Virtual clinics Flashcards
1
Q
What are the clinical features of ADHD?
A
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
2
Q
What could be some differentials for ADHD?
A
trauma; learning difficulties; hearing problems; epilepsy; anxiety; depression
3
Q
What is the mx of ADHD?
A
CBT/ social skills training; education; methylphenidate, atomoxetine, dexamfetamine, or lisdexamfetamine remove additives + artificial flavourings from diet
4
Q
What are some sx of inattention?
A
easily distracted; careless mistakes; forgetful; difficulty concentrating on boring or long tasks/ following instructions; difficulty organising; constantly change task
5
Q
What are some sx of hyperactivity/ impulsiveness?
A
fidget; excess movement or talking; difficulty turn taking; interrupt others; little sense of danger
6
Q
What is a shared care protocal?
A
“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
7
Q
What is the difference between primary, secondary and subclinical hypothyroidism?
A
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)
8
Q
What are causes of primary vs secondary hypothyroidism?
A
Primary hypo causes: iodine deficiency; autoimmune thyroiditis; iatrogenic, amiodarone, lithium, transient thyroiditis
Secondary hypo: pituitary or hypothalamus disorder
9
Q
What are the symptoms of primary hypothyroidism?
A
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
10
Q
What are the sx of secondary hypothyroidism?
A
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.
11
Q
What is the most common cause of hypothyroidism in the UK?
A
Autoimmune thyroiditis - this + goitre = hashimoto’s disease
12
Q
What thyroid antibodies may be found in autoimmune disease?
A
Thyroid antibodies: thyroid peroxidase antibodies (TPOAb), thyroglobulin antibodies (TgAb), and thyroid stimulating hormone receptor antibodies
13
Q
What is sublinical hypothyroidism?
A
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.
14
Q
Why is T4 tested and not T3?
A
changes show up in T4 first as T4 is converted into T3 - so better to look at T4
15
Q
What is the treatment for hypothyroidism?
A
levothyroxine
16
Q
What are the adverse effects of levothyroxine?
A
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.
17
Q
What is the presentation of a thyrotoxic storm?
A
hyperpyrexia (>41 degrees) dehydrated HR >140 N+V+D +abdo pain delirium coma and seizures
18
Q
What is the management of a thyrotoxic storm?
A
carbimazole
after 4 hrs iodine solution to stop to prevent new hormone synthesis
beta blockers
hydrocortisone
19
Q
When is reflux normal in children?
A
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
20
Q
What are red flags with reflux in children?
A
- 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)
21
Q
What is the mx of physiologically normal reflux?
A
reduce the feed volumes only if excessive for the infant’s weight; trial of smaller, more frequent feeds; trial of thickened formula; gaviscon
22
Q
How may GORD be treated in a child?
A
Try PPI/ H2RA if: distressed, feeding difficulties, faltering growth, proven oesophagitis
23
Q
What are sx of B12 and folate deficiency anaemia?
A
cognitive changes; dyspnoea; headache; loss of appetite; palpitations; tachypnoea; visual disturbance; weakness
24
Q
What kind of anaemia is B12 and folate deficiency?
A
macrocytosis- raised MCV >100
25
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
26
What are sx of B12 deficiency?
neuropathy (legs> arms; retinal); weakness; incontinence; psychiatric disturbances
27
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
28
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.
29
What are differential causes for macrocytosis?
alcohol; antimetabolite drugs eg methotrexate, hydroxycarbamide; haematology eg aplastic anaemia, myeloma; CLD, pregnancy; hypothyroid; smoking
30
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
31
What is the mx for folic deficiency?
PO folic acid OD for 4 months
32
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
33
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
34
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
35
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
36
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
37
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.
38
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
39
What are RF for a DVT?
PMhx DVT; cancer; age; obesity; male; HF; thrombophilia; inflammatory disorders; immobility; OCP; pregnancy; dehydration; cancer
40
What is the main complication you should be concerned with after a DVT?
PE
41
How does a DVT present?
unilat pain and swelling; tenderness, skin changes including oedema, redness, warmth; vein distension.
42
What are differentials for a DVT?
trauma; superficial thrombophlebitis and post-thrombotic syndrome; ruptured bakers cyst; cellulitis; dependent oedema
43
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
```
44
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
45
What is the mx of DVT?
anticoagulant: 1st line: DOAC;
| 2nd line: dalteparin s/c;
46
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
47
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
```
48
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
49
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
50
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
51
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
52
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
53
What are the differentials for an acute cough?
ACE-inhibitor; pneumonia (remember atypical); URTI; asthma; post-nasal drip; foreign body inhalation
54
How does acute bronchtis (URTI) present?
cough w/wo sputum, wheeze, SOB; may have systemic features w/wo raised temp; normal CXR
55
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
56
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
57
What is the mx of acute bronchitis?
supportive mx unless underlying problem eg COPD or asthma
| honey; pelargonium; guaifenesin; cough suppressants
58
How long will cough from acute bronchitis last?
around 3 weeks
| 25% pts will have post-infective cough after acute bronchitis lasting ~4 weeks
59
What is post-bronchitis syndrome?
lasts many months; productive; pt not unwell; XCR normal
60
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
61
If suitable, what abx would be given for acute bronchitis?
adults: doxycycline; paeds: amoxicillin (second line: erythro and clarithromycin)
62
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
63
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
64
What is the mx of alcoholism?
motivational interviewing; CBT; AA; disulfiram- causes hangover straight after alcohol consumption; naltrexone - blocks euphoria of alcohol
65
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
66
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
67
How is Wernicke/ Korsakoffs managed?
emergency
| IV thiamine with glucose once thiamine levels corrected
68
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
69
What are RF for HIV?
MSM + their female partners; IVDU; certain countries; those with other STIs
70
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
```
71
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
```
72
Why are people resistent to HIV testing?
Affects insurance, job prospective, goes on permanent record
73
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
74
What are bursa?
allow smooth motion of the joints
75
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
76
What are causes of bursitis?
trauma; recurrent minor injury; infection usually secondary to knee injury; RA; gout
77
What are RF for bursitis?
immunocomp/ child for infection + jobs w long period kneeling eg carpet fitters, concrete finishers and roofers.
78
What ix may you do for bursitis?
diagnosis made O/E unless suspect infection - aspirate; if doesnt get better can test for RA
79
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
80
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
81
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
82
What are the sx of bursitis?
pain (dull ache), swollen, unilat; erythema; pain increase on movement; if infection - fever
83
How can you determine the cause of nipple soreness?
Establish if shes happy with positioning and attaching
| Any systemic sx eg fever
84
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
85
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
86
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.
87
How does COPD present?
suspect if >35 with RF plus one of: exertional SOB; chronic cough; regular sputum production; frequent winter bronchitis; wheeze
88
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.
89
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
90
What ix should be done for COPD?
CXR, FBC (Anaemia or polycythemia), BMI, Spirometry: for diagnosis and monitoring - measure spirometry post bronchodilator
91
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
92
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)
93
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.
94
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
95
What do you do in an exacerbation of COPD?
Exacerbation plan - eg abx and steroids
| Exacerbations mx: CXR; ABG; ECG; sputum MCS; bld cultures;
96
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?
97
What are the causes of dyspepsia?
GORD; dysmobility; peptic ulcer
98
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)
99
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
100
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
101
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
```
102
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
103
What meds are used for GORD?
antacid + alginate - gaviscon ->
PPI eg omeprazole ->
H2 antagonist
104
What are the tests for H. Pylori (cause of gastritis)
stool antigen or carbon-13 urea breath test.
105
mx of h.pylori?
1st line: PPI; amox; clarithromycin; metronidazole BD
106
What are the sx of dyspepsia?
abdo pain, heartburn, reflux, N+V, worse when flat
107
What are differentials for GORD?
gastritis, pancreatitis, biliary colic
108
What are the differentials for 4 week long hx of lump in the groin?
testicular cancer; SCC scrotum; Epididymo-orchitis; cyst; Varicocele; Hydrocele; Haematocele; inguinal hernia
109
What should you ask about in a history of a groin lump?
Ask about: pain (onset, duration, severity etc.), prev eps; LUTI; discharge; parotid swelling; N+V; trauma
110
What should you examine for in a groin lump?
position swelling; tenderness; testicular lie; consistency swelling; lymphadenopathy; abdo mass; prehn sign; transillumination; features inguinal hernia (lying + standing); skin changes
111
What is prehns sign?
lifting testicle relieves the pain of epididymitis but not pain caused by testicular torsion
112
When should a scrotal swelling be referred for U/S?
unsure if testicular or extra-testicular; body of the testis cannot be distinguished; hydrocele 20–40 years of age (at-risk age group for cancer); chronic or non-traumatic haematocele; history of trauma and scrotal pain, or persistent testicular symptoms.
113
How does testicular cancer present?
painless, non-tender, dragging sensation, younger, testicular enlargement,
On palpation, there is a solid, firm swelling involving all or part of testis
may be associated with back or flank pain, lymphadenopathy; abdo mass, gynaemastia, wt loss
114
How does testicular torsion typically present?
```
acute;
unilat severe pain,
N+V,
young,
cremasteric reflex absent,
pmhx trauma,
Abnormal high position of the testes in the scrotum, with abnormal transverse direction,
Neonatal cases of testicular torsion may present with scrotal swelling and discoloration (similar to scrotal haematoma).
```
115
What is the pathophysiology of testicular torsion?
testicular torsion around the spermatic cord (made of vas deferans; arteries; veins; nerves; lymph; tunica vaginalis from deep inguinal ring to the testicle) this cuts off the blood supply
116
How may torsion of the appendix testis present?
acute, tender over the head of the testis or epididymis, An infarcted appendage may be seen through the skin (the 'blue dot sign').
117
How does epididymo-orchitis generally present?
acute,
painful,
Prehns sign,
palpable swelling,
can be similar to torsion,
possible discharge and hx UTI /STI or parotid swelling,
O/E hard, irregular, spermatic cord thickened
118
How may a epididymal cyst or spermatocele present?
chronic, painless, smooth, soft, round, cant transilluminate
119
How may a varicocele present?
```
chronic,
bag of worms,
dragging sensation,
disappear on lying down and reappear standing + valsalva maneuver,
pain on standing,
cant transilluminate,
usually on L
```
120
What must you consider in varicocele?
Varicocele can be a sign of malignancy (RCC) due to compression of the renal vein between the abdominal aorta and the superior mesenteric vein - known as the nutcracker angle
121
How may hydrocele present?
```
acute or chronic,
painless,
transilluminates,
common in neonates,
fluctuates,
congenital; tumour; trauma; inflammation; post surgery may cause
```
122
What is a hydrocele?
ovoid swelling enveloping the testis or located above the testis along the spermatic cord, may accompany other problems ---> serous fluid in tunica vaginalis -
123
How may an inguinal hernia present?
acute or chronic,
may be pain,
dragging sensation,
May enlarge with Valsalva-type manoeuvres, and disappear on lying down (if reducible).
On examination, it is not possible to 'get above' the swelling!!, or palpate the spermatic cord or inguinal ring; and there is a positive cough impulse.
124
What is the difference between a direct and indirect inguinal hernia? + which is more common?
→ bowel enters inguinal canal:
direct = through abdo wall
indirect= through deep inguinal ring- more common
125
What should you be concerned about with an inguinal hernia?
check for strangulation (irreducible, tender) or obstruction (vomit, constipation, abdo pain, distension) - admit to hospital
126
What is the management of an inguinal hernia?
admit hospital if obstructed or strangualted
otherwise watchful waiting if less concerned - may resolve by itself
surgery
127
WHat should be checked at the 8 week baby check?
check for any parental concerns
weight, head circumference,
inspect: colour, behaviour, breathing, activity, and skin; tone,
head (fontanelles, face, nose, palate, symmetry);
eyes (red reflex and visual fixing);
heart (position, murmur, rate, femoral pulses);
lungs (added sounds and rate);
abdo (shape, organomegaly, hernias),
genitals (normal, testicular descent),
hips (Barlow and Ortolani tests, symmetrical hip creases,leg-length discrepancy );
spine (eg spina bifida)
128
What may be some abnormal findings at an 8 week baby exam?
- VSD -Look out for: cyanosis; heaves; resp distress; RR >55 suspicious; displaced apex beat; murmur
- DDH
- glaucoma; congenital cataract; retinoblastoma
- undescended testes
- developmental abnormalities
129
How may an innocent baby murmur sound?
Innocent murmurs are common and are typified by low intensity, localised to a small area of praecordium and in the absence of other symptoms or signs
130
What are the different classifications of cryptoorchidism?
- true: along normal path of descent just not in scrotum
- ectopic: not in path of decent or scrotum
- ascending: testes previously in scrotum but has moved higher
- Absent testis: prev in scrotum but has moved out
131
What should you ask a parent if they have a child with cryptoorchidism?
Ask about pmhx endocrine problems and other RF; if ever had palpable testes and gestational age
132
What are potential complications of cryptoorchidism?
infertility; cancer!
133
How would you asses the cryptoorchidism?
- warm room and warm hands
- inspect the external genitalia and scrotum for abnormalities;
- palpate the scrotal sac on each side;
- attempt to milk the testis from the external ring to the scrotum along the inguinal canal if the testis is not located in the scrotal sac, and assess whether it can be manipulated into the scrotum.
134
WHat is the management of undescended testis?
undescended bilat testes urgent refer paeds
unilat undescended 6-8 weeks check at 4-5 months and refer for surgery at 6 months.
Need to advise self-exam during and after puberty as there is a higher risk of testicular cancer.
If retractile need annual follow up and re-examination until after puberty, as there is a significant risk of ascending testis
135
How may you follow up on a patient who has DNA their 8 week baby check several times?
If necessary speak to health visitor - there are five mandatory checks by health visitors, third of which is at 6-8 weeks, so should have seen recently - ask about safeguarding
136
What are some causes of an AKI (think pre/renal/post)?
pre renal: hypovolaemia + decreased CO
Renal: nephritis; nephrotoxic drugs (ACE-i; ARB2; diuretics)
Post-renal: bladder obstruction, renal stones
137
What is the criteria for an AKI?
increase creatinine >26 micromol/48 hrs; >50% rise creatine/ 7 days; fall urine output <0.5mL/kg/hour for >6 hrs
138
What ix should be done for an AKI?
blood vol (BP, pulse, JVP, CRT); U+E (exclude hyperkalaemia); urine dipstick (renal damage); assess AKI stage and causes
139
What drug is associated with an interference in creatinine interference?
REMEMBER trimethoprim interferes with tubular secretions of creatinine causing it to rise and is not truly associated with GFR change
140
Name the RF for an AKI?
age; CKD; heart/ lung/ liver disease; DM; less fluids eg dementia; pmhx AKI; frail; nephrotoxic drugs; dehydration; volume depletion; infections or connective tissue disorders → nephritis
141
Give a list of nephrotoxic drugs (remember DAMON SANG mneumonic)
```
Diuretics;
ACE-i/ ARB;
Metformin;
Opiods;
NSAIDs (impair PG mediated vasodilation of afferent arteriole);
Sulphonylureas;
Aldosterone antagonist eg Spironolactone;
NOAC;
Gabapentin
```
142
Name the triggers of an AKI?
sepsis; critical illness; shock; burns; trauma; surgery; radiocontrast agents; UTI or acute urinary retention
143
What do you want to ask when taking a history from a pt with AKI in a community setting?
fluid status? Acutely unwell eg from sepsis, hypotension, urinary tract obstruction? Medications? Home alone? Able to increase intake fo fluids?
144
How should you mx an AKI in the community?
CAUSE: sepsis, hypotension? Intrinsic kidney disease? Urinalysis? UT obstruction? MEDS: consider withholding NSAIDs, diuretics, anti-htn etc.
FLUIDS: pt volume state? When did they last pass urine? Do they need IV fluids? Carer or support?
REVIEW: acute admission or safety net
145
When is POP preferrable for COCP?
POP - safer than COCP for people with migraines; raised BP; overweight; smoke; DM
146
When is 2WW referral needed for cancer suspicion and lung cancer?
2WW for:
suspicious CXR findings
>40 + unexplained haemoptysis or 2 of unexplained sx or 1 of the unexplained sx + smoker/ asbestos exposure
unexplained sx: Cough; Fatigue; SOB; chest pain; wt loss; appetite loss; chest signs of cancer
Consider if >40 + persistent chest infection/ thrombocytosis/ clubbing/ supraclavicular/ cervical lymphadenopathy
147
What are sx of lung cancer?
cough, dyspnoea, haemoptysis, SVCO, Hoarseness (recurrent laryngeal nerve involvement), systemic sx, lymphadenopathy
148
what are ix for lung cancer?
CXR: this may show a peripheral circular opacity, hilar enlargement, consolidation, pleural effusion
CT: staging
bronchoscope: histology
149
What are differentials for lung cancer?
```
Abscesses.
Granuloma - eg, tuberculosis.
Encysted effusion (fluid, blood, pus).
Cyst.
Foreign body.
Skin tumour (eg, seborrhoeic wart).
```
150
non-small cell vs small cell lung cancer?
non small cell carcinoma - most common
| small cell - less common, faster growing
151
What are the sx of post natal depression?
persistent low mood; lack pleasure and interest; lack energy; insomnia; difficulty bonding with baby; withdrawing from contact with others; low conc; thoughts of harming baby; appetite changes; feelings of guilt, hopelessness and self-blame; thguths suicide/ self harm
152
What should you ask about in a hx of post natal depression?
DA?
Are they supported at home?
Thoughts of harm to themselves or baby?
153
What anti depressants can be used in post natal depression?
Sertraline and paroxetine usual SSRIs for breastfeeding
| Imipramine and nortriptyline are the preferred tricyclics in breastfeeding. Doxepin should be avoided.
154
Describe the three different types of catheter
Intermittent: catheters are inserted several times a day, for just long enough to drain your bladder, and then removed.
Indwelling: changed every 3 months, empty via valve straight into toilet or with bag eg if poor motor control or neuro condition
Suprapubic: surgically inserted via abdomen - if urethra blocked
155
What is the difference between a floppy and hyperactive bladder?
Depending on the type of injury, the bladder becomes either ‘floppy’ (flaccid), failing to contract, or ‘hyperactive’ (spastic or reflex)
A floppy bladder loses its muscle strength and too much urine can easily overstretch it. This can damage the bladder wall and increase the risk of infection. A hyperactive bladder contracts automatically, causing incontinence.
156
What are the possible complications of TV
infertility + sepsis/ preterm pregnancies
157
What are the female sx of TV?
Female sx: sometimes asx; discharge- may be thick/ frothy yellow/ thin/ rarely strawberry cervix; itching; offensive odour; dysuria;
158
What are the male sx of TV?
Male sx: asx; discharge; dysuria; irritation urethra, urinary freq, occasionally prostatitis; Rarely balanoposthitis.
159
What ix are done for TV?
Ix: female: Swab taken from posterior fornix during speculum examination (III,B); NAAT if available
Men:collect discharge with loop or swab for microscopy - in terms of sensitivity microscopy< culture< NAAT
160
mx for TV?
screen for other STIs - Sexual contact(s) - last month should be treated
1st line: Metronidazole
2nd line: Tinidazole
161
What are some mechanical causes of back pain?
annular tear (ligament that connects vertebrae to disc);
Spondylolysis (fracture vertebra);
Spondylolisthesis (vertebra move);
spinal stenosis (narrowing spinal canal)
162
What are some non-mechanical causes of back pain?
Neoplasm (primary or secondary); referred pain (eg from aorta; major viscera; urogenitals; hip)
Infection (discitis; osteomyelitis; paraspinal abscess)
Inflammation (spondyloarthropathies; sacroiliitis)
Metabolic: osteoporetic vertebral collapse (problem with bone that already formed -brittle);
pagets disease
osteomalacia
hyperparathyroidism
163
What is pagets disease?
osteoclast absorbs faster than osteoblast can make - larger but weaker
164
What is osteomalacia?
bone formation problems- soft, due to low vit D
165
What do the nerve roots do?
L2: Hip flexion, adduction
L3: Knee extension, knee reflex
L4: Ankle dorsiflexion, knee extension, knee reflex
L5: Foot inversion, Great toe dorsiflexion, Knee flexion
S1: Ankle plantar flexion, Knee flexion, ankle reflex
166
What are red flags for back pain?
Spinal fractures – sudden onset of severe central spinal pain, a history of major trauma, point tenderness over a vertebral body.
Cancer – age >50, gradual onset of symptoms, unexplained weight loss, no symptomatic improvement in pain after four to six weeks of conservative therapy, past or current history of cancer.
Infection – fever, diabetes, IVDU, immuno-suppression (HIV)
cauda equina: Bilateral sciatica; Bladder dysfunction; Perineal paraesthesia; Gait disturbance; Lower limb weakness; Erectile dysfunction
other: neuro signs; claudication
167
What ix may you do for back pain?
Ix: if suspect underlying. CT best bones. MRI best soft tissue eg discs and nerve roots
168
How does sciatica present?
straight leg test - true sciatica goes to ankle
unilateral leg pain to toes; low back pain- less severe than leg pain, numbness/ paraesthesia/ weakness/ loss reflex in one dermatome, positive straight leg test and positive babinskis
169
How does spinal stenosis present?
low back pain; leg pain; pseudoclaudication (gets better with rest and bending forward) - MRI/CT - surgery if severe
Progressive bilateral neurological deficit and sphincter disturbance
170
How does cauda equina present?
caused by herniation, tumour, infection, masses.
Sx: lower back pain; bilateral sciatica; saddle anaesthesia; incontinence. severe/ progressive neuro deficit legs; urinary retention - caused by bladder distension and nerves can’t sense fullness; incontinence; saddle anaesthesia; decreased tone PR
Do an urgent MRI!!
171
How does facet arthorosis?
facet joint pain, local or diffuse back pain with leg pain and NO neuro signs.
172
What are the spondyloarthorpathies?
ank spond, psoriatic, reactive - sx: iritis, enthesitis, back/ buttock pain with morning stiff; mx: exercise and NSAIDs
173
What is spondylosis and how does it present?
stress fracture - often through extension-flexion-rotation movement eg bowling or cricket. Commonly lumbosacral due to fixed pelvis.
Sx: localised pain; worse extension and rotation and at night - diagnose with CT or oblique radiograph - treat with rest.
Surgery if worsens or neuro signs
174
What is Spondylolisthesis?
vertebral sliding
175
What is a sacroiliac issue?
caused by stress, trauma, infection.
Felt in buttock, lower back and thigh. Extension makes it worse. Claudication.
Bone scan can show infection.
Mx: rest, NSAID, steroid injection.
176
How may an annular tear present?
Pain worse with extension and rotation
177
What is a sign of mechanical/ non-specific back pain?
worse with movement and varies with posture
178
mx of non-specific back pain?
NSAID first line, codeine second line
| Refer her for CBT/ exercise/ group exercise/ pain clinic
179
How does a spinal fracture present?
severe central pain; relief upon lying down; hx trauma or repeated lifting if have osteoporosis; point tenderness over vertebrae; Structural deformity of the spine -such as a step from one vertebra to an adjacent vertebra
180
What are the signs of malignancy causing back pain?
>50; gradual onset; pain worse at night and when supine; worse with straining; local spinal tenderness; no improvement; wt loss; pmhx cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine
181
What are the signs of infection and back pain?
fever; recent TB or UTI; DM; IVDU; immunocompromised
182
What is the difference between leg cramps and restless legs?
restless legs: urge to move legs with unpleasant sensations; worse at rest; relief by movement; sx worse in eve/ night
leg cramps: severe acute calf or foot pain, muscle tightens; pain usually lasting seconds to less than 10 minutes; single muscle (or part of muscle) involvement; exam normal; responds to stretching; residual tenderness; sleep disrupted
183
What are the main sx of the menopause?
due to fluctuating hormone levels: vasomotor sx (75%); mood changes; sleep disorders; MSK sx; urogenital sx and sexual disturbance
184
What ix may you do for the menopause?
>45 yrs no ix necessary, unless atypical sx (test is for FSH levels- OCP interferes with the result)
185
What are the SE of oestrogen?
SE: oestrogen (fluid retention; breast tenderness; nausea; leg cramps; dyspepsia)
186
What are the SE of progesterone?
SE: progesterone (Headaches + migraines; breast tenderness; mood swings; depression; acne; lower abdo pain)
187
What is the million women study?
showed that for women starting HRT at age 50 and taking it for 5 years, an extra 1 woman will be diagnosed with breast cancer between age 50 and 59 years for every:
50 women taking continuous combined HRT.
70 women taking combined monthly cyclical HRT.
200 women taking oestrogen only HRT.
188
What are CI to HRT?
```
breast cancer.
Known or suspected oestrogen-sensitive cancer.
Undiagnosed vaginal bleeding.
Untreated endometrial hyperplasia.
Previous VTE unless the woman is already on anticoagulant treatment.
Active or recent CVD
Untreated htn.
abnormal LFTs
Pregnancy.
```
189
What are risks vs benefits of HRT?
Benefits: stops hot flushes and vaginal dryness; some evidence it improves mood, sleep and MSK sx
Risks: DVT - higher risk with combined, no risk if use patch or gel;
breast cancer increased risk, especially with the combined and the longer it is taken;
risk of stroke in oestrogen only or combined but not patch/ gel;
uterine cancer risk if take oestrogen only HRT
190
Apart from HRT how may you manage vasomotor and vag dryness sx of the menopause?
Vasomotor → fluoxetine, citalopram, or venlafaxine. Clonidine.
Vaginal dryness → a vaginal lubricant or moisturizer or vaginal oestrogen
191
How does RA typically first present?
20-50 yrs
typically first presents affecting the small joints of the hands and the feet (usually both sides equally and symmetrically)
Sx of synovitis include pain, swelling, heat and stiffness
192
What are the late stage hand deformities of RA?
boutonneires deformity of the thumb
ulnar deviation of MTP
swan neck deformitiy of fingers
193
What are the systemic manifestations of RA?
Eyes: Sjögren's syndrome, scleritis and episcleritis.
Skin: leg ulcers especially in Felty's syndrome (association of rheumatoid factor positive rheumatoid arthritis, neutropenia and splenomegaly). Rashes, nail fold infarcts.
Rheumatoid nodules: these are common, and may occur in the eyes, may be SC, and may be in the lung, heart and occasionally the vocal cords.
Neurological: polyneuropathy
Respiratory system: pleural involvement, pulmonary fibrosis, Caplan's syndrome.
Cardiovascular system: pericardial involvement, valvulitis and myocardial fibrosis, immune complex vasculitis.
Other: thyroid disorders, osteoporosis, depression, splenomegaly.
194
How is RA managed? (1st, 2nd, 3rd and 4th line)
1st line: NSAID +PPI
2nd line: cDMARD eg methotrexate, leflunomide, or sulfasalazine
3rd line: combo cDMARD or biological agent eg rituximab
(May bridge between DMARDs with short term glucocorticoids)
4th line: Surgical referral if: Persistent pain/ Worsening joint
195
What are the different types of biological DMARD?
Anti-T cell therapy (abatacept) ; Anti B-cell therapy (rituximab); Anti IL-6 therapy (tocilizumab); Anti-TNF therapy(infliximab, adalimumab etc.)
196
What are the sx of endometriosis?
dysmenorrhoea that affects QOL/ daily activities; subfertility; deep dyspareunia and cyclical or continuous pelvic pain; possible cyclical LUTS and bowel sx
197
What are the differentials for PCB?
infection; cervical ectropion from OCP; polyps; cervical + vaginal cancer; dryness; abuse
198
What are the differentials for PMB?
pregnancy, polyps, infection, cervical ectropion, fibroids, endometrial cancer; tamoxifen; post-smear; drugs altering clotting
199
What is the gold standard ix for endometriosis?
laparoscopy (may see choc cysts aka endometrioma) - give consent for endometriosis to be treated at the same time (via excision, division adhesions)
200
What may you find O/E that signifies endometriosis?
O/E -
pelvic and speculum exam if sexually active - may find mass on abdo/ pelvic exam (endometrioma);
lower abdominal or pelvic tenderness;
fixed and retroverted uterus (sign of adhesions);
tender fornices;
blue-block endometriotic lesions in vag
201
medical mx of endometriosis?
Analgesia (codeine, NSAID, paracetamol); neuro-modulators (gabapentin, amitriptyline); hormonal (COCP; POP; depo-provera IM; Mirena IUS) - COCP can be given unlicensed back to back with 4 day shorter break
can also refer for a trandvag US
202
What is tested for with cervical screening?
tests for cytology of the cervix with subsequent HPV test is abnormal and colposcopy for cervical intraepithelial neoplasia (CIN) if referred by GP
203
When is cervical screening offered?
people with vaginas 5–49 offered screening every 3 years. 50–64 offered screening every 5 years.
204
What are the different cervical screening cytology results?
Cytology may be normal, inadequate (repeat 3 months) or abnormal (sub classified as borderline, low grade and high grade)
Borderline and low grade — lab test the cervical cytology sample for HPV → if positive then 6 week colposcopy referral
High-grade - suspected invasive cancer, or glandular neoplasia → 2WW colposcopy
205
What are the risks of LLETZ and cone biopsy?
Women who have had a cone biopsy or LLETZ are at slightly greater risk of miscarriage and premature labour, before 37 weeks, because of their weakened cervix. A cone biopsy poses a greater risk than LLETZ treatment.
206
What are the sx of cervical cancer?
PMB; IMB; IMB; changes PV discharge
207
What are the sx of BPH?
freq (day, night, vol), urgency, hesitancy (dribble and poor stream), incomplete emptying, straining
208
What may you find O/E of the prostate?
abdo - palpable bladder indicating chronic obstruction or neurogenic bladder (neuro exam);
DRE (tone, size - shouldn't be more than two finger breadths big; hard or firm, craggy or smooth, palpate median sulcus between the lobes)
209
What ix should you do for LUTS?
MSU, dipstick, PSA,
210
How can BPH be mx?
alpha-blockers, reduce the tone in the muscle of the neck of the bladder. Eg tamsulosin. 5-alpha reductase inhibitor, surgery
211
How may prostate cancer present?
LUTS (though that alone is not suspicious); haematuria, dysuria, incontinence, Haematospermia, suprapubic pain, tenesmus, impotence, kidney issues, mets
212
What ix are done for prostate cancer?
Ix and exam: abdo for obstructed bladder, DRE, urine dipstick, biopsy and staging, PSA, MRI, biopsy
213
What scoring system is used for histological scoring in prostate cancer?
Gleason score for histology
214
What may cause abnormal results on a PSA?
can also be UTI, prostatitis, BPH, biopsy or cystoscopy 6 weeks before, vigorous exercise 48 hrs before, orgasm 48 hrs before
215
What are the positives of PSA?
reassures you if normal; may find early cancer and save your life
216
What are the negatives of PSA?
the risk of a false negative (1/7)- meaning false reassurance or a likely false positive (3/4) meaning he may feel unnecessary worry and have unnecessary tests.
cancer could be slow growing one that wouldn't have killed them - test cannot differentiate between
217
mx of prostate cancer?
watchful waiting;
active surveillance (with PSA, biopsy and MRI); prostatectomy (which can cause incontinence; bleeding, infection, will cause infertility so need to freeze sperm if still want children);
radio (diarrhoea; pain, tiredness, cystitis) → with Brachytherapy bowel sx less but urinary sx more; hormone therapy (block testosterone so cancer grows less quickly which may cause ED, loss libido, hot flush, weight gain, breast growth);
TURP (relief bladder sx- a loop inserted into urethra and pieces of the prostate are removed);
HIFU (U/S - less SE, more recent);
chemo (if advanced; SE: infection, fatigue, hair loss, sore mouth, N+V)
218
How does polymyalgia rheumtica present?
severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle.
associated with GCA
219
What are the differentials for PMR?
inflammatory eg RA; rotator cuff disease; OA; myalgia (eg from statins); malignancy (eg lymphoma - check lymph nodes); infection (eg TB, IE); parkinsonism; fibromyalgia; thyroid
220
Ix for PMR?
Ix: Raised ESR/ CRP; FBC; U&Es; LFTs; Bone profile; Protein electrophoresis; TFTs; Creatine kinase; Rheumatoid factor; Urinalysis.
221
What are sx of GCA?
jaw claudication; headache, visual disturbance
222
What is the mx of PMR?
Glucocorticosteroids high dose eg pred 15mg for three weeks - not as urgent as GCA
223
What are the SE of long-term corticosteroid use?
Change in mood, higher blood sugar, insomnia
Osteopenia and osteoporosis
Cataracts and glaucoma
Increased risk of infection
Increase BP
Weight gain, Thin skin and bruising, weakness and cramps (low K), buffalo hump, moon face - cushing's iatrogenically caused
Acne
224
What are the RF for osteoporosis?
age; female; low BMI <18.5; parental hx hip fracture; pmhx fragility fracture; cushings; corticosteroids; alcohol >3 units/ day; smoking; conditions (visual disturb, lack neuromuscular coordination/ strength, sedatives); secondary causes (eg RA, hypogonadism, hyperthyroid, CKD); PPI, antidepressants
225
What is the mx of someone at risk of osteoporosis?
FRAX before BMD via DEXA
skip to DEXA if : Over 50 years of age with a history of fragility fracture.
Younger than 40 years of age who have a major risk factor for fragility fracture
Consider starting drug treatment in people with vertebral or hip fractures without undertaking DXA
Mx: primary → calcium + vit D supplements (unless Ca adequate then just do vit D alone); good diet; reduced salt, phosphates, alcohol and smoking + weight bearing exercises
Secondary → bisphosphonates eg aledronic acid
226
What are RF for gout?
diuretics!! + other drugs (ACE inhibitors, beta-blockers, ciclosporin, pyrazinamide, ritonavir, tacrolimus, and lead exposure.)
More associated with older ages.
diet high in purines!!! eg seafood, red meat, fructose
alcohol intake
fhx of gout
Obesity
pmhx: OA, htn, hyperlipidaemia, DM, congestive HF, IHD, severe psoriasis, sickle cell anaemia, CKD, history of renal colic or nephrolithiasis.
Low fluid intake
227
What are the sx of gout?
1-2 weeks of red, hot, swollen joint, MTP likely first presentation, . It is also common in the midfoot, ankle, knee, fingers, wrist and elbow joints although can effect any joint
228
What is gout caused by?
Purine metabolism disorder - high uric acid in blood!! (most important RF) and urate crystals in joints
229
What are the 3 phases of gout?
Three phases: 1) asx hyperuricaemia 2) bouts of gout arthritis with asx intervals 3) final period of chronic tophaceous gout - Tophi (firm, white nodules under translucent skin).
230
What does gout put you at risk of?
Gout is a RF for IHD, CVD and CKD
231
What si the mx for gout attacks?
Mx: treating attacks: 1st line: NSAID/ colchicine until 1-2 days after sx resolve;
2nd line: corticosteroids; rest, cold compress, wt loss and smoking cessation
232
What is the mx for preventing gout attacks? When should this be done?
Preventing attacks: Urate-lowering therapy (if two or more attacks of gout within a year or in people with tophi, chronic gouty arthritis, joint damage, renal impairment, known urinary stones, long-term diuretic medication or young age of onset.) - usually life-long
1st line ULT: Allopurinol;
2nd line: Febuxostat
3rd line: Co-prescription of low-dose colchicine/ NSAID
233
Pseudogout vs gout?
Pseudogout: caused by calcium pyrophosphate crystals rather than uric acid crystals, more common to start in knee than MTP, on aspirate is positive birefringent rhomboid crystals.
Gout is negative birefringent needle shaped crystals.
234
What are the causes of wt loss in the elderly?
Organic: cancer (GI, prostate, ovarian, lung, lymphoma); GI ( motility or swallowing disorders, peptic ulcers, gallstones, mesenteric ischaemia, and malabsorption disorders such as coeliac disease); cardio resp (HF, COPD)
Oral and dental issues
Drugs: anorexia; N+V; dry mouth, altered taste or smell
Depression!
Socioeconomic: malnutrition, cant afford food/ no one to get them food
235
What ix should be done for wt loss in the elderly?
Ix: FBC, U+E, LFT, TFT, CRP, glucose, lactate dehydrogenase; CXR; urinalysis, fecal occult blood
If no obvious cause is found, the referrer can undertake the three months of watchful waiting or refer to secondary care (medicine for the elderly)
FBC: anaemia, type may indicate underlying issue; WCC may indicate infection or malignancy
LFT: alkaline phosphatase is particularly useful because it can be raised when liver or bone disease is present.
TFT: Hypothyroid
CRP + ESR: indicate inflammation and malignancy
Glucose: DM
Lactate dehydrogenase: >500 IU/L is associated with an increased likelihood of a malignant cause
CXR: resp disease, both malignant and non-malignant
FOB: due to high prevalence of GI disease and wt loss in elderly can indicate if colonoscopy is necessary
236
What is cachexia?
the disproportional loss of skeletal muscle rather than body fat, which leads to skeletal and cardiac muscle wasting, loss of visceral protein, and alterations in physiological functions including impaired immunity and a systemic inflammatory response)
237
What is the mechanism of action of a statin? What is second line treatment for high cholestrol after a statin? Common SE of statins?
Statins are HMG CoA reductase inhibitors.
Asthenia is abnormal physical weakness or lack of energy which is a common side effect of statins.
Gastrointestinal disturbance and headache are very common, particularly on starting treatment.
second line: Ezetimibe / Bezafibrate
238
septicaemia vs bacteraemia?
septicaemia- The definition is the multiplication of bacteria in the bloodstream, rarer
bacteriaemia is the presence of bacteria in the bloodstream.
239
Summarise AF
-caused by IHD/ thyroid/ valve disease
- ECG will have no P-waves, a chaotic baseline, and an irregular ventricular rate.
mx:
-Assessing stroke risk using the CHA2DS2VASc
-rate control:
1st: Beta blocker (e.g. atenolol 50-100mg once daily)
2nd: Calcium-channel blocker (e.g. diltiazem) (not preferable in heart failure)
3rs: Digoxin (only in sedentary people, needs monitoring and risk of toxicity)
-rythym control:
in emergency: Consider either pharmacological (e.g. flecainide, amiodarone) or electrical cardioversion
long-term: Beta blockers are first line for rhythm control
Dronedarone is second line for maintaining normal rhythm where patients have had successful cardioversion
Amiodarone is useful in patients with heart failure or left ventricular dysfunction
240
Summarise dilverticular disease
- older person, L lower abdo pain (during divertilculitis get fever, bowel change etc)
- sac-like protrusions of mucosa through the muscular wall of the colon
- mx: lifestyle advice, laxatives
241
Describe chronic constipation
- The Rome IV diagnostic criteria for constipation include spontaneous bowel movements occurring less than three times a week.
- Offering drug treatment with oral laxatives using a stepped approach, such as bulk-forming laxatives first-line, then adding or switching to an osmotic laxative, then adding a stimulant laxative if needed.
- Blood tests for full blood count, thyroid function tests, HbA1c, and serum electrolytes and calcium, to look for an underlying cause.
242
Describe gallstones
-Gallstones occur when there is a problem relating to the chemical composition of bile. This then can result in precipitation of one or more of the constituents.
-Biliary colic is the most common complication and acute cholecystitis is the second most common complication of gallstone disease. Other complications are uncommon or rare, but some are life-threatening such as cholangitis and pancreatitis.
-ix:US +LFT
-For severe pain, diclofenac or an opioid should be administered intramuscularly.
For intermittent mild to moderate pain, paracetamol or a nonsteroidal anti-inflammatory drug (NSAID), should be offered.
-admit if jaundice/infection suspected
243
LOSS mneuonic for OA?
L: loss of joint space
O: osteophytes
S: subchondral cysts
S: subchondral sclerosis
244
Descibe conjuncitivits
The most common bacterial causes of conjunctivitis are Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae.
Viral conjunctivitis is the most common infectious conjunctivitis — the majority of cases are caused by adenoviruses.
Hyperacute conjunctivitis is a rapidly developing severe conjunctivitis typically caused by infection with Neisseria gonorrhoeae.
sx: Conjunctival erythema.
Discomfort which may be described as ‘grittiness’, ‘foreign body’ or ‘burning’ sensation.
Watering and discharge which may lead to transient blurring of vision — purulent or mucopurulent discharge may cause the lids to be stuck together on waking.
mx: chloramphenicol
245
Describe otitis externa
Ear pain, itch, discharge, and hearing loss.
Swollen, red, or eczematous ear canal and/or external ear.
aka swimmers ear
246
Describe otitis media
AOM occurs frequently in children but is less common in adults.
In older children and adults, AOM usually presents with earache. Younger children may hold or rub their ear, or may have non-specific symptoms such as fever, crying, poor feeding, restlessness, cough, or rhinorrhoea.
On examination the tympanic membrane is distinctly red, yellow, or cloudy and may be bulging.
amox first line mx if unwell
247
Describe multiple myeloma
Multiple myeloma is a progressive malignant disease characterized by proliferation of abnormal plasma cells in the bone marrow and abnormal monoclonal immunoglobulins (M proteins) in the blood.
Bone pain, often in the lower back.
Fatigue.
Confusion, muscle weakness, constipation, thirst, and polyuria (due to hypercalcaemia).
Weight loss.
Recurrent infection.
Headache, visual disturbance, cognitive impairment, mucosal bleeding, and breathlessness (due to hyperviscosity of the blood).
Sensory loss, paraesthesia, limb weakness, walking difficulty, sphincter disturbance, and spinal deformity (due to spinal cord compression).
Arrange a full blood count, serum calcium, and plasma viscosity or erythrocyte sedimentation rate (ESR) for people over 60 years of age with persistent bone pain, particularly back pain, or unexplained fracture.
Arrange very urgent serum electrophoresis, serum-free light chain assay, and Bence-Jones protein urine assessment
248
Describe otitis media w effusion
Otitis media with effusion (OME), also known as 'glue ear', is characterized by a collection of fluid within the middle ear space without signs of acute inflammation.
OME is more common in children with cleft palate, Down's syndrome, cystic fibrosis, primary ciliary dyskinesia, and allergic rhinitis.
Myringotomy, and insertion of grommets (ventilation tubes) is the most common surgical option for otitis media with effusion (OME), with or without adenoidectomy.
249
duodenal vs gastric ulcer?
gastri ulcer - worse after eating (think acid will go up when eat so will irritate stomach)
duodenal ulcer - better after eating (think acid will be mopped up by stomach bc of food so ulcer will be better)
250
What is HAS BLED score?
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assessment tool for establishing a patient’s risk of major bleeding whilst on anticoagulation
H – Hypertension
A – Abnormal renal and liver function
S – Stroke
B – Bleeding
L – Labile INRs (whilst on warfarin)
E – Elderly
D – Drugs or alcohol
```
251
Describe eczema
dry, red, itchy and sore patches of skin over the flexor surfaces (the inside of elbows and knees) and on the face and neck
mx: emoillients for maintanence; wet wraps and steroids for flare ups
in severe eczema: zinc impregnated bandages, topical tacrolimus, phototherapy and systemic immunosuppressants, such as oral corticosteroids, methotrexate and azathioprine.
252
Describe Eczema herpeticum
widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake.
viral skin infection caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV).
253
Describe acne vulgaris mx
if mild leave it
Topical benzoyl peroxide reduces inflammation, helps unblock the skin and is toxic to the P. acnes bacteria
Topical retinoids (chemicals related to vitamin A) slow the production of sebum
Topical antibiotics such as clindamycin (prescribed with benzoyl peroxide to reduce bacterial resistance)
Oral antibiotics such as lymecycline
Oral contraceptive pill can help female patients stabilise their hormones and slow the production of sebum
254
What is Pityriasis Rosea?
Pityriasis rosea a generalised, self limiting rash that has an unknown cause. It often occurs in adolescents and young adults. It may be caused by a virus such as human herpes virus (HHV-6 or HHV-7), but no definitive causative organism had been established.
faint red or pink, slightly scaly, oval shaped lesions, usually less than 2 cm in diameter. On the torso they can be arranged in a characteristic “christmas tree” fashion, following the lines of the ribs.
No need for mx
255
Describe urticaria
aka hives
Urticaria are caused the release of histamine and other pro-inflammatory chemicals by mast cells in the skin
mx with anti-histamines
256
Summarise metformin
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1st line T2DM med
Mechanism: increases insulin sensitivity; gluconeogensis and GI glucose absorption
SE: GI and lactic acidosis
GOOD FOR HIGH BMI AND NO HYPOS
ONLY ONE GOOD IN PREGNANCY
```
257
Summarise sulfonureas eg gliclazide
Mechanism: attaches to beta cells and stimulates insulin release
SE: wt gain, SIADH, hypos and peripheral neuropathy
258
Summarise pioglitazone
Pioglitazone is a “thiazolidinedione”. It increases insulin sensitivity and decreases liver production of glucose.
SE: wt gain, fluid retention + worsening HF, bladder cancer w long-term, # risk
NO hypos
259
Summarise SGLT2s inhibs
the -flozins
SE: UTI, thrush, DKA, lose weight
mechanism: block renal uptake of glucose so more is excreted into the urine
260
Summarise DPP4 inhibitors
the -gliptins
SE:
mechanism: inhibit GLP1 degradation
261
Summarise GLP-1
SC
| USed 4th line for pt with high BMI instead of insulin as it causes wt loss
