Routine Problems Flashcards
A 37 year woman patient presents with night sweats, give 5 differentials to consider?
Infective causes
Menopause
Anxiety
Hyperthyroid
Diabetes
Medications
Malignancy
Name three drug groups that could cause night sweats?
Antidepressants
Hormonal medications
Diabetic medications which can cause hypoglycemia
A 37 year old female presents with night sweats, you can’t find any obvious causes in the history, name what initial investigations may you consider?
FBC
Thyroid function
HbA1c
Inflammatory markers/ U+E/ LFT
Consider TB/ HIV/ CXR etc if indicated
A 32year old gentleman presents with a wart on the inferior aspect of his R hemiscrotum - what is the suggested management?
Podophyllotoxin 0.5% solution (Condyline® or Warticon®) or 0.15% cream (Warticon®) - better if soft (non keratinised)
Imiquimod 5% cream (Aldara®) - either keratinised or non keratinised
(Apply for 3 days consecutive, then four days off - upto 4 weeks)
(Advise often 1-6 months active treatments, high failure and relapse rates, often multiple courses and treatments needed)
What is slapped cheek syndrome, how does it present/ how managed?
Parvovirus B19 infection
Classic red cheeks, can spread to rash on body
Usually preceded by viral unwell, coryzal, sore throat, temp, headache
Manage as viral illness
Avoid pregnant people (risk to mum/ baby)
Rash usually settles within 2 weeks
What are the milk options which can be prescribed in primary care for CMPA?
EHF (Extensively hydrolysed formula) - First line, 90% of children
(Aptamil Pepti 1/2, Nutramigen LGG 1/2, SMA Althera, Similac)
AAF (Amino acid formula) - only needed by 10%
(Neocate LCP, nutramigen puramino, SMA alfamino)
Name 3 bits of practical advice you should give mums when trialing new formula milk for CMPA?
Try a formula for a minimum of two weeks and avoid product switching
- It takes 2 to 6 weeks without allergen to improve symptoms
If infant is struggling to take, can try to titrate with current formula (but will take longer to improve)
Stools may change and have a green tinge
Formula generally should only be prescribed for up to one year, and up to the age of 2 (around 2/3 by this point)
Challenge with cows milk every 6 months to see if developed tolerance, start at bottom and move up the milk ladder
During a routine set of bloods a patient of yours had an isolated raised ALT (ALT = 68), what is the most appropriate next step?
1) Look for obvious cause (alcohol, drugs), if no obvious repeat in 4-6 weeks
2) If persistent - full liver bloods, autoimmune/ hepatitis screen, USS of liver, hba1c etc.
Note 1 in 5 of random population in primary care with have abnormal LFT’s, only small amount of those with have other pathology found
A 43 year old female presents with itching, soreness and a thick white discharge from the vagina, what is the most appropriate first line management?
OTC Canesten (Clotrimazole) or Duo (Clotrimazole and Fluconazole) mainly useful for vulval symptoms (treat for 2 weeks)
Fluconazole 150 mg oral capsule as a single dose first-line (CI in pregnancy and breast feeding)
- Clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated (adults only)
Whilst going through your bloods we see a raised ALP - how would you interpret this alongside a gamma GT?
High ALP + normal GGT - Most likely bone (Check ca, bone etc)
High ALP + high GGT - Most likely liver (do liver screen)
Isolated raised bilirubin with otherwise normal other LFT’s, what is the most likely diagnosis?
Gilberts syndrome
(Could also be due to hemolysis, worth checking FBC, reticulocytes etc)
A 43 year old female presents with itching, soreness and a thick white discharge from the vagina, she has had 14 days of canesten along with a single dose fluconzole but there is no resolution of symptoms? What is the most appropriate next step?
For induction, prescribe three doses of oral fluconazole 150 mg (to be taken every 72 hours) first-line.
If severe and recurrent, for maintenance, prescribe oral fluconazole 150 mg once a week for six months first-line.
What is the starting dose of sertraline, and how would you titrate up?
Start 50mg
Titrate up by 50mg at most every 1-2 weeks as needed
Max 200mg daily
You are stopping sertraline and starting citalopram for a young female patient, how should you cross taper?
Straight swap
When going between SSRI and SNRI or vice versa cross tapering is not necessary and direct switch.
(Although whenever cross tapering check the NICE CKS on swapping antidepressents)
A 72 year old man currently taking Clopidogrel and atorvastatin post CVA complains of dyspepsia. A trial of OTC Gaviscon has not helped, what is the most appropriate next step in management?
Add lansoprazole (15-30mg)
(Note omeprazole and esomeprazole are both CI with Clopidogrel)
What is the DVLA driving guidance post TIA/ multiple TIA/ stroke?
1) Don’t drive for 1 month following single TIA, don’t notify DVLA
2) People who have multiple TIAs must not drive for 3 months and must notify DVLA. Driving may resume after 3 months if there have been no further TIAs
3) After stroke:
- Don’t drive for 1 month
- If after 1 month no neurological deficit, can drive and not notify DVLA
- If neurological deficit, visual field defects, cognitive defects, impaired limb function need to notify DVLA and not drive
What is first line self care advice for varicose veins?
Weight loss
Light to moderate physical activity
Avoid prolonged sitting/ standing
Elevate legs as much as possible
When should varicose veins be referred to vascular surgeons for consideration of intervention?
Symptomatic despite conservative tx (Pain, swelling)
Venous ulceration
Lower limb venous eczema
Superficial vein thrombosis (localized red, hard and hot superficial vein)
Following lifestyle changes, what are the conservative options for management of varicose veins?
Compression stockings (once arterial disease excluded with ABPI)
What should you advise a patient before h.pylori testing?
No PPI in last 2 weeks
No ABx in last 4 weeks
When does retesting for h.pylori following initial eradication therapy take place?
Never routinely
If done, at least four (ideally 8) weeks after eradication therapy. Urea breath test first line but stool antigen test possible
(usually if poor compliance with eradication or if patient requests)
What is the standard triple therapy regime for h.pylori eradication?
PPI twice daily (Lansoprazole 30mg, Omeprazole 40mg, Esomeprazole 20mg)
Amoxicillin 1g BD
Clarithromycin 500mg BD (or metronidazole 400mg BD)
If pen allergic both clarithomycin and metroidazole
Your obese patient with deranged ALT that you sent off for USS + liver screen results are back. USS shows fatty liver with an otherwise unremarkable liver screen. What is the most appropriate next step?
Diagnose and code NAFLD
Fib4 or NAFLD score
Lifestyle advice, control CVD risk factors
Annual CVD risk assessment and QRISK
Repeat FIB4 every 5 years
A 21 year old female comes in asking to delay her period for two weeks as she is going on holiday? What are the considerations and prescription options?
1st Line: Norethisterone 5mg TDS (BNF says for up to 10 days but can push to 28)
2nd Line: Medroxyprogesterone 10mg TDS
- If clot risk (Overweight, smoker, over 35yrs etc)
A 19y old wants to start the COCP, what are the 6 broad areas the consultation should cover?
1) Alternative contraception options?
2) Benefits
3) Risk assessment (VTE, BP etc.)
4) Side effects
5) How to take and missed pill rules
6) Follow up
You are risk assessing a young woman who wants to start the COCP, what questions do you ask to check there are no UKMEC contraindications?
BAP CHAVSS
B- BMI >35
A- Age > 50
P- Post partum (up to 6 weeks if breast feeding)
C- Cancer (breast) or FHx
H- Hypertension (BP >14/90)
A- migraine with Aura
V- VTE + FHx
S- Smoker over 35
S- Stroke or major CV risk factors
A 19 year old is starting the COCP for the first time, when will it be effective from?
If taken on:
D1- Immediately
Any other time - after 7 days of use
What are the options of administration regimes for COCP?
1) Take 21 days and then 7 day break
2) Tailored (Tricycling 3x21 active pills then 7 day break) or continuous
NB: Tailored or continuous are supported by FSRH but are off license uses
What are the most common side effects to advise about with the COCP?
1) Breakthrough bleed (most common in first few months)
2) Temporary: Breast tenderness, headaches, nausea - usually settle in 3 months
NB: Mood changes - minimal evidence, weight gain - no evidence
What vitamin D levels would be classed as a) deficient b) inadequate and c) sufficient?
a) Below 25
b) 25-50
c) Over 50
(serum 25[OH]D)
What treatment should be offered for deficient/ inadequate levels of vit D if rapid correct needed?
300,000 IU
Given over 6-10 weeks as either daily or weekly doses
(i.e. 50,000 once weekly for 6 weeks or 1000IU QDS for 10 weeks)
What treatment should be offered for deficient/ inadequate levels of vit D if no rapid correction is needed? Is this prescribed or OTC?
Vit D3 - 800-2000IU daily with no loading doses
(Prescribed if osteoporosis/ malabsorbtion, all other patients should by OTC)
A patient presents asking about prevention of vitamin D deficiency, what should you advise RE supplimentation?
All adults over 65/ with RF (low sun exposure, darker skin, CKD, liver disease, obsese) to take:
400 IU daily year round
All other UK adults to consider taking 400IU either just autum/ winter or year round
(Both OTC)
When should antiviral treatment be considered in patients with shingles (indications/ timeframe)?
Aim to start within 72 hours of rash starting, consider up to 1 week
Prescribe if no indications for referal if rash/ pain moderate or worse, any with non truncal involvement and any immunocompromise, age over 50
What dose/ length of aciclovir is used for shingles in a well patient who does not need referral?
800mg five times daily
7 days
(if immunocompromise consider until 2 days after crusting of lesions, up to 10 days)
What are the pain managment options for a patient with shingles?
1) Paracetamol
2) + codiene/ NSAID
3) + Amitryptiline/ gabapentin/ pregabalin/ duloxetine (one of not in combination)
4) Can consider steroids along with antiviral
What blood tests should be done as part of a memory screen?
FBC/ U+E/ LFT
Bone profile + calcium
TFT’s
HbA1c
B12 and folate
What is the quickest/ easiest cognitive assessment tool to use in GP?
6-item cognitive impairment test
(Available on patient UK)
1) Year 2) Month 3) Give address
4) About what time (within one hour)
5) Count back from 20-1
6) Months of year in reverse
7) Repeat address
Or GPCOG
A 57 year old patient presents with unexplained weight loss, give four examples of 2ww referral considerations that could be relevant?
WL > 50 + no rectal bleed > ?FIT test
WL > 40 + abdo pain = 2ww
WL > 40 + ever smoker = Urgent CXR (in 2wks)
WL > 55 + upper abdo pain/ reflux = UGI 2ww
What are the indications for blood tests in determining menopause? (2)
Consider blood test to confirm if:
- Age under 45
- Age over 45 with atypical symptoms
- This includes if considering premature ovarian failure