Week 3 Flashcards
72 year old male presents with 4/7 history of neck lump. 4/52 history of sore throat, but this is resolving. No fever, no weight loss, no cough, no dysphagia or dysphonia.
- O/E: Lump is 2cm diameter, red, non-tender, mobile and firm. No lymphadenopathy, throat clear, obs normal.
a) Most likely diagnoses?
b) Things to comment on re: lump
c) What are the three areas of the neck, with borders?
d) What feature do epidermoid cysts often have?
e) If moves on swallowing - could be…?
f) Causes of recurrent/persistent sore throat
a) Pustule, epidermoid cyst, reactive lymph node (unlikely in midline)
b) Size (2cm), site (midline neck), shape (round), colour (red), consistency (smooth), character (mobile, firm, non-pulsatile), tenderness (none), skin changes (none)
c) Midline, anterior triangle (SCM, midline, mandible), posterior triangle (SCM, trapezius, mandible)
d) Central punctum
e) Thyroid mass, thyroglossal cyst (moves on protruding tongue)
f) Recurrent laryngitis/pharyngitis, thrush, reflux-associated, malignancy
10 year old girl presents with 3/7 history of sore throat. Odynophagia, but still eating and drinking OK. Chest sore. Cough. Patient happy and active.
O/E: tonsils appear red and swollen but no exudate present. Temp 36.7C. No cervical lymph nodes
a) What is her Centor score?
b) What is her FeverPAIN score?
c) Management in this case?
d) Beware patients on what drugs?
e) Urgent hospital admission -criteria?
f) Antibiotics - 1st line, 2nd line, pregnancy
g) Referral criteria for tonsillectomy
a) Centor: Cough present (0), Exudate absent (0), Nodes absent (0), Temperature absent (0). Centor = 0
b) FeverPAIN: Cough present (0), no history of fever, symptom onset 3 days ago (1), severe tonsil inflammation (1), no exudate (0). FeverPAIN = 2
c) Based on Centor = no ABx. Based on FeverPAIN: delayed prescription.
Advise adequate fluids, PRN calpol or NSAID. Salt water gargling may help. Safety net. Take ABx if get worse.
d) Immunosuppressives, chemotherapy, carbimazole
e) Peritonsillar abscess, breathing difficulty, sepsis, dehydration, immunosuppression, rare diagnosis suspected (Kawasaki, diphtheria)
f) Phenoxymethylpenicllin (if allergic - clarithromycin), pregnancy - erythromycin
g) - >7 episodes per year for one year,
- 5 per year for 2 years
- 3 per year for 3 years
(…and for whom there is no other explanation for the recurrent symptoms)
ECG - leads
a) Lateral
b) Anterior
c) Inferior
d) Right ventricle
a) Leads: I, V5, V6 and aVL
b) Leads V1 - V4
c) Leads II, |II and aVF
d) aVR
ECG - Bundle branch block
a) Any bundle branch block must have what feature?
b) LBBB - appearance in V1 and V6 (or similar leads)
c) RBBB - appearance in V1 and V6 (or similar leads)
d) Causes of LBBB
e) Causes of RBBB
a) Prolonged QRS (>120s)
b) V1: dominant S wave (due to R-L depolarisation);
V6: lack of Q wave, monophasic (or notched) R wave.
c) V1: rSR (double R wave/ rabbit ears: ‘M’ appearance);
V6: slurred S wave
d) Ischaemia, LV hypertrophy (eg HTN, DCM), aortic stenosis, anterior MI
e) RV hypertrophy/cor pulmonale, PE, ischaemia
Glandular fever.
a) Presentation
b) Investigations/diagnosis
c) Management (including avoidance of…)
d) When to admit
e) Complications
a) Fever, tonsillitis, fatigue, malaise, macular non-pruritic rash, upper lid oedema, lymphadenopathy, jaundice, joint and muscle pains
b) Non-EBV heterophile antibodies (Monospot/ Paul-Bunnell test). If these are negative after 6 weeks, test for EBV antibodies
c) Reassurance, fluids, stay active and at work/school, PRN analgesia/antipyretic,
- graded activity.
- Avoid contact sports or heavy lifting for 4 weeks (risk of splenic rupture).
- Avoid kissing/sharing utensils to avoid spread of disease
d) Stridor/breathing difficulty, dehydration, systemically unwell, abdominal pain (splenic rupture)
e) Splenic rupture, jaundice, glomerulonephritis, chronic fatigue and depression
Depression: history
a) Core symptoms
b) Supporting symptoms
c) Biopsychosocial importance
d) Establish what?
a) Low mood + anhedonia + anergia
b) Poor sleep (EMW), poor concentration, low libido, suicidal thoughts
c) Physical disease (chronic health problems, thyroid/ hypercalcaemia, etc.), substance misuse, social situation,
d) Why they are presenting now? (trigger)
Depression: management
a) Mild-mod
b) Mod-severe
a) IAPT - psychological interventions (CBT, cCBT, counselling, group therapy) but no medication
b) Antidepressant + psychological therapy
Depression: choosing the right antidepressant
a) Safest (interactions, tolerance, etc.)
b) Risk of QT prolongation
c) Help with sleep also
d) Help with pain also
e) Licensed in children (but must liaise with CAMHS)
a) sertraline
b) TCAs, citalopram
c) mirtazepine, amitryptilline
d) duloxetine, amitrytilline
e) fluoxetine
Depression: management
a) Titrating antidepressants
b) Stopping antidepressants
c) Review
a) Start low, advise about side effects (especially SUICIDAL IDEATION), review frequently, optimise dose
b) wiki.psychiatrienet.nl/index.php/SwitchAntidepressants
c) Within 1 week if suicidal or if < 30 years. Within 2 weeks otherwise. Then space the reviews 2-4 weekly. Then monthly, 3 monthly, 6 monthly, etc. (If years-long stability, consider switch to annual review).
81 year old man presents with painful, red 1st MTPJ on right foot. Started 3 days ago, tender, swollen. No other joints affected. Has OA in hips and hands. Similar presentation last year, treated with co-codamol.
Takes rivaroxaban for AF.
- O/E: hot, red, swollen MTPJ.
a) Likely diagnosis? Important DDx? (ask about…?)
b) Management
a) Gout. DDx: septic arthritis, cellulitis (ask about trauma, check obs, etc.)
b) - Avoid NSAIDs and steroids in this patient (bleeding risk with NOAC)
- If no interactions, trial colchicine
- If interactions, prescribe co-codamol
- Advise increase fluids and avoid risk factors (given diet sheet - alcohol, purines, etc.)
- Advise ice packs
- Uric acid blood test in 2 weeks (not during acute attack). If raised - allopurinol
32 year old woman presents with 3/7 hx of swelling in 4th PIPJ. Sudden onset, red and swollen, painful limited ROM. No known trauma to area. No skin changes, no other joints affected. Recent cold, otherwise fit and well. Takes Cerelle, no other meds. No alcohol.
- O/E: Swollen, good ROM. No tenderness on MCPJ squeeze. No other joints involved.
a) Top 3 differentials.
b) Important questions to ask to rule out severe cause
c) Management in this case
a) Inflammatory arthritis (post-viral, RA, etc.), gout, septic arthritis
b) Morning stiffness, family history of RA, systemic illness
c) - Topical NSAID (e.g. voltarol gel - diclofenac)
- Ice to reduce swelling
- Bloods requested for 2 weeks time (FBC, ESR/CRP, arthritis screen, uric acid)
- Advised TCI if worsening or if other joints involved
28 year old female involved in RTA yesterday presents with neck and shoulder pain. Hit from behind, wearing seat belt and good head rest position. No collision anteriorly. Taken 2 co-codamol 30mg this morning, which have helped.
- O/E: limited ROM in neck and shoulders, some tenderness in trapezius and paravertebral muscles.
a) Likely diagnosis
b) Usual presentation
c) Recommended management
a) Ligament sprain/muscle strain (‘whiplash’)
b) Pain and stiffness in the neck (usually appears on day of crash or day after), pain and stiffness in the back or down the arms, headache, dizziness, irritability, blurred vision
c) - Prescribed co-codamol 30mg - counselled on risk with driving and constipation
- Advised heat packs/hot shower might aid movement
- Recommended gentle exercises to maintain good ROM in neck and back
- Posture and single firm pillow advice given
- Advised to look at insurance policies for physiotherapy if no better in a few days
62 year old female presents with red, itchy scalp with white scaling dandruff. Started 5 weeks ago. Tried coal tar shampoo and E45 shampoo but no benefit. No other skin areas affected, no joint involvement or systemic disease.
a) What are the main DDx?
b) How would you manage this case?
a) Scalp psoriasis, seborrhoeic dermatitis
b) - Seborrhoeic derm: ketoconazole shampoo.
- If no better TCI and trial topical steroid (?psoriasis)
18 year old male presents with first psychotic episode. 2nd person auditory hallucinations, broadcasting of thoughts.
a) What questions MUST you ask?
b) Management of a first psychotic episode - referral, treatments
c) What are Schneider’s first rank symptoms?
a) Risk assessment: Self (harm, suicide), Others (aggression, threats, dependants, etc.)
b) - Referral to early intervention service (if available): same day if risk to self/others. If not available, refer to crisis team/CMHT/etc.
- Treat comorbid disorders (eg depression, anxiety, substance misuse, physical health conditions)
- Psychological: CBT, family therapy, art therapy
- Antipsychotics: trial low-dose oral antipsychotic
- NB. Only start antipsychotic after liaising with consultant psychiatrist / after specialist assessment
- Put together crisis plan
- Review and monitor
c) Delusional perception, 3rd person auditory hallucinations, thought alienation (insertion, withdrawal, broadcasting), passivity phenomena (control of thoughts, actions, impulses or sensations by external force)
Mental Health Act (1983/2007).
a) Two criteria that must be fulfilled
b) Section 2 - overview, requirements
c) Section 3 - overview, requirements
a) Mental disorder of severity warranting admission AND danger to self/others
b) 28 days, assessment only, cannot be extended.
- Requires AMHP + 2 doctors, one of whom must be section 12-approved (usually psychiatrist) and one who is acquainted with patient (usually their GP)
c) 6 months, treatment, can be renewed.
Requirements same as Section 2.
