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.
What is an exanthem and list causes of them
An “exanthem” is an eruptive widespread rash
- measels
- scarlet fever
- slapped cheeks syndrome
- rubella
- roseola infantum
- kawasaki disease
What is rubella?
Management?
Complications?
Risk in pregnancy?
A GENERALLY MILD DISEASE!
Rubella is caused by the rubella virus. It is highly contagious and spread by respiratory droplets. Symptoms start 2 weeks after exposure.
It presents with a milder erythematous macular rash compared with measles. The rash starts on the face and spreads to the rest of the body. The rash classically lasts 3 days. It can be associated with a mild fever, joint pain and a sore throat. Patients often have enlarged lymph nodes (lymphadenopathy) behind the ears and at the back of the neck.
Management is supportive and the condition is self limiting. Rubella is a notifiable disease and all cases need to be reported to public health. Children should stay off school for at least 5 days after the rash appears. Children should avoid pregnant women.
Complications are rare but include thrombocytopenia and encephalitis. Rubella is dangerous in pregnancy and can lead to congenital rubella syndrome, which is a triad of deafness, blindness and congenital heart disease
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I think basically its mild, focus of the pathognomnic things in the other exanthems - kawasiki 5 day fever, scalded palms and feet, cervical lyphadenopathy, conjunctivitis, strawberry tongue
scarlet fever - strawberry tongue, cervical lyphadenopathy, sandpaper rash
measels - conjunctivitis and koplik spots. Rash behind ears.
Eczema:
- presentation - when and where on the body?
- Pathophysiology?
- Management - maintenance vs flares
- steroid ladder
- Two main complications of eczema and their management
flexor surfaces are the ones that overlay the flexor muscles - pits of elbows and knees
Eczema usually presents in infancy with dry, red, itchy and sore patches of skin over the flexor surfaces (the inside of elbows and knees) and on the face and neck. Patients with eczema experience periods where the condition is well controlled and periods where the eczema is more problematic, known as flares.
The simplified pathophysiology is that eczema is caused by defects in the barrier that the skin provides. Tiny gaps in the skin barrier provide an entrance for irritants, microbes and allergens that create an immune response, resulting in inflammation and the associated symptoms.
Management
Maintenace - emollients and avoiding perfumes or harsh soaps
Ointments are thicker and greasier than creams.
Flares - topical steroids and thicker emollients
Other specialist treatments in severe eczema include zinc impregnated bandages, topical tacrolimus, phototherapy and systemic immunosuppressants, such as oral corticosteroids, methotrexate and azathioprine.
The steroid ladder from weakest to most potent - spells HEBD
Mild: Hydrocortisone 0.5%, 1% and 2.5%
Moderate: Eumovate (clobetasone butyrate 0.05%)
Potent: Betnovate (betamethasone 0.1%)
Very potent: Dermovate (clobetasol propionate 0.05%)
Complication
- opportunistic bacterial infection of the skin with staphylococcus aureus - impetigo. Rx w/ Flucloxaccilin
- eczema herpeticum - HSV or VZV infection of the skin. Can make patients very unwell - widepread rash with fever. Rx w/ Aciclovir.
THESE COMPLICATIONS ARE KEY I THINK
Roseola Infantum is common viral illness that affects infants and toddlers. It presents with a high fever (up to 40ºC) that comes on suddenly, lasts for 3 – 5 days and then disappears suddenly. There may be coryzal symptoms, sore throat and swollen lymph nodes during the illness. When the fever settles, the rash appears for 1 – 2 days. The rash consists of a mild erythematous macular rash across the arms, legs, trunk and face and is not itchy.
Children make a full recovery within a week and do not generally need to be kept off nursery if they are well enough to attend.
- Which virus causes roseola infantum?
- One main complication of roseola?
Roseola is caused by human herpesvirus 6 (HHV-6) and less frequently by human herpesvirus 7 (HHV-7).
The main complication to be aware of is febrile convulsions due to high temperature. Immunocompromised patients may be at risk of rare complications such as myocarditis, thrombocytopenia and Guillain-Barre syndrome.
Define Allodynia
Allodyniarefers to when pain is experienced with sensory inputs that do not normally cause pain (e.g., light touch).
Define neuropathic pain, what are the typical features of neuropathic pain? (5)
Neuropathic painis caused by abnormal functioning or damage of the sensory nerves, resulting in pain signals being transmitted to the brain. Typical features suggestive of neuropathic pain are:
- Burning
- Tingling
- Pins and needles
- Electric shocks
- Loss of sensation to touch of the affected area
What are the three steps of the analgesic ladder?
The World Health Organisation (WHO) analgesic ladder was originally to help manage cancer-related pain. It is also often used for acute and chronic painful conditions. The idea is that patients with mild pain start on the first step, and when pain is more severe or does not respond to the lower steps, higher steps on the ladder are used until the pain is adequately managed.
There are three steps to the analgesic ladder:
Step 1: Non-opioid medications such as paracetamol and NSAIDs
Step 2: Weak opioids such as codeine and tramadol (tramadol has multiple mechanisms of action, including being an SNRI and agonist of opioid receptors)
Step 3: Strong opioids such as morphine, oxycodone, fentanyl and buprenorphine
What are the ‘adjuvants’ to the analgesic ladder?
Other medications that can may be combined with the analgesic ladder for additional effect (calledadjuvants) or used separately to manage neuropathic pain. These are:
- Amitriptyline– a tricyclic antidepressant
- Duloxetine– an SNRI antidepressant
- Gabapentin– an anticonvulsant
- Pregabalin– an anticonvulsant
- Capsaicin cream(topical) – from chilli peppers
What are the 5 key side effects of opiods?
The key side effects ofopioidsare:
- Constipation
- Skin itching (pruritus)
- Nausea
- Altered mental state (sedation, cognitive impairment or confusion)
- Respiratory depression (usually only with larger doses in opioid-naive patients)
Anti-cholinergic medications are used to treat Asthma, CVD, COPD, parkinson’s, urge incontinence. What are some of the side effects of this class of medication? (6)
anti-cholinergic = anti-parasympathetics so basically so sympathetic effects (dilated pupils…)
- Blind as a bat - non reactive mydriasis (dilated pupils) and paralysis of accomodation reflex
- dry as a bone - dry mouth and constipation, anhydrosis
- red as a beet - cutaneous vasodilation
- mad as a hatter- delirium
- full as a flask - retention (para to pee)
- hot as a hare - hyperthermia
Can’t see, Can’t pee, Can’t shit, Can’t shoot (ejaculation) but also mad as a hatter, red as beet and dry as a bone (ahydrosis)
what is the difference between chronic primary and chronic secondary pain?
Chronic primary pain – where no underlying condition can adequately explain the pain
Chronic secondary pain – where an underlying condition can explain the pain
KEY Management of chronic pain - 5 things
- Supervised group exercise programs
- Acceptance and commitment therapy (ACT)
- Cognitive behavioural therapy (CBT)
- Acupuncture
- Antidepressants (e.g., amitriptyline, duloxetine or an SSRI)
What is the appropriate medical management of chronic primary pain (where no underlying condition can adequately explain the pain)?
- Antidepressants (e.g., amitriptyline, duloxetine [SNRI] or an SSRI)
It is worth noting that the NICE guidelines (2021) advise that forchronic primary pain(where no underlying condition can adequately explain the pain), patients shouldnotbe started on:
- Paracetamol
- NSAIDs
- Opiates
- Pregabalin
- Gabapentin
TOM TIP: Chronic pain is incredibly common. It is worth noting these recent guidelines that clearly state to avoid basically all forms of analgesia (other than antidepressants) in patients with chronic primary pain. These guidelines may come up in exams, potentially asking you the most appropriate medication for a patient with chronic primary pain (antidepressants). This is different to chronic secondary pain, where there is an underlying condition that explains the pain.
what tool is used to assess for neuropathic pain?
The DN4 questionnairecan be used to assess the characteristics of the pain and the likelihood of neuropathic pain. Patients are scored out of 10. A score of 4 or more indicates neuropathic pain - hence the name
Douleur Neuropathique en 4
What are the 4 first line treatments for neuropathic pain?
There are four first-line treatments for neuropathic pain:
- Amitriptyline– a tricyclic antidepressant
- Duloxetine– an SNRI antidepressant
- Gabapentin– an anticonvulsant
- Pregabalin– an anticonvulsant
NICE recommend using one of these four medications to control neuropathic pain. If it does not help, it can be slowly withdrawn, and an alternative can be tried. All four can be tried in turn. Only one neuropathic medication should be used at a time.
What is the most common cause of tonsilitis and what is the treatment required?
The most common cause of tonsillitis is a viral infection. Viral infections do not require or respond to antibiotics.
The most common cause of bacterial tonsillitis is group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin). The most common cause of otitis media, rhinosinusitis and the most common alternative bacterial cause of tonsillitis is Streptococcus pneumoniae. Other causes: Haemophilus influenzae, Morazella catarrhalis, Staphylococcus aureus
A typical presentation is a child with a fever, sore throat and painful swallowing. Tonsillitis can present with non-specific symptoms, particularly in younger children. They may present with only a fever, poor oral intake, headache, vomiting or even abdominal pain.
What score can be used to determine whether or not to a tonsilitis is likely to have a bacterial cause? Score at which antibitoics are given?
Antibiotic choice?
What is Quinsy and how does it present?
Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils.
Always examine the ears (otoscopy) to visualising the tympanic membranes and palpate for any cervical lymphadenopathy when assessing a child with suspected tonsillitis.
SCORES:
Centor Criteria
The Centor criteria can be used to estimate the probability that tonsillitis is due to a bacteria infection, and will benefit from antibiotics.
A point is given if each of the following features are present:
Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
Fever PAIN is another score that is basically the same but replaced Cervical lyphadenopathy with attedence within 3 days of Sx onset and inflammed tonsils.
Consider prescribing antibiotics if the Centor score is ≥ 3 or the FeverPAIN score is ≥ 4.
Also consider antibiotics if they are at risk of more serious infections, for example young infants, immunocompromised patients or those with significant co-morbidity, or there is a history of rheumatic fever.
Penicillin V is first line (GA strept is most common bacterial cause, viral is most common cause), clarithromycin if allergic to penecillin
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Quinsy is a peritonsillar absess, which is a complicaiton of untreated tonsillitis. Additional symptoms that can indicate a peritonsillar abscess include:
- Trismus, which refers to when the patient is unable to open their mouth
- Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
Swelling and erythema in the area beside the tonsils on examination
Management - REQUIRES: incision and drainage
Risks factors for oral thrush?
RANDOM BUT WAS A GERIS Q IN THE MOCK THAT I GUESSED CORRECTLY
Oral Candidiasis
Oral candidiasis is also called oral thrush. It refers to an overgrowth of candida, a type of fungus, in the mouth. This results in white spots or patches that coat the surface of the tongue and palate.
Several common factors can predispose someone to develop oral candidiasis:
- Inhaled corticosteroids (particularly with poor technique, not using a spacer and not rinsing with water afterwards)
- Antibiotics (disrupt the normal bacterial flora giving candida a chance to thrive)
- Diabetes
- Immunodeficiency (consider HIV)
- Smoking
Treatment options are:
- Miconazole gel
- Nystatin suspension
- Fluconazole tablets (in severe or recurrent cases)
Different causes of Otitis Externa?
Two bacterial species?
Otitis externa is inflammation of the skin in the external ear canal.
The inflammation in otitis externa may be caused by:
- Bacterial infection
- Fungal infection (e.g., aspergillus or candida) - particularly following multiple corses of topical antibiotics
- Eczema
- Seborrhoeic dermatitis
- Contact dermatitis
Swimming and cotton buds are risk factors.
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The two most common bacterial causes of otitis externa are:
- Pseudomonas aeruginosa
- Staphylococcus aureus
An ear swab can be used to identify the causative organism but is not usually required.
Management of Otitis external?
Mild otitis externa may be treated with acetic acid 2% (available over the counter as EarCalm). Acetic acid has an antifungal and antibacterial effect. This can also be used prophylactically before and after swimming in patients that are prone to otitis externa.
Moderate otitis externa is usually treated with a topical antibiotic and steroid, for example:
Neomycin, dexamethasone and acetic acid (e.g., Otomize spray)
Neomycin and betamethasone
Gentamicin and hydrocortisone
Ciprofloxacin and dexamethasone
Aminoglycosides (e.g., gentamicin and neomycin) are potentially ototoxic, rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a perforated tympanic membrane before using topical aminoglycosides in the ear.
Patients with severe or systemic symptoms may need oral antibiotics (e.g., flucloxacillin or clarithromycin) or discussion with ENT for admission and IV antibiotics.
Fungal infections can be treated with clotrimazole ear drops.
NOTE - THIS IS IN CONTRAST TO OTITIS MEDIA - Most cases of otitis media will resolve without antibiotics, and NICE guidelines from 2018 highlight the importance of not providing antibiotics for otitis media. They state that most cases of otitis media will resolve within 3 days without antibiotics, but it can last for up to a week. Complications (mainly mastoiditis) are rare. Give simple analgesia to help with pain and fever. If needed amoxicillin is first line - cause is URTI (Strept Pneomonia, staph, haemophilus, moraxella)
One Key Complication of otitis externa?
Examination finding?
Malignant otitis externa is a severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull.
Malignant otitis externa is usually related to underlying risk factors for severe infection, such as:
- Diabetes
- Immunosuppressant medications (e.g., chemotherapy)
- HIV
Symptoms are generally more severe than otitis externa, with persistent headache, severe pain and fever.
Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding that indicates malignant otitis externa.
Malignant otitis externa requires emergency management, with:
Admission to hospital under the ENT team
IV antibiotics
Imaging (e.g., CT or MRI head) to assess the extent of the infection
It can lead to complications of:
Facial nerve damage and palsy
Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves)
Meningitis
Intracranial thrombosis
Death
WOULDNT WROTE LEARN JUST GOOD TO BE AWARE OF THIS I THINK.
What is anaemia of chronic disease
Anemia of chronic disease (ACD), also known as anemia of inflammation, is a type of anemia that occurs as a result of chronic illness or long-term inflammation. It is typically associated with various conditions such as chronic infections, autoimmune diseases, cancer, and chronic kidney disease.
This occurs because the immune system and inflammatory mediators (such as cytokines) interfere with the normal function of bone marrow, where red blood cells are made.
In addition to bleeding and bone marrow metastasis this is how cancer can cause anaemia.
GP Ix for Diarrhoea - Bloods and 2 others.
Blood tests include:
- FBC - anaemia, platelet count (raised with inflammation), WCC
- C-reactive protein (CRP) indicates inflammation
- Urea and electrolytes (U&Es) indicate electrolyte imbalances and kidney function
- Liver function tests (LFTs) can show low albumin in severe disease (protein is lost in the bowel)
- TSH - for hyperthyroidism as a cause of diarrhoea
- Anti-tissue transglutaminase antibodies (anti-TTG) for coeliac disease as a differential diagnosis
Stool microscopy and culture can be used to exclude infection as a differential diagnosis (e.g., Salmonella).
Faecal calprotectin is around 90% sensitive and specific for inflammatory bowel disease in adults. It is used as an initial test before moving on to endoscopy.
Me not H.Pylori - that is for GORD not diarrhea
