Week 5 Flashcards
71 year old presents with 4/52 palpitations on exertion. Seen 2 weeks ago, TSH was high, so thyroxine increased from 75mcg to 100mcg. Symptoms have since improved. ECG showed sinus bradycardia. Awaiting cardiology appointment. Recent bloods showed eGFR 56 and macrocytosis (no anaemia) but otherwise NAD.
a) What does eGFR 56 mean (chronic) and how would you counsel patients about this?
b) Diagnosing CKD
c) Initial investigations in CKD
d) Monitoring and management of CKD
e) When should TFTs be repeated?
f) What are the causes of macrocytosis?
a) CKD stage 3A. Tell patients that their kidneys are ageing, and functioning at around 50%, but that this is the same as a healthy young person who’s donated a kidney
b) >3 months of eGFR <60 (with or without signs of kidney damage) or signs of kidney damage e.g. albuminuria, electrolyte abnormalities (with or without reduced eGFR)
c) - Initial investigations: UEs, FBC (?anaemia), urine dip (+/- ACR)
- If atage 4/5: bone profile, vit D, etc.
- If obstructive cause suspected - renal USS
d) - Control BP (if kidney damage or diabetic - aim for <130/80)
- Primary CVD prevention with statin (NOT aspirin - only secondary prevention now)
- Avoid NSAIDs, advise good fluid management and lifestyle advice
- Influenza and pneumococcal vaccines
63 year old male, 10 day history of left leg and back pain. Leg suddenly felt cold when lifting heavy fishing equipment. This evolved to dull ache in left leg, foot and lower back. Worse when sitting down, helped by gentle exercise. Taking 2x co-codamol QDS and ice packs have helped. Some constipation over past week but no other red flags. History of lymphoma 2005.
a) Examination - main points to record for: i) PVD, ii) DVT, iii) Sciatica
b) What is the likely cause of constipation here?
c) 2 main risk factors for PVD
d) Likely cause here - what makes this more likely?
e) Investigations to rule out sinister cause
a) i) PVD - CRT, colour, pulses
ii) DVT - erythema, tenderness, swelling, distended veins
iii) Sciatica - SLR, femoral stretch, power
b) Co-codamol. Ask about any incontinence
c) Smoking and diabetes
d) Muscular - piriformis syndrome (spasm irritating sciatic nerve). More likely due to exacerbation according to position and history of heavy lifting.
e) PVD - HbA1c, lipids
Lymphoma - FBC and CRP
Peripheral arterial disease.
a) 2 biggest risk factors
b) Diagnosis - cutoffs
c) Suspect PAD when…?
d) 5 Ps of acute limb ischaemia
e) Management of IC
f) Management of critical limb ischaemia
a) Smoking and diabetes
b) ABPI: <0.9 = PAD; <0.5 = critical limb ischaemia
c) - Progressive development of a cramp-like pain in the calf on walking or unexplained foot pain at rest (worse at night).
- There are non-healing wounds on the lower limb.
- Peripheral pulses are absent or hard to feel.
d) Pain, perishing cold, pallor, paraesthesia, pulseless
e) - Smoking cessation, exercise programme, manage CVD risk (statins, BP, aspirin, lifestyle, diabetes control)
- If these fail to control symptoms - vascular referral for angioplasty
f) Urgent vascular referral
82 year old male presents with 3 year history of pain in both hands, numbness and paraesthesia. He now struggles to grip cutlery, play golf or drive. Sometimes wakes in the night with pain, especially if wrist is flexed.
a) What examinations/special tests should be performed?
b) What conservative measures may be tried?
c) How should this man be investigated?
a) Hand examination, Phalen’s/Tinel’s for CTS
b) Wrist splinting, NSAIDs
c) Nerve conduction studies
16 year old male presents with 3/52 hx breast lump behind right nipple. Tender. No other changes noticed.
-O/E: Smooth soft 4cm lump under right nipple. No other changes noted.
a) Likely diagnosis
b) Management
a) Pubertal gynaecomastia
b) Reassurance
72 year old male with 2/52 hx pain in right flank and abdomen. Comes on for a few days, then subsides for a few days. Last BO 4 days ago, but pain not related to defecation. No haematuria or dysuria.
- O/E: no renal angle tenderness, no paraspinal tenderness, normal SLR, normal spinal ROM, abdomen SNT, BS present, no masses.
a) Red flags for bowel cancer to inquire about
b) Possible causes of the pain
c) Management
a) Weight loss, diarrhoea, PR bleed
b) Constipation-related; UTI
c) - Urine sample for dip and MSU
- Increase fruit and veg and fluids to ease constipation; lactulose added if necessary
- TCI INB or red flags develop
31 year old female with months long history of left hip pain. Previously under physio, which helped but now can’t get through to them. 1 week ago, sudden pain on sitting down (?twisting movement), went to ED and had XR but unsure of results.
- O/E: painful flexion and external rotation at left hip
a) What physio service can we refer her to?
b) How else should she be managed?
c) Other important Qs to ask
a) First contact physio
b) Regular analgesia, encourage activity
c) Pregnancy - LMP, sexual activity, etc.
Mini-CEX:
13 year old boy with 3/7 hx of headaches, started on left side now on right. No known trauma. Worse on moving head and on coughing. Current coryzal symptoms. Neck stiffness as well, especially after waking up. No visual changes, no gait issues, no vomiting. No fevers.
a) What examinations to perform?
b) What other questions did I not ask?
c) Likely cause. (also MUST rule out what important but rare cause of headaches in children)
d) Management
Also has worsening acne for past year, feels self-conscious. Previously tried benzoyl peroxide but to no avail. Comedones and pustules present on examination, no scarring.
e) Management of this
a) ENT, neurology, fundoscopy
b) Stress at school, rashes. Eye tests?
c) - Related to starting new school year (GCSE) and increased stress.
- Possibly related to sleep position.
- Related to cold symptoms.
- Could be vision-related also
MUST EXCLUDE MENINGITIS
d) - De-stress, try new sleep position, well-hydrated
- Paracetamol PRN
- TCI inb/ red flags develop
- Book eye test
e) Duac gel: clindamycin/benzoyl peroxide combination for 3 months - review after 3 months.
9 year old girl - 2/52 hx right heel pain. Struggles to weight bear, walking on toes. worsening. Ice packs or heat packs help a little, no calpol taken. Stopping her from doing gymnastics. Usually does 7 hours per week.
Has also had intermittent left knee pain, possibly due to jarring it during gymnastics routine. No other joints affected. No fever or recent illness. No swellings or rashes. Felt well otherwise. No morning stiffness.
Older brother has JIA, which affects ankles. No medication. Year 5 - no time off school.
-O/E: mild tenderness on medial calcaneus. Otherwise normal ROM and no joint inflammation. Gait - walks on toes on right foot due to pain.
a) Likely cause
b) Management
c) Other causes of heel/ankle pain (and why unlikely in this case)
a) Severs disease - pain in heels when walking, affects children going through growth spurt (~ 10 years old), especially very active children involved in sports with running and jumping (e.g. gymnastics)
b) - Severs: no cure (will stop when growing), Rest/ice/elevation/analgesia, avoid running/jumping sports or anything that aggravates (swimming may be useful alternative), always wear well-supported shoes.
- Bloods for FBC and CRP/ESR to rule out serious cause for bony pain like malignancy or JIA.
- Review inb / worsening
c) - Calcaneal stress fracture: no point tenderness, no obvious trauma
- Achilles tendonitis - usually calf/supracalcaneal pain rather than heel, more common in adults and runners
- Plantar fasciitis - more common in 40-60 year olds, worse in mornings, improves with moderate activity. Worse on dorsiflexion of foot, Windlass test positive (pain on 1st MT extension). Generally similar management to Sever’s and corrected with podiatry insole support.
62 year old woman with 3/12 hx diarrhoea. BO 6x/day. No PR bleed, no constipation, no weight loss, no abdominal pain but some back pain in last 2/52. TATT.
Previously 2ww - colonoscopy 1/12 ago, NAD. Biopsy showed mild oedema. Faecal calprotectin very raised. Ferritin low.
- o/e: Abdo SNT, BS present. Swelling of abdomen noted.
a) Why is it likely organic cause?
b) What are the causes of a swollen abdomen? What test should I have performed?
c) What further management should proceed?
a) Significant diarrhoea, high calprotectin.
b) Fluid thrill, shifting dullness for ascites
c) USS ovaries and CA-125 as:
- New-onset IBS-type symptoms in >50
- Unexplained loss of appetite
- Persistent abdominal distention/bloating
3 year old boy, 3/7 sore penis and some green discharge from the tip. Itchy, dysuria. Otherwise fit and well. No prior issues
-O/E: red and sore tip, some weepy greenish discharge visible. No other abnormalities.
a) Likely diagnosis
b) Management
a) Penile inflammation ?secondary to fungal infection
b) - Urine dip (MSU if positive)
- Swabs taken
- Prescribed hydrocortisone/miconazole cream to be applied BD
- Advised gentle washing without soap
25 week old boy, constipation for 1/12. Passing black hard rabbit-dropping stools. Appears distressed. No bleeding, normal E and D. Good fluid intake and fruit and veg.
- O/E: SNT, no anal stenosis
a) How to assess for impaction
b) Management
a) Soiling (overflow), mass on abdomen
b) - Movicol first line - titrate up as necessary
- Add in lactulose as necessary
- TCI inb/ red flags develop
11 year old girl with 4/7 hx pain and itch in right eye. Mum says it got a little red and puffy as well, with a mild watery discharge. No red flags.
a) Likely diagnosis and management
b) What would be red flags of severe pathology?
c) Give some examples of severe ocular pathology
d) Bacterial conjunctivitis - assessment and management
e) More severe conjunctivitis with heavy mucopurulent discharge - consider what causes?
f) If vesicles present on eyelid or tip of nose - consider…?
a) Viral conjunctivitis. Reassure, good eye hygiene and non-sharing of towels, etc. TCI inb.
b) Visual acuity changes, ophthalmoplegia, unilateral red eye, severe pain, acute onset, unequal/non-reactive pupils, photophobia, contact lens use, fluroscein staining of cornea
c) Orbital cellulitis, AACG, anterior uveitis, scleritis, physical or chemical trauma, corneal ulcer or contact lens associated red eye, neonatal conjunctivitis
d) Yellow discharge with crusting (esp in morning).
Treat with OTC chloramphenicol eye drops
e) STIs - chlamydia and gonorrhoea
f) Herpes zoster (Shingles) / HSV
Eyelid problems.
a) Inflammation of the eyelid (often at base of the eyelashes) is called…? - management?
b) Cyst on the eyelid is usually due to what? - management?
a) Blepharitis - clean eyelashes, chloramphenicol cream
b) Chalazion - blocked meibomian gland.
- Warm compresses and massage cyst in direction of eyelashes. If affecting vision, refer to ophthalmology
54 year old female with 3/12 forgetfulness. Difficulties with word finding, forgetting where she’s left things, struggling to follow TV programmes. Daughter says she repeats things more often. Has alcohol dependency and currently drinks 40U/week. Also low mood and some thoughts of DSH. 2 admissions for pneumonia this year.
- O/E: alert and orientated. Obs normal. No focal neurology or cerebellar signs.
a) What screening test should be performed for dementia in primary care?
b) What are the likely contributing factors to the memory loss?
c) What else is important to elicit from the history?
d) How should this patient be managed?
a) 6-CIT
b) Alcohol abuse. Low mood. Recent infections.
c) Any falls (?head injury - subdural)
d) - Reduce alcohol intake - liaise with Fitzwilliam
- Delirium/dementia screen: FBC, ESR, UEs, LFTs, calcium, HbA1c, TFTs, B12 and folate
- Brain imaging - CT/MRI
