GP Y3 Flashcards
What does RAPRIOP stand for?
Reassurance and explanation
Advice and counselling
Prescribing
Referral
Investigation
Observation and follow-up
Prevention
What are some general red flags?
Night sweats
Weight loss - unintentional
Excessive tiredness/fatigue
Changes to bowel habit - timing, consistency, blood
What is social prescribing?
Social prescribing is a key component of Universal Personalised Care. It is an approach that connects people to activities, groups, and services in their community to meet the practical, social and emotional needs that affect their health and wellbeing.
Upper Respiratory Tract Infection - s/s
Sore/irritated throat
Nasal irritation, congestion, rhinorrhoea, sneezing
Cough
Hoarse voice
General malaise
Fever, headache, myalgia, loss of taste/smell, eye irritability, feeling of pressure in ears of sinuses
Upper Respiratory Tract Infection - ix
Usually diagnosed based on clinical features
Upper Respiratory Tract Infection - mx
Symptom relief and rest are most appropriate management
Antihistamines and antibiotics are ineffective, may cause adverse effects
Paracetamol or ibuprofen if needed
Upper Respiratory Tract Infection - f-up
Arrange a follow-up appt if symptoms are worsening or persisting
earlier review advised in people with risk factors for complications
Upper Respiratory Tract Infection - complications
Sinusitis
Lower respiratory tract infections
Acute otitis media
Urinary Tract Infections - causative organism
Caused by Escherichia coli (e.coli) in 75-90% of cases
Starting to be caused by ESBL producing E.coli - extended-specturm beta lactamase producing E.coli; highly resistant to most beta-lactam antibiotics; growing cause of hospital acquired infections (HAI) associated with poor outcomes
Urinary Tract Infections - pathophysiology
UTIs result from colonisation and ascending spread of microorganisms from the urethra to the bladder and/or kidney; can also be caused by haematogenous spread via the blood
In women, infection usually starts at the entrance to the vaginal canal and periurethral area, then ascends the urethra to cause infection of the bladder.
In men, UTIs are uncommon because pf the longer urethra, antimicrobial properties of the prostatic secretions and periurethral area tends to be drier
Haematogenous spread tends to be more uncommon urinary microorganisms - staphylococcus aureus, candida albicans, mycobacterium tuberculosis
Urinary Tract Infections - risk factors
Recent sexual intercourse
Diabetes
History of UTIs
Spermicide use
Catheters - major risk factors in secondary care
Urinary Tract Infections - s/s
Symptoms- dysuria; frequency; urgency; incontinence; suprapubic pain; haematuria; nausea/vomiting
Signs- fever; rigors; flank pain; confusion; costovertebral angle tenderness
Urinary Tract Infections - ix
Urine dipstick - measure leucocyte esterase and nitrites
Urinary MC&S - identify causative organism and guide antibiotic sensitivities
FBC, U&Es, CRP - assess for development of AKI
Urinary Tract Infections - mx
Uncomplicated - nitrofurantoin [100mg BD 3/7women, 7-14men], or trimethoprim [200mg BD 3/7women, 7-14/7men]
Influenza - patho
Acute respiratory illness caused by RNA viruses of the family Orthomyxoviridae (influenza viruses)
Influenza A - occurs more frequently, more virulent
Influenza B - co-circulates with I.A, generally causes less severe clinical illness
Influenza C - usually causes mild or asymptomatic infection, similar to common cold
Influenza - complications
Acute bronchitis
Pneumonia
Exacerbations of asthma and COPD
Otitis media
Sinusitis
Influenza - s/s
Coryza (catarrhal inflammation of mucous membrane of nose)
Nasal discharge
Cough
Fever
GI symptoms
Headache
Malaise
Myalgia
Arthralgia
Ocular symptoms
Sore throat
Influenza - ix
Diagnosis is generally made using clinical features alone when it is known to be circulating the community
Can only be confirmed by lab testing
Rapid testing for influenza should be undertaken in all people with complicated influenza but this is typically done in hospital
Influenza - mx
Otherwise healthy people aren’t usually given antiviral drugs; symptomatic relief and supportive treatment is recommended. Adequate fluids, paracetamol or ibuprofen, rest, stay off of work/school until severe symptoms have resolved
People in ‘at risk’ group should be given antiviral drugs [oseltamivir 75mg BD 5/7] - >65y, pregnant, children <6m, immunocompromised or have a chronic condition
Influenza - consider urgent admission to secondary care
A complication [e.g. pneumonia] occurs
Have a concomitant disease that may be affected by influenza [e.g. T1 diabetes]
Suspicion of a serious illness other than influenza [e.g. meningitis]
Oseltamivir - dosage
75mg BD for 5 days if body weight above 41kg (60mg if <41)
Oseltamivir - side effects
dizziness, GI discomfort, herpes simplex, nausea, sleep disorders, vertigo, vomiting
arrhythmia, consciousness impairment, seizure, skin reactions
angioedema, anxiety, abnormal behaviour, confusion, delirium, delusions, haemorrhage, hallucination, hepatic disorders, self-injurious behaviour, severe cutaneous adverse reactions, thrombocytopenia, visual impairment
Nitrofurantoin - dosage
Immediate-release medication: 50mg QDS for 3/7 in women; 7/7 in men and pregnant women
Modified-release medication: 100mg BD for 3/7 in women; 7/7 in men and pregnant women
Nitrofurantoin - side effects
chest pain, chills, chronic pulmonary reaction, confusion, cough, dizziness, nausea and vomiting, pulmonary fibrosis, skin reactions, vertigo, urine dicolouration
Nitrofurantoin - interactions
Amiodarone - increase risk of peripheral neuropathy
Metronidazole - increase risk of peripheral neuropathy
Phenytoin - increase risk of peripheral neuropathy
Trimethoprim - dosage
200mg BD for 3/7 in women; 7/7 in men
Trimethoprim - side effects
diarrhoea, electrolyte imbalance, fungal overgrowth, headache, nausea, skin reactions, vomiting
anxiety, confusion, cough, lethargy, myalgia, renal impairment, seizure
Trimethoprim - pregnancy
Teratogenic risk in first trimester - folate antagonist
Best to avoid during pregnancy
Trimethoprim - interactions
Bendroflumethiazide - increase risk of hyponatraemia
Candesartan - increase risk of hyperkalaemia
Dalteparin - increase risk of hyperkalaemia
Furosemide - increase risk of hyponatraemia
Ibuprofen - increase risk of hyponatraemia and nephrotoxicity and hyperkalaemia
Phenytoin - increases concentration of phenytoin; monitor phenytoin concentration
Warfarin - increase anticoagulant effect of warfarin
Acute Tonsillitis - patho
Acute inflammation of the palatine tonsils secondary to infection
Most commonly viral, associated with URTI. May also be caused by bacteria (Group A Streptococci)
Acute Tonsillitis - s/s
Symptoms - fevers, sore throat, dysphagia, trismus (difficulty opening the mouth), malaise
Signs - enlarged and inflamed tonsils, whiter exudate on tonsils, lymphadenopathy, pyrexia, tachycardia
Exudate is more uncommon and typically suggests a bacterial pathogen, Group A beta-haemolytic streptococcus being the most common bacterial cause
Acute Tonsillitis - ix
Centor and FeverPAIN score are used to guide antibiotic use
Centor criteria for tonsillitis
Tonsillar exudate
Tender anterior cervical lymphadenopathy or lymphadenitis
History of fever >38C
Absence of cough
Score of 3 or 4/4 is indication for antibiotic therapy - phenoxymethylpenicillin or clarithromycin (pen.allergic)
FeverPAIN score for tonsillitis
Fever during previous 24 hrs
Purulence [pus on tonsils]
Attend rapidly [within 3 days after onset of symptoms]
Severely Inflamed tonsils
No cough or coryza [inflammation of mucus membranes in the nose]
The higher the score, the greater the chance the illness is caused by GABHS
Acute Tonsillitis - simple mx
Simple tonsillitis - most can be managed with paracetamol, ibuprofen; C0-2/FP0-1 no abx; FP2-3 may benefit offer a back-up if symptoms persist longer than 3-5 days; C3-4/FP4-5 generally offered antibiotics
Phenoxymethylpenicillin is first-choice; clarithromycin or erythromycin may be used in penicillin allergy
Safety netting must be given to all patients with advice to return if symptoms persist, worsen or there are other concerns
Acute Tonsillitis - severe mx
May have dysphagia and high fevers
Severe tonsillitis - may benefit from IV fluids, antibiotics and a dose of IV steroids may be admitted overnight for observation and reassessed after 12-24hr of IV fluids/analgesia
Acute Tonsillitis - complications
Suppurative (pus-producing): quinsy [peri-tonsillar abscess], acute otitis media, acute sinusitis
Non-suppurative: post-streptococcal glomerulonephritis, acute rheumatic fever
Acute Tonsillitis - referral
Criteria for NHS tonsillectomy:
Malignancy suspected
1+ quinsy or airway obstruction
Recurrent sore throat with disabling episodes preventing normal function (7+ episodes in 1 years; 5+ in each of the last two years; 3+ in each of last three years)
Obstructive sleep apnoea
Phenoxymethylpenicillin - dose
500mg QDS, or 1000mg BD, for 5-10/7
Phenoxymethylpenicillin - side effects
diarrhoea, hypersensitivity, nausea, skin reactions, thrombocytopenia, vomiting
antibiotic associated colitis, arthralgia, leucopenia
angioedema, haemolytic anaemia, seizure
Phenoxymethylpenicillin - interactions
Methotrexate - increase risk of toxicity when given with methotrexate; monitor pt
Warfarin - alters anticoagulant effect of warfarin; monitor INR and just dose accordingly
Clarithromycin - dose for acute tonsillitis
250-500mg BD for 5/7
Clarithromycin - side effects
decreased appetite, diarrhoea, dizziness, GI discomfort and disorders, headache, hearing impairment, insomnia, nausea, pancreatitis, paraesthesia, skin reactions, taste altered, vasodilation, vision disorders, vomiting
Clarithromycin - interactions
Amiodarone - both prolong QT interval; advised not to prescribe both at the same time
Bendroflumethiazide - predicted to cause hypokalaemia
Insulin - hypoglycaemia risk
Simvastatin - increases exposure to Simvastatin; advised to avoid
Ticagrelor - increases exposure to Ticagrelor; advised to avoid
Warfarin - increase anticoagulant effect of warfarin; monitor INR and adjust dose accordingly
Acute Otitis Externa - patho
Inflammation of the external auditory canal - pinna to the tympanic membrane
Infection by bacteria is the most common cause - pseudomonas aeruginosa or staphylococcus aureus; can also be fungal - candida albicans or aspergillus species
Can also be caused by dermatitis - seborrheic or contact dermatitis
Acute Otitis Externa - s/s
Tend to present with a short history of ear pain [otalgia], frequently associated with discharge. In severe cases, swelling of the external auditory canal and debris may result in hearing loss.
Symptoms- itch, tenderness, hearing loss, discharge
Signs- inflamed external auditory canal, erythema, scaly skin, pre-auricular lymphadenopathy
Acute Otitis Externa - ix
Often no investigations aside from a thorough history and examination are necessary. If presentation is atypical, recurrent or treatment-resistant, an ear swab sent for MC&S may be of use
Acute Otitis Externa - mx
Analgesia- paracetamol and ibuprofen
Topical therapy- topical antibiotics +/- topical steroid
Acetic acid 2% spray
Oral abx aren’t usually indicated
Systemically unwell should be urgently reviewed by ENT
Patients should avoid swimming for a minimum of 7-10/7
Acute Otitis Externa - prevention
Ears should be kept dry and clean; ear plugs and swimming caps can help to reduce the incidence
If allergies are a precipitating factor, they should be identified and avoided
Acidifying ear drops can be used prior to sleeping or before and after swimming that may reduce the incidence of otitis externa
Acute Otitis Media - causative organisms
Commonly caused by viruses or bacteria, sometimes both
Bacteria include: streptococcus pneumonia, haemophilus influenzae
Viruses include: RSV, rhinovirus, adenovirus
Acute Otitis Media - patho
Inflammation of the middle ear with effusion and clinical features of a middle ear infection - AOM
Associated with a preceding upper respiratory tract infection; transmission via the eustachian tube to the middle ear may result in AOM
In young children, the less acute angle of the eustachian tube within the wall of the pharynx results in increased transmission of pathogens, particularly when coughing or sneezing
Acute Otitis Media - s/s
Dependent on age group of patient
Neonate- irritability, difficulty feeding, fever
Young children- holding or tugging ear, irritability, fever
Older children and adults- ear pain, hearing loss, fever
Otoscopy is key to identifying signs of AOM
Acute Otitis Media - otoscopy
Red, yellow or cloudy tympanic membrane [as opposed to pearly-grey]
Bulging tympanic membrane or perforated membrane
Air-fluid level behind the tympanic membrane
Acute Otitis Media - mx
General advice- generally self-limiting, analgesia and anti-pyretics advised
Antibiotics- three main approaches no abx, delayed abx, immediate abx
Delayed used when symptoms don’t improve after 3 days; also safety netted if given no abx
Amoxicillin first-line for 5-7/7, clarithromycin if pen allgeric
Amoxicillin - dose for acute otitis media
1-11months - 125mg TDS 5-7/7
1-4 years - 250mg TDS for 5-7/7
5-17 years TDS for 5-7/7
Amoxicillin - side effects
diarrhoea, hypersensitivity, nausea, skin reactions, thrombocytopenia, vomiting
antibiotic associated colitis, arthralgia, leucopenia
specific - rare/very rare - black, hairy tongue
Amoxicillin - interactions
Methotrexate - increases risk of toxicity; advised to monitor
Warfarin - alters anticoagulant effect of warfarin; advised to monitor INR and adjust dose
Acute Otitis Media - admission to hospital
Severe systemic infection
Suspected acute complications [meningitis, mastoiditis, intracranial abscess, sinus thrombosis, facial nerve paralysis]
Children younger than 3m with temp >38C
Consider:
Children younger than 3m
Children 3-6m with temp >39C
Persistent Acute Otitis Media - summary
Should be reviewed, re-examined.
Consider other potential causes of similar symptoms [e.g. glue ear- otitis media with effusion]
Some patients may develop chronic suppurative otitis media as a complication of their AOM
Acute Otitis Media - referral
Persistent symptoms of AOM should be referred to ENT, particularly if lasting longer than 6 weeks or there is persistent hearing loss
Recurrent AOM - referral
ENT referral should be considered, especially if there is a craniofacial abnormality, an adult patient, or debilitating/complicated AOM.
If nasopharyngeal cancer is suspected an urgent ENT referral is required.
Suspect nasopharyngeal if:
*presistent symptoms and signs of otitis media with effusion in between episodes due to obstruction of the eustachian tube orifice
*persistent cervical lymphadenopathy [usually in upper levels of neck]
*epistaxis and nasal obstruction
Acute Otitis Media - complications
Typically resolves without complication
Although can cause:
*Persistent AOM
*Recurrent AOM
*Perforation of tympanic membrane
*Hearing loss
Rarely very serious complications like mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve paralysis can occur
Mastoiditis - as a complication of AOM
Most commonly occurring serious complication.
Potentially life-threatening infection of the mastoid air cells causing pain, swelling and erythema behind the ear and systemic upset.
Tends to affect younger patients [<5]
Early antibiotics and other management including myringotomy [draining of middle ear with hole in tympanic membrane] or mastoidectomy [removal of infected tissue/bone] my be required
Benign Paroxysmal Positional Vertigo - patho
Inner ear disorder, causes episodes of positional vertigo
Caused by otoconia [loose debris composed of calcium carbonate] within the semilunar canals of the inner ear
Attacks are triggered by head movements that result in movement of the otoconia, abnormal motion of endolymph and the feeing of vertigo
Benign Paroxysmal Positional Vertigo - s/s
Typically presents between 5th and 7th decade, but can occur at any age. More commonly affects women.
S/S- short episodes of positional vertigo typically lasting <1 minute
Triggered by head movements or positional changes [e.g. turning over in bed]; can result in nausea and vomiting
Some patients get symptoms that persist longer than expected, and other neurological causes should be considered and excluded
Important negative findings- hearing loss and tinnitus are NOT features of BPPV and should raises suspicions of alternative or concomitant pathology
Benign Paroxysmal Positional Vertigo - ix
Following history and careful examination, the Dix-Hallpike manoeuvre is typically sufficient to diagnose BPPV
Benign Paroxysmal Positional Vertigo - Dix-Hallpike manoeuvre
Contraindications- neck trauma, spinal fractures, cervical disc prolapse, vertebrobasilar insufficiency, carotid sinus syncope, recent stroke or CABG, back/spinal pain
Patient upright on couch, when they lay back their head hangs off end of cough;
Turn head 45 to one side, keep eyes open and look straight ahead;
Move patient swiftly and smoothly from sitting to supine;
Observe eyes for 30s [often a latent period] for any nystagmus while continuing to support head/neck;
Slowly return patient to sitting up position and repeat the test with the head turned 45 to other side.
The ear being tested is the one facing the floor
Benign Paroxysmal Positional Vertigo - mx
May be watchful waiting or canalith repositioning manoeuvres to displace the otoconia from the semicircular canals into the utricle
Should be counselled on BPPV and treatments options
Majority of cases resolve over several weeks [50% at 3m]
Recurrence is common; affecting around half of patients within 5 years
Benign Paroxysmal Positional Vertigo - driving
DVLA advises all people with a ‘liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness’ to stop driving and inform them.
Sinusitis - patho
Symptomatic inflammation of the paranasal sinuses
Acute - triggered by a viral URTI and is defined by symptoms that last for less than 12wks
Chronic - defined by symptoms that last longer than 12wks with objective evidence of sinonasal inflammation on examination
Sinusitis - s/s
Nasal blockage or nasal discharge with facial pain/pressure [or headache] and/or reduction of sense of smell
Examination may reveal purulent discharge, mucosal oedema, tenderness over sinuses, and fever
Sinusitis - causative organisms
Viral rhinosinusitis- Rhinovirus; influenza virus; parainfluenza virus
Bacterial rhinosinusitis- Streptococcus pneumoniae; haemophilus influenza; staphylococcus aureus; moraxella catarrhalis
Sinusitis - referral
Acute: unilateral polyp or mass, bloody discharge - could suggest a neoplasm
Chronic: unilateral symptoms, epistaxis, bloody discharge, crusting, orbital symptoms [diplopia or reduced visual acuity], neurological signs or symptoms
Urgently refer to ENT if above s/s are present
Urgent admission if severe systemic infection, or if complication/s occurs [e.g. orbital or intracranial involvement]
Acute Sinusitis - mx
Advise about natural course and cause of infection
Symptomatic relief - painkillers for pain or fever
Antibiotics considered
High-dose intranasal corticosteroids considered in adults with more severe/prolonged symptoms
Chronic Sinusitis - mx
Manage the existing associated disorder [e.g. allergic rhinitis or asthma]
Avoid exacerbating triggers
Symptomatic relief - nasal irrigation with saline solution
Intranasal corticosteroids considered
Long-term antibiotics considered
Pyelonephritis - patho
Infection of one or both kidneys usually caused by E.coli [Escherichia coli] - responsible for 60-80% of infections
Pyelonephritis - s/s
Flank pain
Fever and chills
Nausea and vomiting
Also LUTS - dysuria, frequency, urgency
Costovertebral tenderness due to kidney involvement
Pyelonephritis - ix
Midstream urine sample should be sent for culture and sensitivity
-Dipstick not necessary but may be a useful adjunct to guide diagnosis
Pyelonephritis - diagnosis
Made in people with loin pain and/or fever if a UTI is confirmed by culturing a urinary pathogen from urine and other causes of loin pain +/- fever have been excluded
Pyelonephritis - mx
Severe s/s or s/s suggesting serious illness or condition should be admitted to hospital
All others should be offered abx - Ciprofloxacin [500mg BD 7/7]; Trimethoprim [200mg BD for 14/7]; Co-amoxiclav [500/125mg TDS 7-10/7]; Cefalexin [500mg BD/TDS 7-10/7]
—LEICESTER GUIDELINES: co-amoxiclav [625mg TDS for 10/7]; ciprofloxacin in pen allergic [500mg BD 7/7]
Pregnant women should be prescribed Cefalexin [500mg BD/TDS for 7-10/7]
if no response to abx within 24hrs consider admission
Co-amoxiclav - dose for pyelonephritis
625mg [500/125mg] TDS for 10/7
Review micro sensitivity and change abx if necessary
Co-amoxiclav - side effects
diarrhoea, hypersensitivity, nausea, skin reactions, thrombocytopenia, vomiting
antibiotic associated colitis, arthralgia, leucopenia
Co-amoxiclav specific s/e
increased risk of infection
dizziness, dyspepsia, headache
black hairy tongue, cholangitis
Co-amoxiclav - interactions
Amoxicillin- methotrexate - ++ toxicity; warfarin - alters anticoag effect
Clavulanate- alcohol, methotrexate, paracetamol, simvastatin, valproate - ++ hepatotoxicity
Ciprofloxacin - dose for pyelonephritis
500mg BD for 7/7
Ciprofloxacin - side effects
May induce convulsions- esp when taking NSAIDs
Tendon damage - rupture may occur within 48/24 of staring treatment
Small risk of aortic aneurysm and dissection
arthralgia, dizziness, fever, nausea, vomiting, tinnitus
Ciprofloxacin - interactions
Diclofenac, ibuprofen, naproxen - ++ seizures; prescribe with caution and monitor
Methotrexate - ++ toxicity; monitor and adjust dose
Phenytoin - ++ conc of phenytoin; monitor and adjust dose
Warfarin - ++ anticoag effect; monitor INR
Antacids decrease absorption of cipro; take 2hrs before or 4hrs after
Pyelonephritis - referral
Considered:
*Significantly dehydrated or unable to take oral fluids and medicines
*Pregnant
*Higher risk of developing complications - known or suspected structural/functional abnormality of GU tract or underlying disease [e.g. diabetes mellitus, or immunosuppression]
*Recurrent UTI [e.g. 2+ episodes in 6/12]
*Men, after single episode with no obvious cause
*Women with recurrent pyelonephritis
Suspicion of urological cancer? 2ww pathway
Pyelonephritis - f-up
Reassess if symptoms worsen at any time
If symptoms don’t improve within 48hrs of taking abx
Consider: other diagnoses; any s/s suggesting something more serious [sepsis], whether previous abx use has led to abx-resistance, referral for specialist urological assessment is needed
Chest infections - examples typically presenting in primary care
Acute Bronchitis
Community-acquired pneumonia
COVID-19
Acute Bronchitis - patho
LRTI causing inflammation in the bronchial airways
Occurs due to viral or bacterial infection; preceded usually by an URTI
Acute Bronchitis - common causative organisms
Influenza A/B; Parainfluenza; Respiratory syncytial virus (RSV); Rhinoviruses
Mycoplasma pneumoniae; Chlamydia pneumoniae; Bordetella pertussis
Acute Bronchitis - risk factors
COPD
Asthma
Smoking
Chronic exposure to air pollution
Acute Bronchitis - s/s
Cough
Chest pain form coughing
Wheeze
Rhonchi that clear with coughing [low-pitched sounds similar to snoring, indicating secretions in the airway]
Mild dyspnoea
Malaise
URTI preceding the above symptoms
Acute Bronchitis - ix
Pulse oximetry
CRP
CXR - rules out pneumonia, not always necessary
Acute Bronchitis - mx
Hospital admission: acute cough with s/s suggesting more serious condition [e.g. PE or lung malignancy]
Advise self-care [paracetamol, good fluid intake]
Stop smoking
Seek further medical help if symptoms worsen rapidly/significantly; do not improve after 3/4 weeks; or if they become systemically unwell
CRP <20mg/L don’t offer abx; 20-100mg/L delayed; >100mg/L offer abx
Doxycycline [200mg on day 1, then 100mg OD 4/7]
Doxycycline - dose for acute bronchitis
200mg on day 1, then 100mg for 4 further days
Doxycycline - side effects
[for all TETRACYCLINES] angioedema, diarrhoea, headache, hypersensitivity, nausea, pericarditis, photosensitivity reaction, skin reactions, SLE exacerbated, vomiting
[specific to doxycycline] dyspnoea, hypotension, peripheral oedema, tachycardia, GI discomfort
Doxycycline - interactions
Lithium - ++ lithium toxicity; avoid or adjust dose
Warfarin - ++ anticoag effect; monitor INR
Antacids - greatly – absorption of doxycycline; separate administration by 2-3hrs
Community-acquired pneumonia - patho
Pneumonia that is contracted in the community: atypical and typical pneumonia
CAP - typical causative organisms
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Tend to present with typical features of pneumonia- productive cough, fever, pleuritic chest pain
CAP - atypical causative organisms
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydophila pneumoniae
Chlamydophila psittaci (psittacosis)
CAP - s/s
Symptoms- fever, malaise, cough (with purulent sputum), dyspnoea, pleuritic chest pain
Signs- dull percussion, reduced breath sounds, bronchial breathing, coarse crackles/crepitations, increased vocal resonance, tachycardia, hypotension, confusion, cyanosis
CAP - ix
Pulse oximetry
CRP
CXR - will show consolidation
Sputum culture - not always done in primary care; only if moderately unwell
Temperature
CURB-65 [CRB65 in 1` care]
CAP - mx
Refer to hospital if s/s suggest more serious illness or s/s are not improving as expected with abx - always use clinical judgement to determine urgency
CRB65- 3+ hospital admission; 1/2 hospital admission considered; 0 treatment as home considered, taking patient into consideration
Self-care: fluids, rest, painkillers
Offer abx- amoxicillin [500mg TDS 5/7]
Stop smoking
Safety net
Explain symptoms can be around for up to 6m, but should feel significantly better after 3/7 of abx
Amoxicillin - dose for community-acquired pneumonia
500mg TDS for 5/7
COVID-19 - patho
Caused by virus: severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2)
Positive strand RNA viruses
COVID-19 - s/s
Fever, chills, cough, fatigue, dyspnoea, anorexia, myalgia, anosmia, cutaneous rash, other non-specific symptoms [e.g. diarrhoea, abdo pain, nausea, headache, dizziness, sore throat, loss of taste]
COVID-19 - ix
Lateral flow testing - easy, results delivered within minutes; nasopharyngeal swab mixed with a solution and applied to testing area
PCR testing
Pulse oximetry
COVID-19 - mx
Admission should be arranged if patient is moderately/severely unwell or has a suspected acute/life-threatening complication
Self-manage symptoms [painkillers, fluid, rest]
Stay isolated to prevent spread
COVID-19 - advice to general public
Get vaccinated
Good hygiene
Consider wearing a face covering/mask when adequate ventilation is not available
Access mental health support if needed
Check travel/entry requirements when travelling abroad
Vaginal Thrush (Candidiasis) - patho
Superficial fungal infection of the vulva/vagina
Very common condition; caused by a candida infection - typically Candida albicans (92% of cases)
Alteration in vaginal pH, sex hormones, sexual activity or even foreign bodies [e.g. contraceptive devices] may disrupt the balance between candida and host immune response leading to overgrowth and superficial infection
Vaginal Thrush (Candidiasis) - risk factors
*Poorly controlled diabetes mellitus
*Oestrogen exposure [rarely seen post-menopausal; cases rise post-menarche though]
*Immunocompromised state [e.g. systemic corticosteroids]
*Broad-spec antibiotics affect/alter vaginal flora
*Local irritants [e.g. vaginal hygiene products]
*Sexual activity [not an STI, but can be triggered by sex]
*Hormone replacement therapy
Vaginal Thrush (Candidiasis) - s/s
Symptoms- vaginal itching, soreness and discharge [characteristically thick and white (‘cheese-like’) and non-malodourous], superficial dyspareunia [painful sexual intercourse], dysuria
Signs- vulvovaginal irritation [erythema affecting vulva, and sometimes labia majora and perineum], vaginal fissuring, excoriation [scratching]
Vaginal Thrush (Candidiasis) - ix
Diagnosis is typically made on the history alone, further investigations not required
Investigations may be required where an alternative diagnosis is suspected or thrush is severe, recurrent or chronic
Vulval examination and speculum examination
Vaginal discharge testing - tested for pH
Microbiology - high vaginal swabs and MSU
Blood tests - HIV and HbA1c
STI screen - chlamydia, gonorrhoea, trichomoniasis, HIV/syphilis - consider referring to a GUM clinic in patients who are considered high-risk
Vaginal Thrush (Candidiasis) - mx
Treated typically with over the counter anti-fungal creams
Intravaginal anti-fungal cream or pessary: Clotrimazole 10% cream
Oral or topical can also be considered: fluconazole 150mg single dose/clotrimazole 1% BD/TDS for vulval symptoms
Vaginal Thrush (Candidiasis) - referral
Consider referral to specialist GUM or gynaecology in the following:
*12-15 years old
*diagnosis doubtful
*treatment failure or ongoing symptoms
*non-albicans candida
Bacterial Vaginosis - patho
Overgrowth of predominantly anaerobic microorganisms in the vaginal flora and loss of normal lactobacilli
Not an STI but more common in sexually-active women
Seen more commonly in black women; women who have sex with women are more at risk due to shared vaginal flora patterns
A rise in pH >4.5 creates an alkaline environment that favours colonisation by anaerobic organisms [e.g. Garnerella vaginalis] and the loss of usually dominant lactobacilli
Absence of inflammation hence the name ‘vaginosis’, instead of vaginitis
Bacterial Vaginosis - risk factors
Sexual contact - sexual activity, change in sexual partner, women who have sex with women
Hygiene - use of vaginal hygiene products
Menstruation
Black women
Copper coil
Smoking
Bacterial Vaginosis - s/s
Symptoms- asymptomatic [50% of cases], vaginal odour [may only be noticed after sexual intercourse], vaginal discharge [typically thin, off-white/grey and homogeneous], irritation of vulva, dysuria, dyspareunia
Signs- vaginal discharge [may be adhered to vaginal mucosa], normal speculum
Bacterial Vaginosis - diagnosis
Diagnosis is based on Amsel criteria; when 3 out of 4 are met diagnosis can be made
*Vaginal pH >4.5
*Typical discharge
*Positive whiff-amine test
*Clue cells on microscopy
Bacterial Vaginosis - ix
Investigations are required or a formal diagnosis of Bacterial Vaginosis
Vulval and speculum examination
Vaginal discharge testing - samples should be taken from lateral wall and tested for pH; can also be checked using microscopy
STI screen - chlamydia, gonorrhoea, trichomoniasis, HIV/syphilis
Bacterial Vaginosis - mx
*Conservative advice on reducing risk factors
*Oral metronidazole [400mg BD 7/7] or
*Intravaginal metronidazole gel [0.75% OD 5/7]
*Single dose high-dose metronidazole [2g] if adherence to treatment would be an issue
Metronidazole - dose for Bacterial Vaginosis
400mg BD for 7/7
OR 0.75% vaginal gel 5g applicator full at night for 5/7
Metronidazole - side effects, with vaginal use
Pelvic discomfort, vulvovaginal candidiasis, vulvovaginal disorders
Menstrual cycle irregularities, vaginal haemorrhage
Metronidazole - interactions
Disulfiram - ++ risk of acute psychoses
Alcohol - could cause disulfiram-like reaction
Amiodarone - ++ risk of peripheral neuropathy
Nitrofurantoin - ++ risk of peripheral neuropathy
Phenytoin - ++ risk of peripheral neuropathy
Meningitis - patho
Inflammation of the meninges - outer membranes covering the brain and spinal cord
Bacterial meningitis is life-threatening
Usually acquired through droplets/secretions from URT; invasion via bloodstream or direct contiguous spread [usually as a result of ENT infection]
Bacteria penetrate the BBB, quickly spreading within the meninges; mild cases are usually confined to the subarachnoid space, but severe cases can affect brain parenchyma underlying pia mater
Bacterial Meningitis - causative organisms
Neisseria meningitidis (gram negative diplococci)
Streptococcus pneumoniae
Haemophilus influenzae
Listeria monocytogenes
Escherichia coli
Bacterial Meningitis - s/s
Symptoms- neck stiffness, photophobia, headache [>80%], fever [70%], nausea/vomiting, fatigue, confusion, irritable/unsettled behaviours [children], altered mental status [>70%]
Signs- tachycardia, hypotension, marked neck stiffness, photophobia, non-blanching rash [concerning sign of meningococcal septicaemia], seizures, focal neurological deficits, reduced consciousness and coma
Classic signs-
Kernig’s sign - inability to fully extend at the knee when the hip is flexed at 90` due to pain
Brudzinski’s sign - spontaneous flexion of the knees and hips on active flexion of the neck due to pain
Bacterial Meningitis - ix
If suspicious, ring 999 immediately as it is a medical emergency
Ix can take place at the hospital [e.g. lumbar puncture]
Bacterial Meningitis - mx
All suspected cases of meningitis are medical emergencies requiring immediate hospital admission by phoning 999
Suspected meningococcal disease [meningitis with a non-blanching rash] requires parenteral abx IM or IV benzylpenicillin at earliest opportunity
1200mg benzylpenicillin IM after arranging hospital transfer via 999
Close contacts should also be managed - prophylactic measure should be undertaken in conjunction with local/regional health protection unit
Bacterial Meningitis - vaccination
UK vaccination programme is important - includes vaccines against H.influenza, N.meningitidis, S.pnaeumoniae
Chickenpox - patho
Acute, infectious disease caused by varicella-zoster virus
14-16/7 incubation period
Dangerous in pregnancy from wk8-20 - congenital varicella syndrome
Chickenpox - s/s
Signs/Symptoms- fever, malaise, feeding problems, vomiting/diarrhoea, headache, rash
Rash starts as small erythematous macules on the scalp, face, trunk and proximal limbs - then progresses to papules and intensely pruritic vesicles before becoming pustules
Chickenpox - diagnosis
Usually made clinically with the presence of the characteristic vesicular rash
Chickenpox - mx
Usually self-limiting and management is supportive - paracetamol but not NSAIDs; calamine lotion and anti-histamines can be helpful with pruritus
Maintain adequate hydration and children should stay away from school until all vesicles have crusted over; stay away from high risk groups e.g. immunocompromised, pregnant, neonates
Fifth Disease - patho
‘Slapped Cheek Syndrome’ or Erythema infectiosum
Caused by parovirus B19
Outbreaks amongst school children; droplet spread through respiratory secretions
Mild and self-limiting disease
Fifth Disease - s/s
Begins with fever, coryza, headache, nausea and vomiting
Malar rash with circumoral pallor; lace-like rash on trunk and extremities
Fifth Disease - mx
Self-care - analgesia, inform patient and family that they should no longer be infectious once rash develops - not necessary to stay off of work or school
Conjunctivitis - patho
Viral is most common [~80%] of cases; adenovirus typically; can also be herpes simplex, molluscum contagiosum, varicella zoster, EPV
Bacterial is second most common, more commonly seen in children and elderly; organisms include streptococcus pneumoniae, staphylococcus aureus, haemophilus influenzae
Conjunctivitis - s/s
Conjunctival erythema [red eye], watery eye, irritation/discomfort, pruritus
Hyperacute conjunctivitis- red-eye, significant purulent discharge, pre-auricular lymphadenopathy
Herpes simplex- red-eye, watery eye, vesicular lesions on eyelid
Conjunctivitis - red flags
Presence of these should prompt referral to ophthalmology
*Reduced visual acuity
*Marked eye pain, headache or photophobia
*Red sticky eye in a neonate [within 30/7 of being born]
*History of trauma or possible foreign body
*Copious rapidly progressive discharge [indicative of gonococcal infection]
*Infection with herpes virus
*Soft contact lens use with corneal symptoms [e.g. photophobia and watering]
Viral Conjunctivitis - mx
Normally self-limiting
Symptomatic relief- cool compress and lubricating eye drops
Prevent spread- good hand hygiene and use of separate towels
Safety netting- if vision changes, eye pain, headache, photophobia, worsening purulent discharge or persistent symptoms then return or seek urgent medical attention
Bacterial Conjunctivitis - mx
Normally self-limiting
Symptomatic relief- cool compress and lubricating eye drops
Prevent spread- good hand hygiene and use of separate towels
Safety netting- if vision changes, eye pain, headache, photophobia, worsening purulent discharge or persistent symptoms then return or seek urgent medical attention
Chloramphenicol drops/ointment - firstline choice, typically for 5/7
Fusidic acid eye drops - second line, typically for 7/7
Conjunctivitis - referral
Referral to ophthalmology nay be required where patients at risk of severe disease and complications or where a serious differential is suspected
Stye - patho
Also known as ‘hordeola’
Acute localised infection or inflammation of the eyelid margin, usually caused by staphylococcal infection
External- appears on eyelid margin, caused by infection of an eyelash follicle or associated gland; far less common
Internal- occurs on conjunctival surface of eyelid, caused by infection of a Meibomian gland
Stye - s/s
Acute-onset, painful, localised swelling near eyelid margin that develops over several days
Unilateral symptoms affecting one eyelid; though styes can be bilateral
Stye - mx
Reassuring styes are usually self-limiting and rarely cause serious complications
Arrange hospital admission urgently is there are signs of significant periorbital or orbital cellulitis
Urget referral to ophthalmology is malignant eyelife tumour is suspected
Self-care advice: warm compress until stye drains/dissolves, avoid using eye makeup or contact lenses until area has healed
Manage co-existing conditions [e.g. blepharitis; acne rosacea] to reduce reoccurrence
Topical antibiotic if there are clinical features of infective conjunctivitis
Sprains/Strains - patho
Sprain- stretch and/or tear of a ligament, classified by severity; typically affect ankles, knees, wrists, thumbs
Strain- stretch and/or tear of muscle fibres and/or tendon, classified by severity; typically affects foot, hamstring, back
Sprain - s/s
Pain around affected joint, tenderness, swelling, bruising, pain on weight-bearing, decreased function
There may be joint instability following severe injuries
Strain - s/s
Muscle pain, cramping, spasm, muscle weakness, inflammation, bruising
Sprain/Strain - PRICE
Protection- protect from further injury
Rest- avoid activity for the first 48-72hrs following injury
Ice- apply ice wrapped in a damp towel for 15-20min every 2/3hrs during first 48-72hrs post-injury
Compression- simple elastic bandage or elasticated tubular bandage, should be snug but not too tight, to help control swelling and support the injury
Elevation- keep injured area elevated and supported until the swelling is controlled
Sprain/Strain - mx
Use analgesia for symptom relief - paracetamol or ibuprofen gel, or ibuprofen orally
start active mobilisation and flexibility exercises as soon as tolerated without excessive pain
NHS patient leaflets are available
Consider medical review after 5-7/7 if worsening symptoms or lack of expected improvement
Consider physio if symptoms are ongoing
Consider orthopaedics if recovery is slow, worsening or new symptoms, symptoms are out of proportion
Headlice - patho
Parasitic insect infestation; infect the hair and feed on blood from the scalp
Headlice - s/s
Itching
Live louse found on combing confirms an active headlice infestation
Headlice - mx
A mixture of the following three treatments may be effective
*Wet combing
*Physical insecticide - dimeticone 92% spray
*Chemical/traditional insecticide - malathion 0.5% aqueous liquid
Direct parents to NHS website for
Scabies - patho
Caused by a parasitic mite
Transmitted through direct skin-to-skin contact
Scabies - s/s
Clinical features primarily result from a local allergic reaction to the presence of the mite rather than being directly caused by the mite itself
Erythematous papules or vesicles, surrounding dermatitis
Burrows - irregular tracks ~1cm long
Scabies - mx
General advice- highly contagious; good hygiene is important [wash all linen, clothes, toys, other items to eradicate scabies]; close contacts need to be examined and treated concurrently
Topical tx- Permethrin 5% cream, applied to whole body ad left on for 8hrs, repeated in 7 days; Benzyl benzoate 25% emulsion in cases of allergy or treatment failure
Systemic tx- Ivermectin [oral scabicide]
Nappy Rash - patho
Irritant contact dermatitis
Secondary infection with candidal abicans or staphylococcal aureus can occur
Nappy Rash - s/s
Child may be distressed, agitated, uncomfortable- rash can be itchy and painful
Well-defined areas of confluent erythema and scattered papules over convex surface in contact with nappy
There may be skin erosions, oedema, ulceration if there is severe involvement
Nappy Rash - mx
Self-management- use nappies with high absorbency; leaving nappies off for as long as possible; changing nappy frequently and as soon as possible after soiling; using water based baby wipes; dry gently; avoid potential irritants
Advise on sources of written information and support
Use of a barrier preparation to protect the skin
Topical hydrocortisone 1% once a day if rash is inflamed and causing discomfort
Nappy Rash - referral
Referral to a paediatric dermatologist should be considered:
*Uncertainty about diagnosis
*Rash persists despite optimal treatment in primary care
*Recurrent, severe unexplained episode
Plantar Fasciitis - patho
Condition in which there is persistent pain associated with degeneration of the plantar fascia as a result of repetitive microtears in the contracted fascia
Plantar Fasciitis - s/s
Symptoms- initial insidious onset of pain, intense pain during first few steps, pain that reduces with moderate activity
Signs- tenderness on palpation of the plantar heel, limited ankle dorsiflexion, tightness of Achilles tendon, antalgic gait
Plantar Fasciitis - mx
Most people recover within a year
Conservative measures- resting foot, wear supportive shoes, avoid walking barefoot, weight loss, regular stretching exercises
Symptom relief- oral analgesics and ice packs
Referral to podiatry or physio if severe or not improved after conservative measures
Consider corticosteroid injection, given with ultrasound guidance
Consider referral to orthopaedic or podiatric surgeon if pain persists following podiatry and physio treatment
Impetigo - patho
Common superficial bacterial skin infection; highly contagious
Commonly caused by staphylococcus aureus [gram positive coccus]
Impetigo - s/s
Small vesicles or pustules develop at site of infection, then rupture leading to release of exudate that crusts over wit ha classic golden/brown colour
May be itchy, but commonly asymptomatic
Impetigo - ix
Commonly a clinical diagnosis based on characteristic appearance
If in doubt, diagnosis can be confirmed with skin swabs for microscopy, culture and sensitivity
Impetigo - mx
Topical antibiotics are usually treatment of choice
Lesion heal without scarring and should maintain good hygiene to reduce transmission; shouldn’t attend school or work until lesion have at least crusted over
Localised vesicles: hydrogen peroxide 1% cream; fusidic acid 2% [5/7]
Widespread vesicles: topical fusidic acid 2%; topical mupirocin 2%; oral flucloxacillin
GORD - patho
Increased acid production from gastric cells
Contents from the stomach re-enter the oesophagus, leading to a burning sensation retrosternally or in the back of the throat
Can have complications [e.g. Barrett’s oesophagus]
GORD - risk factors
High BMI
Smoking
Genetic association
Pregnancy
Hiatus hernia
NSAIDs, caffeine and alcohol
GORD - s/s
Main symptom is heartburn- a burning sensation in the middle of the chest; typically after meals and made worse by lying down or bending forward
Regurgitation, dyspepsia, chest pain, dysphagia, odynophagia [painful swallowing], cough, hoarse voice, nausea and/or vomiting
GORD - ix
pH monitoring and gastroscopy if diagnosis is uncertain/surgery being considered/red flag symptoms
GORD - mx
Conservative- weight loss, smoking cessation and dietary modification, avoid eating within two hours of sleep and elevate the head of the bed
Medical- PPI [inhibition of H+/K+ ATPase in parietal cells]; two week trial; Omeprazole [20mg OD 14/7]
Omeprazole - dose for Gastro-Oesophageal Reflux Disease
20mg once daily for 2 week trial initially; or 4-8 weeks
Omeprazole - side effects
abdominal pain, constipation, diarrhoea, dizziness, dry mouth, GI disorders, headache, insomnia, nausea, skin reactions, vomiting
omeprazole specific - aggression, agitation, bronchospasm, encephalopathy, GI candidiasis, muscle weakness
Omeprazole - interactions
Clopidogrel - –efficacy
Diarrhoea - causes
Infection - gastroenteritis; causes: norovirus, Clostridioides difficle, Escherichia coli, campylobacter, salmonella
Side-effects from some medications
Anxiety
IBD - Crohn’s disease, Ulcerative colitis
IBS - irritable bowel syndrome
Diet
Diarrhoea - definition
Loose or watery stool and frequent bowel movements, typically at least three times a day
Can also include other symptoms if infective- vomiting, cramping, fever, headache, aching limbs
Diarrhoea - mx
Drink lots of water; use rehydration drinks
Eat as normal as possible
See a doctor if you think you are dehydrated
Anti-secretory medications
Constipation - causes
Idiopathic [primary]
Secondary causes: Parkinson’s’ disease, Hirschsprung disease, spinal cord injury, MS, hypercalcaemia, diabetes mellitus, hypokalaemia, panhypopituitarism, hypothyroidism, iron supplements, antispasmodic medication, calcium-channel blockers, opiates, tricyclic antidepressants, systemic sclerosis, myotonic dystrophy, amyloid, IBS, colonic strictures, IBD, rectal prolapse, pregnancy
Constipation - defintion
Passing infrequent and/or hard stools, difficulty passing stools [e.g. straining], and/or feeling of incomplete emptying
<3 spontaneous bowel motions a week
Can be primary [constipation in the absence of an underlying cause] or secondary [due to an underlying pathology: medications, GI disorders, endocrine disorder]
Constipation - s/s
Infrequent bowel motions; hard, lump stools; straining; manually extracting faeces; overflow diarrhoea [liquid stool leak around stool]; overflow incontinence [loss of control over defecation]; feeling of incomplete emptying
Constipation - ix
Majority of patients don’t require extensive investigations
Usually targeted to patients to exclude secondary causes or when there are red flags
Stool tests- faecal calprotectin [FCP], quantitative faecal immunochemical test [qFIT; measures Hb in stool]
Bloods- FBC, renal profile, bone profile, HbA1c, TFTs
Imaging not usually required but can be helpful for diagnosing secondary causes
Constipation - mx
Lifestyle modifications [high in fibre, good fluid intake, exercise]
First-line laxatives [osmotic, bulk-forming, softeners]
Second-line laxatives [stimulants, suppositories and/or enemas]
Consider biofeedback
Change in bowel habit - red flags
Weight loss [unintentional]
Rectal bleeding
Family history of colorectal cancer
Sudden change in bowel habit
Abdominal pain
Iron deficiency anaemia
Pt with red flags should be referred on lower gastrointestinal cancer pathway for 2ww assessment
Crohn’s Disease - patho
Form of inflammatory bowel disease characterised by patchy, transmural inflammation of intestinal mucosa; can affect any part of GI tract from mouth to anus
Incidence peaks between ages of 15-30 and 60-80
Family history is important - genetic predisposition
Smoking increases the risk of CD
Crohn’s Disease - macro/microscopic changes
Macro- cobblestone appearance [caused by superficial ulcers], bowel wall thickening, lumen narrowing, deep ulcers, fistulae, fissures
Micro- lymphoid hyperplasia, non-caseating granulomas, skip lesions and transmural ulceration
Crohn’s Disease - s/s
Symptoms- nausea/vomiting, fatigue, low grade fever, weight loss, abdo pain, diarrhoea [+/- blood], rectal bleeding, perianal disease
Signs- pyrexia, dehydration, angular stomatitis, aphthous ulcers, pallor, tachycardia, hypotension, abdominal tenderness/mass/distension
Crohn’s Disease - extra-intestinal manifestations
MSK- arthritis [large joints affected in up to 20%; ankylosing spondylitis and sacroiliitis may occur]
Skin- erythema nodosum [reddened, raised, tender nodules] and pyoderma gangrenosum [ulcerating nodules characterised by black edges and central pus]
Eyes & mouth- episcleritis, uveitis, conjunctivitis, aphthous ulcers
Hepatobiliary- primary sclerosing cholangitis [more common in UC]; fatty liver and gallstones are seen with increased frequency
Other- renal calculi, osteoporosis, vit B12 deficiency, pulmonary disease, venous thrombosis, anaemia
Crohn’s Disease - ix
Diagnosis is based on macroscopic assessment [endoscopy] and histological evidence [biopsy] of inflammation typical of CD
Faecal calprotectin - stool sample; sensitive marker of intestinal inflammation
Crohn’s Disease - mx
Main aim is to induce and maintain remission
Tailor mx to phase of disease [acute flare or remission]
Surgery may be required to manage complications
Lifestyle modification [smoking cessation]
Regular monitoring, and screening for complications
Corticosteroids are used to manage acute flares [prednisolone]
Biologics are used to maintain remission [infliximab- anti TNF-alpha antibodies]
Ulcerative Colitis - patho
Disease of the colonic mucosa; relapsing-remitting course
Characterised by inflammation of the mucosa, affecting the rectum and may progress proximally through the colon - terminal ileum is only usually affecting in those with extensive colitis
Most common form of IBD; peaks in incidence at 15-25 and 55-65
Often a family history
Smoking is protective [i.e.helps in flares]
Ulcerative Colitis - macro/microscopic changes
Macro- continuous inflammation that extends proximally along the colon; surface of mucosa is erythematous and inflamed; ‘easily friable to touch’; evidence of inflammatory polyps
Micro- Goblet cell depletion; crypt abscesses; inflammatory infiltrate in lamina propria [largely neutrophilic]
Ulcerative Colitis - s/s
Symptoms- weight loss, fatigue, abdominal pain, loose stools, rectal bleeding, tenesmus, urgency
Signs- febrile, pale, dehydrated, abdo tenderness/mass/distension, tachycardic, hypotensive
Ulcerative Colitis - extra-colonic manifestations
MSK- arthritis; osteopenia/osteoporosis; clubbing of hands and feet
Eyes, mouth, skin- uveitis is strongly associated; episcleritis, aphthous ulcers, erythema nodosum
Hepatobiliary- fatty liver disease and autoimmune liver disease; primary sclerosing cholangitis [70-95% pts with PSC have UC]
Haematological- anaemia and thromboembolism
Ulcerative Colitis - ix
Diagnosis is based on macroscopic assessment [colonoscopy] and histological evidence [biopsy] of colonic inflammation
Faecal calprotectin
Ulcerative Colitis - mx
General principle is to induce and maintain remission
Acute flare- steroids
Maintenance- biologics [anti tnf-alpha antibodies]
Surgery is an option; usually in those who aren’t responding to medical management
Crohn’s Disease - complications
Fistulae
Colorectal cancer
Strictures
Perforation
Ulcerative Colitis - complications
Fistulae
Colorectal cancer
Strictures
Perforation
Toxic Megacolon
Primary sclerosing cholangitis
Diabetes Mellitus - patho
Type I - autoimmune destruction of beta cells of the pancreas. Insulin deficiency
Type II - insulin resistance, and insulin deficiency in some cases
Diabetes Mellitus - s/s
Type I - thin, thirsty, polyuria, tired/fatigue. Consider signs of DKA as well as this may be the first presentation of TIDM
Type II - obesity/overweight, thirst, polyuria. May be asymptomatic and only found as an incidental finding
Diabetes Mellitus - ix
Random blood glucose
In TII and asymptomatic, two blood glucose >11mmol/L are required for a diagnosis
Urine dip, FBC, U&E, TFT
Imaging not required usually
Diabetes Mellitus - mx
TI - insulin, either through multiple daily injections or through a pump. Will require daily glucose monitoring as well. Should be referred to other services for monitoring of eye health and foot health. GP should ensure there are regular checks of HbA1c and glucose. ACEi can have kidney protective effects too, so perhaps one should be taken at some point.
TII - can be controlled with diet and exercise alone, smoking cessation and alcohol intake reduction. May require oral hypoglycaemic drugs (metformin, gliclazide, dapagliflozin, for example) to manage hyperglycaemia. May require insulin if deficiency is so great or oral hypoglycaemic drugs are not working. Will require check ups to manage complications. Should be checking glucose at home as well.
Diabetes Mellitus - complications
Nephropathy
Neuropathy
Retinopathy
Hypertension
Chronic kidney disease
Leg ulcers, poor wound healing, increased risk of infection
Diabetes Mellitus - f-up
Organs most seriously affected by DM are: kidney, eyes, macrovasculature (coronary arteries, cerebral circulation, peripheral vasculature), skin, nervous system, sexual dysfunction
Optimal glycaemic control helps to minimise risk of complication.
Chronic Obstructive Pulmonary Disease - patho
A respiratory disorder characterised by airflow obstruction, which is usually progressive, not fully reversible and does not change markedly over several months.
Chronic airflow obstruction is caused by a combination of small airway disease (obstructive broncholitis) and parenchyma damage (emphysema)
Chronic Obstructive Pulmonary Disease - s/s
Clinical features include:
- chronic progressive dyspnoea
- chronic cough
- regular sputum production
- frequent winter bronchitis
- wheezing and chest tightness
Also can have fatigue, weight loss, anorexia, syncope during cough, rib fractures due to coughing, ankle swelling, depression/anxiety
O/E can have hyperinflated chest, wheeze, quiet breath sounds, pursed lip breathing, use of accessory muscles, paradoxical movement of lower ribs, peripheral oedema, cyanosis, raised JVP, cachexia
Chronic Obstructive Pulmonary Disease - ix
Spirometry - decrease in both FEV1 and FVC; used to monitor disease progression; doesn’t change after being given a bronchodilator
CXR - r/o other possible diagnoses
FBC - anaemia and polycythaemia
Pulse oximetry to assess need for oxygen therapy
ECG - for cor pulmonale
Sputum culture - if IECOPD
Chronic Obstructive Pulmonary Disease - mx
Goals are to:
- reduce long-term lung function
- prevent and treat exacerbations
- reduce hospitalisations and mortality
- relieving disabling dyspnoea
- improve exercise tolerance and health related QOL
- prevent and treat complications
Smoking cessation
Vaccination
Active lifestyle and exercise
Self mx education - risk factor management, inhaler technique, written action plan
Manage co-morbidities
Chronic Obstructive Pulmonary Disease - f-up
Patients with mild/moderate/severe should be reviewed at least once a year
Review should cover smoking status, desire to quit smoking, adequacy of symptom control, presence of complications, effects of each drug treatment, inhaler technique, need for referral to specialist and therapy services, need for pulmonary rehabilitation, measurement of FEV1/FVC
Very severe COPD patients should be reviewed at least twice a year, review is about the same with extra focus on things like cor pulmonale, oxygen therapy, depression/psychological affects of diagnosis, nutritional state
Chronic Obstructive Pulmonary Disease - complications
Respiratory failure - PaO2 <8, PaCO2 >7
Pulmonary artery hypertension
Cor pulmonale
Polycythaemia
Pneumothorax
Weight loss
Carcinoma of bronchus
Infective exacerbations
Asthma - patho
Inflammatory disorder of conducting airways. Airways become hyper responsive and construct easily in response to a wide range of stimuli.
Asthma - s/s
Typically present with characteristic symptoms such as wheezing, dyspnoea, chest tightness, cough (+/- sputum) varying over time and intensity.
Asthma - ix
Spirometry - FEV1/FVC
Bronchodilator reversibility will be present; improvement of 12% or greater is a positive test
Peak flow - used for monitoring
Asthma - mx
Intermittent reliever inhaler - salbutamol (beta 2 agonist)
Regular prevent inhaler - inhaled corticosteroids
Asthma - complications
Exacerbations of asthma
Asthma - f-up
Should have asthma review for inhaler technique, avoidance of triggers, experience with asthma since last review, exposure to tobacco smoke, co-morbidities/atopic conditions
Ischaemic Heart Disease - patho
90% is caused by coronary heart disease
* Atherosclerosis of coronary arteries
* Platelet aggregation
* Coronary vasospasm
* Non-atherosclerotic coronary artery disease
* Hemodynamic derangements
Ischaemic Heart Disease - s/s
Four principle presentations:
* Angina
* Heart failure
* ACS
* Sudden cardiac death
Ischaemic Heart Disease - ix
Investigate how you would for angina, hf, acs
Ischaemic Heart Disease - mx
Primary prevention - use QRISK2 for assessing CVD risk in people up to 84y; can be put on atorvastatin 20mg for cholesterol mx
Secondary prevention - smoking cessation, dietary advice, bp control, ACEi, dual antiplatelet therapy (aspirin + clopidogrel), b-blocker, statin
Ischaemic Heart Disease - f-up
Review with medications and blood tests to monitor HbA1c, lipids/cholesterol, clotting (esp if they’re on warfarin)
Ischaemic Heart Disease - complications
ACS, sudden cardiac death, heart failure, angina
Hypertension - patho
Persistently raised arterial blood pressure
1 htn has no identifiable cause; 2 htn has an underlying cause [e.g. renal, endocrine, vascular disorder]
Stage 1 - 140/90mmHg
Stage 2 - 160/100mmHg
Stage 3 - systolic bp of >180, or diastolic bp of >120
Be wary of htn with papilloedema and/or retinal haemorrhage
Hypertension - s/s
Typically asymptomatic
Can have signs of end organ damage [e.g. retinal haemorrhage/papilloedema]
Hypertension - ix
Assess for organ damage - haematuria; HbA1c; albumin:creatinine ratio; electrolytes; ophthalmoscopy; 12 lead ECG
Assess cardiovascular risk - cholesterol and HDL cholesterol; QRISK score
Consider investigations to find a secondary cause of HTN, typically in pts under 40y
Hypertension - mx
Investigate fr target organ damage
Diet and exercise - healthy diet and regular exercise can reduce blood pressure
Caffeine - discourage consumption of caffeine
Dietary sodium - keep intake low, salt can increase bp
Smoking - stop smoking
Alcohol - encourage reduced intake, has more health benefits than just lowering blood pressure
Patient advise leaflets can be useful
Pharmacological - ACEi/ARB if under 55 or TIIDM; if >55 or BlackCarribean offer CCB first; then add the other one; then consider a thiazide-like diuretic; depending on K offer spironolactone [K <4.5mmol/L] or alpha-blocker [K >4.5mmol/L]
Hypertension - complications
Increases risk of HF; CAD; stroke; CKD; PAD; vascular dementia
Hypertension - f-up
Use bp monitoring to assess response to tretment
Review annually - encourage adherence to treatment; offer lifestyle advice; check bp; check renal function; measure QRISK score
Heart Failure - patho
Caused by a structural and/or functional abnormality that produces increased intracardiac pressures and/or inadequate cardiac output at rest or with exercise
Heart Failure - s/s
Symptoms- breathlessness [on exertion, lying flat, at rest, nocturnal cough, waking up from sleep breathless]
Fluid retention - ankle swelling, bloated feeling, abdominal swelling, weight gain
Fatigue, decreased exercise tolerance, increased recovery time after exercise
Lightheaedness or hx of syncope
Sings - tachycardia; laterally displaced apex beat; heart murmurs; HTN; raised JVP; hepatomegaly; respiratory signs [tachypnoea; basal crepitations; pleural effusions]; oedema in legs/sacrum; ascites; obesity
Heart Failure - ix
If symptoms are severe - arrange hospital admission
NT-pro-BNP [elevated levels could mean HF]
12 lead ECG
Other ix - CXR; bloods [U&Es, eGFR, FBC, iron studies, TFTs, LFTs, HbA1c, fasting lipids]; urine dipstick [haematuria?]; lung function tests
Assess for underlying causes - valve disease?
Heart Failure - mx
Preserved EF - loop diuretic; stop drugs causing/worsening HF; refer to specialist; consider antiplatelet/statin; optimise mx of co-morbidities screen for mental health problems; offered referral to a supervised exercise-based rehabilitation programme; vaccinations; assess nutritional status
Reduced EF - stop drugs causing/worsening HF; loop diuretic; ACEi and B-blocker; refer to cardiologist if still symptomatic despite optimal mx; consider antiplatelet/statin; optimise mx of co-morbidities; screen for mental health problems; vaccines; nutritional status
Heart Failure - complications
Atrial fibrillation, ventricular arrhythmias
Depression
Cachexia
Anaemia
CKD
AKI
Sexual dysfunction
Sudden cardiac death
Heart Failure - f-up
All pts require follow-up - individualised to the severity and stability of symptoms, treatment and co-morbidities
Assess symptoms of HF, functional capacity, cognitive status and psychosocial needs, nutritional status
Medication review
Provide a self-management plan
Monitor U&Es, eGFR every 6m
Consider referral to specialty services
Hyperlipidaemia - patho
A higher than normal level of cholesterol or triglycerides in your blood
Found in patients who are overweight or have an unhealthy diet. Can also be as a result of too much alcohol. Can also be genetic.
Secondary causes - diabetes, hypothyroidism, obstructive jaundice, cushing’s syndrome, anorexia nervosa, nephrotic syndrome, CKD
Hyperlipidaemia - s/s
Often asymptomatic, typically found during routine screening or part of an annual health check
May have premature arcus senilis, tendon xanthomata, xanthelasma
Hyperlipidaemia - ix
Fasting lipids are best investigation to use to diagnose
Hyperlipidaemia - mx
Diet and exercise
Statin - HMG-CoA reductase inhibitor medications
Hyperlipidaemia - f-up
Monitoring blood tests should be used to monitor response to treatment
Assess cardiovascular risk in follow-up appts using a QRISK score
Hyperlipidaemia - complications
Cardiovascular events
Chronic Kidney Disease - patho
Most prevalent causes: hypertension, diabetes, glomerulonephritis, urinary tract obstructions
HTN - elevated bp causes hypertrophic response
diabetes - chronic hyperglycaemia causes glomerular hyperfiltration
glomerulonephritis - inflammatory and non-inflammatory mechanisms [more in medicine]
Chronic Kidney Disease - staging
Stage 1: kidney damage with normal/increased GFR [>90ml/min/1.73m^2]
Stage 2: [mild] 60-89ml/min/1.73m^2
Stage 3a: [mild-moderate] 45-59ml/min/1.73m^2
Stage 3b: [moderate-severe] 30-44ml/min/1.73m^2
Stage 4: [severe] 15-29ml/min/1.73m^2
Stage 5: [kidney failure] <15ml/min/1.73m^2
Chronic Kidney Disease - s/s
Typically asymptomatic in early stages
Incidental findings
Chronic Kidney Disease - ix
bed: urine dip [early morning for ACR]
blood: U&Es, eGFR
Chronic Kidney Disease - mx
Identify and manage underlying causes
Monitor renal function with serum creatinine and eGFR as well as ACR
Assess/monitor for anaemia [FBC]
Assess/monitor for calcium, phosphate, vit D, parathyroid disorders/dysfunctions
haematuria? 2ww
refer to nephrologist if case is complex/severe
assess for and manage risk factors and co-morbidities
manage htn
lipid-lowering medications [atorvastatin]
antiplatelet
counsel family and patient
vaccinations
Chronic Kidney Disease - f-up
Identify and manage underlying causes
Monitor renal function with serum creatinine and eGFR as well as ACR
Assess/monitor for anaemia [FBC]
Assess/monitor for calcium, phosphate, vit D, parathyroid disorders/dysfunctions
Chronic Kidney Disease - complications
AKI
HTN and dyslipidaemia
CVD
Renal anaemia
Renal mineral and bone disorders
Peripheral neuropathy and myopathy
Malnutrition
Malignancy
End-stage renal disease - may require renal replacement therapy [dialysis or kidney transplantation]
Mortality increases with progressive CKD
Atrial Fibrillation - patho
AF is a supraventricular tachyarrhythmia resulting from irregular, disorganised electrical activity and ineffective contraction of the atria
Paroxysmal- episodes longer than 30s but less than 7d, self-terminating and recurrent
Persistent- episodes longer than 7d, or less than7 requiring pharmacological or electrical cardioversion
Permanent- AF fails to terminate following cardioversion; terminated AF but relapses within 24hr; longstanding AF in which cardioversion has not been indicated/attempted
Atrial Fibrillation - s/s
Irregularly irregular pulse
Breathlessness; palpitations; chest discomfort; syncope/dizziness; reduce exercise tolerance; malaise; decrease in mentation; polyuria
Complications may be presenting feature - stroke, transient ischaemic attack, heart failure
Atrial Fibrillation - ix
To confirm, 12lead ECG is required
paroxysmal may require 24hr ambulatory monitoring
Atrial Fibrillation - mx
onset within 48hrs- urgently admit for electrical cardioversion if haemodynamically unstable
admit to 2`care if there are signs of complex disease
arrange investigations to confirm or r/o underlying causes
refer to a cardiologist for rhythm control
assess for stroke risk/bleeding risk
modify risk factors
DOAC and/or b-blocker typically - apixaban and bisprolol
Atrial Fibrillation - f-up
rate-control [b-blocker] f-up after a week to check tolerance and review of disease
warfarin- monitor INR regularly
review annually once symptoms are controlled and any treatments are established
Atrial Fibrillation - complications
Stroke/TIA/thromboembolism - main complication
heart failure is commonly associated
Can have lower quality of life
increased risk of mortality
Obesity - complications
++ mortality
HTN
dyslipidaemia
TIIDM
coronary heart disease
stroke
gallbladder disease
obstructive sleep apenoa
restrictive lung patterns/spirometry - dyspnoea
some types of cancer
Obesity - mx
healthy balanced diet
regular exercise
lose weight
manage complications/underlying causes or factors
‘Your Weight, Your Health’ booklet from the Department of Health
Obesity - f-up
Check in with patient to assess progress with losing weight and psychological impact of their health and their weight loss journey
Consider referral to specialty services if required
Acute abdomen - causes
cholecystitis; pyelonephritis; ureteric colic; hepatitis; pneumonia; peptic ulcer disease; pancreatitis; MI; gastric ulcer; LB/SB obstruction; appendicitis; AAA; diverticulitis; hernia; IBD; UTI; gynae/testicular problems/; ectopic pregnancy
Acute abdomen - ix
bed: urine dip; ECG; pregnancy test in women
stool: cultures; faecal calprotectin; occult blood test
blood: FBC, U&Es, LFTs, amylase; CRP; G&S; ABG; blood cultures [if sepsis is expected]
imaging: CXR; AXR; ultrasound of the abdomen; CT abdo/pelvis with contrast
Acute abdomen - admission
If patient is clinically unstable; admit
Use good clinical judgement to decide whether management at secondary care would be more appropriate
Acute abdomen - f-up
Not routinely followed-up in 1` care?
Acutely Unwell Child - causes
Infection [measles, mumps, meningitis, encephalitis, otitis]
Kawasaki disease
Malignancy
Acutely Unwell Child - ix
A to E assessment
ask parent/guardian for information about symptoms, severity, timing, etc - how different to normal they are
ask about urine output and bowel movements - very important for assessing a child
bed: urine dip; swabs?
blood: FBC, U&Es, LFTs, CRP
imaging: not needed typically?
Acutely Unwell Child - admission
Red on the traffic light system provided by NICE - tachypnoea; non-blanching rash; no response to social cues - for example
Always use clinical judgement, if patient appears unwell then admission will probably help as treatment is faster/easier in hospital or secondary care
Acutely Unwell Child - f-up
Check recovery from illness/disease
Manage complications in 1` care if necessary
Patient with Chest Pain - causes
ACS; pneumonia; pneumothorax; stable angina; malignancy; MSK pain; costochondritis; pancreatitis; oesophagitis; cholecystitis; rib fracture; arthritis; fibromyalgia; psychogenic chest pain; aortic dissection/aneurysm rupture; cardiac tamponade; acute congestive HF; arrhythmias; pulmonary embolism
Patient with Chest Pain - ix
bed: full respiratory and cardiovascular examination; ECG
blood: FBC, U&Es, amylase; troponins; glucose; lipid profile; TFTs, LFTS, CRP
imaging: CXR; CTPA; ultrasound of the abdomen [pancreatitis; gallstones]
Patient with Chest Pain - admission
admit if you suspect ACS; PE; acute heart failure; pancreatitis; cardiac tamponade; aortic dissection/aneurysm rupture; pneumothorax
use clinical judgement to decide if patient is stable enough to withstand treatment in 1` care; if not then admission is vital
Patient with Chest Pain - f-up
Follow-up may be required if patient had ACS or PE or other causes to manage complications of treatment after the event
Patient with Shortness of Breath - causes
cardiac- acute pulmonary oedema; arrhythmia; cardiac tamponade; HF; MI
pulmonary- asthma; bronchiectasis; COPD; Covid-19; lung/lobar collapse; pleural effusion; pneumonia; PE; malignancy
other- anaemia; anaphylaxis; anxiety
Patient with Shortness of Breath - ix
CXR within 2wks if cough, fatigue, sob, chest pain, weight loss, appetite loss
bed: ECG, peak flow, pulse oximetry
blood: FBC, U&Es, TFTs, LFTs, kidney function tests, BNP, CRP
imaging: CXR, abdominal ultrasound
Patient with Shortness of Breath - admission
urgent admission if rapid onset or worsening symptoms; suspected sepsis; anaphylaxis; ECG suggesting MI or arrhythmia; features of PE/pneumothorax/cardiac tamponade/pulmonary oedema/severe or life-threatening asthma/severe or life-threatening COPD exacerbation; CRB score of 3+
always use clinical judgement when considering admission
Patient with Shortness of Breath - f-up
Consider follow-up to assess recovery and manage any complications of SOB episode
Manage co-morbidities
Patient with Unilateral Weakness - causes
Stroke
TIA
Bell’s palsy
Patient with Unilateral Weakness - ix
use FAST to screen for stroke or TIA
exclude hypoglycaemia
Patient with Unilateral Weakness - admission
Acute onset of unilateral weakness is often a cause for admission - life-threatening/altering events can occur - important not to miss them
Patient with Unilateral Weakness - f-up
Manage complications of stroke/tia event if indicated
Sometimes referral may be required esp for Bell’s palsy if not recovered within 3-4m
Patient with Anaphylaxis - causes
Exposure to allergens
Type I hypersensitivity reaction
Basophils and mast cells degranulate and release ++histamine and other chemical mediators after exposure to a specific antigen
Patient with Anaphylaxis - ix
A to E; quick assessment required; patient will usually require adrenaline - wouldn’t typically present to 1` care with severe angioedema due to severity
Milder forms [e.g. urticarial rash] may present to GP - good history and examination required
Patient with Anaphylaxis - mx
Adrenaline - 500micrograms of 1mg in 1000[1mg/1mL]; 0.5ml and repeat after 5m in no response
Other antihistamines can b3e used if not life-threatening/milder forms of an allergic reaction
Avoid triggers and carry an Epi-pen for emergency exposure
Patient with Anaphylaxis - admission
999 for emergency admission if severe/life-threatening anaphylaxis
signs of shock - admit
Patient with Anaphylaxis - f-up
Allergy specialist can help to identify the trigger if unknown
Self-written management plan
Encourage pt to wear a medical emergency identification bracelet or similar
Smoking Cessation advice
-Leaflet
-Patches/gum/spray - NRT
-Nicotine vapes can be used
-Local stop smoking service
-Rely on family and friends for support if you can
-List reasons why you’re quitting to help maintain abstinent from smoking
-Reward progress
-Enjoy the benefits
Quit Alcohol advice
*try and identify whether you’re dependent or not; with the help of your doctor or self-assessment tools
*know the signs of withdrawal - irritable, shaky, tired, poor concentration, difficulty sleeping, bad dreams, trembling hands, sweating, nausea, headache, vomiting, palpitations, hallucinations, convulsions, fever
*Make your intentions known so family/friends can help
*Avoid temptation
*Reward progress
*Enjoy benefits
*Alcohol support services: Alcoholic anon, Drinkline
Alcohol units/week recommendation
14 over at least 3 days, with 2 days not drinking, no bingeing
How to calculate units of alcohol
ABV x ml / 1000
4% x 568ml / 1000 = 2.2
40% x 50ml / 1000 = 2
12% x 175ml / 1000 = 2.1
Fatigue - causes
psychological: anxiety, stress, emotional shock, grief, depression
physical: anaemia, hypothyroidism, sleep apnoea, pregnancy, overweight/obesity, underweight, cancer treatments, side effects of medications
lifestyle: alcohol, exercise, caffeine, night shifts, daytime naps
Fatigue - ix
blood: FBC, U&Es, LFTs, TFTs
explore psychological reasons with good history taking
investigate lifestyle aspects with the patient
Fatigue - mx
Treat underlying cause
*change medications if necessary
*iron-tablets/fix anaemia through other methods depending on cause of anaemia
*therapy/psychiatric medications
*weight loss/weight gain
*thyroid medications - levothyroxine
*reduce alcohol; modify exercise; reduce caffeine; reduce amount slept during the day
Fatigue - f-up
Monitor symptoms and other signs of their disease/underlying cause of fatigue
Scarlet Fever - patho
Group A Streptococcus
Scarlet Fever - s/s
starts with flu-like symptoms [fever, sore throat, swollen lymph nodes]; progresses to a rash after 12-48hrs [starts on chest/abdomen then spreads] feels like sandpaper
Strawberry tongue - red, swollen tongue covered in little bumps
Scarlet Fever - ix
Consider throat swab for Group A streptococcus but not routinely required
Diagnosis is made clinically if features/signs/symptoms are present
Scarlet Fever - mx
Consider hospital admission if symptoms are severe and can’t be managed in 1`care; complications are present
abx can be given regardless of severity - 10/7 course of phenoxymethylpenicillin or clarithromycin for 10/7 if pen.allergic
notify public health
patinet information leaflet is available
Glandular Fever - patho
Infection most commonly caused by the Epstein-Barr virus
Glandular Fever - s/s
fever, sore throat, fatigue, lymphadenopathy, tonsillar enlargement, splenomegaly [rarely splenic rupture]
Glandular Fever - ix
FBC with differential white blood cell count
Monospot test
LFTs - hepatitis is a complication
Glandular Fever - mx
Admit if symptoms are severe - stridor, difficulty swallowing liquids, serious complication
paracetamol/ibuprofen for pain and fever
self-resolving illness in about 2-4 weeks, but fatigue can stay for a while
no need for bed rest; return to normal activities as soon as possible
Helicobacter Pylori - patho
Chronic active gastritis caused by H.pylori
oral-to-oral or faecal-to-oral route of transmission
Helicobacter Pylori - s/s
PUD; gastritis; dyspepsia
Helicobacter Pylori - ix
Urease breath test
Stool antigen test
Helicobacter Pylori - mx
Triple therapy - amoxicillin [clarithromycin if pen.allergic], metronidazole and lansoprazole
Helicobacter Pylori - f-up
Measure stool antigen to monitor presence of H.pylori
Retesting for H.pylori isn’t usually recommended
Diverticula Disease - patho
Outpouching of mucosa through circular muscle
Diverticula Disease - s/s
Diverticulosis is usually asymptomatic - incidentally found on colonoscopy or CT; but can cause lower left abdo pain, constipation or rectal bleeding
Diverticulitis refers to inflammation of diverticula - pain/tenderness in LIF, fever, diarrhoea, n/v, rectal bleeding, palpable mass
Diverticula Disease - ix
bed: stool sample for culture
blood: FBC, U&Es, TFTs, LFTs, clotting, CRP
imaging: colonoscopy, CT scan
Diverticula Disease - mx
1` - Oral co-amoxiclav, analgesia, only taking clear liquids until symptoms improve, follow-up within 2 days to review symptoms
2` - NBM/clear fluids only, IV abx/fluids/analgesia, urgent investigations, urgent surgery
Diverticula Disease - complications
Perforation, peritonitis, peridiverticular disease, large haemorrhage, fistula, ileus/obstruction
Prostatitis - patho
Inflammation of the prostate
Acute or Chronic [symptoms for at least 3m]
Prostatitis - s/s
Chronic - pelvic pain, LUTS, sexual dysfunction, pain with bowel movements, tender and enlarged prostate
Acute - similar symptoms ^ but more acute onset, may also be systemic symptoms of infection [e.g. fever, myalgia, nausea, fatigue, sepsis]
Prostatitis - ix
urine dip - presence of infection
urine MC&S can identify causative organism and abx sensitivities
STI screen if STI if considered
Prostatitis - mx
Acute- hospital admission for systemically unwell or septic patients; oral abx; analgesia; laxatives if bowel movements are painful
Chronic- alpha-blockers [tamsulosin]; analgesia; psychological tx where indicated; abx if <6m hx; laxatives if bowel movements are painful
Balanitis - patho
Inflammation of the glans penis, and posthitis describes inflammation of the foreskin
Caused by a range of different conditions - dermatitis; other infections; skin conditions; trauma; pre-malignant conditions
Balanitis - s/s
Penile soreness and itch
Bleeding from the foreskin and/or odour, usually developso over a few days
Dysuria, difficulty passing urine, and/or dyspareunia
o/e - redness and swelling of the glans penis with exudate; tightening of the foreskin; inability to retract the foreskin
Balanitis - ix
good history and examination
consider STI screen
measure HbA1c for underlying DM, and HIV if appropriate
Balanitis - mx
good hygiene - clean under foreskin everyday
patient information leaflet
non-specific dermatitis: 1% topical hydrocortisone cream
bacterial balanitis: flucloxacillin 500mg QDS for 7/7
Breast Abscess during breastfeeding - patho
Inflammation and an accumulation of pus underneath the skin, in the tissues of the breast
Caused by staphylococcus aureus
Breast Abscess during breastfeeding - s/s
Physical presence of a painful lump
Fever +/- flu-like symptoms
Skin on breast is hot to touch, erythematous
Breast Abscess during breastfeeding - ix
Examination
Sample can be sent for culture and sensitivities
Breast Abscess during breastfeeding - mx
Needle aspiration [<3cm]
Catheter drainage [>3cm]
Surgical incision and drainage
Antibiotics are also usually prescribed
Chlamydia [STI] - patho
Bacterial sexually transmitted infection
Caused by Chlamydia trachomatis
70% women, 50% men infected are asymptomatic
Chlamydia [STI] - s/s
W- +discharge, post-coital/intermenstrual bleeding, purulent discharge, deep dyspareunia, dysuria, pelvic pain/tenderness, inflamed/friable cervix
M- dysuria, mucopurulent urethral discharge, urethral discomfort, epididymo-orchitis, reactive arthritis
Chlamydia [STI] - ix
W- vulvovaginal swab or endocervical swab can be taken; FCU [first catch urine] can also be collected
M- FCU is specimen of choice; urethral swab is an alternative
Sent for nucleic acid amplification tests
Chlamydia [STI] - mx
Refer to a GUM clinic, but can also be managed in 1` care
Offer written information about disease
Contact tracing
Treat infection - doxycycline 100mg BD for 7/7
Ringworm - patho
Superficial skin infection predominantly caused by dermatophytes such as Trichophyton rubrum
Ringworm - s/s
Sclay, itchy skin
Single or multiple red or pink, slightly raised annular patches of varying sizes
Typically have an active, red advancing edge and a clear central area
Ringworm - ix
Diagnosis is made based on clinical features and history
Ringworm - mx
Advise on self-care strategies
Topical antifungal cream
Short-term topical hydrocortisone
Severe/extensive disease - oral antifungal considered
Bursitis - patho
Inflammation of a bursa [closed, fluid-filled sac]
Most common causes are injury or overuse, can also be caused by infection
Bursitis - s/s
Pain, localised tenderness, limited ROM, swelling/redness if bursa is superficial
Bursitis - ix
X-ray; MRI; ultrasound; aspiration
Blood to rule out other causes - RA, OA, gout, e.g.
Bursitis - mx
Aseptic- RICE, anti-inflammatory [NSAIDs], steroid injection, splints/braces to limit movement
Septic- antibiotics, repeated aspiration, surgical drainage and removal of the bursa
Osteomyelitis - patho
Inflammation of bone and bone marrow, usually caused by a bacterial infection
Staphylococcus aureus is causative organism in most cases of osteomyelitis
Osteomyelitis - s/s
Typical presentation- fever, pain and tenderness, erythema, swelling
Can be quite non-specific with generalised symptoms of infection
Osteomyelitis - ix
bed: examination
blood: FBC, U&Es, CRP, blood cultures
imaging: X-rays; MRI
special: bone cultures for organism and sensitivities
Osteomyelitis - mx
Surgical debridement and antibiotic therapy
6wks of flucloxacillin for acute osteomyelitis
chronic osteomyelitis requires >3m of abx
Septic Arthritis - patho
Infection within a joint
This is an emergency as infection can quickly destroy the joint and cause systemic illness
Common and important complication of joint replacement
Most common causative organism - staphylococcus aureus
can also be caused by Neisseria gonorrhoea in sexually active individuals [gram negative diplococcus]
Septic Arthritis - s/s
Single joint is affected
Rapid onset of hot, red, swollen and painful joint
Stiffness and reduced ROM, unable to weight bear
Systemic symptoms such as fever, lethargy, sepsis
Septic Arthritis - ix
Aspirate the joint prior to antibiotics, send sample for gram-staining, crystal microscopy, culture and antibiotic sensitivities
bloods: cultures [2x], FBC, CRP, U&Es, serum urate and LFTs
imaging: plain X-ray of affected joint, MRI and USS all justified
Septic Arthritis - mx
Low threshold for treating a patient for septic arthritis
Empirical abx given until sensitivities are known
Typically on abx for 3-6wks
Flucloxacillin 2g QDS IV
Rheumatic Fever - patho
Autoimmune condition triggered by streptococcus bacteria [typically strep pyogenes]
Type 2 hypersensitivity reaction
Rheumatic Fever - s/s
Symptoms start 2-4wks after a streptococcal infection
*fever
*joint pain
*rash
*sob
*chorea
*nodules
*migratory arthritis - hot, swollen, painful joints; typically large joints
*heart involvement - carditis can lead to tachy/brady, murmurs [mitral valve], pericardial rub on auscultation, heart failure
*skin involvement - subcutaneous nodules +/- erythema marginatum rash
*nervous system involvement - chorea [irregular, uncontrolled and rapid movements of the limbs]
Rheumatic Fever - ix
Throat swab for bacterial culture
ASO antibodies
ECG, echo and CXR to assess heart involvement
Rheumatic Fever - mx
Tonsillitis [first infection of strep pyogenes] should be managed with phenoxymethylpenicillin for 10/7
Rheumatic fever pts should be referred immediately for specialist management
*NSAIDs
*aspirin and steroids
*prophylactic abx
*monitoring and management of complications
Kawasaki Disease - patho
Systemic, medium sized vasculitis
Affects young children, typically <5
No clear cause/trigger
Kawasaki Disease - s/s
persistent high fever [>39`] for more than 5 days
unhappy and unwell child
widespread erythematous maculopapular rash and desquamation [skin peeling] on the palms and soles
also:
strawberry tongue, cracker lips, cervical lymphadenopathy, bilateral conjunctivitis
Kawasaki Disease - ix
bed: urinalysis
blood: FBC, LFTs, CRP/ESR
imaging: echo
Kawasaki Disease - mx
High dose aspirin to reduce risk of thrombosis [despite risk of Reye’s syndrome]
IV immunoglobulins to reduce risk of coronary artery aneurysms
Rectal Bleeding - causes
anal fissure, constipation, hard stools, haemorrhoids, foreign object, STI, colorectal cancer, ulcers, IBD, angiodysplasia, colitis, infection
Rectal Bleeding - ix
bed: DRE
blood: FBC, U&Es, CRP
stool: culture, calprotectin
imaging: flex sigmoidoscopy, colonoscopy, CT abdo/pelvis with contrast
Rectal Bleeding - mx
Depends on the cause
Typically, don’t get constipated - eat daily requirement of fibre, good oral intake
can use topical steroids for fissures
watchful waiting while referrals/other investigations are arranged
Rectal Bleeding - referral
Typically a 2ww referral for rectal bleeding if: occult blood test is positive; 50+ with unexplained rectal bleeding
Headache - causes
illness, stress, excess alcohol, bad posture, eyesight problems, dehydration, too many painkillers, muscular tension, dental problems, hormones, medication side effect
more serious causes: head injury, brain tumour, ++ICP
Headache - ix
bed: examination of cranial nerves and neuro examination of upper/lower limb; fundoscopy
blood: FBC, U&Es, LFTs, TFTs, CRP, coag/clotting screen
imaging: CT head if indicated
Headache - mx
Depends on the cause
Medication overuse- stop medication
Migraine- b-blocker can be used to prevent episodes
Hormonal headache- cocp can improve symptoms
trigeminal neuralgia- carbamazepine 1st line; surgery for compression or intentional damage to trigeminal nerve can help
tension headache- reassure; analgesia; relaxation techniques; hot towels to local area
Headache - referral
Emergency admission/urgent referral should be arranged with clinical judgement if there are any red flags or a serious underlying cause of secondary headache is suspected
Back Pain - causes
muscle/ligament sprain; joint dysfunction; herniated disc; scoliosis; degenerative changes; sciatica; whiplash
red flag causes: spinal fracture; cauda equina; spinal stenosis; ankylosing spondylitis; spinal infection
Back Pain - ix
good history and examination
bed: urine dip, culture and sensitivities
blood: FBC, U&Es, CRP, LFTs, HbA1c, glucose, HIV
imaging: ultrasound abdomen [r/o AAA, kidney stones, cholecystitis/gallstones], X-ray spine if suspected fracture or malignancy
Back Pain - mx
lower back pain - risk assessment
offer advice about sources of reliable information
reassurance and self-care advice
drug options- no paracetamol alone; offer NSAIDs otc first [consider PPI], consider codeine/co-codamol if NSAIDs wouldn’t be tolerated
exercise programmes, manual therapy, +/- psychological support
advise to request occupational health assessment
advise to arrange review if symptoms persist or are worsening after 3/4wks
Back Pain - referral
Urgent hospital admission or specialist referral if red flag s/s suggesting potentially serious underlying cause
What is the childhood immunisation schedule?
8wks: 6 in 1 [diphtheria, tetanus, pertussis, polio, haemophilus influenza B, hep B]; meningococcal type B; rotavirus
12wks: 6 in 1; pneumococcal; rotavirus
16wks: 6 in 1; meningococcal type B
1y: 2 in 1; pneumococcal; MMR; meningococcal type B
yearly from 2-8: influenza
3y4m: 4 in 1; MMR
12/13y: HPV [2 doses, 6-24m apart]
14: 3 in 1; meningococcal ACWY
Transient Loss of Consciousness - patho
‘a state of real or apparent loss of consciousness with loss of awareness, characterised by amnesia for the period of unconsciousness, abnormal motor control, loss of responsiveness, and a short duration’
Syncope - ‘TLOC due to cerebral hypoperfusion characterised by a rapid onset, short duration, and spontaneous complete recovery’
Transient Loss of Consciousness - causes
Syncope- vasovagal reflex, situational syncope, carotid sinus syndrome, orthostatic hypotension, cardiac syncope
Non-syncopal causes- epilepsy, seizure, psychogenic pseudosyncope or non-epileptic seizures
Transient Loss of Consciousness - ix
bed: obs, BP, glucose, cardio and neuro exam, ECG
blood: FBC, U&Es, HbA1c, glucose, CK, myoglobin
imaging: depends on possible cause
special: 24hr BP monitoring, echocardiogram
Transient Loss of Consciousness - mx
*advice about reliable sources of information
*advise about fitness to drive and safety at work
*referral to specialist if suspected cardiac cause or epilepsy
*advise about triggers, early recognition of prodromal symptoms
*medication review
*provide lifestyle modification
Transient Loss of Consciousness - referral
refer to falls and syncope service or cardiologist if:
*diagnostic uncertainty
*unexplained syncope
*vasovagal syncope during high-risk activity or affecting quality of life
*reflex syncope with an absent or short prodrome
*suspected but unconfirmed OH
*persistent OH despite lifestyle modification
Rheumatoid Arthritis - patho
chronic systemic inflammatory disease of the joints
3x more common in women; typically develops in middle age; FHx relevant
!anti-CCP antibodies!; also RF
Rheumatoid Arthritis - s/s
Typically presents with symmetrical distal polyarthropathy - joint pain, swelling and stiffness
systemic s/s- fatigue, weight loss, flue-like illness, muscle aches and weakness
pain is worse after rest but improves with activity
o/e - Zshaped deformity to the thumb; swan neck deformity; Boutonnieres deformity; ulnar deviation of the fingers at the knuckle
extra-articular manifestations- pulmonary fibrosis with pulmonary nodules [Caplan’s syndrome]; bronchiolitis obliterans; Felty’s syndrome [RA, neutropenia, splenomegaly]; secondary Sjogren’s syndrome; anaemia of chronic disease; CVD; episcleritis and scleritis; rheumatoid nodules; lymphadenopathy; carpal tunnel syndrome; amyloidosis
Rheumatoid Arthritis - ix
Diagnosis is clinical in patients with features of RA
blood: rheumatoid factor; anti-CCP antibodies; CRP/ESR
imaging: X-ray of hands and feet; ultrasound scan of the affected joints can be used to evaluate/confirm synovitis
Rheumatoid Arthritis - X-ray changes
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
Rheumatoid Arthritis - mx
MDT approach is essential
short course of steroids at first presentation and during flare ups to settle disease
NSAIDs/COX-2 inhibitors are often effective, but risk GI bleeds, often avoided or co-prescribed with a PPI
DMARDs - methotrexate, leflunomide, sulfasalazine
Biologics: anti-TNF [infliximab]; anti-CD20 [rituximab]
Osteoarthritis - patho
joint ‘wear and tear’
occurs in synovial joints and is a result of a combination of genetic factors, overuse and injury
RF: obesity, age, occupation, trauma, being female, FHx
thought to be a result of an imbalance between cartilage wearing down and chondrocytes repairing it leading to structural issues within the joint
Osteoarthritis - s/s
Joint pain ad stiffness; worsened by activity; also leads to deformity, instability and reduced function of the joint
X-ray changes - LOSS
loss of joint space
osteophytes
subarticular sclerosis
subchondral cysts
o/e of hands - Heberden’s nodes; Bouchard’s nodes; squaring at the base of the thumb at the carpometacarpal joint; weak grip; reduced ROM
Osteoarthritis - ix
Diagnosis can be made without any investigations if patient is over 45, has typical activity related pain and has no morning stiffness or stiffness lasting less than 30min
X-ray can be useful
Osteoarthritis - mx
Patient education and advise on lifestyle changes [weight loss, physio, occupational therapy and orthotics]
Stepwise approach to analgesia: oral paracetamol and topical NSAIDs/topical capsaicin; add oral NSAIDs and PPI; consider codeine and morphine
Intra-articular steroid injections can provide temporary reduction in inflammation and improve symptoms
Joint replacement in severe cases - typically knee and hip
Osteoporosis - patho
A reduction in the density of the bones
RF: older age, female, reduced mobility and activity, low BMI, RA, alcohol and smoking, long term corticosteroids, SSRIs, PPIs, anti-epileptics, anti-oestrogens
Osteoporosis - s/s
Usually presents with fragility fractures
Osteoporosis - ix
FRAX tool: predicts the risk of a fragility # over 10y
put in info about BMI, co-morbs, smoking, alcohol, FHx, BMD from a DEXA scan
DEXA scan shows how dense bones are
WHO classification of T score
more than -1= normal
-1 to -2.5= osteopenia
less than -2.5= osteoporosis
less than -2.5 with a #= severe osteoporosis
Osteoporosis - mx
Lifestyle - activity and exercise; maintain a healthy weight; adequate calcium and vit D intake; avoid falling; stop smoking; reduce alcohol consumption
Bisphosphonates - 1st line; interfering with osteoclasts and reducing their activity; s/e include reflux and oesophageal erosions, atypical fractures, osteonecrosis of the jaw; alendronate 70mg 1x weekly
Gout - patho
Crystal arthropathy associated with chronically high uric acid levels
RF: male, obese, high purine diet, alcohol, diuretics, existing CV or kidney disease, FHx
typical joints: base of the big toe, wrists, base of thumb
Gout - s/s
Typically presents as a single acute hot, swollen and painful joint [important to r/o septic arthritis]
Gouty tophi are subcutaneous deposits of uric acid typically affecting the small joints and connective tissues of the hands, elbows and ears [DIP joints in hands most affected]
Gout - ix
Diagnosed clinically or by aspiration of fluid from the joint - exclude septic arthritis
Aspirate will show: no bacteria, needle-shaped crystals, negatively birefringent of polarised light, monosodium urate crystals
Joint x-ray can show joint space remains unaffected, lytic lesions in the bone, punched out erosions, erosions can have sclerotic borders with overhanging edges
Gout - mx
Acute flare: NSAIDs; colchicine; steroids
prophylaxis: allopurinol is xanthine oxidase inhibitor [reduces uric acid level]; lifestyle changes can reduce risk of developing gout [weight loss, hydration, minimising consumption of alcohol and purine-based food]
What is the WHO pain ladder?
Stepwise approach to analgesia
Wise to start off simple and then add in more dangerous/addicting substances such as opioids
Lateral Epicondylitis [Tennis Elbow] - patho
Result of repetitive use and injury to the tendons at the point of insertion
Commonly affects patients in middle age
Lateral Epicondylitis [Tennis Elbow] - s/s
Pain and tenderness at lateral epicondyle [outer elbow]
Pain often radiates down he forearm
Can lead to weakness in grip strength
Lateral Epicondylitis [Tennis Elbow] - ix
Clinical diagnosis based on s/s
Mill’s test + indicates lateral epicondylitis
Cozen’s test + indicates lateral epicondylitis
Lateral Epicondylitis [Tennis Elbow] - mx
Most pts it is self-limiting and resolves with time, however s/s can take several years to resolve
Mx can include:
*rest
*adapting activities
*analgesia
*physio
*orthotics
*steroid injections
*platelet rich plasma injections
*extracorporeal shockwave therapy
Medical Epicondylitis [Golfer’s Elbow] - patho
Often called golfer’s elbow
Inflammation at the point where the tendons insert into the epicondyles at the elbow
Specific type of repetitive strain injury
The result of repetitive use and injury to the tendons at the POI
Medical Epicondylitis [Golfer’s Elbow] - s/s
Pain and tenderness at the medial epicondyle [inner elbow]. Pain often radiates down the forearm. Can lead to weakness in grip strength
Medical Epicondylitis [Golfer’s Elbow] - ix
Clinical diagnosis based on s/s
Golfer’s elbow test + indicates medial epicondylitis
Medical Epicondylitis [Golfer’s Elbow] - mx
Most pts it is self-limiting and resolves with time, however s/s can take several years to resolve
Mx can include:
*rest
*adapting activities
*analgesia
*physio
*orthotics
*steroid injections
*platelet rich plasma injections
*extracorporeal shockwave therapy
Olecranon Bursitis - patho
Inflammation and swelling of the bursa over the elbow
Bursitis causes thickening of the synovial membrane and increased fluid production [causing swelling]
Can be caused by a number of things: friction from repetitive movements or leaning on the elbow; trauma; inflammatory conditions; infection [septic bursitis]
Olecranon Bursitis - s/s
Typical presentation is a young/middle-aged man with a swollen, warm, tender, fluctuant [fluid-filled] elbow
Infective causes also have these features: hot to touch, more tender, erythema spreading to the surrounding skin, fever, features of sepsis
Olecranon Bursitis - ix
Aspiration from the bursa is recommended if infection is suspected
aspirate prior to starting antibiotics; send fluid to lab for microscopy, culture; examine for crystals and gram-staining
Olecranon Bursitis - mx
rest, ice, compression, analgesia, protect elbow from pressure or trauma, aspiration of fluid to relieve pressure, steroid injections can be used in problematic cases where infection has been excluded
if infection is suspected/cant be excluded: aspiration for culture and microscopy as well as antibiotics [flucloxacillin, with clarithromycin as alternative]
Eczema - patho
Chronic atopic condition caused by defects in the normal continuity of the skin barrier, leading to inflammation in the skin
There is significant variation of the severity of the condition.
Eczema - s/s
Usually presents in infancy with dry, red, itchy and sore patches over flexor surfaces [inside of elbows and knees] and on face and neck
Eczema - ix
Diagnosis can be made clinically
Eczema - mx
Maintenance and management of flares
Create artificial barrier over the skin using emollients, used as often as possible particularly after washing and before bed [e45 cream, aveeno cream, 50:50 ointment, epaderm ointment]
topical steroids - use weakest steroid for the shortest period required to get skin under control [hydrocortisone, eumovate, betnovate, dermovate]
Acne Vulgaris - patho
Caused by chronic inflammation, with/out localised infection
Acne Vulgaris - s/s
Presents with red, inflamed sore ‘spots’ on the skin, typically distributed across the face, upper chest and upper back
There is significant variation in the severity of acne
Acne Vulgaris - ix
Diagnosis is made clinically typically
Acne Vulgaris - mx
Am is to reduce symptoms, reduce risk of scarring, minimise psychosocial impact of condition
Stepwise approach to severity and response to tx
1- no treatment may be acceptable if mild
2- topical benzyl peroxide can reduce inflammation
3- topical retinoids slow production of sebum
4- topical abx [clindamycin]
5- oral abx
6- oral contraceptive pill
7- only used by specialists - oral retinoids
Allergic Rashes and Urticaria - patho
Caused by the release of histamine and other pro-inflammatory chemicals by mast cells in the skin
May be part of an allergic reaction in acute urticaria or an autoimmune reaction in chronic idiopathic urticaria
Allergic Rashes and Urticaria - s/s
Hives are small itchy lumps that appear on the skin - pruritic weals or hives; round or ring-shaped
They can be localised to a specific area or widespread
May be associated with angioedema and flushing of the skin
Allergic Rashes and Urticaria - ix
Diagnosis is usually made clinically; no further investigations required
Allergic Rashes and Urticaria - mx
Antihistamines are the main treatment for urticaria
Oral steroids may be considered as a short course for severe flares
In very problematic cases referral to a specialist may be required to consider tx with anti-leukotrienes [montelukast]; omalizumab; cyclosporin
Skin Cancers - types
Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
Cholesteatoma - patho
Abnormal collection of squamous epithelial cells in the middle ear
Non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear. Can predispose to significant infections
Cholesteatoma - s/s
Typical presenting symptoms are: foul discharge from ear and unilateral conductive hearing loss
Cholesteatoma - ix
Otoscopy
CT head can be used to confirm the diagnosis and plan for surgery
MRI may help assess invasion and damage to local soft tissues
Cholesteatoma - mx
Surgical removal of the cholesteatoma
Conductive hearing loss - definition
Relates to a problem with sound travelling from the environment to the inner ear
Sensory system may be working correctly but sound isn’t reaching it
Conductive hearing loss - causes
Ear wax or foreign object blocking the canal
Infection
Fluid in the middle ear
Eustachian tube dysfunction
Perforated tympanic membrane
Otosclerosis
Cholesteatoma
Exostoses
Tumours
Sensorineural hearing loss - definition
Caused by a problem with the sensory system or vestibulocochlear nerve in the inner ear
Sensorineural hearing loss - causes
Sudden sensorineural hearing loss [over <72hrs]
Presbycusis [age-related]
Noise exposure
Meniere’s disease
Labyrinthitis
Acoustic neuroma
Neurological conditions [stroke, MS, brain tumour]
Infections [meningitis]
Medications [furosemide, gentamicin, cisplatin]
Weber’s Test
1- strike tuning fork to make it vibrate
2- place in middle of patient’s forehead
3- ask if they can hear the sound and if it’s louder in any particular ear
Normal = equal in both ears
SN = louder in normal ear
C = louder in affected ear
Rinne’s Test
1- strike the tuning fork to make it vibrate
2- place flat end on the mastoid process
3- ask pt to tell you when they can’t hear the humming noise
4- when they can no longer hear the noise, remove the tuning fork and hover it 1cm from the same ear
5- ask patient if they can hear the sound now
6- repeat process on the other side
Normal/Rinne’s positive = patient can hear the sound when bone conduction is lost and fork is hovered over the ear
Rinne’s negative = bone conduction is better than air, can’t hear the tuning fork after bone conduction is lost and hovered over the ear - typically suggests a conductive cause of hearing loss
Meniere’s Disease - patho
long term inner ear disorder causing recurrent attacks of vertigo and symptoms of hearing loss, tinnitus, and fullness in the ear
Associated with a build up of endolymph in the labyrinth of the inner ear
Meniere’s Disease - s/s
Typical presentation: 40-50y, unilateral episodes of vertigo, hearing loss, and tinnitus
Vertigo comes in episodes, last for 20m to several hours
Hearing loss typically fluctuates at first, then gradually becomes more permanent. SN hearing loss, unilateral and affects low frequencies first
Tinnitus occurs with episodes of vertigo before eventually becoming more permanent, unilateral
Meniere’s Disease - ix
Diagnosis is clinical, is made by an ENT specialist
Patients require audiology assessment to evaluate hearing loss
Meniere’s Disease - mx
Managing acute attacks:
prochlorperazine; antihistamines
Prophylactic medication to reduce frequency of attacks: betahistine
Presbycusis [Age Related Hearing Loss] - patho
Sensorineural hearing loss that occurs as people get older
Occurs gradually and symmetrically
Causes are complex - several different mechanisms including loss of hair cells in cochlea, loss of neurones in cochlea, atrophy or stria vascularis and reduced endolymphatic potential
RF: advancing age, male sex, FHx, loud noise exposure, diabetes, HTN, ototoxic medications, smoking
Presbycusis [Age Related Hearing Loss] - s/s
Gradual and insidious
Loss of high-pitched sounds at first - makes speech difficult to understand, particularly in loud environments
May present after others have noticed they are not paying attention or missing details of conversations
Patients can present with concerns about dementia
May be associated tinnitus
Presbycusis [Age Related Hearing Loss] - ix
Audiometry is ix of choice
Will give a SN hearing loss pattern, with normal or near-normal hearing at lower frequencies and worsening hearing loss at higher frequencies
Presbycusis [Age Related Hearing Loss] - mx
Effects cannot be reversed
Mx involves supporting the person to maintain normal functioning:
*optimising the environment
*hearing aids
*cochlear implants [for pts where hearing aids are not sufficient]
Bronchiolitis - patho
Inflammation and infection in the bronchioles
Usually caused by RSV [respiratory syncytial virus]
common in the winter
When a virus affects an infants airway, because they are so small to begin with, any swelling/mucus can have a significant effect on infant’s ability to circulate air to the alveoli
Bronchiolitis - s/s
Coryzal symptoms - snotty nose, sneezing, mucus in throat, watery eyes
Signs of respiratory distress - raised rr; use of accessory muscles of breathing [intercostal for example]; intercostal and subcostal recessions; nasal flaring; head bobbing; tracheal tugging; cyanosis; abnormal airway noises
Dyspnoea
Tachypnoea
Poor feeding
Mild fever [>39]
Apnoeas [episodes where child stops breathing]
Wheeze and crackles on auscultation
Bronchiolitis - ix
Clinical diagnosis is usually made
Can be admitted to hospital for further investigations and treatment is there are red flags
*existing conditions or under 3m
*clinical dehydrations
*50-75% or less of their normal intake of milk
*respiratory rate over 70
*oxygen sats below 92%
*moderate to severe rd
*apnoeas
*parent not confident in their ability to manage at home
Bronchiolitis - mx
supportive management only needed usually
adequate intake
saline nasal drops and nasal suctioning
supplementary oxygen
ventilatory support if indicated
Croup - patho
Acute infective respiratory disease affecting children typically 6m to 2y
URTI causing oedema in the larynx
Parainfluenza virus typically causes croup
Croup - s/s
increased work of breathing
“barking” cough, occurring in clusters of coughing episodes
hoarse voice
stridor
low grade fever
Croup - ix
Clinical diagnosis
Croup - mx
Mostly managed at home with simple supportive tx [fluids and rest]
Take steps to avoid spreading infection - hand washing, staying off school
Oral dexamethasone is very effective - single dose of 150mcg/kg
Prednisolone sometimes used as an alternative
Epiglottitis - patho
Inflammation and swelling of the epiglottis caused by haemophilus influenza type B
Can swell to the point of completely obscuring the airway within hours of symptoms developing
It is a life-threatening emergency
Rare now due to vaccination programme
Epiglottitis - s/s
Pt presenting with sore throat and stridor
Drooling
Tripod position - leaning forward with one hand on each knee
High fever
Difficulty/painful swallowing
Muffled voice
Scared and quiet child
Septic/unwell appearance
Epiglottitis - ix
If pt acutely unwell and epiglottitis is suspected, the ndo not perform investigations
A lateral neck x-ray can show a characteristic ‘thumb sign’ - soft tissue shadowing
neck x-rays used to exclude a foreign body
Epiglottitis - mx
It is an emergency and there’s an immediate risk of airway closing
Do not distress the patient - leave them alone and within their comfort zone
Alert a senior paediatrician and anaesthetist right away
Mx centres around ensuring the airway is secure
most don’t require intubation but there’s an ongoing risk of sudden upper airway closure
Additional treatment includes IV antibiotics and steroids
Psoriasis - patho
Chronic inflammatory skin disease due to hyperproliferation of keratinocytes and inflammatory cell infiltration
Psoriasis - s/s
Well demarcated erythematous scaly plaques
Can sometimes be itchy, burning and painful
Common on the extensor surfaces of the body and over the scalp
50% have associated nail changes - pitting, onycholysis
Psoriasis - ix
Clinical diagnosis
Psoriasis - mx
Avoid known precipitating factors, emollients to reduce scales
Topical therapies for localised/mild psoriasis - vit D, corticosteroids
Phototherapy for extensive disease
Oral therapies for extensive and severe psoriasis, or psoriasis with systemic involvement - methotrexate, retinoids
Nasal Polyps - patho
Growths of the nasal mucosa that can occur in the nasal cavity or sinuses. Often associated with inflammation
Usually grow slowly and gradually obstruct the nasal passage
Associated with several conditions: chronic rhinitis, sinusitis, asthma, cystic fibrosis
Nasal Polyps - s/s
May be found o/e in patients presenting with chronic rhinosinusitis, difficulty breathing through the nose, snoring, nasal discharge, loss of smell
Examine the nose with a nasal speculum, or an otoscope
Specialists perform nasal endoscopy to visualise the cavity and assess any polyps
They appear round, pale grey/yellow growths on the mucosal wall
Nasal Polyps - ix
O/e in pts with symptoms
Nasal speculum or otoscope with a large speculum attached
Specialists can perform nasal endoscopy
Nasal Polyps - mx
Unilateral polyps should be referred for specialist assessment to exclude malignancy
Medical mx involves intranasal topical steroid drops or spray
Surgical mx involves removing the polyps
Developmental milestones in children
https://zerotofinals.com/paediatrics/development/milestones/
https://abg.ninja/milestones
Hayfever - patho
allergic rhinitis is an IgE-mediated type 1 hypersensitivity reaction
Allergic inflammatory response in the nasal mucosa
Very common and can significantly affect sleep, mood, hobbies, work and school performance, and quality of life
Hayfever - s/s
Runny, blocked, and itchy nose
Sneezing
Itchy, red, and swollen eyes
Hayfever - ix
Typically diagnosed based on the history
Skin prick testing can be useful, particularly testing for pollen, animals and house dust mite allergy
Hayfever - mx
Avoid trigger
hoovering and changing pillows regularly and allowing good ventilation of the home
staying indoors during high pollen counts
minimise contact with pets that are known to trigger allergies
Oral antihistamines are taken prior to exposure to reduce allergic symptoms - cetirizine, loratadine
Nasal corticosteroid spray [fluticasone] can be taken regularly to suppress local allergic symptoms
Nasal antihistamines may be a good option for rapid onset symptoms in response to a trigger
Referral to an immunologist may be necessary if symptoms are unmanageable
Describe the normal menstruation cycle
Oestrogen - peaks just before ovulation, another smaller peak around day 22
Progesterone - peaks in the luteal phase around day 24
LH - peaks day 14, stimulates ovulation
FSH - fairly low, small peak around the same time as LH
Menstruation occurs between days 1-8 - shedding of the superficial and middle layers of the endometrium
What is menarche?
First period - occurs around age 8-16
What is menopause?
12m after a woman’s last period
Occurs due to hormone levels being insufficient
Occurs between 45 and 55y
What is dysmenorrhoea?
Pain associated with menstruation
What is menorrhagia?
Heavy menstrual bleeding or menstrual bleeding lasting for longer than 10 days
What is metrorrhagia?
Abnormal bleeding from the uterus
What is oligomenorrhoea?
Infrequent or very light menstruation
Periods occuring at intervals of greater than 35 days
What is primary amenorrhoea?
Failure to reach menarche
What is secondary amenorrhea?
Absence of three or more periods in a row by someone who has had periods in the past
Common cx - stress, pregnancy, eating disorder, perimenopause, ovarian insufficiency
Red flag symptoms for common gynaecological cancers [ovarian, endometrial, cervical, vulval]
High blood glucose and visible haematuria 55y+ - endometrial
low Hb - endo
appetite loss/early satiety 50y+ - ovarian
abdo distention 50+ - ovarian
abdo/pelvic mass - ovarian
IBS symptoms, change in bowel habit, unexplained fatigue, urine urgency, unexplained weight loss within 12m in 50y+ - ovarian
vaginal mass, vulval bleeding, vulval lump or ulceration - vulval
Inter-menstrual bleeding - definition and causes
Vaginal bleeding [other than post-coital] at any time during the menstrual cycle other than normal menstruation
cx - pregnancy-related [ectopic]; physiological [vaginal spotting at ovulation, hormonal fluctuation during perimenopause]; vaginal causes [adenosis, vaginitis, tumours]; cervical causes [infection, cancer, polyps, cervical ectropion]; uterine causes [fibroids, polyps, cancer, adenomyosis, endometritis]; ovarian secreting tumours; tamoxifen; post-smear test; missed oral contraceptive; drugs altering coagulation/clotting
Postcoital bleeding - definition and causes
non-menstrual bleeding that occurs immediately after sexual intercourse
cx - infection, cervical ectropion, cervical or endometrial polyps, vaginal or cervical cancer, trauma/sexual abuse, vaginal atrophic change
important to note that no specific cause for bleeding is found in 50% women
Breakthrough bleeding - definition and causes
Irregular bleeding associated with hormonal contraception
cx - COCP, POP, Depot injections, IUS or implant, emergency hormonal contraception
Common when a new contraceptive method is started, often settles without intervention
important to exclude pregnancy and also any underlying infection
bleeding problems are more common with p-o methods
smokers have a higher risk of this type of bleeding
Menorrhagia - definition and causes
Refers to heavy bleeding [typically >80mL]. Women may pass clots and/or experience flooding/ Women may have to wear tampons and pads simultaneously
Local causes - adenomyosis, fibroids, endometrial polyps
Systemic causes - clotting problems, hypothyroidism
Menorrhagia causes mnemonic
PERIODS
Polyps and pelvic inflammatory disease
Endometriosis and endometrial carcinoma
Really bad hypothyroidism
Intrauterine contraceptive device [copper coil]
polycystic Ovary syndrome
Dysfunctional uterine bleeding
Submucosal fibroids
Menorrhagia - ix
Diagnosis is made upon agreement between patient and clinician that menstrual bleeding experienced is heavy
Investigations may be warranted depending on PC and examination of patient
All red flags and/or intermenstrual bleeding and/or postcoital bleeding should be explored
Menorrhagia - mx
1` care interventions - IUS [progesterone coil/mirena coil], tranexamic acid, COCP, long-acting progestogens
2` care interventions - GnRH analogues, surgical [endometrial ablation, hysterectomy]
Dysmenorrhoea - defintino and causes
Painful periods
1 dysmenorrhoea - beginning when first periods start
2 dysmenorrhoea - pain starts later, previously had normal periods
cx - endometriosis/adenomyosis, fibroids [myomas], PID, ovarian cancer, cervical cancer, IUD insertion
Dysmenorrhoea - ix
good history
examination - abdo and pelvic examination
ultrasound - r/o fibroids, endometriosis, assess IUD
high vaginal and endocervical swabs
pregnancy test
Dysmenorrhoea - mx
1` - NSAIDs, paracetamol, 3-6m trial of hormonal contraceptive
non-drug alternatives - hot water bottle, TENS
2 - if serious cause or red flags - refer to gynaecologist
consider and manage other 2ry causes of dysmenorrhoea
Amenorrhoea - definition and causes
Absence of periods
1 [periods never started, no menarche] - pregnancy, constitutional delay, genitourinary malformation, ovarian failure, hypothalamic failure
2 [periods began but then stopped] - pregnancy, PCOS, hyperprolactinaemia, primary ovarian insufficiency, menopause, contraceptive use, weight loss, thyroid disease, Cushing’s, adrenal or ovarian carcinoma
Amenorrhoea - ix
good history
examination - BMI, abdo/vaginal/external genitalia/pelvic exam may be appropriate
bed: pregnancy test
blood: FSH, LH, prolactin, testosterone, TFTs
imaging: pelvic ultrasound
Amenorrhoea - mx
Referral to secondary care if there are genetic causes
Referral to fertility clinic
Contraception
HRT for women with premature ovarian failure
reassurance and waiting for constitutional late puberty
surgery for structural abnormalities
Menopause/Perimenopausal period - s/s
Initial change to menstrual pattern
Hot flushes/night sweats
Cognitive impairment and mood disorders
Urogenital symptoms [vulvovaginal irritation, discomfort, burning, itching, dyspareunia, reduced libido, urinary frequency/urgency/recurrent UTIs]
Altered sexual function
Sleep disturbance
Menopause/Perimenopausal period - ix
Ix not always required; possible to make a clinical diagnosis of perimenopause [vasomotor symptoms and irregular periods]; menopause [no periods in 12m]
Types of contraceptives
Hormonal - COCP, POP, IUS, Implant, Depot injections
Non-hormonal - IUD [copper coil]
Barrier methods - condoms [male and female]
Mx for menopausal symptoms
Lifestyle measures
Vasomotor symptoms - oral/transdermal combined preparation
Mood disorders - oral or transdermal HRT
Urogenital symptoms - low-dose vaginal oestrogen 1st line
Altered sexual function - seek specialist advice
Give combined HRT to women with a uterus to protect the uterus from oestrogen
Review after 3months; and at least annually thereafter
Non-hormonal options are available
SSRIs for vasomotor symptoms
CBT, antidepressants for low mood/depression/anxiety
Vaginal lubricants for urogenital symptoms
What is urinary frequency?
Going to the toilet more often than usual
Typically more than 7 times a day
What is polyuria?
Excessive or an abnormally large production or passage of urine
What is nocturia?
Complaint from an individual having to wake up during the night one or more times for voiding
What is hesitancy?
Condition in which you have difficulty urinating - challenging to start a stream or keep it flowing
What is poor flow?
Weak urine flow typically means that the bladder is not emptying properly
What is terminal dribbling?
When a pt continues to leak urine after micturition has ceased
Denotes abnormal sphincter function
Urinary Incontinence - definition and types
any involuntary loss of urine
Stress -involuntary leakage on effort/exertion/sneezing/coughing
Urge -involuntary leakage accompanied by a sudden compelling desire to pass urine which is difficult to defer
Mixed -stress and urgency; involuntary leakage is associated with both urgency and physical stress
Overflow -incontinence as a result of urinary retention and leakage of urine
Urinary Incontinence - Stress - mx
Refer urgently if cancer is suspected
Refer to appropriate specialist if there are complex symptoms [palpable bladder, voiding difficulty, persistent bladder pain, pelvic mass, associated faecal incontinence, neurological disease, UTIs]
Manage reversible contributing factors
Lifestyle advice - reduce caffeine, monitor fluid intake, weight loss, smoking cessation
Self-help resources
Offer trial of at least 3m supervised pelvic floor muscle training
Surgical mx - colposuspension, autologous rectus fascial sling
Offer duloxetine as 2nd-line but only if pt prefers drug to surgical mx
Urinary Incontinence - Urge - mx
Refer is cancer is suspected or there are complicated s/s
Exclude or manage treatable causes of overactive bladder syndrome
Advise about lifestyle measures and fluid intake
Self-help resources
Offer bladder training [at least 6wks]
Offer oxybutynin if symptoms persist
Review after 4wks of drug mx
Post-menopausal pts may require intravaginal oestrogen therapy
Urinary Incontinence - Mixed - mx
refer is symptoms are troublesome - cancer, etc
Manage the patient according to the most predominant type or urinary incontinence
Urinary Incontinence - Functional
This is common in older people
There are no particular stress or urge symptoms
Aetiology is often related to a combination of wider health problems - disability, cognitive impairment, mobility problems
LUTS in men - ix
good history
examination - abdomen, external genitalia, DRE, perineum and/or lower limbs for motor and sensory function
ask pt to complete a urinary frequency volume chart for at least 3 days
Exclude serious causes - cancers, infection, sciatica
urine dipstick; eGFR; PSA
Male with voiding symptoms - mx
active surveillance - reassurance, lifestyle advice, regular followup
conservative mx - pelvic floor muscle training and bladder training, advise about fluid intake, use of containment products
moderate to severe symptoms: alpha-blocker [tamsulosin]
enlarged prostate and high risk of progression: finasteride
Acute urinary retention - send to 2` care for catheterisation
Male pt with overactive bladder - mx
Exclude or manage treatable causes of OAB
Advise about fluid intake, lifestyle measures
Offer temporary urine containment products
Offer referral for supervised bladder training
Offer oxybutynin if symptoms persist
Review every 4-6wks to assess symptoms and tolerance to mx until symptoms are stable
Erectile dysfunction - definition and causes
Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
cx - vasculogenic [CVD, HTN, PAD, hyperlipidaemia, TI and TIIDM, metabolic syndrome, smoking, obesity]; Neurogenic central [Parkinson’s disease, MS, stroke, spinal cord trauma]; Neurogenic peripheral [DM, CKD, CLD, polyneuropathy]; anatomical/structural [penile cancer, congenital curvature, phimosis]; endocrine [hypothyroidism, hypogonadism]
psychogenic causes - lack of arousability, disorders of sexual intimacy, partner/relationship problems, stress, depression, psychosis
Drugs - antihypertensives, diuretics, antidepressants, antiepileptics
Erectile Dysfunction - ix
good hx - psychosexual factors, other pmhx
examination - obs, bmi, external genitalia, DRE for prostate if indicated
blood: HbA1c, serum lipid profile, fasting serum total testosterone, PSA, TFTs, LFTs, renal function
Erectile Dysfunction - mx
evidence of priapism - emergency hospital admission
referral to specialist if there are serious underlying causes
mental health services
advise about sources of reliable information
lifestyle modification - weight loss, smoking cessation, alcohol reduction
optimise mx of reversivble/modifiable RF
review medications
consider sildenafil [Viagra] if not at high risk of cardiac issues
review 6-8wks after tx started
Erectile Dysfunction - mx
evidence of priapism - emergency hospital admission
referral to specialist if there are serious underlying causes
mental health services
advise about sources of reliable information
lifestyle modification - weight loss, smoking cessation, alcohol reduction
optimise mx of reversible/modifiable RF
review medications
consider sildenafil [Viagra] if not at high risk of cardiac issues
review 6-8wks after tx started
What are a woman’s options for post-coital contraception?
Levenorgestrel-only contraception - 0-96hrs following UPSI; no c/i
Ulipristal acetate - 0-120hr following UPSI;
IUD [copper coil] - effective up to 120hr post UPSI; can be used long term
What are a male or female patient’s options for sterilisation?
Male - vasectomy; Vas deferens is interrupted, preventing sperm from entering the ejaculate
Female - tubal occlusion; Fallopian tubes are tied/clipped so they are occluded and eggs cannot reach the uterus
Depression - s/s
low mood*
loss of interest/pleasure*
significant weight change
insomnia/hypersomnia
psychomotor retardation/agitation
fatigue*
feelings of worthlessness
low concentration
recurrent thoughts of suicide or death
*required for most days for 2 weeks for formal diagnosis
Depression - Core Symptoms
feeling down, depressed, hopeless
little interest or pleasure in doing things they used to enjoy
-present for most days, most of the time for at least 2 weeks
Depression - ix
PHQ-9 questionnaire
bloods: FBC, U&Es, TFTs
consider other psychiatric conditions, anxiety, substance misuse, schizophrenia, psychotic depression, dementia
consider drug s/e
Depression - mx
bio: SSRIs (monitor for suicidal thoughts, 2w f-up)
psycho: CBT is first line
social: support from family/friends/carers; housing support; CPN; CMHT support
consider MHA assessment if psychotic or severe depression, risk of self-harm/suicide/harm to others
local safeguarding if vulnerable
active monitoring and follow-up required
Anxiety - s/s
excessive anxiety and worrying [more days than not for 6+m]
worry or anxiety is difficult to control
three+ of the following:
*restlessness
*fatigue
*sleep disturbance
*irritability
*muscle tension
*trouble concentrating
Anxiety - ix
GAD7 questionnaire
consider thyroid dysfunctin and other endocrine disorders
