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AKT Prep > Routine Problems 3 > Flashcards

Routine Problems 3 Flashcards

1
Q

How should a new diagnosis of gout be confirmed?

A

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

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2
Q

What are the management options in gout?

A

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

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3
Q

In gout, which groups (4) should be offered urate lowering therapy (strongest recommendation)?

A

Multiple or troublesome flares
eGFR <60
Diuretic therapy
Tophi
Chronic gouty arthritis

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4
Q

In gout, which groups should be have urate lowering therapy discussed but not neccasrily offered?

A

After a single attack

(After first attack very likely to have further - but weighing up alloupurinol a lifelong treatment - may want to wait)

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5
Q

What is the target for serum uric acid?

A

360umol/ L

For those with tophi, flares on treatment or chronic gouty arthritis aim <300

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6
Q

What are the only group who should definitely have allopurinol over feboxistat?

A

Those with pre-existing cardiovascular disease

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7
Q

What information should be given to patients taking uric acid lowering therapy?

A

Lifelong medication
Don’t stop in flare up
DO stop it if you get a rash (think similar to SJS)

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8
Q

What are the medication prophylactic options to prevent gout whilst trying to reduce urate acid level?

A

Colcicine
(But can also use NSAID or steroid)

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9
Q

Which patients with gout should be referred?

A

Diagnostic uncertainty
Not tolerating urate lowering therapy
Max tolerate dose urate lowering therapy doesn’t bring to target
eGFR <45
Transplant patients

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10
Q

How often should serum uric acid levels be measured?

A

At least annually

More reguarlly if not to target (<360umol/L)

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11
Q

How should cellulitis be managed?
Normal vs. impaired circulation?

A

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)

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12
Q

How should facial cellulitis be managed?

A

Co-amoxiclav
OR
clarithromycin + metronidazole

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13
Q

A patient has been treated with 7 days of fluclox - when would you expect improvement?

A

D2- Check no worsening
D7 - Check should be improving - consider need for longer course

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14
Q

When should you start prophylaxtic antibiotics in cellulitis?

A

Not in primary care but refer if

> 2 episodes at same site within 12 months

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15
Q

What is the time cut off to consider anticoagulation for VTE?

A

If you can’t do d-dimer or scan within 4 hours start DOAC

Wells - low score - d-dimer
Wells- high score - scan

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16
Q

You did a wells score for DVT which showed patient was high risk. You performed the USS which was negative. How should you proceed?

A

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)

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17
Q

You think the risk of PE is low, what scoring tool can you use to clinically exclude?

A

PERC (if under 50)

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18
Q

What are NICE guidelines on adjusting d-dimer for age?

A

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

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19
Q

When should you refer patients with VTE for consideration of thrombophillia?

A

Unprovoked VTE
+
First degree relative with VTE

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20
Q

Name 3 RF’s for ectopic pregnancy?

A

Smokers
IVF
Tubal damage

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21
Q

What is the classic triad of ectopic pregnancy? Name 3 alternative presenting symptoms?

A

Abdominal pain
Vaginal bleeding
Ammenorrhoea

Shoulder tip pain
Passing tissue
Pain on defacation
GI upset
Breast tenderness

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22
Q

How can you distinguish between testicular torsion and epidydmo-orchitis?

A

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

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23
Q

What tests should be done for suspected epidydo-orchitis? (4)

A

Urine dip
Urine for gonorrhoea and chalmydia
Urine MSU
Uretrhal swab

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24
Q

How should epididymo-orchitis be managed?

A

High risk STI - send to STI clinic

Low risk STI - Quinolone (Ciprofloxacin) or co-amoxiclav

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25
Q

What are the scabies guideliens for closed settings around treating whole groups?

A

If more than 2 linked cases in 8 weeks - treat all simultaneously

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26
Q

What is the management of tinea capitis?

A

Oral terbinafine 250mg daily for 4 weeks

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27
Q

When should a child be referred for imaging of the renal tract with regards to UTI?

A

All under 6 months with UTI

Over 6m:
- 2 or more upper UTI’s
- 3 or more lower UTI’s

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28
Q

Name 5 possible symptoms of UTI in children under 3 months?

A

Fever
Vomiting
Lethargy
Poor feeding
Irritability
FTT

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29
Q

What is the quick wee method?

A

Undress infant, clean genitals

Rub suprapubic area with very cold guaze, a flannel or cottom wool (water from fridge)

20% wee within 5 mins

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30
Q

How should dipstick interpretation be performed in children 3months - 3 years with suspect UTI?

A

Any both, or nitrates positive - Send MSU and treat

Leuks positive - send MSU and only treat if suspicious

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31
Q

How should you manage a child with suspect UTI under 3 months?

A

All should be referred to secondary care

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32
Q

What is first line antibiotic for UTI in children?

A

Trimethoprim or nitrofurantoin?

Note liquid nitrofurantoin costs £100’s so tri to use trimethoprim

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33
Q

When should trimethoprim not be used for UTI in children?

A
  • If used in last 3 months
  • Previous trimethoprim resistent organism
  • High local rates of resistance
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34
Q

How should upper UTI be treated in children?

A

Cefalexin or co-amoxiclav for 7-10days

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35
Q

How common is UTI in pregnancy?

A

Up to 1 in 5 pregnant women

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36
Q

Name 5 red flags for symptomatic UTI in pregnancy requiring same day hospital assessment?

A

Severe abdominal or loin pain
Vomiting
Visible haematuria
Uterine activity/ rigid uterus
Rigors
Significant comorbidity
Fever/ dehydration

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37
Q

What is the NICE guidance on managing UTI in pregnancy?

A

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

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38
Q

How should asymptomatic bacteriuria be managed in pregnancy?

A

Treated with any of nitro/cefalexin or amox for 7 days

Tx as high risk
(Again send MSU after treatment to ensure resolution)

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39
Q

How should ‘mixed growth’ on a urine sample be managed in pregnancy?

A

Treat if symptomatic of UTI

Otherwise don’t needed to

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40
Q

When should urine cultures be performed in pregnancy?

A

Both before starting treatment AND always after treatment to ensure resolved

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41
Q

What are the 3 S’s of managing UTI in men?

A
  • 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
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42
Q

How should smelly, cloudy urine be managed in an asymptomatic catheterised patient?

A

Send CSU but don’t prescribe antibiotics unless symptomatic

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43
Q

What are the symptoms of acute prostatitis?

A

Uncommon but severe bacterial diagnosis

Fever
Frequency/ dysuria
Urinary retention
Abdominal or back pain
Pain on opening bowels

Tender or swollen prostate on examination

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44
Q

How should we manage suspected acute prostatitis?

A

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

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45
Q

What are the main safety issues with quinolones (ciprofloxacin)?

A

Tendon/ muscle/ joint or nerve damage which can cause permenant disability

46
Q

How should neonatal conjunctivits be managed?

A

A red eye in <28 days should be referred for same day assessment

47
Q

What is the management where you have:
a) A high suspicion of GCA?
b) A low suspicion

A

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

48
Q

How are IgE mediated and non IgE mediated allergies characterised?

A

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)

49
Q

How are IgE mediated and non IgE mediated allergies investigated?

A

IgE mediated - Can be diagnosed with skin prick testing or serum IgE antibodies

Non IgE mediated - No specific diagnostic tests, just cut out allergen

50
Q

What are the investigative options to diagnose IgE mediated allergy?

A

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

51
Q

What are the 4 types of allergic reactions and how are they characterised?

A

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)

52
Q

Give at least 2 examples for each of the 4 types of allergic reactions:

A

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

53
Q

What is pollen food syndrome and how does it present?

A

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

54
Q

NICE recommends consideration of food allergy in which 3 groups not presenting with typical allergen presentation?

A

Those with non-improving atopic eczema

Those with non improving GORD

Those with non improving GI symptoms such as constipation

55
Q

How should pollen food syndrome be managed?

A

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

56
Q

How do you manage a rash from a latex allergy or other form of contact dermatitis?

A

If mild symptoms (no anapylaxisis)
- Oral antihistamine
Rashes may respond well to 1% topical hydrocortisone

57
Q

How should suspect occupational contact dermatitis be managed (in addition to symptom management)?

A

All should be referred to dermatology
- Emplyers have legal duty to report a case of occupational skin disease to Health and Safety Executive

58
Q

In the case of insect bites, how should visible stingers be removed?

A

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

59
Q

When should a suspect bite or sting (not causing anapylaxis) be referred to an allergy specialist?

A

If large local reaction (oedema, erythema) more than 10cm in diameter

(Peaks 24-48 hours after sting)

60
Q

How should suspected covid 19 be managed in:
a) High risk patients
b) Lower risk patients

A

a) Lateral flow (if negative rpt 3x over 3 days)

b) Stay at home, avoid contact with people if symptoms like fever

61
Q

How should confirmed covid 19 be managed in:
a) High risk patients
b) Lower risk patients

A

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

62
Q

Name 3 groups eligeble for seasonal COVID vaccines?

A

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

63
Q

What is the guidance on how many autoinjectors a child with anapylaxis should be prescribed?

A

4 devices
- 2 for each bag (so 2nd dose can be give), one for them and one to be kept at school

64
Q

What immunisations are given in the 1st year of life?

A

8 weeks - 6 in 1, rotavirus, MenB
12 weeks - 6 in 1, pneumococcal, rotavirus
16 weeks - 6 in 1, MenB

65
Q

What immunisations are given to children 2-15 years?

A

1 year - Hib/ MenC, MMR, pneumococcal, MenB

3yrs - MMR, 4 in 1 preschool

12-13yrs - HPV vaccine

14yrs- 3in1 booster, MenACWY vaccine

66
Q

When are children eligable for flu vaccines?

A

Age 2-15
(Childrens flu vaccine every year until finish Y11 secondary school)

67
Q

What vaccines are over 65 years eligeable for?

A

Flu - annual after 65
Pnemococcal - one off @ 65
Shingles - one off (if turned 65 after sept 23), otherwise betwwen 70-79

68
Q

What vaccines are pregnant women eligable for?

A

Flu vaccine during flu season

Whooping cough (from 16 weeks)

69
Q

What are the risks of aquiring hep B, hep C and HIV from needlestick injuries?

A

HepB- 30% (1 in 3)
HepC - 3% (1 in 30)
HIV - 0.3% (1 in 300)

70
Q

What are the indications to test for IgG or IgM or compliment (usually C3/C4)?

A

IgM - Current/ active infection

IgG - Previous infection or immunity

C3 + C4 - Diagnose and monitor autoimmune conditions (Lupus, RA etc)

71
Q

Give 5 examples of live vaccinatinations that shouldn’t be given to immunosuppresed individuals?

A

MMR
Rotavirus
Shingles
BCG
Oral typhoid
Varicella
Yellow fever

Live influenza possible but in the UK no injected flu vaccines are live

72
Q

How should exposure to HIV (occupational needlestick or sexual) be managed?

A

HIV/ sexual health clinic
- PEP not recommended for needlestick or human bites

  • PEPSE should be given within 72 hours (ideally 24)
73
Q

Name 3 groups who should be offered a test for HIV in primary care?

A
  • Pt requests (never discourage)
  • Have risk factors for HIV
  • Any other STI
  • Clinical indication for HIV testing
  • New patient in area with high prevalence
74
Q

How long after acute gout flare would you recheck uric acid levels if trying to determine acurate level?

A

2-4 weeks
(Can be falsely lowered during attacks, let settle for 2-4 weeks)

75
Q

What weight loss should patients be advised to aim for in one week? What’s the overall aim?

A

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.

76
Q

Which ethnic group has the lowest level of childhood obesity?

A

White

(Black, asian etc are higher)

77
Q

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

A

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.

78
Q

What is the role of very low calories diets, when does nice recommend they are used?

A

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.

79
Q

What is the weight loss target following orlistat initiation?

When may this be looser?

A

5% of initial body weight has been lost following a three-month trial with orlistat.

Looser if T2DM etc

80
Q

What are the categories of:
a) Overweight
b) Obese class 1
c) Obese class 2
d) Obese class 3

A

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.

81
Q

Which antimalarial medication is contraindicated in pyschiatric disorders and can cause neuropyschiatric side effects?

A

Mefloquine

82
Q

What are the criteria for starting orlistat?

A

BMI over 30

BMI over 28 with risk factors

83
Q

What is the PPV of a positive screening fit test?

A

7%

84
Q

Whar are the weight cut off’s for bariatric surgery?

A

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

85
Q

Name 3 classical features of Lewy body dementia?

A
  • 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.

86
Q

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?

A

10 years

87
Q

What NICE guidelines relate to hoarseness?

A

Anyone aged 45 and over with persistent and unexplained hoarseness urgently to the head and neck team

88
Q

What ABx treatment should be given for human bite?

A

Tx if broken the skin and drawn blood/ high risk area/ high risk patient

Co-amox 1st line

89
Q

Treatment for PTSD is not recommended until at least how long after the event?

A

4 weeks

90
Q

What is the TUGT?

A

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.

91
Q

Best alcohol screening questionnaire?

A

AUDIT

NOT AUDIT-C

92
Q

Where are most childrens vaccines given?

A

Thigh

93
Q

Angina - chest pain more severe than normal/ associated with sweating/ SOB - when to call ambulance?

A

Straight away

Don’t try GTN

94
Q

An X-ray of the lumbar spine is the equivalent radiation to how many chest X-rays?

A

`120

95
Q

Most common SE of lantus insulin?

A

Pain at injection site

(Disolved in acid)

96
Q

Average delay to endometriosis diagnosis?

A

8 years

97
Q

How many days do inactivated vaccines take to produce an antibody response?

A

10-14 days

98
Q

What is the high risk sepsis urine criteria in adults?

A

Not passed urine in 18 hours

99
Q

When are odds ratio and relative risk similar?

A

The odds ratio is almost identical to the relative risk when events are very rare

100
Q

What percentage of UK drink alcohol to harmful levels?

A

10%

101
Q

What is UK diabetes prevalence?

A

6%

102
Q

A patient presents with hayfever in February. What is the single most likely trigger?

A

Tree pollen

103
Q

Graves disease accounts for what percentage of hyperthyroid cases?

A

80%

104
Q

What proportion of patients with Type 1 DM in a recent BMJ study are driving who should not be?

A

55%

105
Q

What is prevalence of urinary tract infection (UTI) amongst young children with a fever but no obvious source?

A

Approx 5%

106
Q

What is the age cut off for risk decision in COCP prescribing in those with FHx breast Ca?

A

35yrs

Below this fine, above advise increased risk breast cancer

107
Q

First line laxative in pregnancy?

A

Fybogel/ isphalgya
(Need bulk former)

108
Q

Watery grey discharge with fishy odour - MLD?

A

Bacterial vaginosis

109
Q

Vulval pain and yellow vaginal discharge, which is slightly frothy. MLD?

A

Trichomonas vaginalis

110
Q

What are the paradise criteria for sore throats?

A

Tonsilectomy if:
> 7 infections in 1 year
> 5/y in 2 years
> 3/y for 3 years

AKT Prep (22 decks)

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