Conditions Flashcards
How would the acute abdomen present?
sudden onset, severe abdomen pain,
Pain!! may be unremitting/ radiating/ sharp/ focal/ N+V
What red flags would concern you with an acute abdomen?
bleeding - internal AAA, ruptured ectopic, peptic ulcer
peritonism - vicseral perforation?
falling vitals - tachycardia, hypotension etc
What differentials would you consider in the case of an acute abdomen?
severe pain out of proportion to signs, raised lactate - ischaemic bowel
bowel obstruction
lower right quadrant pain/ peritonism if ruptured - Appendicitis
colic - biliary causes
strangulated hernia
how would you manage an acute abdomen in general practise?
Hx and examination if possible, urine dip?
conduct A to E and determine need fro stabilisation with IV funds and then A&E if severe causes
consider referrals for admission or surgery (appendicitis)
What would you look for when assessing an unwell child?
appearance, breathing, circulation
fluid status
temperature
eating and drinking
urine output
sepsis?
How would you assess a patient presenting with SOB? what would you ask?
A : r/o obstruction, anaphylaxis, tension pneumothorax
B: RR, SATS, correct O2 needs (COPD with caution)
C: HF and pulmonary oedema?
ask about onset, duration, triggers, relieving and aggravating factors, exercise tolerance
PMH, drug hx, travel history
allergies? new pets? new changes into life?
SOB at night/ needs to prop up onto pillows?
infection? cough/ productive?
examination - CVS, resp, neuro exam, investigations like FBC for anaemia, D-dimers etc
What differentials would you be considering in a patient presenting with sob?
PULMONARY
acute asthma, COPD exacerbations, pneumonia, collapse, PE, pleural effusion, pneumothorax, lung cancer
CARDIAC
cardiac tamponade, CAD, SVT, MI, CCF, HTN
OTHER
acute blood loss, hyperventilation. anxiety, metabolic, neuromuscular, anaemia, obesity
how are you managing a patient with SOB in GP?
if saturations are low give oxygen until waiting
*assess and determine if admission required eg: asthma attack, COPD exacerbation, PE
- treat cause : anxiety, anaemia, pneumonia abx etc
- 2 week cancer referral if appropriate
- further investigations
- inhalers etc as required
How would you assess a pt with unilateral weakness in GP?
neuro exam
what differentials would you want to rule out with this presentation of uni weakness?
TIA
Bells palsy
how would you assess a pt presenting with anaphylaxis?
how would you manage???
Ambulance
how would you want to stabilise a patient before sending them to hospital?
oxygen and BP?
How might you assess back pain presenting in gp?
- ask about onset, time frame, radiation, morning stiffness
- exclude any red flags such as caudal equina symptoms, malignancy and fracture
- assess impact on day to day life
- examine gait, anal tone, neuro exam for lower limb and reflexes
- assess underlying cause
- MSK examination of affected
What differentials would you want to rule out and why in back pain?
BL leg weakness and pain, incontinence, saddle parasthesia –> caudal equina
severe central spinal pain, relieved by lying down –> spinal fracture
unremitting back pain, even at night affecting sleep, weight loss –> cancer
systemically unwell, IVDU, DM –> vertebral osteomyelitis, spinal or epidural abscess
N+V, urinary symptoms –> pyelonephritis kidney infection
how would you manage back pain ?
cause depending
- reassurance
- rest, offer sick note
- analgesia : paracetamol, IB gel or spray, physiotherapy if it gets worse
- lifestyle advice to lose weight and stop smoking
*admission with red flags
- review in 3-4 weeks if persisting
how would inflammatory joint disease present in gp?
- joint stiffness
- reduced range of motion
- red, swollen, hot to touch joint
- systemic illness like in lungs etc
- general lethargy and weakness
what differentials would you be considering for inflammatory joint disease?
RA
lupus
psoriatic arthritis
ankylosing spondylitis
psoriatic arthritis
( juvenile idiopathic arthritis )
gout
pseudo gout
how would you manage inflammatory joint disease in primary care?
*depends on cause
- anti-inflammatories such as NSAIDS
- DMARDs for RA
- physiotherapy
- MDT support
*exclude septic arthritis as risk of osteomyelitis developing
*referral to rheumatology
how would RA be presented in GP?
persistent symmetrical joint swelling (synovitis)
boggy feeling swelling, not bony
bilateral
morning weakness lasting longer than 1h
better with movement
*other symptoms like vasculitis (a rash of red, inflamed capillaries), malaise, fever, RA FH
how is RA managed and followed up in GP?
*referral to rheumatology where specialists will usually offer DMARDs 3m since onset of sympt
- regular blood checks for FBC, LFT : BM suppression
- glucocorticoids offered to treat flare ups
- ensure rapid access to specialists during flares
- drug monitoring, assess treatment targets, complications, lease with specialists
- pneumococcal and influenza vaccines
- offer help understanding of condition
When would you suspect a RA flare up?
- stiffness, joint pain, swelling, general fatigue worsening
- joint synovitis, joint tenderness, loss of joint function
- increased inflammatory markers CRP
how is OA presented in GP?
morning stiffness less than 1h or none
unilateral
functional impairment
activity related joint pain
bony swellings on joints, crepitus on movement
how Is OA managed in GP?
provide advice and support
weight loss, exercise, physio
psychological help
analgesia - topical NSAIDs
arrange referral according to clinical judgement
referral to physio, MSK clinic, OT, pain clinic and mental health help
how would osteoporosis present in GP?
what in hx would make you suspect?
- often no specific symptoms but a low impact fracture would make you suspect, loss height due to vertebral collapses
- diagnosed with a DEXA scan to measure density
- menopause, steroid use, female, older age, smoking, alcohol, previous fragility fracture, parental hx of hip fracture, high BMI
how is osteoporosis managed in GP?
treat underlying condition
bisphosphonates for bone protection
calcium and vitamin D
HRT for younger menopausal women to prevent
exercise, diet, stop smoking, drink alcohol within limits
how would bursitis present in GP?
dull achy pain
red, hot to touch over joint + surrounding area
painful when you press
swollen area over affected
how would you manage bursitis in GP?
rest, ice and reduced activity
compressive bandaging
analgesic for pain relief - paracetamol or NSAIDs
consider aspiration if swelling uncomfortable
if persisting suspect septic arthritis : aspirate, flucloxacillin
REFER? especially if not getting better
how would gout present to GP?
what are the indications in hx?
rapid onset, often overnight, and painful joint
swelling, redness in one or both MTP (usually big toe)
tophi - hardened nodules of crate crystals
family history, PMH
r/o septic arthritis
?previous bouts, high red meat, diuretic use, CKD, chemo
how are common analgesics used in primary care?
ladder?
how would bronchitis present?
child
how would croup present in GP?
barking cough
how would head lice present in GP and what would you do?
hygeine
how would chicken pox present in GP and why would parents concerned?
spots, strep A
how would viral wheeze present in GP in a child?
whistling sound heard on expiration during viral infection, which continues following infection
- presents with wheeze, chest tightness, cough, cold/ chest infection
*r/o differentials of asthma, respiratory infection or foreign body!
how would you manage a viral wheeze in gp?
blue reliever inhaler of salbutamol with spacer
nebuliser if very breathless
2-3 days of prednisolone sometimes to settle chest inflammation
how would toddler diarrhoea present in gp?
chronic non-specific diarrhoea which is a diagnosis of exclusion of frequent poorly formed offensive stool
- food material recognisable in stool
- active, unimpaired growth and otherwise well
- normal or increased fluids
*r/o infection, dietary intolerances, IBD, coeliac
how would toddler diarrhoea be managed in gp?
avoid full strength fruit juice as could act as osmoles
reassurance
reduce peas, corn as not chewed adequately
*usually faeces become firm by age 3 when toilet trained
how would GORD in a child present?
despite reflux being normal in children with sphincter relaxation, if severe may require treatment
- heartburn, retrosternal pain, epigastric pain
*if forceful voting, bile stained vomit, blood in stool present consider other causes
*r/o psychological, migraine, mesenteric adenitis
how is GORD in child managed?
4 week trial of PPI or H2 antagonist if persistent
if no improvement refer to endoscopy
weight loss may help if obese
how does osgood-schlatters present in gp, in children?
self listing in adolescents, caused by inflammation at tibial tuberosity where patellar ligament attaches
- anterior knee pain worsening with exertion
- palpable visible tender lump over tibial tuberosity
*r/o injury, Perthus (bone necrosis), slipped upper femoral epiphysis
how is osgood-schaltters managed?
reduce activity and rest
ice over tibial tuberosity
reassess and consider referral to paeds, physio or orthopaedic surgeon
how would a child with threadworms present in gp?
faeco-oral transmission by ingesting eggs
-might be asymptomatic but could have perianal itching particularly in nighttime and girls may get vulval symptoms
*r/o candida
how are threadworms managed?
anthelmintic - mebendazole
hygiene to prevent transmission
safety net with white discharge
how would you identify infantile colic?
crying uncontrollably, otherwise healthy and normal growth
- less than 5m old, recurrent and prolonged crying, fussing or irritability
- clench fists, red face, knees to tummy and arch back, tummy rumbles and windy
*r/o infantile reflux, dietary intolerance, pyloric stenosis
how is infantile colic managed?
soothe baby with cuddles
warm baths
distractions
*usually stops at 6m
what is functional constipation in a child?
decrease in bowel movements, less than 3 complete stools a week, hard and large stool, rabbit droppings with associated straining and pain
idiopathic - caused by low fibre?
how is functional constipation managed in a child?
- only if red flags excluded
- reassure, laxatives like macrogol first line
- dietary advice, toileting advice
- referral if red flags or no response or distressed
*safety net with abdomen distension, vomiting (intestinal obst), ribbon stool (anal stenosis), faltering growth, motor delays
How would you follow up functional constipation?
- tailor follow up as per families needs
- lease with others in primary care health visitor, school health adviser
- advice on reducing maintenance laxative dose
how would a child with atopic eczema present in GP?
dry, red, sore, itchy patches inside elbows, knees, face and neck - in flare ups
increases likelihood of asthma etc
*in children 5 and below
how is topic eczema managed in gp?
emollients
topical corticosteroids - hydrocortisone
sedating antihistamines if sleep affected
clinical psychologists
self care
*referral if eczema herpeticum, herpes simplex via vesicles and punched out erosions
how would you manage hay fever in gp?
advice on windows closed, limit time outside, filters to prevent pollen in cars or house
meds - chlorpheniramine (piriton drowsy), loratidine (non drowsy), citerezine // eye drops, nasal spray, steroid spray, steroid tablets if severe
safety net for anaphylaxis as allergy high risk
how would URTI presenting GP?
cough, fever, hoarse voice, runny noise, fatigue, ore throat, lymphadenopathy
assessed with symptoms, respiratory exam
how are URTI managed in gp?
mostly viral hence self limiting : give advice for fluids, steam inhalation, analgesia
decongestants maybe prescribed for any post nasal drip
tonsilitis managed with phenoxymethylpenicillin
(penicillin V)
how do UTI present in GP?
increased frequency, urgency
dysuria - burning sensation when urinating
fever, N+V, rigours and back pain if pyelonephritis
*diagnosed with urine dip
how are UTI managed in GP?
*hospitalisation for pyelonephritis
abx - nitrofurantoin or trimethoprim 3 days if uncomplicated and 7 if complicated
encourage lot of fluid intake to wash out infection
advice on self care measures such as wiping techniques
how do chest infections present in gp?
cough - productive or dry (if productive think colour, yellow/green suggests bacterial)
dyspnoea, fever, crackles
*assess CRB-65 to see if needed admission
r/o sepsis
how are chest infections treated?
doxycycline or amoxicillin
acute bronchitis - self limiting, 3-4 weeks and won’t need abx, offer abx (doxy) if acutely unwell, delayed if high risk
pneumonia - first line amoxicillin
reassess as required
how do abscesses present in gp?
swollen, pus filled lump under skin
hot to touch
painful in area
high temperature and generally unwell
*if multiple abscesses diabetes status maybe assessed
how are abscesses managed in gp?
abx prescribed - flucloxacillin
moist heat application to assist drainage
drainage maybe offered to alleviate pain
how is candidiasis presented at gp?
vaginal - itching, soreness, pandering sex, discomfort when urinating, abnormal discharge
oral - white patched on inner cheek, tongue, roof of mouth
invasive - immunocompromised
how is candidiasis managed in gp?
antifungals - oral or pessary
- miconazole oral gel, fluconazole oral
*hospitalise if invasive and oesophageal shown as swallowing difficulty
*refer if recurrent
how does influenza present in gp?
nasal discharge, cough, fever, headache, malaise, ore throat
*if complicated may show lower resp infection signs
kids may also have more generalised symptoms like nausea, vomiting, diarrhoea etc
how is influenza managed?
reassurance and fluids in healthy
oseltamivir for high risk, not immunosuppressed
zanamivir for immunosuppressed
how does GORD present in GP?
*As dyspepsia (indigestion)
heartburn
acid regurgitation
retrosternal or epigastric pain
bloating
nocturnal cough
hoarse voice
when is GORD referred?
referral to endoscopy can be made when peptic ulcers or malignancy suspected
evidence of GI bleed (coffee ground vomiting or malaena) emergency admission and endoscopy
suspected cancer sent in 2 week pathway so endoscopy done within 2w (dysphagia, weight loss, treatment resistant dyspepsia, low Hb, over 55y/o)
how is GORD managed in GP?
lifestyle - reduce caffeine, lighter meals, upright after meals, weight loss and smoking cessation
acid neutralising medication - gaviscon, rennie
PPI - omeprazole, lansoprazole
H2 receptor antagonist - ranitidine
*offer H pylori testing for dyspepsia
