Primary care Flashcards
medication for weight loss
orlistat -→ energy wastage→ poo out fat
liraglutide →appetite suppression
pharmacological interventions for people with alcohol dependence or disease caused by alcohol
e.g. acamprosate
(disulfiram used less regulary now)
serious consequenc of alcohol
Wernickes →Korakoffs
A 34-year-old woman has just given birth 24 hours ago. She states she is not planning on having any more children in the immediate future and would like to start a long-term contraceptive. She has a past medical history of heavy menstrual bleeding and is planning to exclusively breastfeed.
What is the most appropriate contraception for this patient?
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks
but due to history of heavy bleeding- IUS
A 21-year-old woman at 34 weeks gestation telephones her GP for advice. Her pregnancy is progressing well but she is keen to explore which contraceptive options are available to her following childbirth. After an extended discussion, her preferred option would be the contraceptive implant. The patient has no underlying medical conditions and does not plan to breastfeed.
From what timepoint could this patient commence on this treatment?
A contraceptive implant can be safely inserted any time after childbirth
A 32-year-old female requests emergency contraception. She had unprotected sexual intercourse 28 hours ago and is not using any regular contraception. She has a diagnosis of obesity, severe asthma and uterine fibroids with distortion of the uterine cavity.
Levonorgestrel (double standard dose)51%
within 72hours
double dose due to obesity
A 41-year-old female called this morning to request emergency contraception. She had unprotected sexual intercourse 48 hours before calling and is not using any regular contraception. Currently, she is breastfeeding. There is no medical history of note and she weighs 55 kg. She declined an intrauterine device and you prescribed an emergency hormonal contraception however she calls during your afternoon clinic to say she vomited one hour after taking this.
Levonorgestrel (standard dose)
Vomiting occurs in around 1% of patients who take levonorgestrel. If vomiting occurs within 3 hours then the dose should be repeated.
A 29-year-old female requests emergency contraception. She had unprotected sexual intercourse 7 days ago. Her LMP was 16 days ago, her cycle is usually 30 days. She was using condoms intermittently for contraception and takes no regular medications.
The copper intrauterine device can be used as emergency contraception if it is inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date.
A 32-year-old woman is reviewed at 3 days post-partum on the postnatal ward. She had an uncomplicated, elective lower-segment caesarean section. This was her first child and she is keen to exclusively breastfeed. Her lochia is normal and she is mobilising to the bathroom independently. She is to be discharged later that day and is keen to start contraception immediately. At different points in time before her pregnancy, she reports using the combined oral contraceptive pill and an intrauterine device, both of which suited her.
What should she be offered?
Postpartum women (breastfeeding and non-breastfeeding) can start the progestogen-only pill at any time postpartum
A 32-year-old woman is reviewed at 3 days post-partum on the postnatal ward. She had an uncomplicated, elective lower-segment caesarean section. This was her first child and she is keen to exclusively breastfeed. Her lochia is normal and she is mobilising to the bathroom independently. She is to be discharged later that day and is keen to start contraception immediately. At different points in time before her pregnancy, she reports using the combined oral contraceptive pill and an intrauterine device, both of which suited her.
What should she be offered?
Postpartum women (breastfeeding and non-breastfeeding) can start the progestogen-only pill at any time postpartum
A 24-year-old woman presents to the clinic for family planning. She requests a form of contraception that will not interfere with sexual intercourse and is reversible upon stopping.
She currently experiences heavy, painful, and irregular periods, but is otherwise fit and well. It is suggested she starts the combined oral contraceptive pill (COCP) as there are no contraindications and it might help her symptoms.
What additional health benefits might this medication provide?
benefits
- lighter and less painful periods
- protective against ovarian and endometrial cancer
negatives
- increased risk of breast and cervical cancer
describe elevated solid lesions
<1cm
papule
>1cm
nodule
>2cm
plaque
describe flat lesions
<1cm
macule
>1cm
patch
describe fluid filled lesion
<1cm
Vesicle
>1cm
Bulla
describe pus filled blister
<1cm
pustule
>1cm
abscess
hypersensitivity reaction (just learn)
Type 1- allergy
Type 2- haemolytic reaction
Type 3- SLE
Type 4- contact dermatitis
A 19-year-old with a few papules and pustules with some erythema mainly on the forehead and cheeks. He has tried a few over-the-counter creams with no success.
opical adapalene (topical retinoid) with benzoyl peroxide
A 32-year-old female reports that she is still experiencing facial acne despite continuing to use the benzoyl peroxide cream prescribed by her GP. She is in the process of weaning off her baby from breast milk. She would like to try an oral tablet.
Erythromycin is safe in breastfeeding, unlike tetracyclines or retinoids, and is, therefore, the most appropriate choice as the baby is still partly breastfeeding. Antibiotics can be used for up to 3 months for acne. They should be co-prescribed with benzoyl peroxide, which she is using.
A 77-year-old man presents to his GP with a painful rash around his ear. He first noticed pain in his left ear 3 days ago and is now also complaining of vertigo and tinnitus. On examination, you note a vesicular rash around his left ear.
Given the most likely diagnosis, what is the most appropriate treatment for this patient?
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
Otosclerosis may be precipiated by pregnancy in those who are genetically predisposed
audiograms
Audiograms are usually the first-line investigation that is performed when a patient complains of hearing difficulties. They are relatively easy to interpret as long as some simple rules are followed:
- anything above the 20dB line is essentially normal (marked in green on the audiogram below)
- in sensorineural hearing loss both air and bone conduction are impaired
- in conductive hearing loss only air conduction is impaired
- in mixed hearing loss both air and bone conduction are impaired, with air conduction often being ‘worse’ than bone
the combined pill increases your risk of which cancers
breast
cervical
the combined pill decreases your risk of which cancers
endometrial
ovarian
management of COPD
Make sure patient has correct inhalation technique. Nebulised treatment should be considered for patients with distressing or disabling breathlessness
- Initial treatment: SABA or SAMA
- Step up treatment for patient without asthmatic features or features suggesting steroid responsiveness: LABA and a LAMA (discontinue SAMA if LAMA given)
- SABA continued throughout all stages of treatment
- Patients on LAMA and LABA who have severe exacerbations or at least 2 moderate exacerbations, consider addition of ICS INHALER (TRIPLE THERAPY)
- Step up treatment for patient with asthmatic features or features suggesting steroid responsiveness
- LABA and ICS
- Patients on LABA and ICS who have severe exacerbations or at least 2 moderate exacerbations, consider addition of LAMA
management of ectopic preganacy
methotrexate
- small (<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of <1500 IU/L, no intrauterine pregnancy and no pain
Laparoscopic salpingectomy (or salpingotomy where there is risk of infertility).
This should be offered where the ectopic is larger than 35mm, is causing severe pain or if the B-hCG level is >1500. There is a risk of infertility if a problem arises with the remaining Fallopian tube in the future.
manageemnt of unwanted pregnancy
Misoprostol and mifepristone
pharmacological interventions for people with alcohol dependence or disease caused by alcohol
Reveal Answer
e.g. acamprosate
(disulfiram used less regulary now)
wernickes encephalopathy
caused by alcohol dependence causing vitamine B (thiamine) def
- confusion
- ataxia
- visual changes
korsakoff
comes after wernickes
- amnesia
- confabulation
- psychosis
what should not be prescribed to pregnant women quiting smoking
- arenicline or bupropion should not be prescribed
- NRT can be
Iron deficiency anaemia vs anaemia of chronic disease
A 65-year-old woman attended the GP 4 days ago feeling lethargic and tired for the past 3 months. Her only past medical history is rheumatoid arthritis for which she takes paracetamol as required for pain. She is a non-smoker, does not drink alcohol, and retired 10 years ago from her job working in a factory producing ceramic paints. Bloods show:
Anaemia of chronic disease
Ferritin is low in iron deficiency anaemia but high or normal in anaemia of chronic disease
causes of microcytic anaemia
T- thalassaemia
A- anaemia of chronic disease
I- iron deficieny anaemia (low ferritin)
L- lead poisoning
S- sideroblastic anaemia
sideroblastic anaemia
a disorder where the body produces enough iron but is unable to put it into the haemoglobin
Vitamin B6 deficiency
causes of macrocytic anaemia
- Liver diseases.
- Thyroid function.
- Levels of vitamin B12 and folate.
cause of normocytic anaemia
look at reticulocyte count
- high- haemolytic
- haemolysis
- blood loss
- low - non-haemolytic
- marrow hypoplasia
When can the COCP be started again after pregnancy
The combined oral contraceptive pill CAN be given if requested 6 weeks postpartum even if breastfeeding. BUT they can get pregnant from day 21 postpartum so if they have had unprotected intercourse from day 21 postpartum, a pregnancy test should be performed first
A 33-year-old female presents to her GP as she missed her Noriday pill (progestogen only) this morning and is unsure what to do. She normally takes the pill at around 0900 and it is now 1230. What advice should be given?
Noriday needs to be taken within 3hours (unlike desogesterol which cna be taken within 12 hours)
She should: Take missed pill as soon as possible and advise condom use until pill taking re-established for 48 hours52%
A 12-year-old girl presents to your GP clinic requesting some contraception. She has had a boyfriend for 8 months who is aged 13. What is the most appropriate immediate course of action to take?
A child under the age of 13 is always considered to be unable to consent for sexual intercourse. This is regardless of whether they are Gillick competent. As a result all consultations with this age group should automatically trigger child protection measures.
A 24-year-old woman books a routine appointment. She has recently started a sexual relationship and would like to start long term contraception as they have no intentions to have children for the foreseeable future. Her mother was diagnosed with breast cancer 10 years ago, the patient along with the rest of her family was tested at the time and she was found to have a BRCA1 mutation.
According to the Faculty of Sexual and Reproductive Health (FSRH) guidelines which is the safest method of contraception?
Suspected/personal history of breast cancer or confirmed BRCA mutation - copper coil is the safest form of contraception
Contraceptives - time until effective (if not first day period):
Contraceptives - time until effective (if not first day period):
- instant: IUD
- 2 days: POP
- 7 days: COC, injection, implant, IUS
You are a junior doctor working in a GP practice. A 13-year-old girl comes to see you requesting a prescription for the oral contraceptive pill. On further questioning, she tells you she has a sexual relationship with her 14-year-old boyfriend. She is refusing to speak to her parents about it and states that she will continue having sex even if she doesn’t get the pill and she understands the risks associated with this. She is otherwise well with no history of migraines and she has normal blood pressure. What do you do?
A 35-year-old woman is due to be discharged from the postnatal ward 12 hours after delivering her son via normal vaginal delivery. She enquires about contraceptive options as she feels her family is now complete.
She has no past medical history and there were no complications during her pregnancy or labour. In the past, she has used the intrauterine system (IUS) and would ideally like to go back to this.
What advice should she be given?
The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks
Hearing Disability is defined as:
- Normal hearing is defined to be 20dB or better.
- Mild hearing loss is between 21-40dB.
- Moderate hearing loss is between 41-70dB.
- Severe hearing loss is considered to be 71-90dB.
- Profound hearing loss is worse than 90dB.
which ear
- In the left ear, the light reflex should be positioned at approximately 7 o’clock to 8 o’clock.
which ear
- In the right ear, the light reflex should be positioned at approximately 4 o’clock to 5 o’clock.
arterial supply of the nose includes
ophthalmic artery- posterior nose bleeds (ethmoidal arteries)
maxillary artery- most common source of bleeding
management of nose bleed
Management
- All nosebleeds should be approached using a DRABCDE resuscitation approach and a stepwise approach to the management for epistaxis.
- Take a brief history: Which side? Trauma? Anticoagulants/antiplatelets? Relevant past medical history.
Direct Compression
- Direct compression of the nasal alae (cartilaginous part) is first-line management for epistaxis as most anterior bleeds resolve after 10-15 minutes of compression without interruption. The patient should be sitting up and leaning forward to minimise blood entering the oral cavity and pharynx. A common misconception is that compression of the nasal bones controls bleeding.
- If direct compression of the nasal alae for 10-15 minutes does not resolve epistaxis, the next most appropriate management step in this patient would be nasal cautery as there is a visible bleeding site and this patient also suffers from recurrent epistaxis. He is calm and thus may be able to tolerate cautery.
Cautery
- Before cautery, a topical anaesthetic spray and vasoconstrictor (lidocaine with phenylephrine) is usually applied to reduce pain and helps control bleeding respectively.
- Cautery can either be chemical or electrical (thermal).
- Chemical cautery involves applying 75% silver nitrate sticks to the identified bleeding site for 3-10 seconds.
- Afterwards the cauterised area is dabbed with a clean cotton bud to remove excess chemical or blood and a topical antiseptic preparation such as Naseptin (chlorhexidine and neomycin) is applied to the nostrils 4 times daily for 10 days to reduce crusting and vestibulitis.
Nasal Packing
- If nasal cautery fails or there isn’t a bleeding point identified or there is severe bleeding, nasal packing would be the next most appropriate management step to tamponade the local bleeding.
- Nasal tampons, inflatable packs and ribbon gauze impregnated with Vaseline can be used in nasal packing.
Aggressive Therapies
Aggressive therapies such as nasal balloon catheter and transnasal endoscopy with direct cautery/arterial ligation are reserved for patients with posterior bleeds and uncontrollable severe bleeding unamenable to nasal packing.
sensory supply of the tongue
nervous supply to the tongue
- Anterior 2/3
- Sensation- trigeminal (V3)
- Taste- facial
- Posterior 1/3
- Sensation and tase- glossopharyngeal
malignant causes of thyroid nodules
papillary- most common - good prognosis
follicular- good prognosis
medullary- produce calcitonin
anaplastic- bad prognosis
what kind of eye movement is associated with BPPV
rotatory nystagmua
A 45-year-old female presents to the general practitioner with a two-week history of progressive paraesthesia of the fingers, toes and peri-oral area, associated with muscle cramps and spasms. She recently underwent a thyroidectomy for Graves’ disease but is otherwise well with no drug allergies.
Given the likely diagnosis, what is this patient’s ECG likely to show?
isolated QTc elongation
Complications of thyroid surgery - damage to parathyroid glands can result in hypocalcaemia
A 48-year-old woman is admitted to the acute medical unit with sudden-onset dizziness, which she describes as the room spinning around. The dizziness is persistent and does not settle with rest. It is associated with severe nausea and vomiting. She also complains of hearing loss in her left ear. Other than a recent cough and coryza episode, she has been well with no past medical history.
On examination, Rinne’s test shows air conduction is greater than bone conduction in both ears. Weber’s test lateralises to her right ear. She has a normal range of eye movements with mild horizontal nystagmus on lateral gaze. Her coordination is intact.
Viral labyrinthitis stereotypical history: recently developed an upper respiratory tract infection presents with vertigo and vomiting. Hearing is also affected. The symptoms came on suddenly
A 57-years-old woman presents to the emergency department with a sudden intense episode of dizziness. Her symptoms began while lying in bed when she turned her head to the side. She experienced two bouts of vomiting accompanied by a sensation that the world was spinning around her.
She has experienced such episodes in the past lasting around 30-60 seconds before self-resolving. Her past medical history is significant for migraines and hypertension. She denies tinnitus or any hearing changes.
Her observations are:
- Temperature: 36.9 °C
- Blood pressure: 145/90 mmHg
- Pulse: 95/min.
Which of the following is the most appropriate immediate management for this patient’s condition?
BPPV
- Dix-Hallpike manoeuvre is diagnostic
- Epley manoeuvre is for treatment
A 62-year-old male presents with right ear pain and a longstanding purulent discharge from his right ear. On examination you notice he has a facial nerve palsy. Which of the following is the biggest risk factor for malignant otitis externa?
DM
A 58-year-old lorry driver presents with a lump in his neck. He first noticed it after recovering from a ‘cold’ 2 months ago. The patient reports no change in the size of the lump. He is otherwise well in himself and denies dysphagia, odynophagia, weight loss or loss of appetite. He is a heavy smoker and drinks alcohol daily. On examination, you feel a hard, fixed lump in the anterior triangle of the neck.
Which of the following is the best next investigation?
US is the imaging modality of choice for ALL neck lumps
A 12 year old boy suffers from episodes of rhinorrhoea, nasal blockage and recurrent sneezing. This is worse during the summer and also became more frequent after his family adopted a dog. He has a past medical history of childhood eczema and asthma. On examination, the nasal mucosae appear generally inflamed but no abnormalities are visualised. What is the pathophysiology that underpins the most likely diagnosis?
type I sensitivity reaction
Types of hyperparathyroidism
- Primary - one parathyroid gland (or more) produces excess PTH. This may be asymptomatic or can lead to hypercalcaemia.
- Secondary - there is increased secretion of PTH in response to low calcium because of kidney, liver, or bowel disease.
- Tertiary - there is autonomous secretion of PTH, usually because of chronic kidney disease (CKD).
causes of primary hyperparathryoidism
- Parathyroid gland adenoma (single gland)
- Hyperplasia of all four glands
- Two adenomas
- Parathyroid carcinoma (rate)
Causes of secondary hyperparathyroidism
- Vitamin D deficiency
-
Loss of extracellular calcium
- Pancreatitis
- Rhabdomyolysis
- Hungry bone syndrome
- Calcium malabsorption
-
Abnormal parathyroid hormone activity
- Chronic kidney disease
- Pseudohypoparathyroidism
- Inadequate calcium intake
causes of tertiary hyperparathyroidism
Usually occurs after prolonged secondary hyperparathyroidism
- The glands become autonomous, producing excessive PTH even after the cause of hypocalcaemia has been corrected.
- Long-standing kidney disease is the most common cause.
Management
- Cinacalcet (a calcimimetic that mimics teh action of calcium on tissues)
- Total or subtotal parathyroidectomy
A 70 year old man presents with hearing loss and tinnitus. He also experiences left sided occipital pain. On examination, Rinne’s test is positive bilaterally and Weber’s test localises to the right ear. There is loss of the corneal reflex on the left eye. Otoscopy is unremarkable. What is the most likely diagnosis?
vestibular schwannoma
