GP community and public health

Question 1

What are the 4 main determinants of health?

Answer 1

1. Lifestyle.
2. Access to healthcare.
3. Genes.
4. Environment.

Question 2

Define equity and equality.

Answer 2

Equity = what is fair and just
Equality = concerned with equal shares

Question 3

Define horizontal equity

Answer 3

Equal treatment for equal need

e.g. individuals with pneumonia (with all other things being equal) should be treated equally

Question 4

Define vertical equity.

Answer 4

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

Question 5

Give 2 factors that affect equity

Answer 5

1. Spatial
   - geography
2. Social
   - age
   - gender
   - socioeconomic
   - ethnicity

Question 6

What are the 3 domains of public health?

Answer 6

1. health improvement - social interventions aimed at preventing disease through promoting health
2. health protection - concerned with measures to control infectious disease risks
3. health care - organisation and delivery for healthcare services

Question 7

Define health psychology

Answer 7

Emphasises the role of psychological factors in the cause, progression and consequences of health and illness.

Promotes healthy behaviours

Question 8

What are the 3 main categories of health categories?

Answer 8

1. health behaviour
2. illness behaviour
3. sick role behaviour

Question 9

Define health behaviour

Answer 9

a behaviour aimed to prevent disease e.g. eating healthy

Question 10

Define illness behaviour

Answer 10

a behaviour aimed to seek remedy (e.g. going to the doctor)

Question 11

Define sick role behaviour

Answer 11

Sick role Behaviour: any activity aimed at getting well (e.g. taking prescribed medications; resting)

Question 12

What are health damaging behaviours?

Answer 12

Health damaging behaviours are often related to mortality e.g. smoking, alcohol, high risk sexual behaviours.

Question 13

What are health promoting behaviours?

Answer 13

Behaviours that seek and maintain health e.g. exercise, eating healthily, having vaccines.

Question 14

What factors affect medication adherence?

Answer 14

• not knowing what the medication does
• poly pharmacy
• side effects
• they feel well
• don’t take it properly

Question 15

What sort of health behaviour interventions are there?

Answer 15

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

Question 16

What are the 3 3lv3ls of intervention of behaviour change?

Answer 16

individual behaviour
Local community
Population level

Question 17

What is unrealistic optimism?

Answer 17

Individuals continue to practise health damaging behaviour sue to inaccurate perception go risk and susceptibility

Question 18

What are the perceptions of risk influenced by?

Answer 18

1. Lack of personal experience with problem
2. Belief that preventable by personal action
3. Belief that if not happened by now, it’s not likely to
4. Belief that problem is infrequent
5. situational variability (seemed a good idea at the time)
6. cultural variability

Question 19

What did Davison’s study of patients perception of risk show?

Answer 19

• 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

Question 20

What is a cross-sectional study?

Answer 20

Observations made at a specific point in time (now)

Question 21

What are the pros and cons of a cross sectional study?

Answer 21

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

Question 22

What is a case control study?

Answer 22

(Past) select participants with and without outcome and look back to see who had exposure

Question 23

Strengths and weaknesses of case control study?

Answer 23

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

Question 24

What is a cohort study?

Answer 24

(future)
collect participants info on a sample (some have exposure, others don’t)
Follow up over time, see who gets outcome

Question 25

Strengths and weaknesses of cohort study?

Answer 25

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

Question 26

What is an RCT? Pros and cons?

Answer 26

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

Question 27

What is a crossover trial? pros and cons?

Answer 27

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)

Question 28

What is ‘Health Needs Assessment’?

Answer 28

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.

Question 29

Health Needs Assessment: define need.

Answer 29

The ability to benefit from an intervention.

Question 30

Health Needs Assessment: briefly describe the planning cycle.

Answer 30

(is the need met) Needs assessment -> planning -> implementation -> evaluation -> needs assessment etc…

Question 31

What is felt need?

Answer 31

Individual internalised perception of variation from normal health

Question 32

What is expressed need?

Answer 32

Individual seeks help to overcome variation in normal health (demand)

Question 33

What is normative need?

Answer 33

Professional defines intervention appropriate for the expressed need

Question 34

What is comparative need?

Answer 34

Comparison between severity, range of interventions and cost

Question 35

Health needs assessment: define demand.

Answer 35

what people ask for

Question 36

Health needs assessment: define supply.

Answer 36

What is provided

Question 37

What is the inverse care law?

Answer 37

The availability of good medical care can vary inversely with the need for it (greater unmet need for disadvantaged people)

Question 38

Name 3 different types of health needs assessment.

Answer 38

Epidemiological. Comparative. Corporate.

Question 39

Give 3 negative points for epidemiological health needs assessments.

Answer 39

1. Required date may not be available. 2. Variable data quality. 3. Ignores felt needs.

Question 40

Who might be involved with corporate health needs assessment?

Answer 40

Politicians. Press. Providers. Professionals. Patients.

Question 41

Give 3 negative points for corporate health needs assessments.

Answer 41

1. Difficult to distinguish need from demand. 2. Groups may have vested interests. 3. May be influenced by political agendas.

Question 42

Briefly describe a comparative health needs assessment.

Answer 42

Compares services received by one population with other populations.

Question 43

Give 3 negative points for comparative health needs assessments.

Answer 43

1. Required date may not be available. 2. Variable data quality. 3. It is hard to find comparable populations.

Question 44

What are the challenges and benefits of a health needs assessment?

Answer 44

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

Question 45

Define Acne vulgaris and its cause.

Answer 45

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

Question 46

Describe the appearance of acne vulgaris

Answer 46

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

Question 47

What is the aim of acne vulgarise treatment?

Answer 47

- reduce symptoms - reduce risk of scarring - minimise psychosocial impact of condition (explore anxiety and depression)

Question 48

Management of acne vulgaris.

Answer 48

1. No treatment if mild 2. Topical Benzoyl peroxide = reduce inflammation & toxic to Propionibacterium acnes bacteria 3. Topical retinoids = slow production of sebum 4. Topical antibiotics = e.g. clindamycin with benzoyl peroxide to reduce bacterial resistance 5. Oral antibiotics = lymecycline 6. Oral contraceptive pill = help stabilise female hormones & reduce production of sebum 7. Oral retinoids = severe, last line, tetragenic so with contraceptives

Question 49

What is the Oral retinoid used for treating acne vulgaris and its mechanism?

Answer 49

Isotretinoin (Roaccutane) - reduces production of sebum - reduce inflammation - reduce bacterial growth Only prescribed by dermatologist

Question 50

What are the side effects of isotretinoin?

Answer 50

- 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

Question 51

Define: Acute bronchitis

Answer 51

Lower respiratory tract infection which causes inflammation in the bronchial airways

Question 52

Define: pneumonia

Answer 52

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)

Question 53

What are the symptoms of acute bronchitis?

Answer 53

- cough - may have sputum, wheeze, breathlessness - chest pain present from cough - may have raised temp

Question 54

Investigations: Acute Bronchitis

Answer 54

- listen to chest = wheeze - check temp & ops - refer to get CXR if severe

Question 55

Management: Acute Bronchitis

Answer 55

- self limiting, cough for 3-4 weeks - fluid, paracetamol or ibuprofen, cough medicine - smoking cessation - antibiotics = only if systemically unwell

Question 56

Define: Acute Stress Reaction

Answer 56

Follows a sudden severe stressor and lasts for only a few days Occurs in an individual without previous psychological disorder

Question 57

What are common causes of Acute Stress Reaction?

Answer 57

- rape or other assault - war or natural disaster - breakup of intimate relationship

Question 58

What are features of an Acute Stress Reaction?

Answer 58

- fear, anxiety, depression - palpitations, sweats, restlessness, insomnia - avoidance - denial and repression

Question 59

Management: Acute Stress Reaction

Answer 59

1. sympathetic listening 2. short term anxiolytics 3. encouragement to recall event and to express emotion 4. Improve coping strategies 5. Help with long term consequences of stressful reaction such as disability

Question 60

What are the types of allergies seen by GPs?

Answer 60

- allergic rhinitis - angio-odema + anaphylaxis - Asthma - conjunctivitis - Cow's milk allergy in children - Food allergy Insect bites and stings - Tiredness/fatigue in adults - Urticaria

Question 61

Define: Allergic rhinitis

Answer 61

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

Question 62

Cause: Allergic Rhinitis

Answer 62

- house dust mites - pollens - moulds - animal hair - occupation

Question 63

Management: Allergic rhinitis

Answer 63

- nasal spray - anit-histamines - avoid trigger - allergy testing

Question 64

Management: milk or food allergy

Answer 64

- allergy testing - send to A&E if severe - paediatric dietician

Question 65

Define: anaemia

Answer 65

Low red blood cell production due to low iron stores in the body

Question 66

What are the causes of anaemia?

Answer 66

- dietary deficiency - malabsorption e.g. coeliac, H.pylori, gastrectomy - increased loss e.g. chronic blood loss - Increased requirement = pregnant

Question 67

Symptoms: Anaemia

Answer 67

Symptoms - dyspnoea - fatigue - headache - cognitive dysfunction - restless leg syndrome - weak - pruritus Signs - pallor - atrophic glossitis - damaged hair - alopecia - angular cheilosis - koilonychia

Question 68

Investigations: Anaemia

Answer 68

1. FBC (low Hb and MCV) men = below 130 women over 15 yrs = below 120 children = below 120 2. Ferritin level If MCV <95 3. check B12 and folate

Question 69

Management: Anaemia

Answer 69

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

Question 70

Define: Anal Fissure

Answer 70

Tear or ulcer in lining of the anal canal which causes pain on defecation

Question 71

What are the causes of anal fissures?

Answer 71

- constipation - IBD - Colorectal cancer - Anal surgery or sex

Question 72

Management: Anal Fissure

Answer 72

- Ensure stools are soft = laxatives - manage pain = paracetamol or ibuprofen, steroid cream - Topical antibiotics - Surgery if fails to heal Refer if rectal cancer suspected

Question 73

Define: anaphylaxis

Answer 73

Severe, life threatening generalised hypersensitivity reaction with rapid airway/breathing/circulation problems

Question 74

Management: Anaphylaxis

Answer 74

- A+E - 500mg intramuscular - allergy info - advice on biphasic reaction

Question 75

Define: Generalised anxiety disorder

Answer 75

Characterised by excessive worry about every issue that is disproportionate to any inherent risk

Question 76

What are the symptoms for Generalised anxiety disorder?

Answer 76

3 of symptoms present at all times: - restlessness - nervousness - fatigue easily - poor concentration - irritability - muscle tension - sleep disturbance

Question 77

What assessment is used for generalised anxiety disorder?

Answer 77

GAD-7 anxiety questionnaire - helps establish the severity of the diagnosis

Question 78

Management: Generalised anxiety disorder

Answer 78

1. communicate the diagnosis early, provide info 2. refer for counselling, guided self help, groups 3. High intensity CBT 4. Medication = sertraline SSRI

Question 79

Define: OCD

Answer 79

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'

Question 80

What are the screening questions for OCD?

Answer 80

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

Question 81

Management: obsessive-compulsive disorder

Answer 81

- referral to CAMHS - patient and carer education 1. CBT = exposure and response prevention - SSRIs medications 2. TCA = clomipramine 3. severe = antipsychotics e.g. aripiprazole or risperidone

Question 82

Define: arrhythmias

Answer 82

Abnormal heart rhythms - interruption to the normal electrical signals that coordinate the contraction of the heart muscles

Question 83

What are the different types of arrhythmias?

Answer 83

1. Cardiac arrest rhythms shockable: - ventricular tachycardia - ventricular fibrillation Unshockable: - pulseless electrical activity - asystole 2. Narrow Complex Tachycardia (QRS<0.12s) - sinus tachycardia - supraventricualr tachycardia - atrial fibrillation - atrial flutter 3. Broad complex tachycardia (QRS >0.12s) - ventricular tachycardia - AF with bundle branch block - supra ventricular tachycardia with BBB

Question 84

Management: Arrhythmias

Answer 84

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

Question 85

What are the causes of AF?

Answer 85

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

Question 86

Investigations: AF

Answer 86

- ECG (Absent P waves narrow QRS irregularly irregular ventricular rhythm) - 24 hr ECG - Echo

Question 87

Management: atrial fibrillation

Answer 87

1. CHADVASC high risk >2 - anticoagulation = DOAC then warfarin/aspirin (HAS-BLED score for bleed on anticoagulation) 2. Rate control (1st line for symptom control) 1. BB e.g. bisoprolol 2. CCB e.g. verapamil 3. Digoxin 3. Rhythm control (severe symptoms or HF) 1. antiarrhymthmic drugs - amiodarone, flecainide 2. electrical cardio version 3. catheter ablation Anticogulation (persistent AF) e.g. DOAC or warfarin

Question 88

Define: Asthma

Answer 88

Chronic respiratory condition associated with airway inflammation and hyper-responsiveness

Question 89

How to diagnose asthma?

Answer 89

1. presence of more than one symptoms = wheeze, cough, breathlessness and chest tightness - diurnal = worse at night/ early morning 2. FH of atopic conditions 3. Fractional exhaled nitric oxide testing = positive >40 4. Spirometry = FEV1/FVC <70% 5. Bronchodilator reversibility = improvement of FEV1 of 12% or more 6. Variable peak expiratory flow readings = >20 % variability

Question 90

What is the aim of asthma management?

Answer 90

- no daytime symptoms - no night time waking - no need for rescue medication - no asthma attacks - no limitations on activity including exercise - normal lung function

Question 91

Management: Asthma

Answer 91

1. SABA - short acting beta agonist 2. Add low ICS (if deliver inhaler used 3 or more times a week) 3. Add Leukotriene receptor antagonist LTRA 4. Add LABA 5. Change to MART (ICS + LABA ) 6. Increase ICS dose 7. Add muscarinic receptor antagonist, theophylline or high ICS dose

Question 92

What should be checked before increasing asthma medication?

Answer 92

- recheck adherence - check inhaler technique - check elimination of trigger factors

Question 93

What should be monitored at an asthma a review?

Answer 93

- monitor number of asthma attacks - nocturnal symptoms - adherence - lung function - bronchodilator overuse - smoking status - possibility of occupational asthma

Question 94

What are the different risk stages of future asthma attacks?

Answer 94

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

Question 95

What are the features for moderate asthma exacerbation?

Answer 95

- PEFR > 50-75% - normal speech

Question 96

What are the features for acute severe asthma exacerbation?

Answer 96

- 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%

Question 97

What are the features for life threatening asthma exacerbation?

Answer 97

- 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

Question 98

Treatment: Moderate asthma exacerbation

Answer 98

- oxygen face mask - pressurised meter-dose inhaler with a large volume spacer

Question 99

Treatment: life threatening + severe asthma exacerbation

Answer 99

- oxygen mask - nebulised salbutamol - add nebulised ipratopium bromide - first dose of prednisolone

Question 100

Define: Domestic Abuse

Answer 100

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.

Question 101

What are the types of domestic abuse?

Answer 101

- psychological - physical - sexual - financial - emotional

Question 102

How can domestic abuse impact on health?

Answer 102

1. Traumatic injuries following assault e.g. fractures, miscarriage. 2. Somatic problems or chronic illness e.g. chronic pain, headaches. 3. Psychological problems e.g. PTSD, depression, anxiety.

Question 103

Give 3 potential indications of domestic abuse.

Answer 103

1. Unwitnessed by anyone else. 2. Repeat attendances to GP or A+E. 4. Delay in seeking help. 5. Multiple minor injuries.

Question 104

What assessment tool can be used to determine someones risk of domestic abuse?

Answer 104

DASH assessment

Question 105

What action would you take if someone was at high risk of domestic abuse?

Answer 105

Refer to MARAC or IDVAS.

Question 106

What are the 4 features of the Health Belief Model?

Answer 106

1. Believe they are susceptible to the condition in question 2. believe it has serious consequences 3. Believe that taking action reduces susceptibility 4. Believe that the benefits of taking action outweighs the costs

Question 107

‘Cues to action’ are another important aspect of the health belief model. What is meant by this?

Answer 107

- 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.

Question 108

Give 3 disadvantages of the health belief model.

Answer 108

1. Health beliefs may be affected by alternative factors e.g. outcome expectancy and self efficacy. 2. The model does not consider the influence of emotions on behaviour. 3. Cues to action are often missing in research. 4. It does not differentiate between first time and repeat behaviours.

Question 109

Define: Theory of Planned behaviour

Answer 109

Proposes the best predictor of behaviour is intention

Question 110

What does the Theory of Planned Behaviour say intention is determined by?

Answer 110

- 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

Question 111

How do we help people to act on their intentions?

Answer 111

1. Perceived control = recall own success 2. Anticipated regret = link to sustained intentions 3. Preparatory actions = dividing a task into sub-goals increases self-efficacy 4. Implementation intentions = 'if then' plans facilitates the translation of intention in to action 5. Relevance to self

Question 112

What are some criticisms of the Theory of Planned Behaviour model?

Answer 112

- 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

Question 113

What are the 5 stages of change in the transtheoretical model?

Answer 113

1. precontemplation 2. contemplation 3. preparation 4. action 5. maintenance (Relapse - at any point with in stages)

Question 114

What are the pros and cons of the Transtheoretical model?

Answer 114

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.

Question 115

Give 3 external factors that are important when thinking about behaviour change.

Answer 115

1. Impact of personality traits. 2. Assessment of risk perception. 3. Impact of past behaviour/habit. 4. Social environment.

Question 116

Define: atopic dermatitis/eczema

Answer 116

A chronic inflammatory skin condition that affects people of all ages

Question 117

What are the symptoms/appearance of eczema?

Answer 117

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

Question 118

How to classify eczema?

Answer 118

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

Question 119

How to categorise the impact of eczema on quality of life?

Answer 119

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

Question 120

Management: Mild eczema

Answer 120

- prescribe lots of emollients - consider mild topical corticosteroid Refer to dermatology if diagnosis uncertain or eczema uncontrolled

Question 121

Management: Moderate eczema

Answer 121

- consider trigger factors or infection - emollients - if inflamed skin = moderately potent topical corticosteroid (max 5 days) Preventative - maintenance regime of topical corticosteroids

Question 122

Management: severe eczema

Answer 122

- 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

Question 123

Management: infected eczema

Answer 123

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

Question 124

Define: Atrophic vaginitis

Answer 124

Refers to dryness and atrophy of the vaginal mucosa due to a lack of oestrogen - occurs in women entering menopause

Question 125

What is the pathophysiology of atrophic vaginitis?

Answer 125

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

Question 126

What are the symptoms of atrophic vaginitis?

Answer 126

- itching - dryness - dyspareunia - bleeding sue to localised inflammation can present with - recurrent UTIs - stress incontinence - pelvic organ prolapse

Question 127

What is seen on examination for atrophic vaginitis?

Answer 127

- pale mucosa - thin skin - reduced skin folds - erythema and inflammation - dryness - sparse pubic hair

Question 128

Management: Atrophic vaginitis?

Answer 128

1. vaginal lubricants = fro dryness 2. topical oestrogen - estriol cream - estriol pessaries - estradiol tablets - estradiol ring (HRT SE = breast cancer, angina, venous thromboembolism)

Question 129

Define: bacterial vaginosis

Answer 129

An overgrowth of bacteria in the vagina specifically anaerobic bacteria due to loss of lactobacilli (friendly bacteria)

Question 130

What are the risk factors for bacterial vaginosis?

Answer 130

- multiple sexual partners - excessive vaginal clearing - recent antibiotics - smoking - copper coil

Question 131

What are the symptoms for bacterial vaginosis?

Answer 131

- fishy smelling watery grey or white vaginal discharge

Question 132

Investigations: bacterial vaginosis

Answer 132

- speculum examination = view typical discharge - vaginal pH = swab + pH paper >4.5 - Charcoal vaginal swab for micro (clue cells = gardnerella vaginalis)

Question 133

Management: bacterial vaginosis

Answer 133

Can resolve without treatment 1. antibiotic = metronidazole oral or vaginal gel 2. check for chlamydia and gonorrhoea

Question 134

What should be avoided when taking metronidazole?

Answer 134

Alcohol - cause 'disulfirman-like reaction' with nausea and vomiting, flushing and sometimes hock and angioedema

Question 135

What are the complications of bacterial vaginosis?

Answer 135

- miscarriage - preterm delivery - premature rupture of membranes - chorioamnionitis - low birth weight - postpartum endometritis

Question 136

Define: Bell's palsy

Answer 136

An acute unilateral facial nerve weakness or paralysis of rapid onset and unknown cause

Question 137

What are the symptoms for Bell's palsy?

Answer 137

- 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

Question 138

Management: Bell's palsy

Answer 138

Prednisolone within 72 hrs - 50 mg for 10 days or 60mg for 5 days

Question 139

What are the types of eyelid disorders?

Answer 139

- blepharitis - Stye - Chalazion - Entropion - Ectropion - trichiasis - periorbital cellulitis - orbital cellulitis

Question 140

What is Blepharitis? Cause and management?

Answer 140

- 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

Question 141

What is a Stye?

Answer 141

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

Question 142

What is the treatment for Stye's?

Answer 142

Hot compress Analgesia Antibiotics if conjunctivitis or symptoms remain

Question 143

What is an chalazion and treatment?

Answer 143

Meibomian gland becomes blocker and swells - swelling in eyelid non tender Treat: warm compress and gentle massage towards eyelashes to drain

Question 144

What is entropion vs ectropion?

Answer 144

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

Question 145

What is the treatment for entropion and ectropion?

Answer 145

Entropion - tape eyelid down + lubricate - surgical Ectropion - lubricate drops - significant cases = surgical

Question 146

What is trichiasis?

Answer 146

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

Question 147

What is periorbital cellulitis?

Answer 147

AN eyelid and skin infection in front of the orbital septum - hot, woollen, red skin around the eyelid and eye

Question 148

Management: Periorbital cellulitis

Answer 148

1. CT scan = Must differentiate from orbital cellulitis 2. systemic antibiotics

Question 149

What is orbital cellulitis?

Answer 149

An infection around the eyeball involving the tissues behind the orbital septum - eye pain - reduced eye movements - vision changes - abnormal pupil reactions - proptosis

Question 150

Management: orbital cellulitis

Answer 150

1. Emergency admission 2. IV antibiotics 3. surgical drainage if abscess forms

Question 151

Define: Benign paroxysmal postural vertigo

Answer 151

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

Question 152

Management: postural vertigo BPPV

Answer 152

1. most people recover over several weeks without treatment 2. repositioning manoeuvre can alleviate symptoms 3. advice not to drive

Question 153

Define: benign prostatic hyperplasia

Answer 153

Hyperplasia of the stroll and epithelial cells of the prostate

Question 154

What are the symptoms of BPH?

Answer 154

- hesitancy - weak flow - urgency - frequency - intermittency - straining - terminal driblling - incomplete emptying - nocturia

Question 155

Investigations: BPH

Answer 155

1. digital rectal exam = BPH feel smooth, symmetrical, soft 2. abdominal exam = palpable bladder 3. urianry frequency volume chart 4. urine dipstick = infection, haematuria 5. Prostate specific antigen = unreliable

Question 156

What are reasons for a high PSA?

Answer 156

- prostate cancer - BPH - prostatitis - UTI - vigorous exercise - recent ejaculation

Question 157

Management: BPH

Answer 157

1. alpha blockers e.g. tamsulosin - relax smooth muscle 2. 5-alpha reductase inhibitors e.g. finasteride - gradually reduce size of prostate 3. surgical - TURP, TEVAP, open prostatectomy

Question 158

Define breast abscess + mastitis

Answer 158

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

Question 159

What is the presentation of mastitis?

Answer 159

- nipple changes - purulent nipple discharge - localised pain - tenderness - warmth - erythema - hardening of the skin - swelling

Question 160

Management: Mastitis

Answer 160

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

Question 161

Management: breast abscess

Answer 161

- referral to surgical team - antibiotics - ultrasound - drainage = needle aspiration or surgical incision ans drainage - micro culture and sensitivities of the drained fluid

Question 162

Define: bronchiolitis

Answer 162

Inflammation and infection in the bronchioles, the small airways of the lungs Usually caused by respiratory syncytial virus (RSV)

Question 163

What is the presentation for bronchiolitis?

Answer 163

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

Question 164

What are the signs of resp distress in paediatrics?

Answer 164

- raised resp rate - use of accessory muscles - intercostal and subcostal recessions - nasal flaring - head bobbing - tracheal tugging - cyanosis - abnormal airway noises = wheezing, grunting, stridor

Question 165

Management: bronchiolitis

Answer 165

1. ensuring adequate intake - don't overfeed as a full stomach will restrict breathing 2. saline nasal drops and nasal suctioning 3. supplementary oxygen <92% 4. ventilatory support Prevention - Palivizumab injection given monthly (ex-premature and congenital heart disease) - provides passive protection

Question 166

Define: bursitis

Answer 166

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)

Question 167

What is the cause of bursitis?

Answer 167

- Friction from repetitive movements - Trauma - Inflammatory conditions (e.g., rheumatoid arthritis) - Infection – referred to as septic bursitis

Question 168

Management: bursitis

Answer 168

- rest - ice - analgesia - physio = hip - aspirate going = elbow - steroid injections infected elbow = aspirate for micro and antibiotics

Question 169

What is presentation and tests for trochanteric bursitis?

Answer 169

- aching or burning pain - worse with activity - tenderness on examination Hip exam - trendelenburg test - resisted abduction of hip - resisted internal rotation - resisted external rotation

Question 170

What does aspirate appearance indicate in olecranon bursitis?

Answer 170

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

Question 171

Define: vaginal candidiasis/ thrush

Answer 171

Vaginal infection with a yeast of the candida family (Candida albicans)

Question 172

What are the risk factors for candidiasis?

Answer 172

- Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause) - Poorly controlled diabetes - Immunosuppression (e.g. using corticosteroids) - Broad-spectrum antibiotics

Question 173

What is the presentation of candidiasis?

Answer 173

- Thick, white discharge = does not typically smell - Vulval and vaginal itching, irritation or discomfort

Question 174

Investigations: Candidiasis

Answer 174

- vaginal pH <4.5) (distinguish between bacterial vaginosis + trichomonad pH >4.5) - charcoal swab with micro

Question 175

Management: candidiasis

Answer 175

1. 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) 2. oral - mild = nystatin oral suspensions or miconazole oral gel - severe = oral fluconazole 3. neonates - oral = nystatin oral suspension - severe = oral fluconazole (monitor) (Canesten duo - over the counter) (anti fungal cream can damage latex condoms)

Question 176

Define: chlamydia

Answer 176

Chlamydia trachomatis = gram negative bacteria causes STI

Question 177

What is the presentation for chlamydia?

Answer 177

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

Question 178

Investigations: chlamydia

Answer 178

Nucleic acid amplification tests (NAAT) - swab checking the DNA/RNA of organism - swab endocervical, vulvovaginal and then urine

Question 179

Management: chlamydia

Answer 179

1. Doxycycline 100mg twice a day for 7 days - abstain from sex for 7 days - inform all partners + refer for testing - advice on future prevention

Question 180

What are some consequences of chlamydia?

Answer 180

Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis

Question 181

How to diagnose chronic fatigue syndrome?

Answer 181

- sleepiness = indicate sleep apnoea or another sleep disorder - weakness = neuromuscular cause 1. persistent fatigue for a min of 6 weeks 2. debilitating fatigue worsened by activity 3. post-exertional malaise = onset delayed by hours of days, disproportionate to activity 4. unrefreshing sleep or sleep disturbance 5. cognitive difficulties = struggling to remember words

Question 182

Investigations: chronic fatigue syndrome

Answer 182

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

Question 183

Management: chronic fatigue

Answer 183

- refer if underlying cause - refer to chronic fatigue specialist

Question 184

What is the presentation of chronic kidney disease?

Answer 184

Fatigue Pallor (due to anaemia) Foamy urine (proteinuria) Nausea Loss of appetite Pruritus (itching) Oedema Hypertension Peripheral neuropathy

Question 185

Investigations: CKD

Answer 185

1. eGFR 2. Proteinuria = urine albumin:creatinine ratio 3. Urine dipstick = haematruia 4. renal USS 5. BP 6. HbA1c 7. Lipid profile

Question 186

What are the classifications for CKD?

Answer 186

G1 Over 90 G2 = 60-89 G3a = 45-59 G3b = 30-44 G4 = 15-29 G5 = Under 15

Question 187

What are the complications of CKD?

Answer 187

Anaemia Renal bone disease Cardiovascular disease Peripheral neuropathy End-stage kidney disease Dialysis-related complications

Question 188

Management: CKD

Answer 188

1. Optimising diabetic control Optimising hypertension control Reducing or avoiding nephrotoxic drugs (where appropriate) Treating glomerulonephritis (where this is the cause) 2. Slow progression - ACEi - SGLT - 2 inhibitors e.g. dapagliflozin 3. Manage complications: - Oral sodium bicarbonate = metabolic acidosis - Iron and erythropoietin = anaemia - Vitamin D, low phosphate diet and phosphate binders = renal bone disease 4. Dialysis 5. Renal transplant

Question 189

What is the presentation of COPD?

Answer 189

Shortness of breath Cough Sputum production Wheeze Recurrent respiratory infections, particularly in winter NO CLUBBING, HAEMOPTYSIS OR CHEST PAIN

Question 190

What are the grades of the MRC dyspnoea scale?

Answer 190

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

Question 191

How to diagnose COPD?

Answer 191

Spirometry - FEV1/FVC ration <70% - No bronchodilator reversibility with salbutamol

Question 192

What are the grades of severity for COPD?

Answer 192

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

Question 193

Management: COPD

Answer 193

- stop smoking - flu vaccine 1. SABA + SAMA (short acting muscarinic antagonists = ipratropium bromide ) 2. No asthmatic features: LABA + LAMA OR asthmatic features: LABA + ICS 3. LABA, LAMA + ICS 4. pulmonary rehab 5. Long term oxygen therapy

Question 194

Define: conjunctivitis

Answer 194

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

Question 195

How does conjunctivitis present?

Answer 195

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)

Question 196

What are the causes of an acute painful red eye?

Answer 196

Acute angle-closure glaucoma Anterior uveitis Scleritis Corneal abrasions or ulceration Keratitis Foreign body Traumatic or chemical injury

Question 197

What are the causes of an acute painless red eye?

Answer 197

Conjunctivitis Episcleritis Subconjunctival haemorrhage

Question 198

Management: conjunctivitis

Answer 198

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)

Question 199

Management: constipation

Answer 199

1. lifestyle changes - healthy diet with fibre - increased fluid intake - increased activity - regular toilet routine 2. Bulk forming laxatives - ispaghula 3. Osmotic laxative e.g. macrogol 4. Stimulant laxative (stools soft but difficult to pass) Ask person to gradually reduced and stop laxative once soft stool formed 3 times a week

Question 200

What are secondary causes of constipation?

Answer 200

- medications - diabetes - IBD - neurological conditions - anal problems (fissures, structures, haemorrhoids)

Question 201

Define: Contact dermatitis

Answer 201

Inflammatory skin condition which occurs as a result of exposure to an external irritant or allergen

Question 202

How to diagnose contact dermatitis?

Answer 202

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

Question 203

Management: contact dermatitis

Answer 203

- avoid trigger - emollient and soap substitutes - topical corticosteroids

Question 204

Define: Croup

Answer 204

Acute infective respiratory disease affecting young children (6months to 2 yrs) - upper resp tract - oedema in the larynx

Question 205

What is the cause of croup?

Answer 205

MC = Parainfluenza virus Influenza Adenovirus Respiratory Syncytial Virus (RSV)

Question 206

What is the presentation of croup?

Answer 206

Increased work of breathing “Barking” cough, occurring in clusters of coughing episodes Hoarse voice Stridor Low grade fever

Question 207

Management: croup

Answer 207

1. Oral dexamethasone (usually single dose of 150mcg/kg) 2. Oxygen 3. Nebulised budesonide 4. Nebulised adrenalin 5. Intubation and ventilation

Question 208

Define: Gout

Answer 208

Crystal arthropathy - high blood uric acid levels - urate crystals deposited in joint - single acute, hot swollen, painful joint (big toe, base of thumb)

Question 209

Investigations: gout

Answer 209

1. raised urate blood test 2. Joint aspiration = monosodium urate crystals with needle shaped negatively birefringent of polarised light 3. X-ray - maintained joint space - lytic lesions in bone - punched out erosions - erosions have sclerotic borders

Question 210

Management: Gout

Answer 210

Acute 1. NSAIDs (naproxen) with PPI 2. colchicine 3. oral steroids e.g. prednisolone Prophylaxis (xanthine oxidase inhibitors = lower uric acid level) - allopurinol - febuxostat

Question 211

Define: Pseudogout

Answer 211

crystal arthropathy caused by calcium pyrophosphate crystals collecting in the joints. It is formally known as calcium pyrophosphate deposition disease (CPPD) or chondrocalcinosis.

Question 212

What is the presentation of pseudogout?

Answer 212

- 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)

Question 213

Investigation: Pseudogout

Answer 213

1. Joint aspiration = calcium pyrophosphate crystals with rhomboid shaped positively birefringent of polarised light 2. X-ray - calcium deposits in joint cartilage - similar to OA with LOSS

Question 214

Management: pseudogout

Answer 214

Symptoms usually resolve on their own over several weeks 1. NSAIDs (e.g., naproxen) with PPI 2. Colchicine 3. Intra-articular steroid injections (septic arthritis must be excluded first) 4. Oral steroids

Question 215

Define: Ringworm

Answer 215

A fungal infection of the skin Tinea capitis = scalp Tinea pedis = feet, athletes foot Tinea cruris = groin Tinea corporis = body Onychomycosis = fungal nail infection

Question 216

What is the presentation of ringworm?

Answer 216

Itchy rash that is erythematous, scaly and well demarcated edge - hair loss - deformed nails

Question 217

Mangement: ringworm

Answer 217

1. Anti-fungal creams e.g. clotrimazole and miconazole 2. Anti-fungal shampoo e.g. ketoconazole for tinea capitis 3. Oral anti-fungal medications e.g. fluconazole, griseofulvin and itraconazole

Question 218

Management: Cutaneous warts

Answer 218

1. Cause no symptoms and usually resolve 2. cryotherapy 3. topical salicylic acid

Question 219

Mangement in GP: Dementia

Answer 219

1. provide person and family with info 2. ask person with consent to share info with services 3. discuss care 4. treat symptoms 5. review medication

Question 220

What routine screening is offered in the UK?

Answer 220

- 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

Question 221

What neonatal/newborn screening is offered?

Answer 221

- 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)

Question 222

Define: diverticular disease

Answer 222

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

Question 223

What is the presentation for acute diverticulitis?

Answer 223

- pain and tenderness in lower left abdomen - fever - diarrhoea - nausea and vomiting - rectal bleeding - palpable abdominal mass - raised inflammatory markers

Question 224

Investigations: diverticulosis

Answer 224

Colonoscopy or CT scans

Question 225

Management: Acute diverticulitis

Answer 225

- 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

Question 226

How to diagnose hypertension?

Answer 226

above 140/90 in clinical settings above 135/85 at home

Question 227

What are the causes of secondary hypertension?

Answer 227

ROPED Renal, disease Obesity Pregnancy or pre-eclampsia Endocrine Drugs

Question 228

What are the stages for hypertension?

Answer 228

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

Question 229

What should be checked in a newly diagnosed hypertension patient?

Answer 229

- urine albumin:creatinine ratio = proteinuria, dipstick for haematuria - bloods = Hb1Ac, renal function, lipids - Fundus examination = hypertensive retinopathy - ECG = cardiac abnormalities eg. left ventricular hypertrophy

Question 230

Management: hypertension

Answer 230

1. Under 55/type 2 diabetic = ACEi (e.g. ramipril) Aged over 55/black African = CCB (e.g. amlodipine) 2. Add ACEi/CCB 3. Add Thiazide like diuretic e.g. candesartan 4. <4.5 potassium = spironolactone >4.5 potassium = alpha blocker (e.g. doxazosin) or beta blocker (e.g. atenolol)

Question 231

Define: Malignant hypertension

Answer 231

High BP over 180/120 with retinal haemorrhages or papilloedema

Question 232

Management: malignant hypertension

Answer 232

- Fundoscopy = check for retinal haemorrhages or papilloedema - same day referral - IV sodium nitroprusside, labetalol, glyceryl trinitrate, nicardipine

Question 233

Define: fibromyalgia

Answer 233

Presence of chronic widespread pain, fatigue, cognitive symptoms, IBS With no known cause

Question 234

Management: Fibromyalgia

Answer 234

- investigations to rule out other causes - lifestyle changes = increased exercise - talking therapies - medication = antidepressants - pain clinic

Question 235

Define: folliculitis

Answer 235

Infection and inflammation of one or more hair follicles

Question 236

What are the causes of folliculitis?

Answer 236

- infection - physical irritation e.g. shaving - chemical irritation - blockage of hair follicle - excessive sweating - steroid creams - inflammatory skin conditions

Question 237

Management: folliculitis

Answer 237

- 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

Question 238

Define: GORD

Answer 238

Acid from the stomach flows through the lower oesophageal sphincter and into the oesophagus, where it irritates the lining and causes symptoms

Question 239

What are the causes/triggers of GORD?

Answer 239

- greasy, spicy foods - coffee and tea - alcohol - NSAIDs - stress - smoking - obesity - hiatus hernia

Question 240

What is the presentation of GORD?

Answer 240

Dyspepsia (indigestion - heart burn - acid reflux - retrosternal or epigastric pain - bloating - nocturnal cough - hoarse voice

Question 241

What are the red flag features of GORD?

Answer 241

- 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

Question 242

Investigations: GORD

Answer 242

1. oesophagi-gastro-duodenoscopy (OGD) 2. CXR/ CT scan for hiatus hernia 3. H.pylori stool test or urea breath test

Question 243

Management:

Answer 243

1. Lifestyle changes = reduce tea, coffee, alcohol, avoid smoking 2. Reviewing medications (e.g., stop NSAIDs) 3. Antacids (e.g., Gaviscon, Pepto-Bismol and Rennie) – short term only 4. Proton pump inhibitors (e.g., omeprazole and lansoprazole) 5. Histamine H2-receptor antagonists (e.g., famotidine) 6. Surgery = laparoscopic fundoplication

Question 244

Define: gonorrhoea

Answer 244

Gram negative diplococcus bacteria - it infects mucous membranes with a columnar epithelium - spreads via contact with mucous secretions

Question 245

What is the presentation for gonorrhoea?

Answer 245

- odourless purulent discharge = green or yellow - dysuria - pelvic pain or testicular pain for men

Question 246

Management: Gonorrhoea

Answer 246

1. Nucleic acid amplification testing = detect RNA or DNA present 2. Single dose of IM ceftriaxone (sensitivities not known) Single dose of oral ciprofloxacin (sensitivities KNOWN)

Question 247

What is disseminated goncoccal infection?

Answer 247

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

Question 248

Define: haemorrhoids

Answer 248

Enlarged anal vascular cushions - often caused by constipation and straining - MC in pregnancy, obesity, increased age and increased intra abdominal pressure

Question 249

What are the classifications of haemorrhoids?

Answer 249

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

Question 250

Symptoms: haemorrhoids

Answer 250

- painless, bright red bleeding - sore - itchy - feeling a lump around or inside anus

Question 251

What are the 2 types of haemorrhoids?

Answer 251

1. External (prolapsed) haemorrhoids = are visible on inspection as swellings covered in mucosa 2. Internal haemorrhoids = may be felt on a PR exam (although this is generally difficult or not possible)

Question 252

Management: haemorrhoids

Answer 252

1. proctoscopy 2. test fo anaemia if prolonged bleeding 3. rule out other red flags 4. Increase fibre and laxatives 5. topical treatment to reduced swelling e.g. anusol 6. Surgical = ligation, haemorrhoidectomy, staples

Question 253

Define: Herpes simplex virus

Answer 253

Infection of genitals, ocular or oral

Question 254

How to diagnose herpes simplex virus?

Answer 254

- multiple painful crops of blisters - dysuria, vaginal or urethral discharge - headache

Question 255

Management: herpes simplex virus

Answer 255

- advice on self-care measures - advice on informing sexual partners - swab for micro 1. Aciclovir 400mg three times a day for 5 days

Question 256

Define + types: hiatus hernia

Answer 256

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

Question 257

Investigations: Hiatus hernia

Answer 257

CXR Ct scan endoscopy barium swallow testing

Question 258

Management: hiatus hernia

Answer 258

1. Conservation - treat GORD symptoms 2. surgical repair = laparoscopic fundoplication

Question 259

Define: hypothyroidism

Answer 259

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)

Question 260

What are the causes of hypothyroidism?

Answer 260

1. Hashimoto's thyroiditis = autoimmune condition causing inflammation of the thyroid gland due to anti-thyroid peroxidase antibodies and anti-thyroglobulin antibodies 2. iodine deficiency 3. Medication for hyperthyroidism 4. lithium 5. amiodarone Secondary - tumours - surgery to pituitary - radiotherapy - trauma

Question 261

What is the presentation for hypothyroidism?

Answer 261

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

Question 262

Management: hypothyroidism

Answer 262

1. oral levothyroxine (synthetic version of T4)

Question 263

Causes: hyperthyroidism

Answer 263

- graves disease = antibodies stimulate thyroid gland - toxic multi nodular goitre = nodules produce excess - thyroiditis = inflammation of thyroid - excessive iodine intake - thyroid cancer = rare

Question 264

Presentation: hyperthyroidism

Answer 264

fast - weight loss - palpitations, tachycardia, AF - tremors - heat intolerance - sweating - diarrhoea - enlarged thyroid gland

Question 265

Investiagtions: hyperthyroidism

Answer 265

1. serum thyroid function tests - low TSH , high T4 + T3 2. thyroid antibodies - TSH receptor antibodies = graves - thyroids peroxidase antibodies = graves / thyroiditis 3. thyroid imaging - USS - radioactive iodine uptake 4. ECG - to assess for arrhythmias

Question 266

Management: hyperthyroidism

Answer 266

1. carbimazole 2. beta blockers e.g. propanolol = for palpitations and tremors 3. radioactive iodine therapy - taken orally - contraindicated in pregnant women 4. thyroidectomy - if large goitre causing issues - tolerant to medication

Question 267

Define: Impetigo

Answer 267

A superficial bacterial skin infection - caused by Staph aureus bacteria - contagious - enters through a break in the skin e.g. eczema, dermatitis

Question 268

What is the presentation of the 2 types of impetigo?

Answer 268

Golden crust Non - Bullous - around nose and mouth - exudate from lesions dries to form crust Bullous - grown in vesicles that then burst

Question 269

Define: infectious mononucleosis

Answer 269

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

Question 270

Presentation: EBV

Answer 270

Fever Sore throat Fatigue Lymphadenopathy (swollen lymph nodes) Tonsillar enlargement Splenomegaly and in rare cases splenic rupture

Question 271

Investigations + management: EBV

Answer 271

1. monospot test = EBV anitbodies 2. EBV specific serology (when monospot test negative) = IgM+IgG IgM antibody - rises early, acute IgG antibody - suggests immunity 3. 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

Question 272

Define + presentation: influenza

Answer 272

- 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)

Question 273

Mangement: Influenza

Answer 273

healthy patients don't need treatment 1. oral oseltamivir OR inhaled zanamivir

Question 274

How to diagnose IBS?

Answer 274

- 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

Question 275

Management: IBS

Answer 275

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

Question 276

Management: soft tissue injury

Answer 276

1. RICE Sprain = bracing, physical therapy Strains = rest, slowly increase mobility Contusions = bruises

Question 277

Define: Lyme disease

Answer 277

An infection caused by a tick bite Present with erythema migraines - bull's eye - spreading redness with well-defined edge

Question 278

Management: Lyme disease

Answer 278

1. offer ELISA test 2. Doxycycline 3. amoxicillin 3. Azithromycin

Question 279

Define and presentation: measles

Answer 279

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

Question 280

Management: measles

Answer 280

Usually self-limiting - stay away from school or work fully vaccinated

Question 281

Define: menopause

Answer 281

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

Question 282

What are hormones levels in menopause?

Answer 282

Oestrogen and progesterone = low LH and FSH = high (in response to absence of negative feedback from oestrogen)

Question 283

What are perimenopausal symptoms?

Answer 283

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

Question 284

Management: perimenopausal symptoms

Answer 284

- 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

Question 285

What are the 4 main types of migraines?

Answer 285

1. Migraine without aura 2. Migraine with aura 3. Silent migraine (migraine with aura but without a headache) 4. Hemiplegic migraine = unilateral limb weakness

Question 286

what are the 5 stages of migraine?

Answer 286

1. Premonitory or prodromal stage (can begin several days before the headache) 2. Aura (lasting up to 60 minutes) 3. Headache stage (lasts 4 to 72 hours) 4. Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping) 5. Postdromal or recovery phase

Question 287

Presentation: migraine

Answer 287

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

Question 288

management: migraines

Answer 288

Acute - NSAIDS - paracetamol - triptans e.g. sumatriptan - antiemetics Prophylaxis - propanolol - amitriptyline - topiramate

Question 289

Define + presentation: Mumps

Answer 289

Viral infection spread by resp droplets 1. prodrome - fever - muscle aches - lethargy - reduced appetite - headache - dry mouth 2. Parotid gland swelling - abdominal pain - testicular pain + swelling - confusion

Question 290

Management: Mumps

Answer 290

- PCR testing - antibodies - notify public health - supportive with fluids and analgesia

Question 291

Presentation: Osteoarthritis

Answer 291

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

Question 292

Investigations: OA

Answer 292

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)

Question 293

Management: OA

Answer 293

1. lifestyle = exercise, weight loss, OT 2. topical NSAIDs 3. oral NSAIDs with PPI 4. weak opioids + paracetamol for short term 5. steroid injections 6. joint replacement

Question 294

Define: Osteoporosis + osteopenia

Answer 294

osteoporosis = reduction in bone density <-2.5 osteopenia = less severe decrease in bone density -1 to -2.5

Question 295

Investigations: osteoporosis

Answer 295

assess: - anyone on long term corticosteroids - anyone >50 with risk factors - all women >65 yrs - all men >75 yrs 1. QFracture tool 2. FRAX score 3. >10% for DEXA scan

Question 296

Management: osteoporosis

Answer 296

1. lifestyle = exercise, reduce weight, stop smoking, reduce alcohol 2. check / increase calcium dn vitamin D intake 3. bisphosphonates e.g. alendronate, risedronate, zoledronic acid 4. MAB , HRT

Question 297

Define: Otitis Externa

Answer 297

Inflammation of the skin in the external ear canal - swimming - trauma to ear canal - removal of ear wax

Question 298

Presentation: otitis externa

Answer 298

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

Question 299

Management: Otitis externa

Answer 299

Otoscopy = examination of ear 1. mild = acetic acid 2% 2. Moderate = topical antibiotics + steroids e.g. neomycin + betamethasone 3. severe = oral antibiotics OR discussion with ENT for admission Fungal infection = clotrimazole ear drops (likely after multiple courses of antibiotics)

Question 300

Define: otitis media

Answer 300

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

Question 301

What bacteria is likely to cause otitis media?

Answer 301

1. step pneumoniae Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus

Question 302

What is the presentation of otitis media?

Answer 302

- ear pain - reduced hearing - malaise - fever - cough - sore throat - balance issues and vertigo

Question 303

Management: Otitis media

Answer 303

otoscope = tympanic membrane looks red, bulging and inflamed resolve within 3 days if unresolved >4 days 1. amoxicillin 2. Clarithromycin

Question 304

Define + presentation : Parkinson's disease

Answer 304

progressive reduction in dopamine in the basal ganglia - asymmetrical - resting tremor (improves on movement) - cogwheel rigidity - bradykinesia --> shuffling gait - reduced facial expression

Question 305

Management: Parkinson's disease

Answer 305

Diagnosis = history + examination 1. Levodopa (with peripheral decarboxylase inhibitors) e.g. carbidopa 2. COMT inhibitors e.g. entacapone 3. Dopamine agonists e.g. pergolide, cabergoline 4. Monoamine oxidase-B inhibitors e.g. selegiline

Question 306

Define: pelvic inflammatory disease

Answer 306

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

Question 307

What are the causes and risk factors of pelvic inflammatory disease?

Answer 307

Usually by an STI - neisseria gonorrhoea - chlamydia trachomatis - mycoplasma genitalium or bacterial vaginosis RF - not using barrier contraception - multiple sexual partners - IUDs - STD

Question 308

What is the presentation of pelvic inflammatory disease?

Answer 308

Pelvic or lower abdominal pain Abnormal, purulent vaginal discharge Abnormal bleeding (intermenstrual or postcoital) Pain during sex (dyspareunia) Fever Dysuria

Question 309

Management: pelvic inflammatory disease

Answer 309

NAAT swab, HIV swab 1. IM ceftriaxone --> gonorrhoea 2. Doxycycline --> chlamydia + mycoplasma genitalium 3. metronidazole --> Gardnerella vaginalis

Question 310

Define: peripheral vascular arterial disease

Answer 310

Narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas - claudication

Question 311

What are the types of claudication?

Answer 311

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)

Question 312

What are the differences between an arterial and venous ulcer?

Answer 312

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

Question 313

Investigations: Peripheral vascular disease

Answer 313

- ankle brachial pressure index (>1.3 = calcification) - duplex USS - angiography CT or MRI

Question 314

Management: peripheral vascular disease

Answer 314

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

Question 315

Opioid misuse: name a drug that can be used for detoxification.

Answer 315

Buprenorphine

Question 316

Opioid misuse: in what type of people would maintenance therapy be indicated?

Answer 316

Stabilisation/maintenance is needed for the following: 1. Those who have been addicted for a long time. 2. IVDU

Question 317

Give 3 signs of addiction.

Answer 317

1. Cravings. 2. Tolerance. 3. Compulsive drug-seeking behaviour. 4. Physiological withdrawal state.

Question 318

What formula is used to work out how many units of alcohol there are in a drink?

Answer 318

Strength of drink (%ABV) X Volume (ml) / 1000

Question 319

How effective are opioids for acute and chronic pain?

Answer 319

- opioids very effective for acute pain - chronic pain longer than 3 months

Question 320

What are the negative effects of chronic pain?

Answer 320

- central sensitisation - allodynia = pain from non-painful stimulus - deconditioning - biomechanics problems - depression - cognitive impairment - dysfunctional relationships - suicide risk

Question 321

What opioid is given in renal failure?

Answer 321

Fentanyl

Question 322

What are the negative effects of opioids?

Answer 322

- 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

Question 323

What are the signs of an opioid overdose?

Answer 323

- not moving- tiny pupils - slow or no breathing - choking, gurgling, snoring sounds - blue lips and nails - clammy or cold skins

Question 324

What is given to treat an opioid overdose?

Answer 324

Naloxone = opioids Acetylcysteine — paracetamol. Digoxin-specific antibody fragments — digoxin. Flumazenil injection = benzodiazepine - take bloods - ECG

Question 325

What guidance is given on treating chronic pain?

Answer 325

- 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

Question 326

Define: malnutrition and triple burden

Answer 326

Malnutrition = deficiencies, excesses or imbalances in a person intake of energy and/or nutrients - Undernutrition or - overweight/obesity - triple burden = micronutrient deficiencies (hidden hunger)

Question 327

Name 2 early influences on feeding behaviour.

Answer 327

1. Human foetuses swallow amniotic fluid = maternal diet 2. Breast feeding. 3. parenting practices

Question 328

Give 3 advantages of breast feeding on feeding behaviour.

Answer 328

1. More likely to accept novel foods in weaning. 2. Less fussy eaters in childhood. 3. More likely to have a diet rich in fruit and vegetables.

Question 329

Give 3 ways in which parents can tackle fussy eating.

Answer 329

1. Modelling healthy eating behaviours and eating as a family. 2. Provide a variety of food. 3. Avoid pressure to eat. 4. Restriction. 5. Authoritative parenting. 6. Not using food as a reward.

Question 330

What is the public health issue for breastfeeding?

Answer 330

Breastfeeding low in: - young mothers - disadvantaged socio-economic groups

Question 331

What are the 4 dimensions of food insecurity?

Answer 331

1. Availability of food 2. Access - economic and physical 3. Utilisation - opportunity to prepare food 4. Stability - of the 3 dimensions over time

Question 332

What are the challenges of weight loss?

Answer 332

- 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

Question 333

Define: polymyalgia rheumatica

Answer 333

Chronic, systemic rheumatic inflammatory disease - aching, morning stiffness in neck, shoulders pelvic girdle - over 50 yrs old

Question 334

Investigations + management: polymyalgia rheumatica

Answer 334

1. ESR and CRP bloods = both raised 2. exclude giant cell arteritis 3. Trial of oral prednisolone 1 week 4. start reducing prednisolone when symptoms controlled typically treatment is required between 1-2 years

Question 335

Presentation: prostate cancer

Answer 335

Can be asymptomatic - LUTS - haematuria - erectile dysfunction - weight loss - bone pain

Question 336

Investigations: prostate cancer

Answer 336

1. PSA antibody test - very unreliable 2. prostate examination - cancer feel hard, craggy, asymmetrical 3. Multiparametric MRI 4. Prostate biopsy - MRI scale 3 or above - Gleason grading system - TNM staging 5. Isotope bone scan - look for bone metastasis

Question 337

Management: prostate cancer

Answer 337

1. surveillance 2. external beam radiotherapy 3. brachytherapy - implanting radioactive seeds in prostate 4. hormone therapy - reduce levels of androgens 5. surgery - radical prostatectomy

Question 338

Define + presentation: psoriasis

Answer 338

Chronic autoimmune condition with psoriatic skin lesions - dry - flaky - scaly - erythematous - raised - elbows and knees and scalp

Question 339

What are the signs suggestive of psoriasis?

Answer 339

1. Auspitz sign = small points of bleeding when plaques are scraped off 2. Koebner phenomenon = the development of psoriatic lesions to areas of skin affected by trauma 3. Residual pigmentation = of skin after the lesions resolve

Question 340

Management: psoriasis

Answer 340

1, topical steroids 2. topical vitamin D analogues 3. topical dithranol 4. topical calcineurin inhibitors 5. phototherapy

Question 341

Define + presentation: back pain + sciatica

Answer 341

Mechanical back pain = no specific disease causing it sciatica = irritation of sciatic nerve at L4-S3 Chronic lower back pain

Question 342

What are the causes and red flags of back pain?

Answer 342

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

Question 343

Presentation: sciatica

Answer 343

- 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

Question 344

Investigations: sciatica

Answer 344

- X-ray spine - Emergency MRI = caudal equina - raised inflammatory markers = ankylosing

Question 345

Management: sciatica

Answer 345

1. amitriptyline or duloxetine 2. epidural corticosteroid or local anaesthetic injections 3. spinal decompression

Question 346

Define: reactive arthritis

Answer 346

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

Question 347

Management: reactive arthritis

Answer 347

1. rule out septic joint = joint aspiration + micro 2. Antibiotics for infection 3. NSAIDs 4. steroid injections into joint 5. systemic steroids if multiple joints

Question 348

Define + causes: sinusitis

Answer 348

Inflammation of the parasternal sinuses in the face - Viral URTI - allergies - obstruction of drainage - smoking

Question 349

Presentation: sinusitis

Answer 349

Nasal congestion Nasal discharge Facial pain or headache Facial pressure Facial swelling over the affected areas Loss of smell tenderness on palpation fever

Question 350

Management: sinusitis

Answer 350

usually self-limiting >10 days 1. antibiotics = Pen V then clarithromycin 2. high dose steroid nasal spray

Question 351

Define + causes: syphilis

Answer 351

STI caused by Treponema palladium - sex - vertical transmission - IV drugs - blood transfusion

Question 352

Presentation: syphilis

Answer 352

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

Question 353

Management: syphilis

Answer 353

Antibody testing = PCR or dark field microscopy 1. IM benzathine benzylpenicillin

Question 354

Presentation + management: tension headache

Answer 354

Pressure band around the head - caused by stress, depression, alcohol, dehydration 1. Stress managing techniques 2. simple analgesia 3. frequent headaches = amitriptyline

Question 355

Define + presentation: Tonsillitis

Answer 355

Inflammation of tonsils - MC viral infection - sore throat - fever - pain on swallowing

Question 356

What is the criteria for giving antibiotics for tonsillitis?

Answer 356

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

Question 357

Management: tonsillitis

Answer 357

1. Penicillin V (phenocymethylpenicllin) 2. clarithromycin

Question 358

Define + Increase risk of: trichomonad vaginalis

Answer 358

Parasite spread through sexual intercourse Increase risk of: - contracting HIV - bacterial vaginosis - cervical cancer - pelvic inflammatory disease - pregnancy related complications

Question 359

Presentation: trichomoniasis

Answer 359

- vaginal discharge = frothy, yellow, green - itching - dysuria - dyspareunia (painful sex) - balanitis (inflammation to glans penis)

Question 360

Management: trichomoniasis

Answer 360

Women: Charcoal swab with microscopy --> from posterior fornix of vagina Men: urethral swab or first catch urine 1. metronidazole

Question 361

Presentation + management: trigeminal neuralgia

Answer 361

Intense facial pain in distribution of nerve: ophthalmic, maxillary, mandibular - unilateral 1. carbamazepine 2. surgical

Question 362

What are the types of urinary incontinence?

Answer 362

1. Urge = caused by overactivity of detrusor muscle of the bladder 2. stress = pelvic flaw muscles weak so urine leaks through at increased pressures 3. mixed 4. overflow = obstruction to the outflow of the urine

Question 363

What is the grading system for urinary incontinence?

Answer 363

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

Question 364

Investigation: urinary incontinence

Answer 364

- bladder diary - urine dipstick testing - post-void residual bladder volume - urodynamic testing = catheter inserted and measure pressure in bladder + rectum

Question 365

Management: Stress incontinence

Answer 365

1. avoid caffeine, overfilling bladder, weight loss 2. supervised pelvic floor exercises 3. surgery = tension-free vaginal tape, sling procedures 4. Duloxetine

Question 366

Management: urge incontinence

Answer 366

1. bladder retraining 2. anticholinergic medication = oxybutynin 3. Mirabegnon 4. invasive = botulin toxin injection, sacral nerve stimulation, augmentation cytoplasty

Question 367

Define: lower urinary tract infection

Answer 367

Infection in the bladder causing cystitis (inflammation of the bladder) - usually caused by E.coli

Question 368

Presentation: Lower urinary tract infection

Answer 368

- dysuria - suprapubic pain - frequency - incontinence - haematuria - cloudy or foul smelling urine - confusion in older patients (pyelonephritis = fever, back pain, nausea, renal angle tenderness)

Question 369

Investigations: lower urinary tract infection

Answer 369

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

Question 370

Management: lower urinary tract infection

Answer 370

1. trimethoprim 2. nitrofurantoin 3 days = in women 5-10days = immunosuppressed women, abnormal anatomy or impaired kidney function 7 days = men, pregnant women, catheter

Question 371

What antibiotics are used in lower urinary tract infection in pregnancy?

Answer 371

1. Nitrofurantoin = avoided in 3rd trimester Trimethoprim = avoided in 1st trimester (folate antagonist) 2. Amoxicillin 3. Cefalexin

Question 372

Define + presentation: urticaria

Answer 372

Hives - small itchy lumps appear on the skin - patchy erythematous rash - angioedema - flushing

Question 373

What are the causes of urticaria?

Answer 373

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

Question 374

Management: urticaria

Answer 374

1. antihistamines - fexofenadine 2. oral steroids = short term for flares 3. Anti-leukotrienes such as montelukast 4. Omalizumab, which targets IgE 5. Cyclosporin

Question 375

Why do varicose veins develop?

Answer 375

1. deep and superficial veins are connected by vessels 2. valves incompetent = blood flows from the deep veins back into the superficial veins and overloads them 3. leads to dilatation of superficial veins

Question 376

Presentation: varicose veins

Answer 376

Heavy or dragging sensation in the legs Aching Itching Burning Oedema Muscle cramps Restless legs chronic venous insufficiency = e.g., skin changes and ulcers

Question 377

What are the special tests for varicose veins?

Answer 377

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

Question 378

Management: varicose veins

Answer 378

1. weight loss, exercise, elevate leg, compression stockings 2. 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

Question 379

Define + physiology: vasovagal syncope

Answer 379

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

Question 380

Presentation + things to rule out: syncope

Answer 380

- 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

Question 381

Investigations: syncope

Answer 381

ECG = arrhythmia, QT interval 24 hr ECG ECHO Bloods = FBC (anaemia), electrolytes (arrhythmias + seizures), blood glucose (diabetes)

Question 382

Management: syncope

Answer 382

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

Question 383

Define + 6 types: viral exanthemas

Answer 383

eruptive widespread rash 1. Measles = kopek grey spots on buccal mucosa, rash starts on face, behind ears 2. Scarlet Fever = red blotchy, macula rash, sandpaper skin, starts on trunk 3. Rubella (AKA German Measles) = starts on face, lasts 3 days, mild fever, sore throat 4. Dukes’ Disease = no organism found, non-specific 5. Parvovirus B19 = bright red rash on both cheeks 6. Roseola Infantum = fever first, then rash appears across arms, legs, trunks, not itchy

Question 384

Define + presentation: gastroenteritis

Answer 384

inflammation of stomach and bowels - abdo pain - nausea - vomiting - diarrhoea

Question 385

What are the causes of gastroenteritis?

Answer 385

1. E.coli 2. campylobacter jejuni 3. shigella 4. salmonella 5. bacillus cereus 6. yersinia enterocolitica 7. staph enterotoxins 8. giardiasis

Question 386

Management: gastroenteritis

Answer 386

1. faeces sample for micro 2. ensure hydrated 3. antidiarrhoeal drugs (loperamide) + antiemetics (metoclopramide) 4. antibiotics = only when organism confirmed

Question 387

Define: whooping cough

Answer 387

Upper resp tract infection caused by bordetella pertussis - whooping sound as they forcefully suck in air - apnoea

Question 388

Management: whooping cough

Answer 388

1. nasal swab with PCR testing or serology (if lasted longer than 21 days for IgG) 2. notify public health 3. supportive care 4. antibiotics (if within 21 days) - azithromycin, erythromycin, clarithromycin 5. prophylactic antibiotics to close contacts

Question 389

Define + presentation: chicken pox

Answer 389

caused by varicella zoster virus - generalised vesicular rash - fever - itchy - general fatigue High contagious

Question 390

Management: chicken pox

Answer 390

self limiting 1. aciclovir = immunosuppressed patients, adults >14 yrs, neonates

Question 391

What are the 5 level’s of Maslow’s hierarchy of needs?

Answer 391

1. Physiological needs. 2. Safety needs. 3. Love and belonging. 4. Esteem. 5. Self-actualisation.

Question 392

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.

Answer 392

1. Other factors may be involved. 2. There may be a time lag between service and outcome. 3. Large sample sizes may be needed. 4. Data may be unavailable or there may be issues with data quality.

Question 393

What is the Avedia Donedebian's 3 stage model of evaluating the quality of health ?

Answer 393

1. Structure - buildings, staff, equipment 2. Process - tests, examinations, counselling, prescribing 3. Outcome - morbidity - mortality - satisfaction

Question 394

What is Maxwell's 6 dimensions of quality?

Answer 394

(3Es and 3As) Acceptability Accessibility Appropriateness (Relevance) Effectiveness Efficiency Equity

Question 395

Define prevalence

Answer 395

total number of cases of a disease (new and existing) in a population at a given time

Question 396

Define incidence

Answer 396

the rate of new cases of a disease in a population over a specific time period

Question 397

Define odds ratio

Answer 397

measure used to compare the odds of an outcome between 2 groups

Question 398

Define relative risk

Answer 398

compare the risk of an outcome between 2 groups (it is a measure of association, not of the severity)

Question 399

define case fatality rate

Answer 399

proportion of people diagnosed with a particular disease who die from the disease

Question 400

Define: specificity

Answer 400

proportion of patients without the condition who have a negative result TN / (TN+FP)

Question 401

Define: sensitivity

Answer 401

proportion of patients with the condition who have a positive screening result TP / (TP+FN)

Question 402

define: positive predictive value

Answer 402

Proportion of people with a positive test result that have the disease TP / (TP+FP)

Question 403

Define: negative predictive value

Answer 403

proportion of patients who got a negative test result who don't have the disease TN / (TN+FN)

Question 404

What is reliability vs validity?

Answer 404

validity = tests accuracy reliability = consistency of a measure

Question 405

What are the 3 levels of prevention?

Answer 405

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