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My General Practise > Oxford Summary 3 > Flashcards

Oxford Summary 3 Flashcards

1
Q

BC risks

A
  • Developed counties
  • Age, SES
  • Obesity, high- fat diet, alcohol
  • Early menarche, lare menopause
  • Nulliparity, non breastfeeder
  • OCP, HRT
  • Past hx breast disease: carcinoma in situ, hyperplasia, papilloma with fibrovascular core
  • Ionizing radiation
  • Fhx: BRCA 1/ BRCA2
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2
Q

BC Management

A
  • Urgent refer to breast surgeon
  • Mammogram, USS ± FNA or core bx
  • Tumour markers
  • CT/MRI, liver USS, bone scan
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3
Q

BC Tx

A

RT, CT
• Surgery: lumpectomy ± axillary clearance, mastectomy
• Endocrine therapy:
o Tamoxifen: ER+. SE- endometrial ca, DVT
o Aromastase inhibitor- anastrozole, letrozole, exemastane: block estrogen synthesis. Postmenopausal»
o Trastuzumab: MAB against HER2. IV every 3 weeks for 1 year

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4
Q

BC PC

A
  • Breast lump>, pain, skin changes
  • Nipple change, discharge (eczema = pagets- intraepidermal, intraductal ca)
  • Fhx
  • Skin changes
  • Distant met
  • Elderly: extensive local lesions
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5
Q

BC Prognosis

A
  • 73% women diagnosed will live 10years
  • Recurrence usually <2yrs after treatment
  • Depends on age (best if 50-59), stage, grade, and ER status
  • Affluent areas have better prognosis
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6
Q

BC psych impact

A

depression, anxiety, marital and sexual problems

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7
Q

Menorrhagia DDx

A

• Dysfunctional uterine bleeding
• Fibroids, polyps
• Congenital uterine abnormality- bicornuate uterus
• Pelvic infection, endometriosis,
• Endometrial carcinoma, hormone- producing tumour
IUCD

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8
Q

Menorrhagia Tx

A

• Nonhormonal: mefenamic acid, tranexamic acid
• Hormonal
• Surgical
o Myomectomy, polypectomy
o Endometrial ablation
o Hysterectomy
• Interventional radiology: uterine artery embolization

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9
Q

Menorrhagia Sx suggestive of pathology

A 
•	Irregular bleeding/ sudden change in bleeding 
•	PCB, IMB
•	Dyspareunia 
•	Pelvic pain 
Premenstrual pain
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10
Q

Menopause Dx

A

Amnorrheoa >12 months
• Average is 51 years and brought forward 2 years if smoker
• FSH >40iU on 2 occasions >1month apart

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11
Q

Menopause Sx

A

• Flushes and sweats
• Psychological: depression and anxiety
• Ischaemic heart disease
• Osteoporosis
• Urogenital
o Vaginal dryness and atropy sexual dysfunction- tx lubricants and topical estrogen
o Loss of libido- treat with androgen with HRT
Incontinence, nocturia, urgency- tx topical E to improve outcome of surgery

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12
Q

Menopause premature

A 
under 40
•	Idiopathic 
•	Infection- TB, mumps 
•	Surgery- BSO 
•	RT/ CT 
•	FSH R abnormalities 
•	Turners 
AI: DM, hypothyroidism, addisions
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13
Q

Menopause Tx

HRT

A

• Contraindications: estrogen sensitive cancer, hx DVT, liver disease, migraines
• Indications
o Early menopause- continue till 51years
o Hysterectomy before menopause
o Second-line tx osteoporosis
• Choice of preparation:
o W/o uterus: unopposed estrogen, unless endometriosis
o Intact uterus: combined
• SE
o Estrogenic: fluid retention, breast enlargement and tenderness, nausea and headaches
o Progesterone: headache, weight gain, bloating
• Risks: breast cancer, DVT, stroke, GB disease, ovarian ca
• Short term benefits: alleviate symptoms, decrease UTI
• Long- term benefits: decrease osteoporosis and colorectal ca

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14
Q

Menopause Tx

Tibolone

A

oestrogenic, progesteronic and weak androgen

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15
Q

Menopause Tx

Topical vaginal prep

A

pessaries, creams, rings
• For vaginal dryness/ atrophy
• 3-6 months if uterus

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16
Q

Menopause Tx

Tx of hot flushes

A

• Lifestyle changes: exercise, cool temperature, avoid alcohol, caffeine, spicy foods
• Medications
o HRT
o Megestrol acetate 40mg od- same risks as HRT
o SSRI/ SNRI- venlafaxine 3.7mg bd
o Gabapentin 300mg tds
Clonidine- can cause hypotension

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17
Q

Ovarian cancer

urgent referral

A

ascites or ovarian mass

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18
Q

Ovarian cancer

check Ca-125 levels if

A 
•	New IBS >50 years 
•	Weight loss, fatigue, change in bowel habit 
•	>12 month history of: 
o	Bloating 
o	Pelvic/ abdominal pain 
o	Early satiety/ loss of appetite 
o	Increased frequency/ urgency
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19
Q

Epithelial ovarian cancer

A

90% of all cancers
• Age: 50-70
• Family history
• Increased ovulation: infertility, nulliparity
• Lifestyle: obesity and smoking
• Breast cancer <40, cervical cancer, endometriosis, benign cysts

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20
Q

Ovarian cancer

Sex-cord stromal tumours:

A

• Thecoma, fibroma, setoli/leydig cell, granulosa cell tumour
• Early presentation with hormone production
o Precocious puberty, PMB, virlism
• Granulosa cell tumour linked w/ endometrial hyperplasia/ ca

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21
Q

Ovarian cancer

Germ - cell tumours:

A
  • Immature and mature teratoma (dermoid cyst), dysgerminoma, endodermal sinus tumour (yolk sac), mixed
  • Peak incidence in early 20s
  • Increase in AFP and BHCG
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22
Q

4 common symptoms in pregnancy

A

Abdominal pain
Bleeding
Insomnia
Itching/ pruitis

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23
Q

common preg Sx

Backache:

A

2nd trimester + and worse in evenings
• Exercise
• Simple analgesia, physiotherapy ± massage

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24
Q

common preg Sx

Breast soreness

A

Nipples enlarge and darken around 12 weeks

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25
Q

common preg Sx

Carpal tunnel syndrome

A

Resolves after pregnancy

Use night splints and if severe steroid injections

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26
Q

common preg Sx

Constipation

A
  • Increase fluid and fiber intake
  • If necessary use bulk- forming laxative- ispahula husk
  • Avoid bowel stimulants bc increase uterine activity
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27
Q

common preg Sx

Cramp

A

Worse at night, try raising foot of bed at night

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28
Q

common preg Sx

Fatigue

A
  • Early: almost everyone and peaks at 12-15 weeks. Advice rest
  • Late: due to increased physical effort and sleep deprivation
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29
Q

common preg Sx

Haemorrhoids: 8% in 3rd trimmers

A
  • Px: itching, pain and bleeding

* Advice to increase fiber intake and treat prolapse with ice packs and replacement

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30
Q

common preg Sx

Headache: tension>

A
  • Check BP and urine

* Treat with rest and analgesia

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31
Q

common preg Sx

Heartburn- 3rd trimester

A
  • Advice low-fat, bland food, small + frequent meals, no caffeine
  • Avoid eating at night and consider raising head in bed
  • Antacid preperations- magnesium trisilicate
  • Check BP and urine
32
Q

common preg Sx

Hypotension

A
  • Common in early pregnancy

* Check no bleeding

33
Q

common preg Sx

Nausea and Vomiting

A
  • At any time of day, worse with smells and sight of food
  • If severe exclude: multiple, trophoblastic disease and UTI
  • Reassure, frequent small meals, avoid spicy and greasy, fluic
  • If severe: anti-emetic- cyclizine 50mg tds
34
Q

common preg Sx

Peripheral paraesthesia: hands and feet

A

• Reassure- gone after pregnancy

35
Q

common preg Sx

Skin changes

A
  • Pigmentation- linea nigra, chloasma
  • Spider naev, palmar erythema
  • Abdominal straie
36
Q

common preg Sx

Sweating and feeling hot

A
  • Common, check if pyrexic

* If apyrexic- reassure

37
Q

common preg Sx

Swelling

A
  • Ankles, hands/ fingers, face

* If severe or sudden check BP/ urine dipstick

38
Q

common preg Sx

Symphysis pubis dysfunction

A
  • Separates and causes discomfort/ pain in lower abdomen/ pelvic area and radiates to lower back, upper thighs, perineum
  • Constant, worse on movement and relief at rest
  • Treat with analgesia, physiotherapy
39
Q

common preg Sx

Urinary frequency

A

Do MSU- UTI common and a/w premature delivery

40
Q

common preg Sx

Vaginal discharge

A

Investigate if smelly, itchy, sore or a/w dysuria

41
Q

common preg Sx

Varicose veins

A
  • Aching legs, fatigue, itch, swelling
  • Exclude PET
  • Elevate legs, support stockings, encourage walking
  • Complications: thrombophlebitis and DVT
42
Q

General postnatal problems

A 
Abdominal pain
Dyspareunia
Hair loss
Haemorrhoids
Perineal bruising 
Baby blues
Poor abdominal and pelvic muscle tone
Peripheral paraesthesia
Skin changes
Sweating and feeling hot
Swelling 
Symphysis pubis dysfunction
Superficial thrombophlebitis  
Urinary frequency 
Vaginal discharge 
Varicose veins
43
Q

Breast:

postnatal problems

A
  • Engorgement
  • Sore/ cracked nipples- topical remedieis and rest
  • Skin infection- local around nipple- candida> tx miconazole gel
  • Blocked duct- hard, tender lump. Massage during feeing
  • Mastitis: tender, hot, red ± fever. Tx flucloxacillin 500mg qds + NSAID ibuprofen 400mg tds prn
  • Abscess: incision and drainage
44
Q

Persistent lochia

postnatal problems

A 
bleeding >6 weeks. Causes: 
•	Infection, RPC 
•	Unhealed tears 
•	Resumptiom of cycle 
•	SE of contraception 
•	Cervical/ uterine pathology 
•	Abdominal exam, VE, speculum, Abx if infection
45
Q

Postnatal depression

postnatal problems

A

10-15% peak ~12wks
Screen all moms 4-6 weeks and 3-4 months postpartum

Risks
o Depression during pregnancy, past hx, Fhx
o Bad birth experience
o Social problems, alcohol or drug use

46
Q

Puerperal pyrexia

postnatal problems

A

> 38C within 14 days of delivery/ miscarriage
• Ask about urinary symptoms, breast, color and smell of lochia, pain, cough, sore throat
• Superficial perineal infection: flucloxacillin
• Endometritis: offensive lochia, lower abdo pain, tender uterus- amoxicillin 500mg tds + metronidazole 400mg tds or co-amoxiclac 375 tds
• Mastitis
DVT/ PE can px with fever

47
Q

N+V

postnatal problems

A

• At any time of day, worse with smells and sight of food
• If severe exclude: multiple, trophoblastic disease and UTI
• Reassure, frequent small meals, avoid spicy and greasy, fluic
If severe: anti-emetic- cyclizine 50mg tds

48
Q

Puerperal psychosis

postnatal problems

A

1:500 births

Severe depression, suicidal, mania, psychotic symptoms

49
Q

Anaphylaxis CAUSES

A
  • Food: nuts, milk, fruit, fish, shellfish, eggs, beans, peas
  • Drugs: Abx, aspirin and other NSAIDs, opiods
  • Insect stings: wasp, bee
  • Latex
50
Q

Anaphylaxis Sx

A

o Airway problems: difficulty breathing/ swallowing, throat closing, hoarseness, stridor
o Breathing problems: tachypnea, wheeze, SOB, O2 sat <92%, cyanosis, confusion due to anoxia, respiratory arrest
o Circulation problems: shock (pallor, clammy, tachy, brady is late), hypotension, dizziness, collapse, confusion, LOC
• Skin/ mucosal changes: flushing, erythema, utricaria ± angioedema, rhinitis, conjunctivitis
• Other: abdominal pain, vomiting or incontinence, anxiety

51
Q

Anaphylaxis DDx

A
  • Life- threatening: severe asthma, septic shock

* Non- life threatening: simple faint, panic attack, lone urticarial/ angioedema

52
Q

Anaphylaxis follow up

A
  • Warn about reoccurrence
  • Advice to wear medic-alert bracelet
  • Supply with Epipen- IM adrenaline
53
Q

Shock PC

A

hypotension, tachycardia, peripheral cyanosis, low urine output

54
Q

Shock TYPES

A 
•	Anaphylactic shock 
•	Septic shock 
•	Cardiogenic shock
o	Hypotension- systolic BP <80-90 
o	Pulse can be normal, high or low 
o	SOB ± cyanosis 
•	Neurogenic: cerebral trauma or haemorrhage 
•	Poisoning, liver failure
55
Q

Shock IMMEDIATE MANAGEMENT

A

• Sit up, call for ambulance, IV access
• Atropine for bradycardia
• Diamorphine, fureosemide, GTN spray if LVF
100% O2 unless COPD then 24%

56
Q

Hypovolemic shock

A

• Initially: tachycardia, pallor, sweating ± restlessness
• Later: decompensation- sudden fall in HR and BP
Causes: HI bleed, menorrhagia, laceration, ruptured AAA, dissecting thoracic aneurysm, epistaxis

57
Q

Ruptured AA PC

A
  • ~80% die before reaching hospital and 10% during surgery

* Px: hypotension + abdominal pain

58
Q

Dissecting Thoracic Aneurysm Px

A

sudden tearing chest pain radiating to back
With dissection, branches of aorta are occluded hemiplegia, unequal pulses and BP in arms, paraplegia, acute renal failure, aortic incompetence, MI

59
Q

Action for ruptured AAA or dissecting thoracic aneurysm

A
  • Lie flat and raise legs, call ambulance
  • IV access: FBS, cross- match, IV fluids
  • 100% O2
60
Q

Epistaxis
ruptured BV on nasal septum
Young causes

A

nose picking
coryza
allergic rhinitis
blood dyscrasias

61
Q

Epistaxis elderly causes

A 
degenerative arterial disease = arteriosclerosis
HT
nose picking
coryza
allergic rhinitis
medications (warfarin, aspirin)
blood dyscrasias
telangiectasia
tumour
62
Q

Chest Pain and Palpitations

Hx + Exam

A

ACS, PE, dissecting aneurysm, pericarditis
• General appearance, BP in both arms, JV and carotid
• HS, apex beat
• Lung fields
• Tenderness, pain on moving chest, rash, legs

63
Q

Chest Pain and Palpitations

Investigations

A

ECG and chest XRAY
Increased ICP symptoms
Septicaemia symptoms

64
Q

Chest Pain and Palpitations

DDx

A 
ACS
Pericarditis
Dissecting thoracic aneurysm
PE
Pleurisy
Pneumothorax
Esophageal spasm, esophagitis
MSK pain
Costochondritis
Shingles
Bornholm's disease
Idiopathic chest pain
65
Q

ACS PC

A

Central dull aching pain, ratiates to jaw and L arm

Nausea, sweating, SOB

66
Q

Pericarditis PC

A
  • Sharp constant sternal pain relieved by sitting forward, radiates to L shoulder ± arm or into abdomen
  • Worse on left side, on inspiration, swallowing, coughing
67
Q

PE PC

A
  • Acute SOB, sharp chest pain worse on inspiration, haemoptysis ± syncope
  • Tachycardia and mild pyrexia
68
Q

Pleurisy PC

A

Sharp, localized chest pain worse on inspiration

69
Q

Pneumothorax PC

A

Sudden pleuretic chest pain or SOB ± pallor, tachy

70
Q

Esophageal spasm, esophagitis PC

A

Central burning chest pain ± acid reflux

71
Q

MSK pain PC

A

Localized pain, worse on movement with hx injury

72
Q

Costochondritis PC

A

Tenderness over costochondral junction

73
Q

Shingles PC

A
  • Intense, sharp, unilateral pain
  • Poor response to analgesia
  • Px days before rash
74
Q

Bornholm’s disease PC

A
  • Unilateral chest and/ or abdominal pain, rhinitis
  • Coxsakie virus infection
  • Treat with analgesia
75
Q

Idiopathic chest pain PC

A
  • Young and elderly

* Males>

76
Q

ACS Action

A

Ambulance
Morphine 5-110mg, O2, GTN spray, aspirin 300mg, clopidogrel
Antiemetic- metoclopramide 10mg
Atropine 500mcg (max 3mg) if bradycardia
ECG

77
Q

ACS includes

A

STEMI
• ECG: ST elevation or new LBBB
• Raised troponin levels

NSTEMI
• ECG: normal or MI signs- ST depression, T-wave inversion
• Raised troponin levles

Unstable angina
• ECG: normal or signs of MI
Normal troponin levels

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