Week 2 Flashcards
62 year old female with a history of fibromyalgia comes in with lower back pain 1/12, worsening for 1/52. Taken 2x cocodamol TDS, limited effect, interfering with sleep.
a) What other questions must you ask? (and document)
- O/E: tenderness in buttock area. SLR 40 degrees on RHS and 60 degrees on LHS. Stretch test positive on the right.
b) Likely diagnosis?
c) Management?
a) Red flags for CES (weakness, bladder and bowel, saddle anaesthesia)
b) Sciatica (DD: fibromyalgia)
c) 1. Trial gabapentin (amitryptilline makes her drowsy).
2. Advise gentle stretches
3. Review in 3-4 weeks if no improvement
4. Worsening advice given (CES red flags - go to ED)
Hypertension management.
a) Evidence for treatment of mild hypertension - stroke, coronary events, mortality. Limitations?
b) Average SBP reduction from: i) Drugs, ii) Dietary changes, iii) Exercise, iv) Weight loss (per 5% weight reduction), v) Alcohol reduction
c) Dietary plan recommended
a) Systematic review (Sundstrom, 2015) showed RR 20% lower mortality, 30% lower strokes but no significant cardiac event reduction. Limitation: most patients had diabetes. Did not assess absolute risk reduction or NNT.
b) i) 3.6 mmHg, ii) 10 mmHg, iii) 5 mmHg, iv) 3 mmHg, v) 3 mmHg
c) DASH (Dietary Approaches to Stop Hypertension) - rich in fruit and veg, reduced fat and salt intake
49 year old female with a history of chronic sinusitis (2 attacks per year) and eustachian tube dysfunction presents with 3/52 history of facial discomfort in forehead and retro-orbital areas. Also yellow nasal discharge and post-nasal drip. Tried paracetamol, ibuprofen, antihistamines and nasal steroid spray to no avail. Tenderness on palpation of ethmoidal and frontal sinuses, apyrexial.
a) What are the criteria for sinusitis diagnosis?
b) What are the guidelines for antibiotic prescription in sinusitis?
c) First line antibiotic, if tried? 2nd line?
d) Referral to ED criteria
e) Referral to ENT criteria
f) Management in this case
a) Facial fullness, discomfort or pain + nasal discharge + loss of smell
b) If duration < 10 days - No ABx. If duration > 10 days, consider nasal steroid decongestant spray (e.g. mometasone). Also consider deferred antibiotic prescription.
c) Penicillin V - 500mg QDS for 5/7.
2nd line - co-amoxiclav
d) Systemically unwell, orbital or intracranial spread, consider if immunocompromised
e) 3 or more attacks in one year. Persistent symptoms despite 2nd line ABx course
f) 5-day course of penicillin V 500mg QDS (make sure to ask about allergies!), worsening advice given, review if no improvement after course finished.
42 year old male presents with 1/7 history of cough productive of green sputum, SOB, lethargy and night sweats. Smokes 8/day. No asthma, otherwise fit and well. O/E apyrexial, looks well, normal obs, crackles at left lower base.
a) Red flags to ask about
b) Diagnosis and management
c) Criteria and cut-off scores for hospital admission?
d) If penicillin allergic - antibiotic of choice?
e) If CRB-65 score 1 or more, drug choice?
a) Haemoptysis, weight loss
b) CAP. Prescribed 5-day course of amoxicillin 500mg TDS
c) CRB-65: Confusion, RR >30, BP <90/60, age >65.
0 or 1: home care usually suitable (depends on living situation, care needs, etc.). 2: admission. 3 or more: urgent admission.
d) Doxycycline - 5 day course: 200mg first day, then 100mg OD. Or clarithromycin 500mg BD for 5/7
e) Amoxicillin + clarithro OR doxycycline for 7-10 days
49 year old female with sudden onset left shoulder pain that came on at 03:00 this morning. Worse on movement and helped partly by ibuprofen. No precipitating trauma or strain. No inflammatory changes. O/E: pinpoint tenderness over the acromion, limited ROM.
a) Differentials
b) More common causes of shoulder pain (usually less acute)
c) Management in this case
d) Management of frozen shoulder/ rotator cuff disorders
e) Diagnostic criteria for PMR? Must also ask about what?
f) Criteria for secondary care referral
a) Acromio-clavicular joint injury, shoulder dislocation
b) Rotator cuff injury (usually hx of trauma), OA, frozen shoulder (usually diabetic), PMR. Also referred pain: from heart, neck (e.g. thyroid, lymphoma), C-spine, gallbladder
c) Codeine 1-2 tablets 1/52 QDS, also take ibuprofen PRN, advised to keep moving shoulder, review in one week if no improvement
d) Analgesia (paracetamol, NSAIDs), physiotherapy, intra-articular steroid injections. If all fail - surgery.
e) Age >50, duration >2 weeks. Bilateral shoulder or pelvic girdle aching, or both. Morning stiffness >45 mins.
ESR/CRP raised or steroid-responsive.
Ask about headaches, visual changes, etc. (GCA)
f) Acute trauma with limited ROM, failure of conservative management for 3-6 months, significant rotator cuff tear suspected, Hx of recurrent joint instability, occupational need (e.g. sports, manual labour)
50 year old female presenting with low mood, anergia and anhedonia, worsening over the past month. Occasional suicidal ideation but son is protective factor. Thought to be related to psychological trauma. Previously seen by CMHT and currently on trazodone. Feels that counselling support has been helpful in the past. Lives with son. No alcohol or drug abuse.
MSE reveals tearfulness, reduced affect, but no psychotic features.
a) What is trazodone?
b) What is the appropriate management in this case?
a) Atypical antidepressant, similar to an SSRI
b) IAPT self-referral. Review in 1 week (or sooner if necessary) as suicidal ideation (2 weeks if no suicidal ideation; note - all mental health issues need reviewing).
71 year old male referred by podiatrist for BP check. No headaches, visual changes or chest pain. COPD worsening SOBOE, also some orthopnoea and PND. Has angina. Takes preventer and reliever inhaler, and GTN PRN. 1 month ago had episode of large floater and flashes that resolved in a few hours, did not attend ED. Whitecoat HTN on record but patient denies anxiety.
O/E - BP 170/105
a) What other bedside test should be performed?
b) How should management proceed?
a) Fundoscopy - check for papilloedema or hypertensive changes
b) ABPM to confirm HTN. Give lifestyle advice (diet, low salt, exercise, lower alcohol). Refer to optician (? retinal detachment 1 month ago)
30 year old male presents with pain in right testicle. Noticed on palpation last night, dull ache. No new swellings or skin changes. No problems with the other testicle. No urethral discharge or urinary symptoms. No systemic features. No history of urological problems.
O/E - testicles appear and feel normal. Tenderness noted in the epididymal region.
a) What is important to document about this examination?
b) What features of the history and examination could distinguish torsion from epididymitis ?
c) Management in this case
a) Consent and chaperone present
b) Hx - torsion often acute and rapidly progressing, usually younger patients. Cremasteric reflex absent in torsion. Moving testicles superiorly may improve pain in epididymitis. Often STI or UTI features/history in epididymitis.
c) Oral ofloxacin BD for 2/52. Urine dip (negative) and urine sent for chlamydia/gonorrhoea screen.
25 year old male presents with tender red spot with head of pus on lateral left thigh. No trauma or bites to the area. Similar thing occurred on left knee 1 month ago, responded to fluclox.
a) Management
a) Fluclox oral with topical fusidic acid cream.
71 year old female with hx of COPD presents with 2/52 cough productive of white/clear sputum. No chest pain, fever or systemic illness. No haemoptysis or weight loss.
- O/E: apyrexial, normal obs, wheezy throughout but no focal signs.
a) Likely diagnosis
b) Management
c) Criteria for admission
a) Viral exacerbation of COPD
b) Oral prednisolone 7-14 days (no focal signs or purulent sputum so no Abx required). If requiring frequent course (3-4 per year) prescribe bone protection. Advise increasing salbutamol frequency as required. Advise to seek medical attention if worsening.
c) Severe breathlessness, rapid onset of symptoms, acute confusion, cyanosis, worsening peripheral oedema, or impaired consciousness. Inability to cope at home, on LTOT, immunocompromised, severe comorbidity
39 year old male presents with 3/52 history of dull ache in left testicle. Sometimes feels a lump, but this has been present for around 15 years. This lump was imaged and NAD. No skin changes, no dysuria or discharge. No history of STI or UTI, and no new sexual partners. No systemic symptoms (fever, weight loss).
- O/E - NAD, no localised tenderness, no lumps felt.
a) What further tests should be performed?
Patient also has a smooth, cystic mobile lump on the leg, inferolateral to the patella. This interferes with his work as a plumber.
b) Likely diagnosis?
c) How would you manage this?
d) If the cyst were hot and red, how would you manage?
a) Urine dip for UTI. Due to age and sexual history, STI screen probably not necessary
- Refer for an USS of testicle.
b) Sebaceous cyst. DD: lipoma
c) USS to characterise lump. Referral to minor ops if appropriate for excision + histopathology
d) Likely infected. Probably staph so give oral fluclox.
15 year old girl presents with 2/7 hx of bilateral swollen knees. Aching knees present for the past year, but only recently have they become swollen. Pain appears worse climbing stairs, possibly better after exercise. Mum notes they were hot and red also. No other joint involvement. No fever, lympadenopathy or visual symptoms. Patient active in sport and dancing, no time off school. Takes ibuprofen PRN.
- O/E: Knees appear swollen and fluid palpated. No erythema or hotness of joints. Mild tenderness around the joint spaces. Good ROM. Some pain on maximal flexion of right knee.
a) What is the most likely diagnosis? DDx?
b) How would you manage this case?
c) What activities tend to aggravate PFPS?
d) What assessment should be done in a child presenting with an MSK problem?
a) Anterior knee pain (AKA: Patellofemoral pain syndrome), DDx: inflammatory arthritis - postviral, JIA, etc.
b) - Bloods for FBC and ESR.
- Counsel patient and parents that likely benign PFPS and quadriceps strengthening exercises may help.
- Review post-blood results.
- Continue with ibuprofen PRN.
c) Ascending/descending stairs, squatting, kneeling, sitting with knees bent
d) pGALS
8 year old girl presents with red and swollen left little toe. This started as a small blister (likely due to new shoes) 10 days ago, but has now spread towards nail bed. Patient apyrexial and well.
O/E : toe appears red and swollen, with some weeping (non-purulent) and ulceration.
a) Likely diagnosis
b) Management
c) How would you decide on antibiotic regimen?
d) If penicillin allergy - alternative?
a) Blister with secondary staphylococcal skin infection
b) Oral fluclox solution QDS for 5/7 (if not tolerating taste, switch to fluclox capsules)
c) Simple impetigo - use topical fusidic acid. Suspected cellulitis - oral fluclox. Fluclox covers staph and strep; if definite strep - use amoxicillin.
d) Clarithromycin
Steroids: mineralocorticoid side effects
a) Give 5 mineralocorticoid SEs
b) What is the mineralocorticoid effect (high, medium, low, negligible) of:
i) hydrocortisone,
ii) prednisolone,
iii) dexamethasone,
iv) betamethasone
a) Hypertension, hypernatraemia, fluid overload, hypokalaemia, hypocalcaemia
b) i) HC- Medium, ii) Pred - Medium, iii) Dex - Low, iv) Beta - Negligible
Steroids: glucocorticoid side effects
a) Give 5 glucocorticoid SEs
b) What is the glucocorticoid effect (high, medium, low, negligible) of:
i) hydrocortisone,
ii) prednisolone,
iii) dexamethasone,
iv) betamethasone
a) Osteoporosis, diabetes, peptic ulcers, proximal myopathy, immune suppression, bruising and bleeding, weight gain and fat deposits, manic episodes
b) i) HC - Medium, ii) Pred- High, iii) Dex - Very high, iv) Beta - Very High
NB. Generally a higher potency steroid (i.e. higher glucocorticoid effects) results in lower mineralocorticoid effects)
Ref. 1) https://bnf.nice.org.uk/treatment-summary/corticosteroids-general-use.html
2) https://cks.nice.org.uk/corticosteroids-oral#!scenario
