Primary Care 2.0

Question 1

GORD, dyspepsia etc.

Answer 1

GORD, dyspepsia etc.

Question 2

What is dyspepsia? How is it investigated? What does the management depend on?

Answer 2

• dyspepsia = range of symptoms from the upper GI tract - tend to be present for 4w or more + can be:
  
  • upper abdo pain/discomfort
  • heartburn
  • gastric reflux
  • nausea or vomiting
• Investigate the following (endoscopy)
  
  • ? oesophageal or stomach Ca:
    
    • urgent (2ww) if:
      
      • dysphagia
      • upper abdo mass consistent w/ Ca
      • age >55 w/ weight loss and any of:
        
        • upper abdo pain, reflux,dyspepsia
    • non-urgent if:
      
      • haeamtemesis
      • patient age >55 w/
        
        • treatment resistant dyspepsia
        • upper abdo pain w/ low Hb
        • raised platelets w/ any of: n+v, weight loss, reflux, dyspepsia, upper abdo pain
        • n+v w/ any of: weight loss, reflux, dyspepsia, upper abdo pain
  • for ?GORD
    
    • age >55
    • symptoms for >4w or symptoms persisting despite treatment
    • dysphagia
    • relapsing symptoms
    • weight loss
• Treatment then depends on whether endoscopy is done or not + what the endoscopy shows- can split into:
  
  • No endoscopy = undiagnosed dyspepsia
  • Endoscopy –>
    
    • +ve for oesophagitis
    • -ve for oesophagitis –> do pH studies for ? GORD
      
      • if pH study +ve = endoscopy -ve GORD
      • if pH study -ve treat as for undiagnosed dyspepsia

(GORD = endoscopically determined oesophagitis or endoscopy -ve reflux disease)

• Possible causes of dyspepsia:
  
  • Ca - oesophageal/stomach
    
    • (red flags above)
  • GORD
  • Peptic ulcer disease
  • overeating/eating quickly; fatty/greasy/spicy food/ caffeine/alcohol/fizzy drink; anxiety
  • meds- antibiotics, NSAIDs, iron supplements
  • GI: coeliac, gallstones, constipation, pancreatitis etc,

Question 3

Describe the management of the following:

• Undiagnosed dyspepsia (that does not meet criteria for referal for endoscopy)
• GORD:
  
  • endoscopy +ve oesophagitis
  • endoscopy -ve reflux disease
  • also what are possible complications of GORD?

(N.B. if both endoscopy -ve and pH study -ve treat as undiagnosed dyspepsia)

Answer 3

• Undiagnosed dyspepsia
  
  • 1. review medications for a possible cause of dyspepsia
  • 2. lifestyle advice
  • 3. trial of full-dose PPI for 1month OR ‘test + treat’ approach for H.pylori
       * (covered more in peptic ulcer disease FCs)
• GORD:
  
  • endoscopically proven oesophagitis:
    
    • full dose PPI for 1-2m
      
      • if symptoms respond then use low dose treatment as needed
      • if no response then double the PPI dose for 1 month
  • endoscopically -ve reflux disease
    
    • full dose PPI for 1 month
      
      • if symptoms respond then use low dose treatment- ? on PRN basis
      • if no response use H2 blocker or prokinetic for one month
• Complications of GORD:
  
  • oesophagitis, ulcers, anaemia, benign strictures, barrett’s oesophagus, oesophageal carcinoma

Question 4

Peptic ulcer disease

What is this? How does it present? How is it investigated and managed?

Answer 4

• Peptic ulcer disease includes both gastric + duodenal (more common) ulcers, it can be:
  
  • Uncomplicated peptic ulcer disease
    
    • ​Causes:
      
      • most linked w/ H.pylori
      • meds eg. NSAID, SSRIs, steroids, bisphosphonates
      • zollinger-elison syndrome (rare) (gastrin secreting tumour -> refractory peptic ulcer disease)
    • Presentation
      
      • epigastric pain
      • nausea
      • duodenal ulcers
        
        • epigastric pain- worse when hungry + relieved by eating
      • gastric ulcers
        
        • epigastric pain - worse on eating
    • Investigations
      
      • H.pylori testing
        
        • urea breath test or stool antigen test
    • Management
      
      • H.pylori -ve –> PPI until ulcer heals
      • H. pylori +ve –> give eradication therapy for 7 days:
        
        • PPI + amoxicillin + clarithromycin
        • or PPI + metronidazole + clarithromycin
  • Peptic ulcer disease w/ acute bleeding
    
    • ​bleed often from the gastroduodenal artery
    • often presents w/ haemetemesis
    • Management:
      
      • A-E approach
      • IV PPI
      • 1st line: endoscopic intervention
      • if this fails (in approx 10%) then either:
        
        • urgent interventional angiography w/ transarterial embolisation
        • or surgery

Question 5

Gastritis

This is very common - it is inflammation of the lining of the stomach + is normally mild + resolves without treatment BUT it can –> epigastric pain + stomach ulcers.

What are possible causes? How might it present? How would you investigate and manage it?

Answer 5

• Causes:
  
  • H.pylori
  • NSAIDs, aspirin
  • other: stressful event (eg. critical illness, bad injury, major surgery), rarely can be autoimmune reaction, alcohol, cocaine abuse, other infection eg. viral/parasitc/fungal
• Symptoms:
  
  • epigastric pain
    
    • comes + goes, relieved by antacids, worse w/ food, may wake people from sleep
  • other:
    
    • loss of appetite, bloating, retching, n+v, early satiety
• Investigations
  
  • if mild + resolves spontaneously –> nothing
  • if more severe or non-resolving –> FBC (?bleed), endoscopy +/- biopsy (to confirm gastritis), H.pylori testing
• Management
  
  • lifestyle:
    
    • eat small regular meals, avoid irritating foods (spicy, acidic, fried, fatty), don’t drink alcohol, stop smoking, avoid caffeine, reduce stress, ?stop NSAID
    • (give this sort of advice for any dyspepsia)
  • Acid suppression
    
    • antacids
    • ?PPI or H2 blocker
  • H.pylori eradication as needed

Question 6

Sprains and strains

Answer 6

Sprains and Strains

Question 7

What is the difference between a sprain and a strain? How are their severities graded?

Answer 7

• Sprain- stretch and/or partial/complete tear of a ligament (between bone + bone - so must be at a joint)
  
  • typically - ankles, knee, wrist or thumb
  • Severity:
    
    • 1 = mild stretching or micro-tear
      
      • no joint instability
      • minimal bruising/swelling
      • normal weight bearing (if weight bearing joint)
    • 2 = partial tear of ligament complex
      
      • no joint instability
      • moderate bruising + swelling
      • minimal pain on weight bearing
    • 3= complete tear
      
      • joint instability
      • severe bruising + swelling
      • severe pain on weight bearing
• Strain
  
  • stretch and/or tear of muscle fibres and/or tendon (muscle-bone)
    
    • typically- foot, leg (esp hamstring) + back
    • Severity
      
      • 1st degree - few muscle fibres stretched/torn
        
        • tender/painful muscle
        • normal strength
      • 2nd degree - several injured fibres
        
        • severe pain/tenderness
        • mild swelling + loss of strength
        • may be bruised
      • 3rd degree- torn all the way -> pop sensation
        
        • total loss of muscle function
        • severe pain + swelling
        • visible bruise
        • difficulty weight bearing
• Basic management = RICE
  
  • R - rest
  • I - ice
  • C- compression
  • E- elevation

Question 8

What are the different types of ankle sprain that can occur? How are they each investigated and managed?

Answer 8

• High sprains (at the syndesmosis between tibia + fibula)
  
  • Presentation (rare + severe)
    
    • weight bearing is v difficult
    • pain when squeezing tibia + fibula at mid-calf
  • Investigations
    
    • X-ray - widening of tibiofibular joint or ankle mortise
    • MRI if u have high clinical suspicion of syndesmosis injury but normal X-ray
  • Management
    
    • if no diastasis then non-weight bearing orthosis or cast until pain subsides
    • if diastasis or if non-op management fails -> operative fixation
• Low sprains (at the lateral collateral ligaments) = 90%
  
  • presentation
    
    • often due to inversion injury -> pain, swelling + tenderness over affected ligament +/- bruising
    • normally able to weight bear unless severe
  • Investigations
    
    • X-ray - according to ottawa ankle rules - 15% of sprains have an associated #
    • MRI if persistent pain
  • Management
    
    • non-operative w/ RICE
    • in some may need a removable orthosis or cast and/or crutches (for short term symptom relief)
    • if symptoms fail to settle or significant joint instability –> MRI + surgical intervention (rare tho)

Question 9

Medically Unexplained Symptoms

Answer 9

Medically unexplained symptoms

Question 10

What are each of the following?

• Somatisation disorder
• Hypochondrial disorder
• Conversion disorder
• Dissociative disorder
• Factitious disorder (aka Munchausen’s)
• Malingering

Answer 10

• Somatisation Disorder
  
  • multiple physical symptoms present for at least 2yrs
  • Patient refuses to accept reassurance/-ve test results
• Hypochondrial disorder
  
  • persisteny belief in presence of an underlying disease e.g. cancer
  • patient refuses to accept reassurance/-ve test results
• Conversion disorder
  
  • typically involves loss of motor/sensory function
  • patient doesn’t consciously feign symptoms (factitious disorder) or seek material gain (malingering)
• Dissociative disorder
  
  • involves psych symptoms (in contrast to conversion disorder) e.g. amnesia, fugue, stupor
  • dissociation is a process of ‘separating off’ certain memories from normal consciousness
• Factitious disorder (aka munchausen’s)
  
  • intentional production of physical of psychological symptoms
• Malingering
  
  • fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

Question 11

Respiratory Tract Infections

• URTI includes the following (many of which are covered in other notes e.g. paeds/ENT):
  
  • ​Rhinitis
  • Rhinosinusitis (sinusitis)
  • Nasopharyngitis/rhinopharyngitis = common cold
  • Sore throat encompasses:
    
    • pharyngitis + tonsilitis + laryngitis
      
      • ​= laryngitis when voice is hoarse
      • if >45 w/ persistent hoarseness or unexplained lump in neck –> 2ww for ? laryngeal Ca (esp if previous smoker)
  • Epiglottitis (severe in children + adults w/ subglottic stenosis - less severe in most adults)
  • Laryngitis
  • Laryngotracheitis (croup)
  • Tracheitis
  • N.B. bronchitis + pneumonia are LRTIs

Answer 11

Respiratory Tract Infections

Question 12

How long do the following infections last? Also generally what are the rules for when you would prescribe antibiotics in upper resp tract infections/otitis media?

• Acute otitis media
• acute sore throat/acute pharyngitis/acute tonsilitis
• common cold
• acute rhinosinusitis
• acute cough/acute bronchitis

Answer 12

• Duration of illness
  
  • otitis media - 4 days
  • acute sore throat/phayrngitis/tonsilitis - 1week
  • common cold- 1.5w
  • acute rhinosinusitis - 2.5w
  • acute cough/acute bronchitis - 3w
• When to prescribe antibiotics
  
  • for pharyngitis/tonsilitis - use FeverPain
  • Children <2yrs w/ bilateral acute otitis media
  • Children w/ otorrhoea who have acute otitis media
  • Those at risk of developing complications:
    
    • systemically v unwell
    • symptoms/signs suggesting serious illness/complications (pneumonia, mastoiditis, peritonsillar abscess/cellulitis, intraorbital/ intracranial complications)
    • high risk of serious complications due to co-morbidity eg. heart, lung, renal, liver, neuromuscular disease, immunosuppression, cystic fibrosis, young/premature children
    • those over 65 w/ acute cough + 2 or more (or 1 or more if over 80) of:
      
      • hospitalisation in the previous year
      • T1DM or T2DM
      • Hx of congestive heart failure
      • current use of oral steroids

Question 13

What is acute bronchitis and how does it present? How would you investigate and manage it?

Answer 13

• most = viral (altho can get bacterial infection following this)
  
  • N.B. occurs in COPD, bronchiectasis or CF this = an exacerbation of these conditions rather than acute bronchitis
• Presentation
  
  • cough
    
    • initially dry then productive
    • can hang around for 2-3w
  • Other symptoms tends to peak at 2-3 days
    
    • fever, headache, aches, SOB, wheeze
    • older people can -> confusion + rapid breathing
    • Can be preceded by cold symptoms (coryza, sore throat, fatigue, chills)
• Investigations
  
  • mostly clinical diagnosis but consider following:
    
    • CXR- if ? pneumonia
      
      • eg. prolonged fever, crackles/congestion or SOB
      • • to exclude underlying lung disease (eg. Ca) if cough persists >2w
    • ?throat swab if ?influenza or bordatella
    • sputum sample (if pneumonia on CXR)
• Management
  
  • paracetamol for fever
  • increase fluid intake
  • if due to influenza - osteltamivir (tamiflu)
    
    • within 24h of symptom onset
  • in children w/ airflow limitation can use steam vaporiser or bronchodilators

Question 14

Infectious Mononucleosis

(aka. Glandular Fever)

What is this caused by? How does it present? How is it diagnosed and managed? What conditions are associated w/ EBV?

Answer 14

• Cause = EBV (epstein-barr virus) in 90% (aka. HHV-4 - human herpes virus 4)
• Presentation
  
  • main triad (seen in 98%)
    
    • sore throat
    • lymphadenopathy - ant. + post. triangles in neck can both be affected
      
      • (tonsilitis tends to just be upper anterior cervical chain)
    • pyrexia
  • Other features:
    
    • malaise, headache, anorexia
    • palatal petechiae
    • splenomegaly (in 50%)
      
      • only rarely predisposes to splenic rupture
    • hepatitis + transient rise in ALT
    • lymphocytosis
    • haemolytic anaemia (secondary to cold agglutins (IgM))
    • can -> moderate thrombocytopenia
    • If you take ampicillin/amoxicillin –> maculopapular pruritic rash in 99%
  • Symptoms take 2-4w to resolve
• Diagnosis
  
  • Monospot test (heterophil antibody test) + FBC
    
    • do in 2nd week of illness to confirm diagnosis
• Management = supportive
  
  • rest in early stages w/ lots of fluids (avoid alcohol)
  • simple analgesia
  • avoid contact sports for 8w to reduce splenic rupture risk
• Conditions associated w/ EBV:
  
  • non-malignant
    
    • hairy leukoplakia
  • malignant
    
    • Burkitt’s lymphoma
    • Hodgkin’s lymphoma
    • nasopharyngeal carcinoma
    • HIV associated CNS lymphomas

Question 15

Back Pain

Answer 15

Back Pain

Question 16

What are possible causes of back pain? What are red flags associated w/ back pain?

Answer 16

• Causes of back pain:
  
  • most = non-specific muscular pain
  • Must rule out serious pathology:
    
    • Cancer
      
      • Primary bone tumour
      • Spinal Mets
      • Metastatic spinal cord compression
    • Infection
      
      • discitis
      • spinal epidural abscess
    • Trauma
    • Inflammatory conditions
      
      • ankylosing spondylitis
    • Cauda equina
      
      • low back pain, urinary retention/incontinence, reduced perianal sensation, decreased anal tone
  • Other:
    
    • facet joint syndrome
    • spinal stenosis
    • prolapsed disc
    • sciatica (symptom rather than condition)
• Red Flags:
  
  • For ?Ca:
    
    • age <20 or >55
    • acute onset in elderly
    • constant or progressive pain
    • nocturnal pain
    • worse lying down
    • Hx of malignancy
    • abdominal mass
    • thoracic pain (most common region for mets)
  • For ? inflammatory cause
    
    • morning stiffness
  • For ?cord or cauda equina compression
    
    • bilateral or alternating leg pain
    • sphincter dysfunction
  • For ? infection
    
    • immunosuppression eg. steroids, HIV
    • current/recent infection
  • For ?spinal stenosis
    
    • leg claudication or exercise related leg weakness/numbness

Question 17

How do the following present?

• Spinal mets
• Facet joint syndrome
• Spinal stenosis
• Ankylosing spondylitis

Answer 17

• Spinal mets (without compression of cord)
  
  • Presentation:
    
    • unrelenting lumbar back pain
    • any thoracic or cervical pain
    • worse w/ sneezing, coughing or straining
    • nocturnal pain
    • tender
    • (if neuro features - ? cord comperession)
  • Investigations - MRI whole spine within 1w (if neuro features needs immediate management)
  • Mets can be from: breast, lung, prostate
• Facet joint syndrome
  
  • can be acute or chronic
  • pain worse in morning + on standing
  • oe/ pain over facets
  • pain worse on back extension
• Spinal stenosis
  
  • central canal can be narrowed by tumour, prolapse or degenerative changes (most common)
    
    • –> comperession of nerve roots
  • gradual onset unilateral or bilateral leg pain +/- back pain, numbness + weakness
    
    • worse on walking
      
      • better walking up hill than down tho (unlike vasc claudication)
    • relieved by sitting, leaning forewards or crouching
    • clinical examination often normal
    • MRI to confirm
    • treat w/ laminectomy
• Ankylosing spondylitis
  
  • typically young man w/ lower back pain + stiffness
  • worse in morning + improves w/ activity
  • peripheral arthritis (more common in females)

Question 18

How do discitis and spinal epidural abscess present? How are they treated?

Answer 18

• Discitis = infection of intervertebral disc space
  
  • can -> sepsis or epidural abscess
  • Presentation:
    
    • back pain
    • pyrexia, rigors, sepsis
    • neuro feautes (if epidural abscess)
  • Causes:
    
    • bacteria: staph aureus (most common)
    • viral, TB, aseptic
  • Diagnosis
    
    • MRI
    • ? CT guided biopsy (if needed to guide antibiotic treatment)
  • Treatment
    
    • 6-8w IV antibiotic therapy
      
      • drug depends on organism - blood culture or biopsy
• Spinal epidural abscess
  
  • needs urgent investigation + treatment to avoid progressive spinal cord damage
  • Causes
    
    • bacteria (most is S.aureus) enters from:
      
      • adjacent structures (discitis)
      • haematogenous spread (eg. bacteraemia from IVDU)
      • direct infection (eg. spinal surgery)
    • immunosuppression = main RF
  • Presentation:
    
    • fever, back pain, focal neurological deficits (depending on segment of cord affected)
  • Investigations
    
    • bloods (inflam markers, HIV, HepB/C) + pre-op tests (coagulation, G&S)
    • Blood cultures
    • Infection screen (includes CXR + urine culture)
      
      • if primary source unclear then do more e.g. echo + dental X-ray
    • MRI whole spine (can be skip lesions)
  • Management
    
    • long course of antibiotics (based on culture results- start broad b4 these are back)
    • If large compressive abscess or significant/ progressive neuro deficits or not responding to antibiotics –> ?surgical evacuation of abscess

Question 19

How do prolapsed discs present? What is involved in the management?

Answer 19

• Presentation
  
  • clear dermatomal leg pain w/ neurological deficits
  • Features:
    
    • leg pain usually worse than back pain
    • pain worse when sitting
    • features depend on level of compression:
      
      • L3 nerve root (L2/3 herniation)
        
        • sensory loss over the anterior thigh
        • weak quads
        • reduced knee reflex
        • +ve femoral stretch test
          
          • patient lies prone. Knee is flexed + hip is extended. If this causes pain then = +ve test
      • L4 (L3/4)
        
        • sensory loss anterior aspect of knee
        • weak quads
        • reduced knee reflex
        • +ve femoral stretch test
      • L5 (L4/L5)
        
        • sensory loss dorsum of foot
        • weakness in foot + big toe dorsiflexion
        • reflexes intact
        • +ve sciatic nerve stretch test
      • S1 (L5/S1)
        
        • sensory loss posterolateral leg + lateral foot
        • weak plantar flexion of foot
        • reduced ankle reflex
        • +ve sciatic nerve stretch test
          
          • straight leg raise -> pain in posterior thigh + buttock
• Management
  
  • similar to other MSK low back pain:
    
    • analgesia, physiotherapy, exercise
    • if symptoms persist - ? MRI

Question 20

What is sciatica? What can cause it? How do you test for it and how is it managed?

Answer 20

• Sciatica = symptoms of pain/tingling/numbness due to lumbosacral nerve root impingement
  
  • felt in dermatomal distribution of the nerve root +/- motor weakness in corresponding myotome
  • symptoms extend from the buttocks -> across back of thigh -> below knee to outer calf + often to foot/toes
• Causes- anything that can compress nerve roots:
  
  • disc prolapse (in 90%- most at L4/5 or L5/S1)
  • Spondylolisthesis - proximal vertebra moves forward relative to a distal vertebra
  • Spinal stenosis
  • Infection (rare) eg. discitis, vertebral osteomyelitis, spinal epidural abscess
  • Cancer (rare) - most due to mets rather than primary tumour
• Test = straight leg raise
  
  • +ve if causes pain below knee which worsens on foot dorsiflexion
• Management = same as neuropathic pain management
  
  • 1st line: amitryptiline, duloxetine, gabapentin or pregablin
  • 2nd line: try one of the other 1st line agents
  • ? pain management clinics
  • other neuropathic pain guidelines (not specific for sciatica):
    
    • Tramadol can be used as ‘rescue’ therapy
    • Topical Capsaicin can be used for localised neuropathic pain (eg. post-herpetic neuralgia)
    • ​N.B. there are exceptions e.g. trigeminal neuralgia- 1st line = carbamazepine

Question 21

Describe the general investigations and management of lower back pain?

Answer 21

• The main red flags:
  
  • age <20 or >50
  • Hx of previous malignancy
  • night pain
  • Hx of trauma
  • systemically unwell e.g. weight loss
• Investigations
  
  • (do not do lumbar X-ray of spine)
  • MRI if:
    
    • non-specific back pain (ie. not due to malignancy, infection, trauma etc) + only if results of MRI are likely to alter management
    • you suspect malignancy, infection, #, cauda equina or ankylosing spondylitis
• Management of non-specific back pain:
  
  • stay active + exercise
  • Analgesia:
    
    • 1st line: NSAIDs
      
      • (paracetamol monotherapy is ineffective)
    • co-prescribe PPI if >45 + giving an NSAID
  • Other:
    
    • exercise programme
    • manual therapy (spinal manipulation, mobilisation or soft tissue techniques eg. massage)
      
      • only as a package of treatment including exercise +/- psychological therapy
    • radiofrequency denervation
    • epidural injections of local anaesthetic + steroid for acute + severe sciatica

Question 22

Prostatitis

Answer 22

Prostatitis

Question 23

What is prostatitis? What are risk factors for it and how does it present? How is it managed?

Answer 23

• Acute bacterial prostatitis is due to bacteria entering prostate from the urethra
  
  • E.Coli = most common
• Risk factors:
  
  • recent UTI
  • urogenital instrumentation
  • intermittent bladder catheterisation
  • recent prostate biopsy
• Presentation- often sudden onset feverish illness w/
  
  • Pain
    
    • can be referred to: perineum, penis, rectum, lower back, suprapubic
  • UTI symptoms
    
    • dysuria, urgency, retention
    • +/- obstructive voiding symptoms
  • Fever/rigors
  • DRE: v tender, boggy prostate gland
• Management
  
  • 14 day course of a quinolone eg. ciprofloxacin or ofloxacin
  • ? screen for STIs

Question 24

UTI

Answer 24

UTI

Question 25

How should you assess patients aged \<65 in regards to a possible UTI and whether it needs treating?

Answer 25

* Men * ?other genitourinary causes eg. STI, urethritis (post-sex inflam, irritants etc.) * check for: pyelonephritis, prostatitis, sepsis * suspect lower UTI if: * dysuria, frequency, urgency, nocturia, suprapubic discomfort, cloudy/bloody/ foul smelling urine * If UTI suspected - take MSU (for culture) + start antibiotics * follow up after 48h * (if recurrent/relapsing -\> urology referral) * Women * if asymptomatic- don't treat unless pregnant * if symptoms * exclude the following: * vaginal/urethral causes * if vag discharge - 80% = not UTI * sepsis * pyelonephritis * kidney pain/tender under ribs * new myalgia, flu-like illness * rigors/temp 37.9C or more * nausea/vomiting * Once above excluded look for 3 key symptoms: * **dysuria, new nocturia, cloudy urine** * Then depends on no. of symptoms * 2-3 --\> treat * culture if risk of resistance (previous known resistance or antibiotic use for UTI in past 3m) * 1 symptom * urine dip * treat as above if: * +ve nitrites * or +ve leucocytes + rbc * send urine for culture to confirm diagnosis + ?start treatment if severe symptom if * -ve nitrite * +ve leucocytes * consider different diagnosis if * -ve for all, or +ve for only blood/protein * 0 symptoms * if other severe urinary symptoms (urgency, visible haematuria) -\> dipstick * if not -\> ?another diagnosis

Question 26

How should you approach patients over the age of 65 w/ ? UTI?

Answer 26

(for both men + women) * do NOT urine dip * Rule out: * sepsis * pyelonephritis * STI/urethritis * ?other cause of delirium (if relevant) * PINCH ME * pain, infection, poor nutrition, confusion, poor hydration, meds, environment change) * ? other source of infection * resp (SOB, cough, sputum, new pleuritic pain) * GI (n+v, abdo pain, diarrhoea) * skin/soft tissue (redness, warmth) * Once above excluded send urine culture + give antibiotics if: * New onset dysuria (alone) * OR 2 or more of: * temp 1.5C above normal (2x in last 12h) * New frequency or urgency * New incontinence * New/worsening delirium/debility * New suprapubic pain * visible haematuria * (if indwelling catheter for more than 7d consider changing (or removing) it before giving antibiotic + take MSU/urine sample from new catheter)

Question 27

Which antibiotics for UTI should be used in the following situations? When should people be referred to urology? * Women (of any age) with: * lower UTI * Pyelonephritis * Men (of any age) with * lower UTI * pyelonephritis * UTI in pregnancy

Answer 27

* Which antibiotics? * Women (of any age): * lower UTI * 1st: nitrofurantoin (3 day course) * 2nd: trimethoprim (3 day course) * Pyelonephritis * 1st: co-amoxiclac for 10d * 2nd: ciprofloxacin for 7d * ?hosp if no response in 24h * Men (of any age) * lower UTI: * 1st: Nitrofurantoin (7 day course) * 2nd: trimethoprim (7 day course) * Pregnant women: * 1st: nitrofurantoin (7d) OR cefalexin (7d) * (also recommend preventative measures e.g. stay hydrated, mobilise, empty bladder regularly) * Urology referral if: * recurrent UTI in non-pregnant woman (\>3/year) * RF for abnormality of the urinary tract: * past Hx of urinary tract surgery/trauma * past Hx of bladder/renal stones * obstructive symptoms (straining, hesitancy, poor stream) * urea splitting bacteria on culture (proteus, yersinia) * persistent bacteruria despite antibiotics * past Hx of abdo/pelvic malignancy * symptoms of fistula eg. pneumaturia * immunocompromised or have DM * Known abnormality of renal tract who any benefit from surgery eg. cystocele, vesicoureteric reflux, bladder outlet obstruction

Question 28

Community care of babies ## Footnote (up to and including the 6 week check)

Answer 28

Community Care of babies ## Footnote (up to and including the 6 week check)

Question 29

Who is involved in the community care of babies? Also what is the red book?

Answer 29

* Who is involved? * In hospital: * baby weighed at birth * thorough physical examination within 72h of birth * Midwife * blood spot test at 5-8 days * Hearing test (may also be done in hospital) * midwives can visit at home or children's centre till 10 days old (then health visitors take over) * Health visitors * they discuss health + development + any concerns * See the baby within 10-14d + give advice on: * safe sleeping, vaccinations, breast/bottle feeding, caring for baby + baby's development * GP * see baby at 6-8w - full physical examination done * (more details in paeds notes) * Also assess the mother: * mental health + welling * ?vaginal discharge * check BP (if high in pregnancy) * check episiotomy/C-section scar * ask about contraception * if due cervical screening test delay till 12w after birth * Red book * shortly before or after birth you get this: PCHR (personal child health record) * should take to all baby clinic/GP visits * records weight, height, vaccinations + developmental milestones (+ more)