Routine Problems 3 Flashcards
How should a new diagnosis of gout be confirmed?
Serum uric acid AT point of symptoms - if over 360 diagnose, if not:
Rpt in 2 weeks - confirm gout if over 360
If not need to consider joint aspiration (do XR, USS or DECT) - XR has good specificity but rubbish sensativity
What are the management options in gout?
NSAID, colchicine or oral steroid
(Usually one of first two most common)
NSAID: Most common, avoid if IHD
Colchicine: Avoid if high risk GI side effects or poor renal function (eGFR <15)
Steroid: If other two not appropriate
In gout, which groups (4) should be offered urate lowering therapy (strongest recommendation)?
Multiple or troublesome flares
eGFR <60
Diuretic therapy
Tophi
Chronic gouty arthritis
In gout, which groups should be have urate lowering therapy discussed but not neccasrily offered?
After a single attack
(After first attack very likely to have further - but weighing up alloupurinol a lifelong treatment - may want to wait)
What is the target for serum uric acid?
360umol/ L
For those with tophi, flares on treatment or chronic gouty arthritis aim <300
What are the only group who should definitely have allopurinol over feboxistat?
Those with pre-existing cardiovascular disease
What information should be given to patients taking uric acid lowering therapy?
Lifelong medication
Don’t stop in flare up
DO stop it if you get a rash (think similar to SJS)
What are the medication prophylactic options to prevent gout whilst trying to reduce urate acid level?
Colcicine
(But can also use NSAID or steroid)
Which patients with gout should be referred?
Diagnostic uncertainty
Not tolerating urate lowering therapy
Max tolerate dose urate lowering therapy doesn’t bring to target
eGFR <45
Transplant patients
How often should serum uric acid levels be measured?
At least annually
More reguarlly if not to target (<360umol/L)
How should cellulitis be managed?
Normal vs. impaired circulation?
5-7 days fluclox (500mg QDS) or clarithromycin
Flucloxacillin 1g QDS if impaired circulation
If lymphoedema for 14 days antibiotics (amoxicllin or clarithro +/- fluclox if pus or staph aureus signs)
How should facial cellulitis be managed?
Co-amoxiclav
OR
clarithromycin + metronidazole
A patient has been treated with 7 days of fluclox - when would you expect improvement?
D2- Check no worsening
D7 - Check should be improving - consider need for longer course
When should you start prophylaxtic antibiotics in cellulitis?
Not in primary care but refer if
> 2 episodes at same site within 12 months
What is the time cut off to consider anticoagulation for VTE?
If you can’t do d-dimer or scan within 4 hours start DOAC
Wells - low score - d-dimer
Wells- high score - scan
You did a wells score for DVT which showed patient was high risk. You performed the USS which was negative. How should you proceed?
NICE says you should do d-dimer, and if positive re-scan in 6-8days
(and stop any anticoagulation)
(Proximal leg USS can miss lower clots - if full leg scan this isn’t needed)
You think the risk of PE is low, what scoring tool can you use to clinically exclude?
PERC (if under 50)
What are NICE guidelines on adjusting d-dimer for age?
NICE say if over 50 can adjust for age
If FEU units (ULN 400-500) then take age and x10 for upper limit of normal
If DDU units (ULN 200-250) then take age x5 for rough upper limit of normal
When should you refer patients with VTE for consideration of thrombophillia?
Unprovoked VTE
+
First degree relative with VTE
Name 3 RF’s for ectopic pregnancy?
Smokers
IVF
Tubal damage
What is the classic triad of ectopic pregnancy? Name 3 alternative presenting symptoms?
Abdominal pain
Vaginal bleeding
Ammenorrhoea
Shoulder tip pain
Passing tissue
Pain on defacation
GI upset
Breast tenderness
How can you distinguish between testicular torsion and epidydmo-orchitis?
AGE: Torsion usually under 20yrs - EO, any age
TIME SCALE: Torsion mins to an hour - EO hours to days
SIGNS: Torsion, man won’t let you examine, retracted testis, horizontal lie - supporting scrotum doesn’t relieve, cremastertic absent - EO - man will let you examine, none of above
OTHER - Fever, penile discharge etc
What tests should be done for suspected epidydo-orchitis? (4)
Urine dip
Urine for gonorrhoea and chalmydia
Urine MSU
Uretrhal swab
How should epididymo-orchitis be managed?
High risk STI - send to STI clinic
Low risk STI - Quinolone (Ciprofloxacin) or co-amoxiclav
What are the scabies guideliens for closed settings around treating whole groups?
If more than 2 linked cases in 8 weeks - treat all simultaneously
What is the management of tinea capitis?
Oral terbinafine 250mg daily for 4 weeks
When should a child be referred for imaging of the renal tract with regards to UTI?
All under 6 months with UTI
Over 6m:
- 2 or more upper UTI’s
- 3 or more lower UTI’s
Name 5 possible symptoms of UTI in children under 3 months?
Fever
Vomiting
Lethargy
Poor feeding
Irritability
FTT
What is the quick wee method?
Undress infant, clean genitals
Rub suprapubic area with very cold guaze, a flannel or cottom wool (water from fridge)
20% wee within 5 mins
How should dipstick interpretation be performed in children 3months - 3 years with suspect UTI?
Any both, or nitrates positive - Send MSU and treat
Leuks positive - send MSU and only treat if suspicious
How should you manage a child with suspect UTI under 3 months?
All should be referred to secondary care
What is first line antibiotic for UTI in children?
Trimethoprim or nitrofurantoin?
Note liquid nitrofurantoin costs £100’s so tri to use trimethoprim
When should trimethoprim not be used for UTI in children?
- If used in last 3 months
- Previous trimethoprim resistent organism
- High local rates of resistance
How should upper UTI be treated in children?
Cefalexin or co-amoxiclav for 7-10days
How common is UTI in pregnancy?
Up to 1 in 5 pregnant women
Name 5 red flags for symptomatic UTI in pregnancy requiring same day hospital assessment?
Severe abdominal or loin pain
Vomiting
Visible haematuria
Uterine activity/ rigid uterus
Rigors
Significant comorbidity
Fever/ dehydration
What is the NICE guidance on managing UTI in pregnancy?
All should get MSU
All get 7 days of ABx:
1st: Nitrofurantoin (unless eGFR <45) or 3rd trimester
2nd: Cefalexin (or amox if culture available)
No trimethoprim in 1st trimester
How should asymptomatic bacteriuria be managed in pregnancy?
Treated with any of nitro/cefalexin or amox for 7 days
Tx as high risk
(Again send MSU after treatment to ensure resolution)
How should ‘mixed growth’ on a urine sample be managed in pregnancy?
Treat if symptomatic of UTI
Otherwise don’t needed to
When should urine cultures be performed in pregnancy?
Both before starting treatment AND always after treatment to ensure resolved
What are the 3 S’s of managing UTI in men?
- Send MSU always
- Seven days of ABx
- Stick test to check any haematuria has resolved
- STI’s - consider this if under 50 as very common under 50
How should smelly, cloudy urine be managed in an asymptomatic catheterised patient?
Send CSU but don’t prescribe antibiotics unless symptomatic
What are the symptoms of acute prostatitis?
Uncommon but severe bacterial diagnosis
Fever
Frequency/ dysuria
Urinary retention
Abdominal or back pain
Pain on opening bowels
Tender or swollen prostate on examination
How should we manage suspected acute prostatitis?
Send urine MSU
?Could be STI - ask about risks - send to GUM
Ciprofloxacin for 14 days or 28 days if higher risk
(2nd line trimethoprim)
- This is despite the known risks with quinolones, but don’t give to higher risk people with quinolones
What are the main safety issues with quinolones (ciprofloxacin)?
Tendon/ muscle/ joint or nerve damage which can cause permenant disability
How should neonatal conjunctivits be managed?
A red eye in <28 days should be referred for same day assessment
What is the management where you have:
a) A high suspicion of GCA?
b) A low suspicion
Both: Immediate bloods
a) Start oral steroids (40-60mg OD)
- Urgent O/P review
b) Phone for rheum advice
If any visual loss - urgent same day opthalmology referral
How are IgE mediated and non IgE mediated allergies characterised?
IgE mediated = Immediate (<2hrs) and consistently reproduceable multi organ symptoms (i.e. anaphylaxis)
Non IgE - Delayed (2 hours - 3 days) after particular exposure
- Usually less severe symptoms (rash, eczema, itch, GI upset)
How are IgE mediated and non IgE mediated allergies investigated?
IgE mediated - Can be diagnosed with skin prick testing or serum IgE antibodies
Non IgE mediated - No specific diagnostic tests, just cut out allergen
What are the investigative options to diagnose IgE mediated allergy?
Skin prick testings
- Negative rules out
- Poor PPV (60% postive won’t be symptomatic)
- Need to withold antihistamine before hand
Serum IgE antibodies
- More expensive#
- Used to have brand name RAST (testing for IgE against lots of different allergens)
- More modern technology now doesn’t use RAST
What are the 4 types of allergic reactions and how are they characterised?
Type 1 - Immediate (secs-mins), IgE mediated
Type 2 - Mins to hours - IgG and IgM mediated.
Type 3 - Immuno complex mediated (hours)
Type 4 - Delayed hypersensitivity (hours to days)
Give at least 2 examples for each of the 4 types of allergic reactions:
Type 1: Anaphylaxis
Asthma, allergic rhinitis, allergic dermatitis, Pollen food syndrome, latex allergy
Type 2: Haemolytic anaemia, ITP, graves, myasthenia gravis
Type 3: Lupus, rheumatoid arthritis
Type 4: Drug hypersensitivity, delayed allergic contact dermatitis
What is pollen food syndrome and how does it present?
aka Oral allergy syndrome
Reaction on oral contact with epitopes present in fruit and veg
Usually mild, transient localised itching and angioedema of the lips and mouth
NICE recommends consideration of food allergy in which 3 groups not presenting with typical allergen presentation?
Those with non-improving atopic eczema
Those with non improving GORD
Those with non improving GI symptoms such as constipation
How should pollen food syndrome be managed?
Avoid foods which cause reactions
Try cooking food, or using canned/ microwaved to see if improved
Tingling and swelling should settle within 1 hour - if concerned then take antihistamine
How do you manage a rash from a latex allergy or other form of contact dermatitis?
If mild symptoms (no anapylaxisis)
- Oral antihistamine
Rashes may respond well to 1% topical hydrocortisone
How should suspect occupational contact dermatitis be managed (in addition to symptom management)?
All should be referred to dermatology
- Emplyers have legal duty to report a case of occupational skin disease to Health and Safety Executive
In the case of insect bites, how should visible stingers be removed?
NICE:
Remove visible stingers as quickly as possible by scraping sideways with a fingernail, a piece of card or a credit card.
Remove ticls as soon as possible, forcepts or tweezers
When should a suspect bite or sting (not causing anapylaxis) be referred to an allergy specialist?
If large local reaction (oedema, erythema) more than 10cm in diameter
(Peaks 24-48 hours after sting)
How should suspected covid 19 be managed in:
a) High risk patients
b) Lower risk patients
a) Lateral flow (if negative rpt 3x over 3 days)
b) Stay at home, avoid contact with people if symptoms like fever
How should confirmed covid 19 be managed in:
a) High risk patients
b) Lower risk patients
a) Antibody and antiviral tx may be offered
(Should be contacted by NHS england within 24 hours of positive test - if not refer)
b) Stay at home, avoid contact for 5 days after test, don’t meet unwell people for 10 days
Name 3 groups eligeble for seasonal COVID vaccines?
Age 65 or over
6mths - 65yrs and increased risk
Living in care home for older adults
Frontline health or care worker
16-64yrs and carer
12-64yrs and live with someone in increased risk group
What is the guidance on how many autoinjectors a child with anapylaxis should be prescribed?
4 devices
- 2 for each bag (so 2nd dose can be give), one for them and one to be kept at school
What immunisations are given in the 1st year of life?
8 weeks - 6 in 1, rotavirus, MenB
12 weeks - 6 in 1, pneumococcal, rotavirus
16 weeks - 6 in 1, MenB
What immunisations are given to children 2-15 years?
1 year - Hib/ MenC, MMR, pneumococcal, MenB
3yrs - MMR, 4 in 1 preschool
12-13yrs - HPV vaccine
14yrs- 3in1 booster, MenACWY vaccine
When are children eligable for flu vaccines?
Age 2-15
(Childrens flu vaccine every year until finish Y11 secondary school)
What vaccines are over 65 years eligeable for?
Flu - annual after 65
Pnemococcal - one off @ 65
Shingles - one off (if turned 65 after sept 23), otherwise betwwen 70-79
What vaccines are pregnant women eligable for?
Flu vaccine during flu season
Whooping cough (from 16 weeks)
What are the risks of aquiring hep B, hep C and HIV from needlestick injuries?
HepB- 30% (1 in 3)
HepC - 3% (1 in 30)
HIV - 0.3% (1 in 300)
What are the indications to test for IgG or IgM or compliment (usually C3/C4)?
IgM - Current/ active infection
IgG - Previous infection or immunity
C3 + C4 - Diagnose and monitor autoimmune conditions (Lupus, RA etc)
Give 5 examples of live vaccinatinations that shouldn’t be given to immunosuppresed individuals?
MMR
Rotavirus
Shingles
BCG
Oral typhoid
Varicella
Yellow fever
Live influenza possible but in the UK no injected flu vaccines are live
How should exposure to HIV (occupational needlestick or sexual) be managed?
HIV/ sexual health clinic
- PEP not recommended for needlestick or human bites
- PEPSE should be given within 72 hours (ideally 24)
Name 3 groups who should be offered a test for HIV in primary care?
- Pt requests (never discourage)
- Have risk factors for HIV
- Any other STI
- Clinical indication for HIV testing
- New patient in area with high prevalence
How long after acute gout flare would you recheck uric acid levels if trying to determine acurate level?
2-4 weeks
(Can be falsely lowered during attacks, let settle for 2-4 weeks)
What weight loss should patients be advised to aim for in one week? What’s the overall aim?
Patients should aim to lose a maximum of 0.5–1 kg per week.
Overall, the aim should be to lose between 5–10% of total body weight.
Which ethnic group has the lowest level of childhood obesity?
White
(Black, asian etc are higher)
What is the name of the syndrome that pre-disposes to bowel cancer risk in the young?
Name 3 other cancer it is associated with
HNPCC or Lynch syndrome, is characterised by early onset of bowel cancer
Associated with cancers of the endometrium, ovaries, stomach, pancreatico-biliary system and urinary tract.
What is the role of very low calories diets, when does nice recommend they are used?
VLCDs should only be considered as part of a multicomponent strategy for people who are obese and have a clinically assessed need to lose weight rapidly – such as those who need joint replacement surgery or who are seeking fertility services.
What is the weight loss target following orlistat initiation?
When may this be looser?
5% of initial body weight has been lost following a three-month trial with orlistat.
Looser if T2DM etc
What are the categories of:
a) Overweight
b) Obese class 1
c) Obese class 2
d) Obese class 3
Overweight: BMI greater than 25 kg/m2
Obesity class 1: BMI of 30–34.9kg/m2
Obesity class 2: BMI 35 kg/m2 to 39.9 kg/m2
Obesity class 3: BMI 40 kg/m2 or more.
Which antimalarial medication is contraindicated in pyschiatric disorders and can cause neuropyschiatric side effects?
Mefloquine
What are the criteria for starting orlistat?
BMI over 30
BMI over 28 with risk factors
What is the PPV of a positive screening fit test?
7%
Whar are the weight cut off’s for bariatric surgery?
BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
Name 3 classical features of Lewy body dementia?
- Fluctuation in awareness
- Signs of parkinsonism e.g. tremor, rigidity, slowness of movement and lack of facial expression
- Visual hallucinations or delusions also occur.
Fluctuating cognitive function is a relatively specific feature of Lewy body dementia.
What is the minimum number of years that must have elapsed for a traveller to be eligible for a tetanus booster (where appropriate), even if they have received five doses of a tetanus-containing vaccine previously?
10 years
What NICE guidelines relate to hoarseness?
Anyone aged 45 and over with persistent and unexplained hoarseness urgently to the head and neck team
What ABx treatment should be given for human bite?
Tx if broken the skin and drawn blood/ high risk area/ high risk patient
Co-amox 1st line
Treatment for PTSD is not recommended until at least how long after the event?
4 weeks
What is the TUGT?
The Timed up and Go Test (TUGT) score denotes the time it takes to stand up from a chair, walk three metres, turn and walk back. It is used as a comprehensive geriatric assessment as part of the Gold Standards Framework proactive identification guidance.
Best alcohol screening questionnaire?
AUDIT
NOT AUDIT-C
Where are most childrens vaccines given?
Thigh
Angina - chest pain more severe than normal/ associated with sweating/ SOB - when to call ambulance?
Straight away
Don’t try GTN
An X-ray of the lumbar spine is the equivalent radiation to how many chest X-rays?
`120
Most common SE of lantus insulin?
Pain at injection site
(Disolved in acid)
Average delay to endometriosis diagnosis?
8 years
How many days do inactivated vaccines take to produce an antibody response?
10-14 days
What is the high risk sepsis urine criteria in adults?
Not passed urine in 18 hours
When are odds ratio and relative risk similar?
The odds ratio is almost identical to the relative risk when events are very rare
What percentage of UK drink alcohol to harmful levels?
10%
What is UK diabetes prevalence?
6%
A patient presents with hayfever in February. What is the single most likely trigger?
Tree pollen
Graves disease accounts for what percentage of hyperthyroid cases?
80%
What proportion of patients with Type 1 DM in a recent BMJ study are driving who should not be?
55%
What is prevalence of urinary tract infection (UTI) amongst young children with a fever but no obvious source?
Approx 5%
What is the age cut off for risk decision in COCP prescribing in those with FHx breast Ca?
35yrs
Below this fine, above advise increased risk breast cancer
First line laxative in pregnancy?
Fybogel/ isphalgya
(Need bulk former)
Watery grey discharge with fishy odour - MLD?
Bacterial vaginosis
Vulval pain and yellow vaginal discharge, which is slightly frothy. MLD?
Trichomonas vaginalis
What are the paradise criteria for sore throats?
Tonsilectomy if:
> 7 infections in 1 year
> 5/y in 2 years
> 3/y for 3 years
