Surgery, Ortho, Rheum Flashcards
When to refer microscopic haematuria
with dysuria OR raised WCC on bloods
Red flags for lower back pain (5)
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
BPH Mx
1st - alpha 1 antagonist (tamsulosin, alfuzosin)
2nd - 5 alpha reductase (finasteride)
Reasons to refer for breast review if patient’s first or second degree relative has the following… (>5)
age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in < 45 years
paternal history of breast cancer (two or more relatives on the father’s side of the family)
Fragility fracture primary care Mx
<75 needs DEXA for FRAX assessment
>75 - start oral bisphosphonate
Ca/ Vit D shoulder be corrected prior to starting bisphosphonates
Features associated with Ankylosing Spondylitis (6)
Apical fibrosis
Aortic regurgitation
AV node block
Amyloidosis
Anterior uveitis
Achilles Tendonitis
Groups that are advised to take vitamin D supplementation (4)
ALL pregnant and breastfeeding women
Children 6 months to 5 years
>65 yo
People not exposed to sunlight eg housebound, head coverings
Rheumatoid arthritis Ix
1st - rheumatoid factor
2nd - anti CCP
3rd - X ray
Lateral epicondylitis (tennis elbow) significant movement test
resisted wrist extension with the elbow extended
hydroxychloroquine (for SLE) side effect
severe retinopathy - monitor visual acuity annually
minimum steroid intake a patient should be offered osteoporosis prophylaxis
Equivalent of prednisolone 7.5 mg or more each day for 3 months
If this is presumed then to start prophylaxis straight away rather than wait 3 months eg Tx for PMR
Bone protection for patients taking corticosteroids age limits
< 65 yrs: DEXA scan first
>= 65 yrs: start alendronate
Mammary duct ectasia Fx
tender breast lump
+/- green discharge
most common around menopause
Fibroadenosis (fibrocystic disease, benign mammary dysplasia) Fx
Lumpy breasts
may be painful
may worsen around menstruation
Denosumab main side effect
atypical femoral fractures
Breast clinic referral
USC
Routine
USC (2WW) - >30yo + unexplained breast lump OR >50 + unilateral nipple change
Routine - <30 + unexplained breast lump
Obesity Bariatric referral cut off for BMI
with risk factors > 35 kg/m^2
no risk factors: > 40 kg/m^2
Risk = T2DM, HTN
If BMI >50 = consider surgery as first line
Diffuse cutaneous systemic sclerosis antibody
anti-scl-70
Limited cutaneous systemic sclerosis antibody
anti-centromere antibody
Carpal tunnel Mx
1st - wrist splint +/- steroid injection
2nd - wrist splint + physiotherapy
3rd - Surgery
Methotrexate and trimethoprim together can lead to
bone marrow suppression and severe pancytopenia
Maximum safest dose of Lidocaine (local anaesthetic) at 1%
3mg/kg
Medial epicondylitis (golfers elbow) is aggravated by what movement
wrist flexion and pronation
DEXA scan
T score
Z score
T score - bone mass of young population
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
Z score - adjusted for age, gender, ethnicity
Z scores tend to be used in children, men below 50 and premenopausal women.
Breast Duct Papilloma
blood stained nipple discharge
if large, may present with a mass
Anal fissure Mx
1st - stool softeners - eg high fibre diet, ispaghula husk (bulk forming)
2nd - lubricants, topical anaesthetics
3rd - Topical GTN (first line for chronic anal fissures)
4th - if GTN not effective after 8 weeks for referral
Sulfasalazine is contraindicated with what medications
Co trimoxazole
Aspirin
Congenital hernias Mx
inguinal
umbilical
inguinal: repair ASAP
umbilical: manage conservatively
Lactational mastitis Mx
(first 24 hours) - self care, express milk
1st - Flucloxacillin
2nd - Co-Amox
Varicose veins Mx
Graduated compression stockings (after ABPI to check for arterial insufficiency first)
Reasons for referral for varicose veins (5)
significant lower limb symptoms e.g. pain, discomfort or swelling
bleeding from varicose veins
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer
Meralgia paraesthetica Fx
compression of lateral cutaneous femoral nerve (outer upper thigh paraesthesia, with no motor loss)
consequence of rapid weight gain
Ix - pelvic compression test
Peripheral artery disease Mx
Clopidogrel and statin (Atorva 80mg)
Prostatitis Mx
Ciprofloxacin (quinolone) 14 days
2nd line - Trimethoprim 14 days
Interpretation of ABPI
> 1.2
1.0 - 1.2
0.9 - 1.0
< 0.9
< 0.5
> 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
1.0 - 1.2: normal
0.9 - 1.0: acceptable
< 0.9: likely PAD.
< 0.5 indicate severe disease which should be referred urgently
Compression bandaging only if ABPI >0.8
Ottawa rules for X rays for ankle and foot injury (3)
lateral malleolar zone tenderness (posterior tip)
medial malleolar zone tenderness (posterior tip)
inability to walk four weight-bearing steps immediately after the injury and in the emergency department
Non specific lower back pain Mx
1st - NSAID
2nd - benzo (if muscle spasm)
Sjogrens syndrome antibody
anti-Ro
anti-La
Rheumatoid factor
Osteoporosis Mx WITH fragility fracture
> 75 - start bisphosphonates (without DEXA)
<75 - DEXA scan then FRAX score
Ca/ Vit D should be corrected prior to starting bisphosphonates
Acute gout Mx
1st - NSAID
2nd - colchicine
3rd - oral steroid
Bone disorders lab values
Primary hyperPTH
CKD
Pagets
Osteomalacia
Primary hyperPTH - all high, Phos low
CKD - all high, Ca low
Pagets - all normal, ALP high
Osteomalacia - ALP/ PTH high, Ca, Phos low.
Rheumatoid arthritis antibody
Anti CCP
Methotrexate adverse effects (4)
Mucositis
Myelosuppression
Pneumonitis
Pulmonary/ Liver fibrosis
Contraindicated in pregnancy. Men should without Methotrexate >6 months if trying to concieve
Osteogenesis imperfecta Fx
AKA “brittle bone disease”
Autosomal dominant
Fractures from minor trauma
blue sclera
deafness secondary to otosclerosis
Breast Duct papilloma Fx
blood stained nipple discharge
no lump or skin changes
Breast mammary duct ectasia Fx
tender lump around areola
green nipple discharge
Behcets syndrome Fx
Oral ulcers
Genital ulcer
Anterior uveitis
Thrombophlebitis/ DVTs
Colchicine common SE
Diarrhoea
New onset synovitis Mx
Urgent Rheum refer
Osteoarthritis Mx in primary care
1st- Top NSAID
2nd - PO NSAID + PPI
3rd - steroid injection (weak opiates not recommended)
Gottron’s papules are roughened red papules over the extensor surfaces and are seen in dermatomyositis
Heberden’s and Bouchard’s nodes are seen in osteoarthritis. Aschoff nodules are pathognomonic of rheumatic fever whilst Muehrcke’s lines are white, transverse lines of the fingernail seen in hypoalbuminaemia
Gottron’s papules are roughened red papules over the extensor surfaces and are seen in dermatomyositis
Heberden’s and Bouchard’s nodes are seen in osteoarthritis. Aschoff nodules are pathognomonic of rheumatic fever whilst Muehrcke’s lines are white, transverse lines of the fingernail seen in hypoalbuminaemia
Vit D supplements need what monitoring
Calcium
If hypercalcaemia - should consider hyperparathyroidism
Methotrexate blood monitoring
FBC, UE, LFT
Sulfasalazine SE
Oligospermia
Rash
Interstitial lung disease
Dermatomyositis Fx
symmetrical, proximal muscle weakness
Skin lesions - maculopapular rash over shoulders/ back, photosensitive, Gottrons papules (rough red papules on extensors of fingers)
Associated with connective tissue disorders and malignancy (ovarian, breast, lung)
Bowel screening UK age criteria
Between 60-74
every 2 years
Men and women
Aromatase inhibitors (e.g. anastrozole) SE
osteoporosis
Female Breast screening age criteria
50-70 yr old
every 3 years
Erectile dysfunction initial bloods
1st - Testosterone, fasting glucose, lipids
If testosterone low then - repeat testosterone, FSH, LH, prolactin
If abnormal for Endocrine
Erectile dysfunction Mx
1st - Sildenafil or Tadalafil
2nd - (if PDE-5i contraindicated or not wanted eg Stroke/ MI in past 6 months) - vacuum erection device
Causes of dupytrens contracture (5)
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
Bowel Ca screening age criteria
60-74 yr old
every 2 years
can self refer after 74
Anorectal disorders
haemorrhoids
anal fissure
anal fistula
Pruritis ani
rectal ulcer
Haemorrhoids - Post defecatory (painless) rectal bleeding on wiping/ in pan
Anal fissure - Most common cause of painful rectal bleeding. Examination is painful, should be delayed until healed.
Anal fistula - usually secondary to ano rectal abscess. painful rectal bleeding
Pruritis ani - Children (worms), Adults (haemorrhoids)
Rectal ulcer - Rectal bleeding - Hx of constipation and straining
Antiphospholipid syndrome biochemistry
(paradoxically) prolonged APTT + low platelets
intraarticular knee fracture X ray findings
fat fluid level
Glucosamine contraindicated with what allergy
shellfish
Rheumatoid arthritis is associated with what conditions
Hypertension
IHD
osteoporosis
depression
Ottawa Knee rules
Age 55 years or older
Isolated tenderness of the patella (no bone tenderness of the knee other than the patella)
Tenderness of the head of the fibula
Inability to flex the knee to 90°
Inability to weight bear both immediately and during the consultation for four steps (inability to transfer weight twice onto each lower limb regardless of limping)
