SCA online - new presentations

Question 1

Achilles tendinopathy

Answer 1

Pain, stiffness, swelling of the strap (or tendon) that connects the heel bone to the calf.

Red flags - Achilles rupture - emergency admission

Risk factors
- Abx eg ciprofloxacin, ofloxacin
- hypercholesterolaemia
- Diabetes

Mx/
Lifestyle
- cold/ heat packs, analgesia, weight bearing exercise
Physio refer
Refer sports physician or ortho if above not suitable

Question 2

Acne

Answer 2

inflammatory skin condition, leading to spots, and sometimes scarring.

Mx/
lifestyle - non oily skin products, avoid over cleaning
Be aware treatments last 8-12 weeks, can make skin more irritated initially
Regular FU
If PCOS - can start COCP

Mild (non inflamed lesions)
Topical Retinoids/ Abx/ Benz peroxide - eg Epiduo, Duac

Mod (more inflamed lesions)
Topical treatment + PO Abx (lymecycline/ doxycycline)

Severe (widespread, scarring, sig psych impact)
Refer Derm

Question 3

Actinic (solar) keratosis

Answer 3

common skin lesion from sun exposure - rough and scaly on head/ face. Very common, often harmless.
Some studies have shown a link to developing SCC

Mx/
often leave them
Use sunscreen daily
Physical Mx - cryotherapy, cautery (burning), curettage (shaving), surgical excision
Top Mx - Diclofenac gel, 5-flurouracil (efudix) - skin can get worse before it gets better
If uncertainty for referral Derm - ?SCC

Question 4

If a carer is unwell in emergency, what to do with the cared person

Answer 4

1st - friends, family who can come and look after cared person

2nd - Emergency scheme for carers
- emergency social services care - free, attend within 2 hours, provide a few days cover

Question 5

ADHD

Answer 5

Common condition, effecting behaviour - difficulty concentrating, restless and impulsive

Referral
if in school - refer through school
if adult - complete self questionnaire, refer to psych neurodevelopment team

Question 6

Asthma

Answer 6

Long term lung condition that leads to temporarily narrowing of the airways - leading to coughing, wheezing, difficulty breathing. With treatment, this can be very well managed

Initial Mx
ICS, peak flow, inhaler technique, personalised asthma action plan
Rv of ICS in 6-8 weeks

Red flags (for referral)
suspected eosinophilia, occupational asthma, abnormal cxr, unclear diagnosis

Question 7

Bells palsy

Answer 7

Temporary weakness of the muscles of one side of the face. Most people fully recover but may take a few months.

mx/
often self resolve
PO pred if <3 days presentation (60mg for 5 days)
any doubt refer to ENT

DDX
ramsey hunt (shingles) - facial pain, vesicles
Stroke - forehead is sparred in UMN
space occupying lesion

Question 8

Carpal tunnel syndrome

Answer 8

The nerve that runs through the middle of the wrist into the hand (aka carpal tunnel) is squashed or compressed. Common and can be managed with treatment

Risk factors - pregnancy, diabetes, use of power tools, obesity, family history

Red flags - for referral
- muscle wasting
- significant impact on daily life - all treatments used up

Mx/
Address underlying risk factors - lose weight, avoid power tools etc
Wrist splints
Analgesia
Physio
Often resolve within 6 months

Question 9

Gout

Answer 9

Type of arthritis (which means joint inflammation), uric acid crystals within the joint - leading to swelling and pain.

Risk factors
- high Calcium, HTN, T2DM, high lipids, osteoarthritis, alcohol, sugary food, meat, obesity, family history

Acute Mx - Colchicine, NSAIDs, analgesia

Long term Mx
- allopurinol (at least 2-4 weeks after acute flare) (+ colchicine whilst starting allopurinol)
- manage risk factors

Question 10

De Quervains Tendosynovitis

Answer 10

tendons (aka strap) at base of thumb become swollen and painful. Very common and treatable condition

Risk factors - new mums carrying new baby

Finkelstein test - thumb inside clasped fist, deviate hand to ulnar side - if pain = positive

Mx/
Non pharm - rest, wrist splint, avoid risk factors
Pharm - analgesia, steroid inject, physio

Question 11

Dengue fever

Answer 11

viral infection spread by mosquitos, mainly in tropical areas. Is NOT spread from person to person.

Fx/ headaches, joint/ muscle pain

Mx/
self resolve within a week or two. Fluids, paracetamol

Red flags
- UGIB, abdo pain, vomit blood - seek medical advice

Question 12

Eustachian tube dysfunction

Answer 12

the tube that connects your ear to your nose does not open or close properly - leading to feeling fullness, pressure, hearing loss on the affected side.

Mx/
Lifestyle
- avoid exacerbating factors - flying, diving
- self manage - chewing gum, Valsalva movements
Medication
- nasal corticosteroids/ decongestants
- antihistamines
Regular FU

Refer is no resolution after a few months, red flags (worsening hearing loss, pain, bleeding)

Question 13

First seizure

Answer 13

Surge of electrical activity inside the brain, leading to a loss of consciousness.

Mx/
refer to neuro
Stop driving until seen by neuro
bloods, examination - assess cause
FU regular

Question 14

Hyperthyroid (Graves) Mx

Answer 14

1st - B block - if symptomatic

2nd - Refer to endocrine - Antithyroid (carbimazole)

Question 15

Haemorrhoids

Answer 15

AKA piles - swollen veins around the anus. Uncomfortable, sometimes bleed.

Risk factors
prolonged sitting - eg truck drivers, office workers
heavy lifting eg labours, weight lifters
Obesity
Diet/ hydration poor

Mx
Address risk factors
PO/ Top analgesia
Anusol HC
Refer if no improvement

Question 16

Hepatitis A

Answer 16

liver infection by a virus spread through contaminated food/ water/ person.

Fx/
tiredness, jaundice, abdo pain, fevers

Mx/
Bloods - confirm diagnosis
Fluids, analgesia, rest
Itch Tx if required
Minimise transmission risk
FU for bloods and symptoms, safety netting

Question 17

Irritable Bowel Syndrome

Answer 17

Common disorder that effects the gut - various symptoms including constipation, changing bowel habits, tummy pain.

Mx/
Assess for red flags (weight loss, bleeding etc.)
Address risk factors - stress, foods
Food diary, FODMAP
Exercise
CBT
Peppermint capsules
Address symptoms
- bloating/ cramping - hyoscine/ mebeverine
- constipation - laxatives
- diarrhoea - loperamide
SSRI/ TCA

Question 18

Angina

Answer 18

Blood vessels that supply the heart become narrow, restricting blood flow to the heart muscle. When resting your heart can manage, but when active, your heart struggles, leading to pain. This is not a heart attack, but can lead to one if not managed appropriately

Mx/
lifestyle - exercise, diet, no smoke
aspirin daily
GTN spray
refer chest pain clinic

DVLA
Group 1 - no drive if symptomatic
Group 2 - no drive, inform dvla, until symptoms free >6 weeks

Question 19

lymphadenopathy

Answer 19

Swollen glands, usually within our neck. Very common, often harmless. Often raised, tender, smooth lumps during URTinfections, stress, self resolve within a few weeks to months.

Red flags - weight loss, night sweats, abnormal bleeding, cough, bone pain

Mx/
self resolve within 6 weeks - if not for USS 2WW review .

Question 20

Pagets disaese

Answer 20

Abnormal process of bone breakdown and regrowth. Weaker more fragile bones, leading to pain and risk of breakage.

Ix/
bloods - raised ALP
XR - lytic lesions on bones

Mx/
Bisphosphonates
Rheumatologist/ Endocrinologist
Refer

Question 21

Peripheral vascular disease

Answer 21

The blood vessels that supply the leg are narrowed. During exercise, the muscles require more blood and oxygen, however, due to the narrowing of the vessels, not enough blood gets to the muscles, leading to acid build up and pain/ cramping. This is resolved at rest.

Mx/
Address risk - smoking, exercise, diet, weight, blood pressure
Clopidogrel > aspirin
Simple analgesia
Refer to vascular

Critical limb ischaemia
Pain
Pulseless
Pallor
Perishingly cold
Paraesthesia
Paralysis

Mx (critical limb) - urgent refer vascular

Question 22

Polymyalgia Rheumatica

Answer 22

inflammatory condition causing pain and stiffness in the neck, shoulders and arms.

Fx/
bilateral shoulder pain
>50yo
morning stiffness

DDx/
Temporal arteritis - headache, jaw claudication
Rheumatoid

Ix/
Bloods inc ESR

Mx/
Low dose steroids, weaning regime - start Pred 15mg OD, reduce every 4 weeks by 2.5mg
Rv patient after 1 week of treatment - should have responded well. - refer rheum if so
bone protection - FRAX score - bisphos/ ca/ vit d

Question 23

Post partum thyroiditis

Answer 23

Autoimmune condition presenting in first year post birth. Consisting of three phases
1 - Hyperthyroid - 1-3 months
2 - Hypothyroid - 3-6 months
3 - Recovery 6+

Mx/
refer endocrine
can start propranolol in hyperthyroid state if indicated

Question 24

Reflux/ Dyspepsia/ Indigestion

Answer 24

Red flags - weight loss, dysphagia, persistent vomit, haematemesis

Mx/
Lifestyle - reduce caffiene, alcohol, smoking, spicy/ fatty/ sugary foods, reduce stress, lose weight
Meds - PPI, Gavison, ranitidine - for 1 month then rv. rv- aspirin, NSAIDs, steroids, bisphosphonates
H.Pylori - test = stool (only if PPI clear for 2 weeks) - 2x abx + PPI

Question 25

Restless legs (in pregnancy)

Answer 25

Uncomfortable sensation in the legs, having the urge to move them. Very common, esp in pregnancy.

Ix/
Bloods - iron,
Risk factors - caffeine, sleep, exercise, diet,

Mx/
lifestyle - address RF, stay hydrated, massage
Iron supplements if deficient
regular monitorign

Question 26

Back pain

Answer 26

Red flags
Ask about mood! Chronic disease = depression
Malignancy - Weight loss, fevers, night pain, cancers, >55yo (worse or new)
Ank spon - <20, morning stiffness
Cauda equina - neuro deficit, urinary/ bowel symptoms, perianal sensation loss

Question 27

Migraine (paediatric)

Answer 27

episodes of headaches, other symptoms include feeling sick, vomiting. Very common but manageable with medication.

DDx/
Cluster - agitation, awful headache
tension - stress related, bilateral, no other symptoms

Mx/
check red flags
Acute - paracetamol, NSAID, aspirin (not under 16s), nasal triptan (not oral for under 18s), anti emetic (eg metoclopramide, prochlorperazine)
Prevention - specialist only
regular FU

Question 28

Sleep apnoea

Answer 28

Causing your breathing to stop whilst asleep. Often waking you up and disturbing your sleep. Due to throat muscle relaxing, leading to narrowing of the airways in the neck.

Epworth sleepiness scale - daytime sleepiness - sitting/ reading, watching tv, in a meeting, passenger of car, lunch, at traffic lights

Mx/
local sleep clinic - sleep studies, CPAP
risk factors - weight, smoking, alcohol
DVLA - stop driving until controlled symptoms. in Group 2 needs to inform DVLA and consultant clearance to drive

Question 29

Thrombocytopenia (low platelets)

Answer 29

DDx/
usually harmless, repeat test in 4-6 weeks.
Ca, leukaemia, myeloma, b12, fol, liver disease, pregnancy, alcohol, infections

Hx/
signs of bleeding - gums, stool, nose, urine
bruising
screen for Ca, infection, disease

Ix/
bloods inc blood film,
If pregnant speak to specialist - eg pre eclampsia, HELLP syndrome

Question 30

tinnitus

Answer 30

Hearing sounds from outside of the body, it is common and can be caused by many factors. Although bothersome, it is not usually harmful.

DDX/
unilateral - Meniere’s (hearing loss, vertigo), Acoustic neuroma (dizziness)
bilateral - noise inducted hearing loss, drug inducted (aspirin, nsiads, ciprofloxacin, furosedmie, gentamicin), presbycusis (age related)

Mx/
Immediate Admission - suicidal, neurological symptoms (inc acute vertigo), stroke, head trauma, sudden with hearing loss
Urgent refer - effecting daily life, gradual hearing loss, persistent otalgia
Routine - persistent despite treatment

Mx in primary care
review risk factors - meds, stress, alcohol, occupation
sound therapy, cbt, hearing aids, address mental health impact

Question 31

Tonsillectomy request

Answer 31

Not routinely performed anymore - as most sore throats are caused by viral infections which will improve without surgery. Most children will grow out of recurrent sore throats, surgery is for those who have severe, frequent and disruptive symptoms.

FeverPAIN - fevers <24hrs, exudate on tonsil, <3 day onset, inflamed tonsils, absence of cough

Criteria for ENT tonsillectomy
- sore throats are due to bacterial tonsillitis
- disturbing normal daily function
- >7 episodes in 1 year, >5/year for 2 years, >3/ year for 3 years

Question 32

transient global amnesia

Answer 32

Short term memory loss for one to 24 hours . Usually harmless, no increase in likelihood of stroke. No further investigations.

Fx/
no neurological deficit, only amnesia

DDx/
TIA/ stroke
Transient epileptic amnesia
migraine associated amnesia

Ix/
bloods, MRI head, EEG - R/O other causes of amnesia/ cognitive impairment

Mx/
reassurance
routine FU
safety netting - if happens again go to hospital

Question 33

Wet age related macular degeneration (AMD)

Answer 33

Blood vessels at the back of the eye leak fluid. Effects the central vision. Need to see an eye doctor immediately.

Fx/
central visual loss - rapid

Mx/
ophthalmology within one week
avoid driving