primary care Flashcards
Can you make a new diagnosis of IBS (irritable bowel syndrome) in someone over the age of 50 years?
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
What is the commonest cause of food poisoning in the UK?
Campylobacter - and its most common in the summer
When taking a history for diarrhoea, what diagnoses might blood in the stool indicate?
Infective- campylobacter, E.coli, shigella.
Inflammatory- IBD.
Neoplastic - bowel cancer.
A patient presents with diarrhoea alongside crampy abdominal pain which is relieved on defecation. What diagnosis may this suggest?
Irritable bowel syndrome (IBS)
When can people who have had gastroenteritis return to work or school?
They should not return to work or school until 48 hours after the diarrhoea has stopped
If a patient has diarrhoea, what medications should they stop taking until the diarrhoea has resolved and why?
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.
Should patients with acute diarrhoea be advised to take Loperamide (Imodium)?
Consider loperamide if it is important to stop the diarrhoea (e.g. before a long journey), but otherwise it should be avoided.
What type of drug is loperamide?
It is an opioid that does not cross the BBB, but increases colonic transit time
Which specific circumstances should loperamide definitely not be used to treat diarrhoea?
In children and in anyone with bloody diarrhoea, as it may increase their risk of complications
Which arm should you use to measure a patient’s blood pressure?
Unless there are good reasons for not doing so (such as patient discomfort), you should use the patient’s right arm
What are the ALARMs symptoms (red flag symptoms) that warrant immediate endoscopy?
Anaemia (iron deficiency) Loss of weight Anorexia Recent onset/ progressive symptoms Melaena / haematemesis Swallowing difficulty
What drugs/ medications can cause heartburn symptoms?
Antibiotics e.g. tetracyclines, NSAIDs, corticosteroids, iron compounds, nitrates, bisphosphonates, calcium preparations, calcium channel antagonists and theophylline.
What is the typical eradication therapy for H. Pylori?
A PPI such as omeprazole and 2 antibiotics e.g. amoxicillin and clarithromycin.
Patients can complete self-certificates for time off work due to illness, how does this work and for how long does it last?
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.
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
bacterial endocarditis
murmur
fever
at higher risk due to injecting steroids
dysuria and nocturia 3 days
no fever
no loin pain
progesterone implant
diagnosis and treatment
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
management for pyelonephritis
fever + loin pain + urinary symptoms
ciprofloxacin
co-amoxiclav
treatment for bacterial vaginosis
metronidazole
persistent dysuria and nocturia
no fever, no loin pain
on trimethoprim but no better - resistant
MSU: high WCC, no RBCs no growth on culture
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
investigation for chlamydia
women: vaginal swab for NAAT (nucleic acid amplification test)
men: urine sample for NAAT
chlamydia management
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
UTI management in pregnancy
nitrofurantoin in first or second trimester
trimethoprim in third trimester
returning from abroad
watery diarrhoea
blood in stool
most appropriate investigation?
what bacteria are likely?
stool sample - look for ova and parasites (if been abroad) - giardia (abroad), campylobacter (chicken esp)
IBD investigation
sygmoidoscopy
diarrhoea with blood
crampy abdo pain
fever
aches and pains
which bacteria most likely causing this gastroenteritis?
campylobacter
campylobacter management
- off work/school for 48hr after end of diarrhoea
- notifiable disease - to public health
- macrolide abx (if extended symptoms)
first line management for HTN <55yrs
ACEi: ramipril
first line management for HTN >55yrs/ black ethnicity
calcium channel blocker: amlodipine
continuing management for HTN
A + C
A + C + D (thiazide like diuretic)
add B-blocker or a-blocker or alternative diuretic
what BP is aimed for in HTN
clinic BP < 140/90 (<150/90 if >80)
when to treat HTN
BP > 140/90
end organ damage
type 2 diabetes
type 1 diabetes >40
investigations
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
primary prevention for high cholesterol
statin - atorvastatin 20mg daily
baseline LFTs, 3months, 1yr
if LFTs rise > x3 then stop statins
side effects of statins
reversible myositis gastro-intestinal altered LFTs headache alopecia
causes for raised cholesterol
hypothyroidism
weight gain
long lasting (weeks) cough with intermittent white/yellow sputum breathless on exertion abx resistance afebrile most appropriate management?
CXR
to rule out lung cancer
lung cancer 2ww guidelines
request urgent CXR in those aged >40 with any 2 of:
- cough
- fatigue
- SOB
- chest pain
- weight loss
- appetite loss
bowel cancer investigation
faecal occult blood test
colonoscopy
CT
COPD
chronic bronchitis + emphysema
mostly caused by smoking
can be caused by genetic abnormality: alpha-1 antitrypsin
COPD management
- STOP SMOKING
- inhaler:
- relievers: salbutamol or ipatropium
- preventers: tiotropium, salmeterol - manage exacerbations:
- corticosteroids
- abx - long term O2 therapy:
- cyanosis
- <92% sats
- cor-pulmonale
- thrombocytosis
breathlessness at rest
oedema
hepatomegaly
most likely diagnosis
heart failure
heart failure management
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
angina management
lifestyle:
- weight loss, smoking cessation,
what are some important points about medical certificates supplied by doctors for statements of fitness to work?
- free of charge
- doctor does not personally have to see the patient
- can be backdated
- cannot be issued for >3 months
which patient groups are exempt from prescription charges?
<18 yrs
>60
pregnant women
diabetes, epilepsy, hypothyroidism, cancer Tx, renal dialysis
which contraceptive might be prescribed for a patient to help with acne?
COCP e.g. co-cyprindiol (Dianette)
which contraceptive method may lead to a delay in fertility
the injection (injectable contraceptives)
how to COCPs work?
inhibit ovulation
advantages of the COCP?
- regulates cycles and reduces pain and amount of bleeding
- reduces symptomatic fibroids and benign breast disease
- reduces risk of ovarian, colorectal and endometrial cancer
for COCP which pills in the packet are ‘most important’ not to miss
important not to miss any of the first 7 pills (stop ovulation from occurring)
what type of patients would the POP be suitable for rather than the COCP
- migraine with aura
- smokers >35yrs
- women breastfeeding
how are POPs taken
- 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
how does POP work
prevents pregnancy by thickening cervical mucus
- desogestrel can also stop ovulation
types of injectable contraceptives and how long they last
- most common: depo- provera - every 13 weeks
- noristat - every 8 wks
- saying press - 13 wks (administered by patient)
side effects of injectable contraceptives
- 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
how long do progesterone implants last
3 yrs
how long do copper and mirena coils last
copper: 5-10 yrs
mirena: 5 yrs
what investigations should you do if the threads of a coil are not palpable or visible
pelvic USS to assess position
if a lady becomes pregnant with a coil in situ, what does this increase the risk of?
ectopic pregnancy
what does the copper coil and mirena IUS do to bleeding
copper coil: menorrhagia (increased)
mirena: lighter bleeding, amenorrhoea
outline the options for emergency contraception
levonelle: up to 3 days after UPSI
Ella one: up to 5 days
copper coil: up to 5 days
what are the key points to remember about the levonorgestrel pill for emergency contraception
- 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
is emergency contraception effective after ovulation has taken place?
no
key points about ulipristal acetate (ellaOne) for emergency contraception?
- 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
what if a patient vomits after taking an emergency contraceptive pill?
if vomit within 2hrs (3 for ellaOne) of taking pill, repeat dose with anti-emetic
what is the most effective emergency contraceptive
the copper IUD
what are the key points about the copper IUD for emergency contraception
- up to 5 days after UPSI
- protected as soon as fitted
- makes periods heavier
- must screen for STDs at insertion
what are some non-/modifiable risk factors for CVD?
non-modifiable: - FHx - age - male - ethnicity modifiable: - smoking - high BMI - HTN - high cholesterol - diabetes - physical inactivity
what tool is used to calculate cardiovascular risk
QRISK3
pharmacotherapies for people who want to quit smoking
- nicotine (Patches, vapes, injections)
- bupropion
- varenicline
e-cigarettes
blood pressure: clinic BP and ABPM/HBPM
- 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)
how do NICE define the stages of HTN
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
when should drug treatment be considered for HTN
- 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)
recommended treating HTN to a clinic BP of what?
<140/90 (or 150/90 in those aged >80)
In the stepwise treatment of HTN, how long after starting a treatment should you wait until you reassess BP?
BP reassessed after 4-6 wks before considering progressing to next stage
What is the stepwise treatment regimen for HTN?
<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)
what antihypertensive should you used in a patient with T2DM?
ACEi
A patient is unable to tolerate their ACE inhibitor (due to cough), what antihypertensive should you consider instead?
An angiotensin II receptor blocker (ARB) e.g. Lorsartan
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
atorvastatin 20mg
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?
refer for physiotherapy
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?
anaemia
