Virtual clinics Flashcards
What are the clinical features of ADHD?
hyperactivity, inattention, and/or impulsivity have been present since childhood.
Present for >6 months
Feel sx in at least two of: home, school, social situations, or work
What could be some differentials for ADHD?
trauma; learning difficulties; hearing problems; epilepsy; anxiety; depression
What is the mx of ADHD?
CBT/ social skills training; education; methylphenidate, atomoxetine, dexamfetamine, or lisdexamfetamine remove additives + artificial flavourings from diet
What are some sx of inattention?
easily distracted; careless mistakes; forgetful; difficulty concentrating on boring or long tasks/ following instructions; difficulty organising; constantly change task
What are some sx of hyperactivity/ impulsiveness?
fidget; excess movement or talking; difficulty turn taking; interrupt others; little sense of danger
What is a shared care protocal?
“Shared Care Protocols are intended to provide clear guidance to General Practitioners (GPs) and hospital prescribers regarding the procedures to be adopted when clinical (and therefore prescribing and financial) responsibility for a patient’s treatment is transferred from secondary to primary care.” - is requested by secondary care and GP accepts
What is the difference between primary, secondary and subclinical hypothyroidism?
Subclinical hypothyroidism: TSH raised; T4 normal
Secondary hypothyroidism: TSH low/ normal; T4 low
Primary hypothyroidism: TSH raised; T4 low
( When thyroxine is low TSH rises to try stimulate the thyroid)
What are causes of primary vs secondary hypothyroidism?
Primary hypo causes: iodine deficiency; autoimmune thyroiditis; iatrogenic, amiodarone, lithium, transient thyroiditis
Secondary hypo: pituitary or hypothalamus disorder
What are the symptoms of primary hypothyroidism?
Sx of primary hypo: fatigue, cold intolerance, weight gain, constipation, depression, weakness, menstrual irregularities; dry skin; hair loss; Oedema- including swelling of the eyelids; voice change; goitre; bradycardia; reflexes relaxing slowly; carpal tunnel; other autoimmune problems
What are the sx of secondary hypothyroidism?
Sx of secondary hypo: as above + possible hypothalamic-pituitary disease eg headache, bilateral hemianopia; possible skin depigmentation, atrophic breasts, galactorrhoea, amenorrhoea, erectile dysfunction, loss of body hair, Cushing’s syndrome, or acromegaly.
What is the most common cause of hypothyroidism in the UK?
Autoimmune thyroiditis - this + goitre = hashimoto’s disease
What thyroid antibodies may be found in autoimmune disease?
Thyroid antibodies: thyroid peroxidase antibodies (TPOAb), thyroglobulin antibodies (TgAb), and thyroid stimulating hormone receptor antibodies
What is sublinical hypothyroidism?
This means that you are making enough thyroxine but the thyroid gland is needing extra stimulation from TSH to make the required amount of thyroxine.
Why is T4 tested and not T3?
changes show up in T4 first as T4 is converted into T3 - so better to look at T4
What is the treatment for hypothyroidism?
levothyroxine
What are the adverse effects of levothyroxine?
Gastrointestinal — such as diarrhoea and vomiting.
Cardiovascular — such as angina, arrhythmias, palpitations, and tachycardia.
Immunological — such as hypersensitivity reactions (including rash, pruritus, urticaria, and oedema).
Metabolic — such as weight loss.
Musculoskeletal — such as arthralgia and muscle weakness.
Neurological — such as anxiety, tremor, restlessness, excitability, insomnia.
Psychiatric — may induce mania.
Reproductive — menstrual irregularities.
General — such as headache, flushing, sweating, fever, heat intolerance.
thyrotoxic storm: hyperpyrexic; HR >140; Nausea, jaundice, vomiting, diarrhoea, abdominal pain. Confusion, agitation, delirium, psychosis, seizures or coma.
What is the presentation of a thyrotoxic storm?
hyperpyrexia (>41 degrees) dehydrated HR >140 N+V+D +abdo pain delirium coma and seizures
What is the management of a thyrotoxic storm?
carbimazole
after 4 hrs iodine solution to stop to prevent new hormone synthesis
beta blockers
hydrocortisone
When is reflux normal in children?
between 8 weeks and 1 yr no sandifers syndrome no complications eg oesophagitis, aspiration pneumonia, otitis media, chronic cough; faltering growth; difficulty feeding no red flags no pain
What are red flags with reflux in children?
- projectile vomit (pyloric stenosis)
- bile stained (obstruction) - do GI contrast study
- Haematemesis (UGI bleed)
- onset >6 months or continues >1 yr (suggests another issue eg UTI)
- blood in stool (gastroenteritis, CMPA, surgical problem)
- distension/ abdo mass (CMPA)
- chronic diarrhoea (CMPA)
- fever, malaise (infection)
- dysuria (UTI)
- bulging fontanelle; Persistent morning headache, and vomiting worse in the morning (raised ICP eg meningitis)
- lethargy/ irritable (meningitis)
- atopy (CMPA)
What is the mx of physiologically normal reflux?
reduce the feed volumes only if excessive for the infant’s weight; trial of smaller, more frequent feeds; trial of thickened formula; gaviscon
How may GORD be treated in a child?
Try PPI/ H2RA if: distressed, feeding difficulties, faltering growth, proven oesophagitis
What are sx of B12 and folate deficiency anaemia?
cognitive changes; dyspnoea; headache; loss of appetite; palpitations; tachypnoea; visual disturbance; weakness
What kind of anaemia is B12 and folate deficiency?
macrocytosis- raised MCV >100
What are the signs of B12 and folate deficiency anaemia?
Brown pigmentation affecting nail beds and skin creases; angular stomatitis; episodic diarrhoea; glossitis; heart murmurs; hepatomegaly; mild jaundice; mild pyrexia; tachycardia; wt loss
What are sx of B12 deficiency?
neuropathy (legs> arms; retinal); weakness; incontinence; psychiatric disturbances
What ix may you do for tiredness?
FBC (MCV; haematocrit and Hb levels); blood film; serum cobalamin and folate levels - NEED to do cobalamin and folate as iron defiency can mask high MCV
May also do LFTs; GGT; TFTs for differentials
What causes of B12/ folate deficiency should be ruled out?
assess diet; check for malabsorption - antiendomysial or anti transglutaminase antibodies. Check for pernicious anaemia: anti-intrinsic factor antibodies.
What are differential causes for macrocytosis?
alcohol; antimetabolite drugs eg methotrexate, hydroxycarbamide; haematology eg aplastic anaemia, myeloma; CLD, pregnancy; hypothyroid; smoking
What is the mx for B12 deficiency?
neuro involvement - haematology referral; hydroxocobalamin IM alternate days until no further improvement then ever 2 months
No neuro involvement - hydroxocobalamin IM three times a week then every 3 months- unless can improve via diet
What is the mx for folic deficiency?
PO folic acid OD for 4 months
What are indications for methotrexate, how does it work and what should you monitor it for?
Methotrexate - indicated in crohns, RA, psoriasis,
mechanism: antimetabolite of the antifolate type.
Monitor for: photosensitivity; bone marrow suppression, GI/ liver/ pulmonary toxicity/ anaemia
What are indications for azathioprine, how does it work and what should you monitor it for?
Azathioprine- Indicated in crohns, RA, lupus (other autoimmunes), polymyositis, eczema, myasthenia gravis.
Inhibits purine synthesis. Purines are needed to produce DNA and RNA. By inhibiting purine synthesis, less DNA and RNA are produced for the synthesis of white blood cells, thus causing immunosuppression.
Monitor for Bone marrow depression; increased risk of infection; anaemia; leucopenia; pancreatitis; thrombocytopenia
What are indications for hydroxycarbamide, how does it work and what should you monitor it for?
Hydroxycarbamide- indicated in SCD, CML, cervical cancer.
Mechanism: decreases the production of deoxyribonucleotides via inhibition of the enzyme ribonucleotide reductase.
Monitor for anaemia
What resouces could you refer a young person to who has anxiety?
young minds; childline; mind
self help: self soothe box; mindfulness; meditation; anxiety UK; local support groups
IAPT and CBT
What are sx of anxiety?
on edge all the time, overwhelmed, full of dread, low appetite, difficulty concentrating, tired and grumpy, HR increase, dry mouth, tremble, feel faint, stomach cramps, diarrhoea, increased urinary freq, sweaty, feel hot
How may type 1 diabetes present?
polydipsia and polyuria (may wet bed in young pts) and wt loss
By chance of urine/ blood test
extreme tiredness
Blurred vision
less common symptoms included fainting, headaches, nose bleeds and mouth ulcers.
If someone autistic loses their job, what should you consider?
Disability and work act - did employer know she was autistic, did they make reasonable adjustments
What are RF for a DVT?
PMhx DVT; cancer; age; obesity; male; HF; thrombophilia; inflammatory disorders; immobility; OCP; pregnancy; dehydration; cancer
What is the main complication you should be concerned with after a DVT?
PE
How does a DVT present?
unilat pain and swelling; tenderness, skin changes including oedema, redness, warmth; vein distension.
What are differentials for a DVT?
trauma; superficial thrombophlebitis and post-thrombotic syndrome; ruptured bakers cyst; cellulitis; dependent oedema
Summarise the Well’s score
Each +1: cancer bedridden/ major surgery calf swelling >3cm compared to other leg nonvaricose superficial veins present entire leg swollen tender along the deep venous system unilat pitting oedema Paralysis, paresis, or recent plaster immobilization pmhx dvt alt diagnosis more likely (-2) > 3 points = DVT likely
What ix should you do for a DVT?
If likely have DVT do a US in 4 hrs -
if this is not possible, interim therapeutic anticoagulation and a proximal leg vein ultrasound scan with the results available within 24 hours should be offered.
If unlikely do D-dimer - if positive do US
What is the mx of DVT?
anticoagulant: 1st line: DOAC;
2nd line: dalteparin s/c;
What is the difference between DOAC and warfarin?
warfarin inhibits vit K, required INR testing, more interactions, higher risk of brain bleed, long term effects better known
DOAC inhibits factor Xa -> reduced thrombin, less easy to reverse and SE less well known
What is an advance care directive for in MND?
decide on future day to day care eg ADRT (refuse tx), decisions about artificial feeding, ventilation, resuscitation, use of antibiotics, place of care and preferred place of death, and other issues such as care of dependants or pets in an emergency; financial plans
How are MND pts palliatively managed?
pain; pressure care; dyspnoea; dysphagia; salivation; insomnia; mental health; restless; bowels; bladder; practical and emotional needs.
Mouth care important - dried out by mouth breathing and minimal fluid intake PO at end of life
Keep up communication - use aids if appropriate
What meds are used in MND?
antimuscarinics to reduce saliva and respiratory secretions
opioids and benzodiazepines, such as midazolam, to manage breathlessness that is exacerbated by anxiety
Reduce anxiety/terminal restlessness, such as haloperidol or levomepromazine
antiemetics for nausea.
analgesics
How should you approach a MND advance directive discussion?
Is this is a good time to discuss?
What do they already know about advance directives?
Explain it as a way for them to feel more in control about what will happen to them and for you to give them the best care possible. Let them know they can change their mind about what they want.
Discuss what they’re worried about for the future
Is already on ventilation at night, has PEG, at home with carers- how do they feel about these?
Unlikely to cover everything as may need time to think about what they want and may not have energy as is “frail”
Ask family to help
Prioritise what they think is important
document
When explaining anything in Gp what should you consider?
what do they already know?
How much do they want to know?
Referring to additional resouces for them to read post-consultation
What sx do you get in MND?
progressive muscle weakness - unsteady, falls, wasting, cramps
SOB and fatigue as effects resp muscles
bulbar sx: speech and swallowing difficulty tongue fasiculations
fronto-temporal dementia
emotional lability
What are the differentials for an acute cough?
ACE-inhibitor; pneumonia (remember atypical); URTI; asthma; post-nasal drip; foreign body inhalation
How does acute bronchtis (URTI) present?
cough w/wo sputum, wheeze, SOB; may have systemic features w/wo raised temp; normal CXR
How may a CAP present (bacterial LRTI)?
cough w/ sputum/ wheeze/ SOB/ pleuritic pain; signs: dullness to percussion; coarse crepitations; vocal fremitus; at least one systemic feature (eg fever, sweats, myalgia); abnormal CXR
When would you do further ix for an acute cough?
haemoptysis ; prominent systemic illness; suspicion foreign inhaled body and suspicion lung cancer require more ix
What is the mx of acute bronchitis?
supportive mx unless underlying problem eg COPD or asthma
honey; pelargonium; guaifenesin; cough suppressants
How long will cough from acute bronchitis last?
around 3 weeks
25% pts will have post-infective cough after acute bronchitis lasting ~4 weeks
What is post-bronchitis syndrome?
lasts many months; productive; pt not unwell; XCR normal
When should abx be given for acute bronchitis?
premature; comorbidities; immunosuppressed; use ICS; hospitalisation in last year - those 65+ with 2 of these or 80 with 1 or more are high risk - do CRP - if over 20 mg/L give abx
If suitable, what abx would be given for acute bronchitis?
adults: doxycycline; paeds: amoxicillin (second line: erythro and clarithromycin)
How would you approach a pt who wants unnecessary treatment/ further ix?
What is the sinister problem they are worried about? Are there other sx they haven’t already mentioned?
Which ix?
Explain how there would be other sx if it was something more sinister
If they develops other sx then can send for further tests (safety net)
educate and reassure
redirect to 111/ patient uk/ NHS choices to use in future
What are complications of alcoholism?
dilated cardiomyopathy; arrhythmias; cirrhosis liver; pancreatitis; increased risk of mouth, breast, throat, liver cancers; vitamin deficiency (usually poor diet) - thiamine deficiency (wernicke- korsakoff’s syndrome) + visual and memory problems; death from cardiac/ resp depression
What is the mx of alcoholism?
motivational interviewing; CBT; AA; disulfiram- causes hangover straight after alcohol consumption; naltrexone - blocks euphoria of alcohol
What is the mechanism of wernicke- korsakoff’s syndrome?
Alcohol interferes with thiamine being converted into its active form -> thiamine helps metabolise glucose → brain is vulnerable to this deficiency
How does wernicke- korsakoff’s syndrome present?
- interferes with cerebellum (movement + coordination); medulla (HR + breathing); brain stem (cranial nerves); mammillary bodies (emotion + memory +behaviour)
- wernicke’s sx- 1st: ophthalmoplegia; ataxia; changes mental state
- korsakoff’s sx- 2nd: antero and retrograde amnesia; confabulation
How is Wernicke/ Korsakoffs managed?
emergency
IV thiamine with glucose once thiamine levels corrected
At what prevalence of HIV is someone screened for it when they join a GP practice?
Prevalence more than 2/1000 recommended that they are screened when join a new GP practice
What are RF for HIV?
MSM + their female partners; IVDU; certain countries; those with other STIs
What are clinical indications for HIV testing?
dementia; unexplained weight loss unexplained pneumonia; peripheral neuropathy; raised total protein; unexplained and continuous thrombocytopenia/ lymphopenia/ neutropenia; unexplained and continuous diarrhoea; unexplained lymphadenopathy; Mononucleosis-like illness; Seborrheic dermatitis
What are some AIDs defining conditions ie opportunistic infections?
TB non-hodgkins lymphoma recurrent pneumonia herpes Candidiasis Cryptosporidiosis diarrhoea for more than 1 month; Cytomegalovirus Kaposi's sarcoma
Why are people resistent to HIV testing?
Affects insurance, job prospective, goes on permanent record
How might you break the bad news of a HIV positive result?
Try to explain in slow, clear way
Ensure is in an appropriate setting, with privacy and have the time necessary to discuss issue
Remind him of the test that was previously done and check his understanding
Ask him if he is happy to discuss the results of the test today
Explain the that the result was unfortunately positive, giving him pause to process
Make a plan together of what happens next and reassure
Give resources
Check understanding of discussion and mx
What are bursa?
allow smooth motion of the joints
What is bursitis? where is it most common?
Inflammation of the bursa, occurs in different joints
most common place is knee is bursitis of prepatella
What are causes of bursitis?
trauma; recurrent minor injury; infection usually secondary to knee injury; RA; gout
What are RF for bursitis?
immunocomp/ child for infection + jobs w long period kneeling eg carpet fitters, concrete finishers and roofers.
What ix may you do for bursitis?
diagnosis made O/E unless suspect infection - aspirate; if doesnt get better can test for RA
What is the mx of bursitis?
Non-infective: rest; ice; elevate; cushion for kneeling; PT; cane; NSAIDs
if infective - give abx (specific to aspirate results; give co-amox in mean time- IM if infection severe).
If dont improve after 48 hrs of abx - drain.
If persists: intra articular steroids; surgical bursa removal
What are the differentials for knee pain?
Tendonitis
Bursitis
Trauma (commonly sports)
Osgood schlatters disease - affects younger ppl, problems with growth plate at top of tibia
Patellofemoral pain syndrome - pain behind or around patella, worse on flexion
Arthritis - OA (pain worse at end of day, stiff in morning (lasts about 30 mins), better on rest, swollen, older)
RA- red, swollen, extra articular sx
Gout - red, swollen, extreme pain
Infective cause - fever, warm, swollen, feel unwell
A woman 6 weeks postnatal comes to clinic. She tells you that her breasts are very sore and slightly red, her nipples are cracked. her baby has a white tongue. What are your differentials?
thrush
abscess
problems with latching and positioning
What are the sx of bursitis?
pain (dull ache), swollen, unilat; erythema; pain increase on movement; if infection - fever
How can you determine the cause of nipple soreness?
Establish if shes happy with positioning and attaching
Any systemic sx eg fever
What are other issues with breastfeeding, aside from pain?
low supply or over supply of milk
child feeding or swallowing difficulty eg tongue tie
prolactin deficiency
raynaud’s disease
How does nipple thrush present?
Starts after having no prev pain when breastfeeding
Severe and lasts hr after feed
Bilat
No fever
Baby- white spots mouth, cant be wiped off, unsettled when feeding, nappy rash wont go away
How is nipple thrush managed?
Treat baby and mother- Miconazole liquid/cream - for baby and mother + Fluconazole PO if necessary
Washing hands after nappy changes
Wash breastfeeding bras
Dont freeze the milk and give once treated from thrush
Can carry on feeding if want
If you don’t see any improvement within 7 days, speak to your health visitor or GP.
How does COPD present?
suspect if >35 with RF plus one of: exertional SOB; chronic cough; regular sputum production; frequent winter bronchitis; wheeze
What are the differentials for COPD?
asthma
lung cancer - wt loss, haemoptysis
heart failure - pink frothy sputum; PND; fatigue; orthopnoea; oedema
bronchiectasis- freq infections; coarse crackles
TB- weight loss, fatigue, persistent cough, breathing difficulty, chest pain, and thick or bloody sputum.
describe the MRC dyspnoea scale
1: only SOB strenuous exercise;
2: SOB hurry/ slight hill;
3: walks slow/ has to stop walking because of SOB;
4: SOB after 100m;
5: SOB means can’t leave house/ dress themselves
What ix should be done for COPD?
CXR, FBC (Anaemia or polycythemia), BMI, Spirometry: for diagnosis and monitoring - measure spirometry post bronchodilator
What indicates an obstructive spirometry?
FEV1/FVC ratio below 0.7 indicates obstructive disease - where narrowing of pulmonary airways hinder a person’s ability to completely expel air from the lungs eg COPD; asthma; bronchiectasis; CF
What ix should be done to exclude the differentials for COPD?
sputum culture (if sputum purulent and persistent);
PEF (exclude asthma);
ECG + A/BNP + echo (IHD + HF);
CT thorax (signs point to fibrosis or bronchiectasis;
CXR abnormalities + same reasons as TLCO);
alpha-1 antitrypsin (min smoking/ fhx);
TLCO (sx disproportionate to spirometry results; assess suitable for lung vol reduction)
How do you distinguish between COPD and asthma?
COPD: smoker; older; productive cough; SOB persistent and progressive; morning cough; responds better to anticholinergics
Asthma: younger; dry cough; Sx diurnal variation; wake at night wheeze/ SOB; dyspnea; atopy; fhx; responds better to bronchodilators + steroids
Otherwise asthma will respond (w over 400ml): bronchodilators/ pred; or will show serial peak flow measurements showing 20% or greater diurnal or day-to-day variability.
mx of COPD?
smoking cessation!
SABA + SAMA; ICS if asthmatic features;
PO steroids/ theophylline/ mucolytic/ prophylactic abx
Oxygen - careful of resp depression due to hypoxic drive;
ventilation
Pulmonary rehab and vaccines and education and follow ups
Surgery: lung vol reduction + transplant
What do you do in an exacerbation of COPD?
Exacerbation plan - eg abx and steroids
Exacerbations mx: CXR; ABG; ECG; sputum MCS; bld cultures;
How may you assess whether a COPD pt needs to go to hospital?
Does he feel able to cope at home?
How is his breathing: How does it sound - Is it shallow/ fast and needs lots of breaks when talking? Is this different to normal? Is there anything that makes you breathless today that didn’t yesterday?
Is he stuck in bed or is he able to get up and about?
Does he use any home oxygen therapy?
Skin changes ? - Blue face or lips/ cold/ clammy
Does he sound confused/ feel confused?
Does he live alone?
Does he feel light headed/ lost consciousness?
Has he been going to the toilet? Are they drinking enough water?
haemoptysis?
What are the causes of dyspepsia?
GORD; dysmobility; peptic ulcer
What sx would you get with dysmobility and gastric ulcers that you wouldn’t with gord
ulcers (also have epigastric pain) or dysmobility (also get bloating, fullness, nausea)
What is barrett’s oesophagus?
metaplasia of the normally squamous lining of the lower esophagus to columnar epithelium caused by GORD.
RF for adenocarcinoma oesophagus
what are some causes of GORD?
Problems w lower sphincter: eg Hiatus hernia, nicotine
Oeseophageal factors: poor clearance; mucus sensitivity and resistance; less saliva
Abdo and gastric: posture; delayed gastric emptying; pregnancy; obesity
Hyperacidity: food; alcohol; rebound after PPI; hypercalcaemia; zollinger-ellison
Genetics + age
What are red flags alongside GORD?
>55 with unexplained wt loss >55 + raised platelets Any age with dysphagia early satiety (malignancy) GI bleed eg anaemia; malaenia; haemoptysis
What lifestyle advice should be given to someone with GORD?
avoid smoking, coffee, alcohol, fatty food, choc, meals 3 hrs before bed
Stop these meds if poss: calcium antagonists; nitrates; theophyllines; bisphosphonates; corticosteroids; NSAIDs
What meds are used for GORD?
antacid + alginate - gaviscon ->
PPI eg omeprazole ->
H2 antagonist
What are the tests for H. Pylori (cause of gastritis)
stool antigen or carbon-13 urea breath test.
