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4th year medicine > primary care > Flashcards

primary care Flashcards

1
Q

Can you make a new diagnosis of IBS (irritable bowel syndrome) in someone over the age of 50 years?

A

You shouldn’t make this diagnosis without first excluding/ considering other causes such as bowel cancer or diverticulosis which are more common with advancing age

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2
Q

What is the commonest cause of food poisoning in the UK?

A

Campylobacter - and its most common in the summer

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3
Q

When taking a history for diarrhoea, what diagnoses might blood in the stool indicate?

A

Infective- campylobacter, E.coli, shigella.
Inflammatory- IBD.
Neoplastic - bowel cancer.

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4
Q

A patient presents with diarrhoea alongside crampy abdominal pain which is relieved on defecation. What diagnosis may this suggest?

A

Irritable bowel syndrome (IBS)

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5
Q

When can people who have had gastroenteritis return to work or school?

A

They should not return to work or school until 48 hours after the diarrhoea has stopped

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6
Q

If a patient has diarrhoea, what medications should they stop taking until the diarrhoea has resolved and why?

A

ACE inhibitors, NSAIDs and diuretics. If the patient continues to take these drugs whilst they have diarrhoea, they run the risk of developing an AKI.

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7
Q

Should patients with acute diarrhoea be advised to take Loperamide (Imodium)?

A

Consider loperamide if it is important to stop the diarrhoea (e.g. before a long journey), but otherwise it should be avoided.

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8
Q

What type of drug is loperamide?

A

It is an opioid that does not cross the BBB, but increases colonic transit time

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9
Q

Which specific circumstances should loperamide definitely not be used to treat diarrhoea?

A

In children and in anyone with bloody diarrhoea, as it may increase their risk of complications

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10
Q

Which arm should you use to measure a patient’s blood pressure?

A

Unless there are good reasons for not doing so (such as patient discomfort), you should use the patient’s right arm

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11
Q

What are the ALARMs symptoms (red flag symptoms) that warrant immediate endoscopy?

A 
Anaemia (iron deficiency) 
Loss of weight
Anorexia 
Recent onset/ progressive symptoms 
Melaena / haematemesis 
Swallowing difficulty
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12
Q

What drugs/ medications can cause heartburn symptoms?

A

Antibiotics e.g. tetracyclines, NSAIDs, corticosteroids, iron compounds, nitrates, bisphosphonates, calcium preparations, calcium channel antagonists and theophylline.

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13
Q

What is the typical eradication therapy for H. Pylori?

A

A PPI such as omeprazole and 2 antibiotics e.g. amoxicillin and clarithromycin.

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14
Q

Patients can complete self-certificates for time off work due to illness, how does this work and for how long does it last?

A

The self certificate will cover the first 7 days off work due to sickness. They complete their own self certificate/ form which is available from their employer.

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15
Q

normally on methadone
not been to pick up methadone

feeling sweaty, shivery
headache, SOB, cough, clear colourless sputum
injection marks
fever
faint systolic murmur over left lower sternal edge

most likely diagnosis

A

bacterial endocarditis

murmur
fever
at higher risk due to injecting steroids

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16
Q

dysuria and nocturia 3 days
no fever
no loin pain
progesterone implant

diagnosis and treatment

A

diagnosis: uncomplicated UTI

management: nitrofurantoin
women: 3 days
men/complicated/ pregnancy: 7 days

(definitely not pregnant as on implant so can use nitrofurantoin)
increasing resistance to trimethoprim so nitrofurantoin used more

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17
Q

management for pyelonephritis

A

fever + loin pain + urinary symptoms
ciprofloxacin
co-amoxiclav

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18
Q

treatment for bacterial vaginosis

A

metronidazole

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19
Q

persistent dysuria and nocturia
no fever, no loin pain
on trimethoprim but no better - resistant
MSU: high WCC, no RBCs no growth on culture

A

persistant dysuria + resistant to abx = resistant UTI or chlamydia

sterile pyuria = chlamydia
(no growth on culture)

man with dysuria much more likely to have chlamydia

women more likely to have UTI

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20
Q

investigation for chlamydia

A

women: vaginal swab for NAAT (nucleic acid amplification test)
men: urine sample for NAAT

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21
Q

chlamydia management

A

azithromycin one off dose

or doxycycline 7 days

takes a week for treatment to be effective - condoms needed
don’t test negative till after 6 weeks

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22
Q

UTI management in pregnancy

A

nitrofurantoin in first or second trimester

trimethoprim in third trimester

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23
Q

returning from abroad
watery diarrhoea
blood in stool
most appropriate investigation?

what bacteria are likely?

A

stool sample - look for ova and parasites (if been abroad) - giardia (abroad), campylobacter (chicken esp)

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24
Q

IBD investigation

A

sygmoidoscopy

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25
Q

diarrhoea with blood
crampy abdo pain
fever
aches and pains

which bacteria most likely causing this gastroenteritis?

A

campylobacter

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26
Q

campylobacter management

A
  • off work/school for 48hr after end of diarrhoea
  • notifiable disease - to public health
  • macrolide abx (if extended symptoms)
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27
Q

first line management for HTN <55yrs

A

ACEi: ramipril

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28
Q

first line management for HTN >55yrs/ black ethnicity

A

calcium channel blocker: amlodipine

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29
Q

continuing management for HTN

A

A + C
A + C + D (thiazide like diuretic)
add B-blocker or a-blocker or alternative diuretic

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30
Q

what BP is aimed for in HTN

A

clinic BP < 140/90 (<150/90 if >80)

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31
Q

when to treat HTN

A

BP > 140/90
end organ damage
type 2 diabetes
type 1 diabetes >40

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32
Q

investigations

A

ABPM if clinic BP > 140/90

urine for protein, blood, glucose

fasting blood for:

  • HBA1c
  • U&Es
  • eGFR
  • total/ HDL cholesterol

ECG

QRISK 2 - 10 yr risk of cardiovascular disease: if >10% then start medication

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33
Q

primary prevention for high cholesterol

A

statin - atorvastatin 20mg daily

baseline LFTs, 3months, 1yr

if LFTs rise > x3 then stop statins

34
Q

side effects of statins

A 
reversible myositis 
gastro-intestinal 
altered LFTs
headache 
alopecia
35
Q

causes for raised cholesterol

A

hypothyroidism

weight gain

36
Q 
long lasting (weeks) cough with intermittent white/yellow sputum 
breathless on exertion
abx resistance 
afebrile 
most appropriate management?
A

CXR

to rule out lung cancer

37
Q

lung cancer 2ww guidelines

A

request urgent CXR in those aged >40 with any 2 of:

  • cough
  • fatigue
  • SOB
  • chest pain
  • weight loss
  • appetite loss
38
Q

bowel cancer investigation

A

faecal occult blood test

colonoscopy

CT

39
Q

COPD

A

chronic bronchitis + emphysema

mostly caused by smoking
can be caused by genetic abnormality: alpha-1 antitrypsin

40
Q

COPD management

A
  1. STOP SMOKING
  2. inhaler:
    - relievers: salbutamol or ipatropium
    - preventers: tiotropium, salmeterol
  3. manage exacerbations:
    - corticosteroids
    - abx
  4. long term O2 therapy:
    - cyanosis
    - <92% sats
    - cor-pulmonale
    - thrombocytosis
41
Q

breathlessness at rest
oedema
hepatomegaly

most likely diagnosis

A

heart failure

42
Q

heart failure management

A

lifestyle:

  • weight loss
  • stop smoking
  • exercise

secondary prevention:

  • aspirin 75mg - all patients
  • anti-hypertensives
  • statins

pharmacological interventions:

  • reduced systolic function: ACEi + b-blocker + diuretic
  • preserved systolic: diuretics (indapamide)

regular ECG monitoring

43
Q

angina management

A

lifestyle:

- weight loss, smoking cessation,

44
Q

what are some important points about medical certificates supplied by doctors for statements of fitness to work?

A
  • free of charge
  • doctor does not personally have to see the patient
  • can be backdated
  • cannot be issued for >3 months
45
Q

which patient groups are exempt from prescription charges?

A

<18 yrs
>60
pregnant women
diabetes, epilepsy, hypothyroidism, cancer Tx, renal dialysis

46
Q

which contraceptive might be prescribed for a patient to help with acne?

A

COCP e.g. co-cyprindiol (Dianette)

47
Q

which contraceptive method may lead to a delay in fertility

A

the injection (injectable contraceptives)

48
Q

how to COCPs work?

A

inhibit ovulation

49
Q

advantages of the COCP?

A
  • regulates cycles and reduces pain and amount of bleeding
  • reduces symptomatic fibroids and benign breast disease
  • reduces risk of ovarian, colorectal and endometrial cancer
50
Q

for COCP which pills in the packet are ‘most important’ not to miss

A

important not to miss any of the first 7 pills (stop ovulation from occurring)

51
Q

what type of patients would the POP be suitable for rather than the COCP

A
  • migraine with aura
  • smokers >35yrs
  • women breastfeeding
52
Q

how are POPs taken

A
  • taken within 3hrs of the same time everyday
  • taken daily without break
  • desogestrel POP can be taken within 12hrs of time its due - first line
53
Q

how does POP work

A

prevents pregnancy by thickening cervical mucus

- desogestrel can also stop ovulation

54
Q

types of injectable contraceptives and how long they last

A
  • most common: depo- provera - every 13 weeks
  • noristat - every 8 wks
  • saying press - 13 wks (administered by patient)
55
Q

side effects of injectable contraceptives

A
  • effective at reducing heavy or painful menstrual bleeding
  • can cause amenorrhoea or regular bleeding
  • unscheduled bleeding or return to fertility can last for up to a yr on stopping
  • risk of osteoporosis
  • weight gain
56
Q

how long do progesterone implants last

A

3 yrs

57
Q

how long do copper and mirena coils last

A

copper: 5-10 yrs
mirena: 5 yrs

58
Q

what investigations should you do if the threads of a coil are not palpable or visible

A

pelvic USS to assess position

59
Q

if a lady becomes pregnant with a coil in situ, what does this increase the risk of?

A

ectopic pregnancy

60
Q

what does the copper coil and mirena IUS do to bleeding

A

copper coil: menorrhagia (increased)

mirena: lighter bleeding, amenorrhoea

61
Q

outline the options for emergency contraception

A

levonelle: up to 3 days after UPSI
Ella one: up to 5 days
copper coil: up to 5 days

62
Q

what are the key points to remember about the levonorgestrel pill for emergency contraception

A
  • taken up to 3 days after UPSI
  • one off dose 1.5mg
  • double dose if >70kg (BMI>26)
  • can start contraception straight away so protected after 7 days for COCP or 2 days for POP
63
Q

is emergency contraception effective after ovulation has taken place?

A

no

64
Q

key points about ulipristal acetate (ellaOne) for emergency contraception?

A
  • can be taken up to 5 days after UPSI
  • protected after your next period if on contraception
  • can’t be taken if on progesterone or severe asthma
  • more effective than levonelle
65
Q

what if a patient vomits after taking an emergency contraceptive pill?

A

if vomit within 2hrs (3 for ellaOne) of taking pill, repeat dose with anti-emetic

66
Q

what is the most effective emergency contraceptive

A

the copper IUD

67
Q

what are the key points about the copper IUD for emergency contraception

A
  • up to 5 days after UPSI
  • protected as soon as fitted
  • makes periods heavier
  • must screen for STDs at insertion
68
Q

what are some non-/modifiable risk factors for CVD?

A 
non-modifiable:
- FHx 
- age 
- male 
- ethnicity 
modifiable:
- smoking
- high BMI 
- HTN
- high cholesterol 
- diabetes 
- physical inactivity
69
Q

what tool is used to calculate cardiovascular risk

A

QRISK3

70
Q

pharmacotherapies for people who want to quit smoking

A
  • nicotine (Patches, vapes, injections)
  • bupropion
  • varenicline
    e-cigarettes
71
Q

blood pressure: clinic BP and ABPM/HBPM

A
  • clinic BP >140/90 repeated - if they differ, repeat 3rd time. the lower of the last two taken as clinic BP
  • ABPM - to confirm diagnosis (14 measurements)
  • HBPM: alternative (7days)
72
Q

how do NICE define the stages of HTN

A

stage 1:
clinic BP>140/90
ABPM> 135/85

stage 2:
clinic BP >160/100
ABPM> 150/95

severe:
clinic BP> 180 or > /110

malignant:
>180/110 + organ damage

73
Q

when should drug treatment be considered for HTN

A
  • immediately (before ABPM) if clinic BP >180/110
  • all stage 2 HTN
  • stage 1 HTN if elevated risk (e.g. QRISK3>10%, diabetes, end organ damage)
74
Q

recommended treating HTN to a clinic BP of what?

A

<140/90 (or 150/90 in those aged >80)

75
Q

In the stepwise treatment of HTN, how long after starting a treatment should you wait until you reassess BP?

A

BP reassessed after 4-6 wks before considering progressing to next stage

76
Q

What is the stepwise treatment regimen for HTN?

A 
<55.                >55/ black
 A.                         C
           A + C
         A+ C + D
add B-blocker, a-blocker, or different D

A: ACEi (ramipril)
C: calcium channel blocker (amlodipine)
D: thiazide like diuretic (indapamide)

77
Q

what antihypertensive should you used in a patient with T2DM?

A

ACEi

78
Q

A patient is unable to tolerate their ACE inhibitor (due to cough), what antihypertensive should you consider instead?

A

An angiotensin II receptor blocker (ARB) e.g. Lorsartan

79
Q

What is the first-line recommended primary prevention drug treatment for high cholesterol? (Include the dosage in your answer)- note I am asking about DRUG treatment but always remember to give lifestyle advice

A

atorvastatin 20mg

80
Q

40yrs
2nd episode left sided back pain radiating to back of left knee for past 5 weeks
paracetamol/ibuprofen not helping
otherwise well
straight leg raise improved
normal power, reflexes, sensation, no foot drop

management option for GP to offer?

A

refer for physiotherapy

81
Q 
82yrs
increasing SOB few months
fatigue after walking 
non smoker 
amlodipine for HTN 
sertraline for depression
ibuprofen for osteoarthritis
pale but not clubbed or cyanosed 
152/76 
vesticular and symmetrical breathing

most likely cause?

A

anaemia

4th year medicine (8 decks)

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