Primary Care 2.0 Flashcards

Question 1

Q

GORD, dyspepsia etc.

Answer

A

GORD, dyspepsia etc.

Question 2

Q

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

Answer

A

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

Q

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

A

Undiagnosed dyspepsia
- 1. review medications for a possible cause of dyspepsia
- 1. lifestyle advice
- 1. 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

Q

Peptic ulcer disease

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

Answer

A

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

Q

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

A

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

Q

Sprains and strains

Answer

A

Sprains and Strains

Question 7

Q

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

Answer

A

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

Q

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

Answer

A

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

Q

Medically Unexplained Symptoms

Answer

A

Medically unexplained symptoms

Question 10

Q

What are each of the following?

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

Answer

A

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

Q

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

A

Respiratory Tract Infections

Question 12

Q

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

A

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

Q

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

Answer

A

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

Q

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

A

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

Q

Back Pain

Answer

A

Back Pain

Question 16

Q

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

Answer

A

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

Q

How do the following present?

Spinal mets
Facet joint syndrome
Spinal stenosis
Ankylosing spondylitis

Answer

A

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

Q

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

Answer

A

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

Q

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

Answer

A

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

Q

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

Answer

A

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

Q

Describe the general investigations and management of lower back pain?

Answer

A

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

Q

Prostatitis

Answer

A

Prostatitis

Question 23

Q

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

Answer

A

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

Q

UTI

Question 25

Q

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

Answer

A

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

Q

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

Answer

A

(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

Q

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

A

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

Q

Community care of babies

(up to and including the 6 week check)

Answer

A

Community Care of babies

(up to and including the 6 week check)

Question 29

Q

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

Answer

A

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)