GP ILAs Flashcards
Identify the cause of vaginal discharge:
1) No itching of the vagina/vulva, fish-like smell, thin grey discharge
2) Itching/burning of the vagina/vulva, fish-like smell, green/yellow discharge
3) Offensive discharge, dysuria and painful sex, bleeding between periods and postcoital
4) odourless purulent discharge, possibly green or yellow associated with dysuria and pelvic pain
5) Thick white discharge associated with itch
6) clear/off white discharge with no associate symptoms
- BV - itching or irritation are not common but are possible
- trichomonas - similar to clamydia and gonorhea with the pain but i think the itching is key
- chlamydia - only one with abnormal bleeding
- Gonorrhoea - pelvic pain, G + C don’t itch!!!
- Candidiasis/thrush
- Physiological
Blood pressure readings required to diagnose hypertension?
Readings for malignant hypertension
The NICE guidelines on hypertension (updated 2022) suggest a diagnosis of hypertension with a blood pressure above 140/90 in the clinical setting, confirmed with ambulatory or home readings above 135/85 - the average reading.
Note 180/120 indicates malignant hypertension and warretns same day assessement
Causes of Hypertension - 2 types?
Essential hypertension accounts for 90% of hypertension. This is also known as primary hypertension. It means a high blood pressure has developed on its own and does not have a secondary cause.
Secondary causes of hypertension can be remembered with the “ROPED” mnemonic:
R – Renal disease -> hyperaldosteronism- When the blood pressure is very high or does not respond to treatment, consider renal artery stenosis, Dx w/ Renal Doppler or Angiogram
O – Obesity
P – Pregnancy-induced hypertension or pre-eclampsia
E – Endocrine (Particularly Hyperaldosteronism (Conn’s syndrome = adrenal adenoma))
D – Drugs (e.g., alcohol, steroids, NSAIDs, oestrogen and liquorice)
Renal disease is the most common cause of secondary hypertension. When the blood pressure is very high or does not respond to treatment, consider renal artery stenosis.
Complications of Hypertension? (7)
High blood pressure increases the risk of:
- Ischaemic heart disease (angina and acute coronary syndrome)
- Cerebrovascular accident (stroke or intracranial haemorrhage)
- Vascular disease (peripheral arterial disease, aortic dissection and aortic aneurysms)
- Hypertensive retinopathy
- Hypertensive nephropathy
- Vascular dementia
- Left ventricular hypertrophy/Heart failure
Patients with a new diagnosis of HTN should have what investigations - 5?
NICE recommend all patients with a new diagnosis should have:
- Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
- Bloods for HbA1c, renal function and lipids
- Fundus examination for hypertensive retinopathy
- ECG for cardiac abnormalities, including left ventricular hypertrophy
- calculating the QRISK score - risk of stroke or MI in the next 10 years. If >10%, offer Atorvastatin
Management of Hypertension:
First Line?
Medical Management - steps?
What drug is used first line in diabetic patients with HTN?
1st line - lifestyle advice includes a healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.
Medications used in management are:
A – ACE inhibitor (e.g., ramipril)
B - Beta Blocker (Bisoprolol)
C – Calcium channel blocker (e.g., amlodipine)
D – Thiazide-like diuretic (e.g., indapamide)
ARB – Angiotensin II receptor blocker (e.g., candesartan)
Step 1: Aged under 55 or type 2 diabetic of any age or family origin, use A. Aged over 55 or Black African use C.
Step 2: A + C. Alternatively, A + D or C + D.
Step 3: A + C + D
Step 4: A + C + D + fourth agent (see below)
Step 4 depends on the serum potassium level:
Less than or equal to 4.5 mmol/L consider a potassium-sparing diuretic, such as spironolactone
More than 4.5 mmol/L consider an alpha blocker (e.g., doxazosin) or a beta blocker (e.g., atenolol)
How does Spironolactone work?
Spironolactone is a potassium-sparing diuretic/An Aldosterone antagonist!. It works by blocking the action of aldosterone in the kidneys, resulting in sodium excretion and potassium reabsorption. It can be helpful when thiazide diuretics are causing hypokalaemia.
Using spironolactone increases the risk of hyperkalaemia. ACE inhibitors can also cause hyperkalaemia.
OMG it is an aldosterone antagonist. The ARBs are the Angiotensive blockers/ACEi alteranties (Sartans)
How do ACE inhibitors work?
Action of Aldosterone on the electrolyte levels in the blood.
ACE inhibitors (e.g., ramipril and lisinopril) work by blocking the action of angiotensin-converting enzyme (ACE). This stops angiotensin I from being converted to angiotensin II, lowering the amount of angiotensin II in the body. Lower angiotensin II results in less vasoconstriction, lower aldosterone, and less cardiac remodelling over the longer term. This means lower blood pressure, less fluid retention and a healthier heart and cardiovascular system.
The RAAS system:
The juxtaglomerular cells are found at the afferent arterioles. They sense the blood pressure in the afferent arterioles and secrete an enzyme called renin, depending on the pressure. They secrete more renin in response to low blood pressure and less renin in response to high blood pressure.
Renin acts to convert angiotensinogen (produced by the liver) into angiotensin I.
Angiotensin I converts to angiotensin II in the lungs with the help of angiotensin-converting enzyme (ACE).
Angiotensin II has three main effects. It stimulates:
Vasoconstriction - smooth muscle of blood vessel walls(acting on the blood vessels directly)
Hypertrophy (thickening) and remodelling of the heart and blood vessels
Aldosterone release by the adrenal glands -> acts in the kidneys to increase sodium reabsorbtion, increase potassium secretion. (Na+/K+ exchange). When sodium is reabsorbed from the filtrate back into the blood, water follows it by osmosis.
What medications can be used to manage dyspnae in heart failure?
Loop Diuretics - furosemide
ILA - morphine is also used to slow down breathing help with the breathless in palliative care.
Management of chronic heart failure
The first-line medical treatment of chronic heart failure can be remembered with the “ABAL” mnemonic:
A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated
B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated
A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone)
L – Loop diuretics (e.g., furosemide or bumetanide)
What are the Physical activity guidelines for adults?
At least 150 minutes/ 2 ½ hours of moderate intensity activity in bouts of 10 minutes or more per week - 5x 30mins. Moderate = brisk walking or cycling
OR
75 mins of vigorous intensity activity
BMI ranges?
How is BMI range altered in different ethnic populations?
Healthy weight: BMI of 18.5-24.9 kg/m2
Overweight: BMI of 25-29.9 kg/m2
Obesity class I: BMI of 30-34.9 kg/m2
Obesity class II: BMI of 35-39.9 kg/m2
Obesity class III: BMI of 40 kg/m2 or greater
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Lower BMI thresholds for health risks: For people of East Asian, South Asian, and Southeast Asian descent, health risks such as diabetes, hypertension, and cardiovascular diseases tend to increase at lower BMI values compared to people of European descent.
Recommended Adjusted BMI Ranges:
Normal weight: 18.5–22.9
Overweight: 23–24.9
Obese: 25 or higher
DONT STRESS JUST KNOW THAT IF YOU ARE ASIAN THEN 25 NOT 30 IS OBESITY CUT OFF
What are the 4 classes of anticipatory medications prescribed in palliative care?
Give an example of each?
Symptoms such as pain, excess secretions and agitation are commonly seen in patients nearing the end of life.
Anticipatory medications are prescribed in advance, or ‘in anticipation’ of these symptoms developing. This ensures timely administration, minimising distress and discomfort.1
There are four main classes of anticipatory medication:
Analgesia: for pain - Morphine Sulfate
Anti-emetic: for nausea and vomiting Haliperidol
Anxiolytic: for agitation Midazolam
Anti-secretory: for respiratory secretions Hyoscine butylbromide (anti-parasympathetic) or Mebeverine
Note of secretions - With reduced levels of consciousness, patients may become unable to swallow or clear their normal respiratory secretions/saliva, resulting in pooling in the upper respiratory tract.
Anxiety Cheat sheet:
Types of Anxiety/Neurotic disorder?
Generalised anxiety disorder (GAD) is a mental health condition that causes excessive and disproportional anxiety and worry that negatively impacts the person’s everyday activity. Symptoms should be persistent, occurring most days for at least six months, and not caused by substance use or another condition.
Panic disorder involves recurrent panic attacks. The panic attacks are recurrent episodes of sudden onset anxiety, in the absence of multi-themed worry (that is GAD). During an acute attack, the person experiences at least four symptoms from the following: shortness of breath, palpitations, shakiness, nausea, hot or cold flushes, dizziness, and fear of dying. Also frequently accompanied by avoidance behaviours (of activities where escape would be difficult).
Phobia involves an extreme fear of certain situations or things, causing symptoms of anxiety and panic. There are many types, including fear of animals, heights, pathogens, flying, injections or environments
Adjustment disorder — suggested by temporary anxiety that has occurred in response to a life stressor and persists for no longer than 6 months after the stressor ends.
Obsessive-compulsive disorder — suggested by anxiety due to compulsions or obsessions. Obsessions are unwanted and uncontrolled thoughts and intrusive images that the person finds very difficult to ignore. Compulsions are repetitive actions the person feels they must do, generating anxiety if they are not done.
Post-traumatic stress disorder — suggested by anxiety that is caused by exposure to reminders of past trauma. The person may report feeling as if they are reliving these events through flashbacks and nightmares.
Me
In phobia, the fear is clearly linked to the specific object or situation.
In panic disorder, the fear centers around the unpredictability of panic attacks themselves and their consequences, there are not specific triggers
In addition to CBT, what medications is used to treat:
- Generalised anaxiety disorder?
- Phobia Disorder?
- Panic disorder?
First line for all anxiety disorders is Sertaline
Propanolol (Beta-blocker) are sometimes used for physical symptoms - panic disorders in particular
Phobias are usually mainly managed with CBT
SSRIs are also used in PTSD and OCD (Clomipramine -TCA) alongside other medicaitons
Refugee rights to access healthcare in the UK?
Primary and emergency care are free for all, including refused asylum seekers.
Secondary care is free for asylum seekers and those appealing decisions, but not for refused asylum claims without appeals, except in specific cases like communicable diseases or maternity care.
Psoriasis is a chronic autoimmune condition that causes recurrent symptoms of psoriatic skin lesions.
- what are psoriatic skin legions?
- two main types of psoriasis
- 3 signs that are specific to psoriasis?
- 3 key things about psoriasis vs eczema
Patches of psoriasis are dry, flaky, scaly, faintly erythematous skin lesions that appear in raised and rough plaques, commonly over the extensor surfaces of the elbows and knees and on the scalp. These skin changes are caused by the rapid generation of new skin cells, resulting in an abnormal buildup and thickening of the skin in those areas.
2 types:
Plaque psoriasis features the thickened erythematous plaques with silver scales, commonly seen on the extensor surfaces and scalp. The plaques are 1cm – 10cm in diameter. This is the most common form of psoriasis in adults.
Guttate psoriasis is the second most common form of psoriasis and commonly occurs in children. It presents with many small raised papules across the trunk and limbs. The papules are mildly erythematous and can be slightly scaly. Over time the papules in guttate psoriasis can turn into plaques. Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months
Pustular psoriasis and Erythrodermic psoriasis are rare severe forms of psoriasis.
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There are a few specific signs suggestive of psoriasis:
- Auspitz sign refers to small points of bleeding when plaques are scraped off
- Koebner phenomenon refers to the development of psoriatic lesions to areas of skin affected by trauma
- Residual pigmentation of the skin after the lesions resolve
Just be aware of these…
Nail psoriasis describes the nail changes that can occur in patients with psoriasis. These include nail pitting, thickening, discolouration, ridging and onycholysis (separation of the nail from the nail bed).
Psoriatic arthritis occurs in 10 – 20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age.
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Some notes on comparing psoriasis with Eczema:
- both are dry but eczema is itchy
- eczema is on the flexor sufaces (Millie is cubital fossa, Mike’s Dad is elbow)
- eczema tends to develop in childhood, psoriasis tends to develop in adulthood, but ovs guttate psoriasis is a thing….
Management options for plaque psoriasis? 4
Management of Guttate psoriasis? 2
The treatment options include:
- Topical steroids
- Topical vitamin D analogues (calcipotriol)
- Topical dithranol
- Topical calcineurin inhibitors (tacrolimus) are usually only used in adults
Guttate psoriasiss usually a self-limiting condition that typically resolves within 3–4 months of onset. No Rx required.
Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis. ME - this is UV not like bluelight for neonatal jaundice
What is Kawasaki disease?
key complication?
Presentation?
Kawasaki disease is also known as mucocutaneous lymph node syndrome. It is a systemic, medium-sized vessel vasculitis.
It affects young children, typically under 5 years. There is no clear cause or trigger. It is more common in Asian children, particularly Japanese and Korean children. It is also more common in boys.
A key complication is coronary artery aneurysm.
Presentation:
A key feature that should make you consider Kawasaki disease is a persistent high fever (above 39ºC) for more than 5 days. Children will be unhappy and unwell. The key skin findings are a widespread erythematous maculopapular rash and desquamation (skin peeling) on the palms and soles of the feet.
Other features include:
Strawberry tongue (red tongue with large papillae)
Cracked lips
Cervical lymphadenopathy
Bilateral conjunctivitis
TOM TIP: If you come across a child with a fever persisting for more than 5 days, think of Kawasaki disease! A rash, strawberry tongue, lymphadenopathy and conjunctivitis will seal the diagnosis in your exams.
Investigations in kawasaki disease
There are several investigations that can be helpful in Kawasaki disease:
- Full blood count can show anaemia, leukocytosis and thrombocytosis
- Liver function tests can show hypoalbuminemia and elevated liver enzymes
- Inflammatory markers (particularly ESR) are raised
- Urinalysis can show raised white blood cells without infection
- Echocardiogram can demonstrate coronary artery pathology
Disease course of kawasaki disease?
management?
further investigation that is indicated?
Disease Course
There are three phases to Kawasaki disease:
Acute phase: The child is most unwell with the fever, rash and lymphadenopathy. This lasts 1 – 2 weeks.
Subacute phase: The acute symptoms settle, the desquamation and arthralgia occur and there is a risk of coronary artery aneurysms forming. This lasts 2 – 4 weeks.
Convalescent stage: The remaining symptoms settle, the blood tests slowly return to normal and the coronary aneurysms may regress. This last 2 – 4 weeks.
Management
There are two first line medical treatments given to patients with Kawasaki disease:
High dose aspirin to reduce the risk of thrombosis (thrombocytosis)
IV immunoglobulins to reduce the risk of coronary artery aneurysms
Patients will need close follow up with echocardiograms to monitor for evidence of coronary artery aneurysms.
TOM TIP: Kawasaki disease is one of the few scenarios where aspirin is used in children. Aspirin is usually avoided due to the risk of Reye’s syndrome. This is a unique fact that examiners like to test.
A child presents with:
- a red-pink, blotchy, macular rash with rough “sandpaper” skin that starts on the trunk and spreads outwards
- fever
- flushed cheeks
- sore throat
- strawberry tongue
- cervical lymphadenopathy?
Diagnosis?
Management?
Scarlet fever is associated with group A streptococcus infection, usually tonsillitis. It is not caused by a virus.
Treatment is with antibiotics for the underlying streptococcal bacterial infection. This is with phenoxymethylpenicillin (penicillin V) for 10 days. Scarlet fever is a notifiable disease and all cases need to be reported to public health. Children should be kept off school until 24 hours after starting antibiotics.
Patients can have other conditions associated with group A strep infection:
Post-streptococcal glomerulonephritis
Acute rheumatic fever
The other disease causing strawberry tongue and cervical lyphadenopathy is kawasaki disease, but here the fever is likely to last more than five days are there is often desquamatisation of the palms and soles of feet.
A child presents with:
- fever
- coryzal symptoms
- conjuctivitis
- 3-5 days later a macular (flat) rash appears on the face, behind the ears and then spreads to the rest of the body
Diagnosis?
pathognomonic sign?
management?
complications?
Measles is caused by the measles virus. It is highly contagious via respiratory droplets. Symptoms start 10 – 12 days after exposure, with fever, coryzal symptoms and conjunctivitis.
Koplik spots are greyish white spots on the buccal mucosa. They appear 2 days after the fever. They are pathognomonic for measles, meaning if a patient has Koplik spots, you can diagnose measles.
The rash starts on the face, classically behind the ears, 3 – 5 days after the fever. It then spreads to the rest of the body. The rash is an erythematous, macular rash with flat lesions.
Measles is self resolving after 7 – 10 days of symptoms. Children should be isolated until 4 days after their symptoms resolve. Measles is a notifiable disease and all cases need to be reported to public health. 30% of patients with measles develop a complication.
Complications include:
Pneumonia
Diarrhoea
Dehydration
Encephalitis
Meningitis
Hearing loss
Vision loss
Death
What causes slapped cheek syndrome/erythema infectiosum?
Presentation?
Management?
Complications?
Parovirus B19
Parvovirus infection starts with mild fever, coryza and non-specific viral symptoms such as muscle aches and lethargy. After 2 – 5 days the rash appears quite rapidly as a diffuse bright red rash on both cheeks, as though they have “slapped cheeks”. A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears that can be raised and itchy. Reticular means net-like.
The illness is self limiting and the rash and symptoms usually fade over 1 – 2 weeks. Healthy children and adults have a low risk of any complications and are managed supportively with plenty of fluids and simple analgesia. It is infectious prior to the rash forming, but once the rash has formed they are no longer infectious and do not need to stay off school.
Patients that are at risk of complications include immunocompromised patients, pregnant women and patients with haematological conditions.such as sickle cell anaemia, thalassaemia, hereditary spherocytosis and haemolytic anaemia. These patients require serology testing for parvovirus to confirm the diagnosis and checking of the full blood count and reticulocyte count for aplastic anaemia. People that would be at risk of complications that have come in contact with someone with parvovirus prior to the rash forming, should be informed and may need investigations.
Complications:
**Aplastic anaemia
**Encephalitis or meningitis
Pregnancy complications including fetal death
Rarely hepatitis, myocarditis or nephritis
Key differential is scarlet fever because of the fever and flushed flushed cheeks. However scarlet fever caused by GA strept has a sandpaper rash, cervical lyphadenopathy, and strawberry tongue.
