caused by bordetella pertussis
- whooping sound as they forcefully suck in air
- apnoea
Management: whooping cough
- nasal swab with PCR testing or serology (if lasted longer than 21 days for IgG)
- notify public health
- supportive care
- antibiotics (if within 21 days) - azithromycin, erythromycin, clarithromycin
- prophylactic antibiotics to close contacts
Define + presentation: chicken pox
caused by varicella zoster virus
- generalised vesicular rash
- fever
- itchy
- general fatigue
High contagious
Management: chicken pox
self limiting
1. aciclovir = immunosuppressed patients, adults >14 yrs, neonates
What are the 5 level’s of Maslow’s hierarchy of needs?
- Physiological needs.
- Safety needs.
- Love and belonging.
- Esteem.
- Self-actualisation.
Although using measures of health outcomes is desirable in evaluation of health services, there are potential limitations.
Explain why it may be difficult to attribute a health outcome to the service provided.
- Other factors may be involved.
- There may be a time lag between service and outcome.
- Large sample sizes may be needed.
- Data may be unavailable or there may be issues with data quality.
What is the Avedia Donedebian’s 3 stage model of evaluating the quality of health ?
- Structure
- buildings, staff, equipment - Process
- tests, examinations, counselling, prescribing - Outcome
- morbidity
- mortality
- satisfaction
What is Maxwell’s 6 dimensions of quality?
(3Es and 3As)
Acceptability
Accessibility
Appropriateness (Relevance)
Effectiveness
Efficiency
Equity
Define prevalence
total number of cases of a disease (new and existing) in a population at a given time
Define incidence
the rate of new cases of a disease in a population over a specific time period
Define odds ratio
measure used to compare the odds of an outcome between 2 groups
Define relative risk
compare the risk of an outcome between 2 groups
(it is a measure of association, not of the severity)
define case fatality rate
proportion of people diagnosed with a particular disease who die from the disease
Define: specificity
proportion of patients without the condition who have a negative result
TN / (TN+FP)
Define: sensitivity
proportion of patients with the condition who have a positive screening result
TP / (TP+FN)
define: positive predictive value
Proportion of people with a positive test result that have the disease
TP / (TP+FP)
Define: negative predictive value
proportion of patients who got a negative test result who don’t have the disease
TN / (TN+FN)
What is reliability vs validity?
validity = tests accuracy
reliability = consistency of a measure
What are the 3 levels of prevention?
primary = prevent disease before it has developed
secondary = prevent progression of condition while asymptomatic or in early stages
tertiary = disease exist, minimise disability and negative effects
