GP/general med

Question 1

Give 3 systemic causes of itch

Answer 1

Medications - opioids, statins, ACEI, NSAIDs, digoxin, antimalarials, sulphonamides
Hepatic -cholestasis eg primary biliary cirrhosis, drug-induced
Pregnancy - pruritus gravidarum, obstetric cholestasis
Endocrine: DM, hypo/hyperthyroid, hyperparathyroid
Haem - polycythaemia rubra vera, iron def, myeloproliferative disorders
Neuro - MS, neuropathy, radiculopathy
Malignancy - Hodgkins, leukaemia, carcinoma lung prostate stomach
HIV
Psych - obsession, schizophrenia
Infection - viral exanthems (chickenpox=papulovesicular, measles and rubella = face, roseola and scarlet fever =trunk, extremeties = hand foot and mouth disease)

Question 2

Give 3 common dermatological causes of itch.

Answer 2

Atopic eczema - itchy red skin creases. can lead to lichen simplex (‘lichenification’= becoming leathery).
Contact/occupational dermatitis - allergens (nickel jewellery, perfume, dyes) or irritants (detergents, water, plants)
Urticaria - atopy, nettle sting appearance
Polymorphic light eruption (prickly heat) - worse after UVA
Scabies - burrows, finger webs, crowded living
Lice - close contact, children, pubic or head
Tinea/ dermatophytosis - ring-like pattern
Bites and stings

Question 3

Give 3 pharmacological treatments for itching of dermatological cause.

Answer 3

Emollients - eg white soft paraffin. used for dry/scaling disorders.
Topical corticosteroids eg hydrocortisone. suppress inflammation eg eczema. use least potent preparation that is effective. apply thin layer to affected areas >30mins prior to emollients OD.
Oral antihistamines when histamine is the main mediator, eg in urticaria and insect bites. Hydroxyzine-> long QT

Question 4

Give 3 investigations you would do for someone presenting in primary care with itch and why.

Answer 4

FBC - haem/malignancy causes anaemia/pancytopaenia, infection causes raised WCCs. iron def, PRV
Urine dip
U+Es - CKD
Glucose - DM
TFTs - hypo/hyperthyroidism
LFT - PBC - elevated AST and ALT suggest hepatocellular disease.

Question 5

Give 3 treatments for non-dermatological causes of itch.

Answer 5

Biliary obstruction -> colestyramine, rifampicin, opioid antagonists, SSRIs
Uraemia -> naltrexone, thalidomide.
CKD -> Gabapentin
Hodgkins -> Cimetidine, corticosteroids
Paraneoplastic -> paroxetine
PVC -> aspirin
HIV -> indometacin

Question 6

What is atrial fibrillation?

Answer 6

A common disturbance of cardiac rhythm that may be episodic (paroxysmal). characterised by rapid irregularly irregular narrow QRS complex tachycardia with absence of P-waves.
(oxford)

Question 7

How is atrial fibrillation diagnosed? What investigations would you do?

Answer 7

Clinical: asymptomatic, palpitations, chest pain, stroke/TIA, dyspnoea, fatigue, light-headedness, syncope.
Examination: anaemia, thyrotoxicosis, anxiety, systemic disease. CVS: heart size, pulse rate/rhythm (apex rate >radial pulse rate in AF), JVP, BP, heart sounds/murmurs, LVF.
Investigations: ECG, CXR. Bloods - TFTs, FBC, U+E. If still not confirmed use 24-hr ambulatory ECG monitor.

Question 8

How is AF managed?

Answer 8

aims: relieve symptoms, prevent thromboembolism, decrease risk of stroke, maintain cardiac function.
Rate control = Keeping rest BP between 60-80bpm
b-blocker or rate limiting CCB eg verapamil 40-120mg tds, Consider digoxin monotherapy for sedentary people with nonparoxysmal AF .Offer if over 65, AF for more than a year, no CCF, predisposing HD eg mitral stenosis, large left atrium, failed cardioversion, anticoag contraindicated, ongoing but reversible cause eg thyrotoxicosis.

Rhythm control = cardioversion (electrical or chemical).
Offer if symptomatic, under 65, CCF, first presentation/new onset, or secondary to a corrected precipitant.

‘pill in the pocket’ approach in paroxysmal AF: consider self-medication with beta blocker prn (eg atenolol)

Stroke prevention:
For most people, the benefit of anticoagulation outweighs the risk of bleeding. Use CHADSVasc and HASBLED scores and if they score 1+ anticoagulate with apixiban, rivaroxiban, dabigatran etexilate or warfarin.

Question 9

What does the CHADS2Vasc scoring system contain and what is it for?

Answer 9

CHA2DS2-Vasc score to assess stroke risk in AF, atrial flutter or continuing risk of arrhythmia after cardioversion
CHD = 1
HTN = 1
Age >65 =1, >74 =2
Diabetes = 1
Stroke, tia or thromboembolism = 2
Sex female = 1 (this is dubious - ask about it. guidelines act as if you should not count it as a score)
Vascular disease eg MI = 1

Question 10

What does the HASBLED score contain and what is it for?

Answer 10

HAS-BLED score to assess risk of bleeding in people on anticoagulation. Offer modification and monitoring for htn, INR, NSAID use and alcohol (new 2014). 
Hypertension = 1
Abnormal renal (=1) and liver (=1) function
Stroke =1
Bleeding =1
Labile INR =1 = Time in Therapeutic Range (TTR) below 60%.
Elderly (>65) =1
Drugs (anticoagulant =1) or alcohol (>8 drinks a week =1)

Question 11

Give 5 important questions to ask a patient with dizziness.

Answer 11

What do you mean?
- Vertigo = abnormal sensation of movement
- Presyncope = light-headed, weak
- Disequilibrium = unsteady, worse when walking, better with rest. eg sensory deficit in elderly patients.
Constant or episodic?
Triggered or spontaneous?
Associated sx? - senses, panic, N+V
RED FLAGS: abnormal neurology (FAST symptoms), new headache?

Question 12

How would you clinically identify a stroke in a dizzy patient? What examinations would you do?

Answer 12

Red flags:
1. Abnormal neurology
2. New headache
3. normal horizontal head impulse test.
HINTS:
horizontal Head Impulse test - person sits upright and is asked to keep their gaze fixed on the examiner. Turn their head to side and watch their eyes. If eyes are dragged off target and you see a saccade as the eyes move back, this suggests PERIPHERAL vestibular pathology. this would be reassuring. if the test was normal (eyes stay fixed) you would consider stroke.
Nystagmus - follow finger.
Test of Skew - cover each eye in turn, look for vertical deviation after uncovering -> suggestive of stroke.

Question 13

What are 5 common causes of dizziness?

Answer 13

True vertigo -> labyrinthitis/vestibular neuronitis, BPPV, vestibular migraine, menieres disease.
Light-headedness -> pre-syncope/postural hypotension.

Question 14

What investigations would you do for a patient with dizziness, when no cause has been identified on hx/exam?

Answer 14

Urinalysis (UTI)
FBC (anaemia, alcohol abuse -> macrocytic)
glucose, U+Es, tft
ECG - arrhythmia
CT has poor sensitivity in acute stroke.

Question 15

How could you manage dizziness in primary care?

Answer 15

(Refer to hosp if ?stroke)
Vestibulosuppressant anti-emetics: cinnarizine, cyclizine, prochlorperazine, hyoscine and promethazine.
Goal setting
Exercises