Routine Problems 2 Flashcards
What is the difference between primary and secondary nocturnal enuresis?
Primary - never dry
SecondarWy - Dry for over 6 months
What age is bed wetting considered to be normal?
Under 5 years of age
Name three common causes of bedwetting where there is also daytime symptoms?
Chronic constipation
UTI (if short history)
Anxiety (if specific situations)
Overactive bladder (can be masked by poor fluid intake)
Consider always family/ behavioral/ maltreatment issues
How should bedwetting over the age of 5 be managed?
1) Advise and reassure process growing out of it
2) 2-week diary of the fluid intake, bedwetting, and toileting patterns
3) Advise on fluids intake, toileting (encourage 6-7 times daily and before bed) and reward charts (positive behaviours)
4) Trial enuresis alarm
5) Trial desmopressin
(If two courses of any combo 4/5 not worked then refer to secondary care)
A 48 year old taking the COCP comes to see you asking how long she is able to take it for. What age must it be stopped?
Stop at 50
(VTE + breast Ca risk) - some bone and heart protection
Over 40 efficacy of COCP decreases, risks increase - screen for these
A 48y lady on the COCP comes to you, she still has reguarly bleeding with her pill but is wondering if she’s menopausal - how could you assess?
FSH generally not used after age 45
- However when on contraception - uncertainty justifies doing FSH
- Can do FSH whilst on progesterone contraception but NOT whilst on COCP - would need to switch to POP for at least 6 weeks before doing FSH
A 48y lady on the COCP comes to you, she still has reguarly bleeding with her pill but is wondering if she’s menopausal - when does she need to take contraception until?
Take contraception until 55 (needs to stop COCP at 50 and go to alternative)
If menopausal (1/2yrs since last period/ FSH >30 depending on under or over 50yrs) then can stop.
A patient is starting the COCP, what are 3 common ostrogenic side effects?
Hair loss
Migraine
Mennorrhagia/ bleeding
Fluid retention (and fluid weight gain)
N+V/ breast tenderness/ diarrhea
A patient is starting the COCP, what are 3 common progesterone side effects?
Acne/ rash/ itch
Low mood
Dry vagina
Appetite increase (and weight gain)
N+V/ headache/ breast tenderness/ diarrhea
What is the difference between first and fourth generation contraceptive pills?
Oestrogen the same
Progesterones become more potent and longer half life as newer generations (and less androgenic)
So Yasmin (4th) is better than Microgynon (2nd) for breakthrough bleeding etc but carries higher VTE risk
A patient who started Microgynon COCP 6 months is struggling with hair loss and migraine (no aura) headaches - which pill could you switch to?
If has ostrogenic side effects on COCP:
Prescribe alternative COCP which has less oestrogen and/or more progesterone (i.e. fermodette)
A patient who started Microgynon COCP 6 months is struggling with acne - which pill could you switch to?
If has progesterone side effects on COCP:
Prescribe alternative COCP which has less or newer progesterone and/or more oestrogen (i.e. Cilest)
If a patient has no preference between POP and COCP, which would you tend to start them on?
COCP if no CI’s
Because cycle planning (progesterone gives unpredictable)
What are two options for managing breakthrough bleeding for a patient on the COCP?
Either:
- Increase oestrogen
OR
- Increase generation of progestrogen (i.e. across to Yasmin or similar, especially if oestrogen side effects)
Which antibiotic is used as prophylaxis in sickle cell disease?
PenV
(Erythromycin if pen allergic)
What antibiotics should be avoided in G6PD deficiency? (2)
Quinolones (Ciprofloxacin)
Nitrofurantoin
Sulfonamides (Co-trimoxazole)
(Can precipitate hemolytic crisis)
How would you describe the key points in a 28 day cycle to a woman?
D1-D5 (average) - Mensuration
D14 - Ovulation
Most fertile between 5 days before and 2 days after ovulation.
How do you calculate gestational age from LMP?
1st day of LMP (so first day of bleeding)
Conception likely around ovulation time so 2 weeks later but for simplicity measure weeks of pregnancy from LMP as difficult to calculate exact conception date
How does hemophilia usually present? (Symptoms, gender)
X-linked recessive (so almost always male)
Presents: Haemarthrosis, muscle bleeds. Increased/ delayed bleeding with injury or post op
What are the two types of haemophillia, what factors are affected and how is it inherited?
Haemophillia A (Factor VIII deficiency)
Haemophillia B (Factor IX deficiency)
Inherited X-linked recessive (almost always affects males)
What is the most common inherited coagulation disorder and how is it inherited?
Von Willebrand disease (1% general pop)
Autosomal dominant disorder
How does Von WIllibrand disease usually present?
Mild to moderate:
Mucocutaneous bleeding (gums, nosebleed, menorrhagia)
What are NICE 2ww criteria for bladder cancer?
Age 45 and over with:
- Unexplained visible haematuria (and no UTI)
- Persistent haematuria after successful UTI tx
Age 60 and over with non-visible haematuria AND either dysuria OR raised WCC
According to NICE, name 3 groups of patients who should be on Vitamin D supplimentation?
- Pregnant/ breastfeeding
- Adults >65
- Not much sun exposure (religious covering)
- Children 6m-5yrs on <500mls formula milk
You have a patient with low folate levels. What should be checked and corrected before starting treatment to replace?
B12
Always correct first
A 60-year-old man, who worked underground in the coal industry for 30 years, has noticed a progressive deterioration in his hearing over several years. He has had a hearing test organised by his former trade union. He brings the audiometry printout to you for your advice. It shows a loss of 60 dB at a frequency of 4 kHz in both ears.
What SINGLE MOST likely condition does this illustrate?
The loss at 4 kHz is characteristic of noise-induced deafness. As the deafness worsens, the loss can extend into the 8 kHz frequency. The loss is typically sensorineural.
Which virus is a risk factor for laryngeal cancer?
HPV (Human papilloma virus)
You see a 62-year-old man with shortness of breath. His wife has noticed that his feet tend to swell up during the day. These symptoms have gradually been worsening over the past 3 months. He is known to have chronic obstructive pulmonary disease (COPD).
A recent blood test has shown a N-terminal-pro brain natriuretic peptide level of 1600pg/ml.
What is the SINGLE MOST appropriate management plan to investigate for possible heart failure?
Echo within 6 weeks
If the BNP is less than 400, heart failure is unlikely. If it is between 400-2000, an echocardiogram should be performed within 6 weeks with a cardiology review; if the level is higher than 2000, the referral and investigation should be done within 2 weeks.
Name 3 ways osteomalacia can commonly present?
- Lower back pain
- Bone pain in the shoulder, ribs, pelvis, or legs;
- Muscle pain and weakness (generally proximal muscles) - i.e. rising from a chair
- Waddling gait
- Impaired physical function.
What would LFT and bone profile bloods show in:
a) Osteomalacia
b) Pagets disease of bone
a) Osteomalacia is vit D deficiency
May see raised ALP, low Ca
b) Pagets disease is cause by increase bone turnover
May see raised ALP and either normal or raised Ca
What is pagets disease of bone?
- How does it commonly present?
Increased bone turnover (most common metabolic bone issue after osteoporosis)
- Usually men over 50
Presents with bone pain/ deformity/ fractures
- Usually isolated ALP rise
How does presbycusis usually present?
Progressive, bilateral sensorineural hearing loss
- Very common after the age of 55 years.
- High frequency perception most affected, making it difficult to understand speech.
What is complex regional pain syndrome (CRPS)
Chronic pain - precipitated by an injury
Pain/ hyperesthesia not in single nerve territory and ongoing odema/ skin changes/ motor symptoms etc
What is best management of CRPS?
NSAIDS if bony or soft tissue trauma.
If simple medication does not reduce the patient’s pain to a mild level after 3–4 weeks, consider using medication for neuropathic pain
Opioids are not recommended.
You see a 62-year-old patient with suspected acute kidney injury.
What is the SINGLE MOST important investigation in the management of acute kidney injury?
How do you assess this from baseline?
Serum Creatinine
(not egfr/ creatinine clearance)
Baseline serum creatinine is assumed to be the lowest value over the previous 3 months
How does NICE define episodic headaches (vs. chronic)
Episodic headaches (tension, migraine, cluster) = frequency of less than 15 per month.
Migraine or tension headaches are described as chronic if they occur on 15 or more days a month, for more than three months.
What are the classic presenting features of cluster headache?
Unilateral severe pain
Localised in or around the eye
Same sided symptoms of eye watering/ nasal congestion/ eyelid or facial swelling or flushing
Which HPV strains cause 90% of genital warts?
HPV 6 and 11
Which HPV strains cause 70% cervical cancer cases?
HPV 16 and 18
A sexually active 30-year-old woman presents with a frothy vaginal discharge, abnormal vaginal odour, dyspareunia, and mild vulval itching. Vaginal examination reveals a ‘strawberry cervix’. A swab and smear test showed flagellated protozoa on microscopy. MLD?
Trichomonas vaginalis
(up to 50% women have no symptoms)
