AKT Flashcards
(56 cards)
1
Q
1. Atrial Fibrillation: Risk Factors Key modifiable risk factors: CATHODE * C- Cholesterol * A- Alcohol *T- Tobacco * H- Hypertension / hyperthyroidism * 0- Obesity or overweight *D-Diabetes * E- Exercise Other risk factors: * Coronary heart disease * L diastolic dysfunction * Valvular heart disease * Heart failure @medica
A
2. Coronary Heart Disease Risks Key modifiable risk factors: TOP CHD * T-Tobacco * O- Obesity or overweight * P- Physical inactivity * C- Cholesterol * H - Hypertension * D- Diabetes Non - modifiable risk factors: AGE * A - Age (increases with age) * G- Genetics (FH of CHD) * E- Ethnicity (South Asian / Afro- Caribbean have higher risk)
2
Q
- Diabetes Diagnosis: WHO criteria
* Random glucose
11.1+ mmol/L
* Fasting glucose
7.0+ mmol/L
* HbA1c
48+ mmol/mol
* OGTT (2 hrs)
11.1+ mmol/L
*1 abnormal reading needed with
classical diabetic symptoms
* Polyuria
* Polydipsia
* Nocturia
* Weight loss
*2 abnormal readings on different days
for asymptomatic patients - if in
doubt, confirm using OGTT
A
- Gestational Diabetes Screening
* Screen only patients at high risk
* BMI 30 kg/m? or more
* Previous macrosomic infant (4.5kg+)
* Previous gestational diabetes
* FH of diabetes (1st degree relative)
* Family origin of & diabetes prevalence
* South Asian, Caribbean, Middle Eastern
* Test of choice: OGTT
* 2 hour reading of 7.8+ mmol/L diagnostic
* Usually done at 24-28 weeks
* If previous gestational diabetes, screen
with early self-monitoring or OGTT
after booking + repeat OGTT at 24-28
weeks
3
Q
- Assessing Blood Pressure
* Check pulse - if irregular, measure BP
manually
* If 1st reading is 140/90+, repeat reading
* If 2nd reading substantially different, repeat
* Record lower of 2nd and 3rd reading
* Clinic BP <140/90 = normotensive
* 140/90+: ABPM / HBPM to confirm
diagnosis
* 180+ systolic OR 120+ diastolic: consider
treatment while awaiting ABPM / HBPM
* 180/120+ with papilloedema / retinal
haemorrhage - admit / refer urgently to
hospital for assessment
A
A+ C+ D + consider further diuretic
Step 4
or alpha-blocker or beta-blocker
Consider seeking expert advice
* A = ACE inhibitor / ARB if ACE not suitable
* C= Calcium channel blocker
* D = Thiazide like diuretic
* At each step, optimise current drug(s) before
moving to next step
* Patients of African or Caribbean heritage that
need an A class drug should be offered an ARB,
rather than an ACE inhibitor
4
Q
- Non-specific low back pain
* Offer all patients self-management advice
* 1st line drug: NSAID e.g. ibuprofen /
naproxen
* Lowest effective dose for shortest time possible
* Offer gastroprotective treatment while on NSAID
* If NSAID unsuitable / ineffective, offer
codeine +/- paracetamol (not paracetamol
alone)
* If patient has muscle spasm, consider
diazepam 2mg TDS for up to 5 days
* Advise follow up in 3-4 weeks if not
improving or if worsening symptoms
* Advise to report any red flag signs /
symptoms
A
- Cauda equina syndrome
* Compression of the cauda equina
below L2
* New onset low back pain / sciatica
with
* Bilateral neurological deficit in legs
* New onset urinary retention /
incontinence
* New onset faecal incontinence
* Saddle anaesthesia or paraesthesia
* Unexpected laxity of anal sphincter
* Neurological emergency
* Arrange urgent admission for assessment
5
Q
- Notifiable diseases
* Statutory duty to notify
“proper officer” (e.g.
public health team) of suspected cases of
certain diseases / organisms
* Remember key vaccinations as a clue:
* Acute meningitis / encephalitis (MenB / MenC)
* Diphtheria, tetanus, pertussis, polio (DTaP/IPV)
* Measles, mumps, rubella (MMR)
* Tuberculosis (BCG)
Some other key infectious diseases / organisms:
* Food poisoning / infectious bloody diarrhoea
* Invasive group A streptococcal disease
* Yellow fever / enteric fever
* Whooping cough, rabies, cholera, anthrax
* Covid-19, SARS-COV-2
* Severe acute respiratory syndrome (SARS)
A
- Live attenuated vaccines
* Should not routinely be given to patients who are
clinically immunosuppressed
* Rotavirus vaccine
* MMR vaccine
* Nasal flu vaccine
* Shingles vaccine
* Chickenpox vaccine
* BCG vaccine against TB
* Yellow fever vaccine
* Oral typhoid vaccine
* Where an immunosuppressed patient needs a live
attenuated vaccine, this should be with specialist
oversight
6
Q
- Antibiotics in sore throat: FeverPAIN
* Use the FeverPAIN score to aid decision
making
* FeverPAIN more accurate than CENTOR
* High score indicates possible bacterial
infection
* Score 1 for each of the following:
* Fever in the last 24 hours
* Purulence
* Attend rapidly (3 days or less from onset)
* Inflamed tonsils
* No cough or coryza
* Score 0-1: No antibiotics
* Score 2-3: Consider delayed script
* Score 4-5: Consider antibiotics
* 1st line: Penicillin V for 10 days
* If allergic: clarithromycin / erythromycin for
5 days
A
- Pre-eclampsia: risk factors
* Age 40+
* BMI 35 kg/m? or more at first visit
* Multiple pregnancy
* First pregnancy
* Pregnancy interval >10 years
* FH of pre-eclampsia
* Hypertension in past pregnancy
* Chronic kidney disease
* Thrombophilia
* SLE / Antiphospholipid syndrome
* Diabetes
7
Q
- Stable Angina: Assessment
* Features of stable anginal pain:
* Constricting discomfort in the front of
chest, neck, shoulders, jaw or arms
* Precipitated by physical exertion
* Relieved by rest or GTN within 5 mins
* 3 features = typical angina pain, offer
diagnostic testing
* 2 features = atypical angina pain, offer
diagnostic testing
* 1 or 0 features = non anginal pain,
consider gastro or musculoskeletal
causes
A
- Stable Angina: Diagnostic Testing
* Patients with typical or atypical
angina pain - offer diagnostic testing
with coronary angiography
* Patients with non-anginal pain need a
resting 12-lead ECG - refer for
diagnostic testing only if ST changes
or Q waves present
* Patients with confirmed CAD - offer
noninvasive functional testing
* Test for exacerbating conditions such
as anemia in all suspected angina
patients
8
Q
- Parkinson’s disease: key features
* Bradykinesia - slowness in initiation of
movement
* Hypokinesia - poverty of movement
* Reduced facial expression / blinking
* Difficulty with fine movement
* Slow, shuffling, festinating gait
* Other typical features include:
* Lead pipe or cogwheel rigidity
* Resting tremor - improves on moving
* Postural instability - assess using the “pull test”
A
* Refer anyone with suspected Parkinson's to a specialist UNTREATED for confirmation * Either neurologist or elderly care physician * Refer within 6 weeks for early / mild disease * Refer within 2 weeks for late / complex disease * If patient is taking a drug known to cause parkinsonism: * Reduce or stop the drug if appropriate / possible * Do NOT delay specialist referral to assess response medica
9
Q
- Mild acne: management
* Provide reassurance about natural
course of condition without trivialising it
* Give advice on self-care
* Do not wash more than twice daily
* Use mild soap or cleanser with warm
water
* Do not scrub vigorously or use exfoliating
agents
Avoid picking acne - it can worsen the
condition
* Topical treatment 1st line
* Benzoyl peroxide
* Topical retinoid +/- benzoyl peroxide
* Topical antibiotic + benzoyl peroxide
* Azelaic acid 20%
* Follow up after 6-8 weeks or sooner if
deterioration significant
A
18.Oral antibiotics in acne
* For moderate acne with high risk of
scarring / pigment change or where
difficult to reach (e.g. back)
* For severe acne while awaiting specialist
assessment
* Oral tetracycline, oxytetracycline,
doxycycline or lymecycline all 1st line
* Erythromycin if tetracyclines not
tolerated or contraindicated (e.g.
pregnancy)
* Do not prescribe oral antibiotic alone
combine with topical retinoid/benzoyl
peroxide
* Do not combine oral + topical antibiotics
* Consider combined oral contraceptive if
contraception also required
@medica
10
Q
- Acute migraine: management
* Adults: Combination treatment 1st line:
* Oral triptan + NSAID
* Oral triptan + paracetamol
* If monotherapy requested, offer either:
* Triptan
* NSAID
* Aspirin 900mg
* Paracetamol
* Consider adding an anti-emetic even in
the absence of nausea or vomiting
* Do NOT use ergots or opioids
* 12-17 year olds: 1st line is paracetamol
or NSAID
* Add nasal triptan if monotherapy ineffective
@medica
A
- Prostate cancer: referral
* Consider PSA and digital rectal
examination to assess for prostate
cancer in men with:
* Lower urinary tract symptoms e.8.
nocturia, frequency, hesitancy, urgency or
retention
* Erectile dysfunction
* Visible haematuria
* Refer within 2 weeks if prostate feels
malignant on digital rectal examination
* Refer within 2 weeks if PSA levels above
the age-specific reference range
* Age 50-69: >=3.0 ng/ml
* Age 70+:
>=5.0 ng/ml
@medica
11
Q
- Vitamin D deficiency: who to test
* Symptoms of osteomalacia:
* Bone pain / discomfort in lower back,
pelvis, and lower extremities
* Impaired physical function
* Muscle aches and weakness
* Symmetric lower back pain
*
Chronic widespread pain
* Other clinical reason for testing:
* Prior to specific treatments which will
affect Vitamin D levels
* Bone disease that may improve with
vitamin D treatment - e.g. osteomalacia,
osteoporosis, or Paget’s disease
* Following a fall
* Patient has features of hypocalcaemia
(rare), including muscle cramps,
carpopedal spasm, numbness,
paraesthesia tetanv or seizures
A
- Vitamin D deficiency treatment
* Based on serum 25-hydroxyvitamin D levels
* Level <25 mol/L= deficiency - treat
* Level 25-50 mol/L= insufficiency - treat if:
* Has fragility fracture / osteoporosis / high fracture
risk
*
On treatment with antiresorptive drug
*
Has symptoms suggestive of deficiency
Has raised parathyroid hormone levels
*
cholestyramine
*
Has a malabsorption disorder (e.g. Crohn’s
disease) or a condition known to cause deficiency
(e.g. CKD)
* Level above 50 mol/L is adequate - advise
on measures to prevent deficiency
12
Q
- Osteoporosis risk assessment
* All women aged 65+, all men aged 75+
* Women aged 50-64, men aged 50-74 with:
* A previous osteoporotic fragility fracture
*
Current or frequent recent oral steroid use
*
History of falls
*
*
LOW BMI (<18.5kg/m2)
Smoker
*
Alcohol intake more than 14 units per week
* A secondary cause of osteoporosis
* People younger than 50 with:
* A previous fragility fracture
*
Current or frequent use of oral steroids
Untreated premature menopause
* People younger than 40 with:
* Current or recent high dose oral steroids
(equivalent to 7.5mg prednisolone for 3
months+)
* Previous fragility fracture of spine, hip,
forearm, or proximal humerus
* History of multiple fragility fractures
@medica
A
- Drugs that increase risk of fractures
* Consider assessing fracture risk in patients
taking these medications:
* Selective serotonin reuptake inhibitors
* Antiepileptic medication - particularly
enzyme-inducing drugs, such as
carbamazepine
* Aromatase inhibitors, such as exemastane
* Gonadotropin-releasing hormone agonists,
such as goserelin
* Proton pump inhibitors
* Thiazolidinediones, such as pioglitazone
* Oral steroids, especially with long term use
medica
13
Q
- Neuropathic pain: management
* For trigeminal neuralgia - offer
carbamazepine
* For any other neuropathic pain offer
either:
* Gabapentin
* Pregabalin
* Duloxetine
* Amitriptyline
* Do NOT prescribe more than 1 drug for
neuropathic pain at the same time
* For localised neuropathic pain or where
oral not tolerated - offer topical
capsaicin
* Refer to pain service if pain is severe or if
treatment fails
A
- Diagnosing IBS in Primary Care
* Assess for IBS if 6 month+ history of
Abdominal pain, Bloating or Change in
bowel habit
* Red flags: Signs or symptoms of cancer or
markers for inflammatory bowel disease
* pipsness,it a bodominaleaj wralievediby
bowel frequency /stool form + 2 of the
following 4:
* Altered stool passage (straining, urgency,
incomplete evacuation)
*
Abdominal bloating, distension, tension or
hardness
Exacerbated by eating
Passage of mucus
* Tests in primary care to exclude other
causes:
* FBC, ESR /plasma viscosity, CRP and antibody
testing for coeliac disease (EMA or TTG).
@medica
14
Q
- Reactive arthritis - Reiter’s syndrome
* Reactive arthritis following either:
* Gastroenteritis (enteric form)
* Sexual activity (genital form)
* Classic triad of symptoms
* Conjunctivitis
* Urethritis
* Arthritis (seronegative)
* Remember: “can’t see, can’t pee, can’t
bend the knee!”
* Treatment separate for each problem
* Conjunctivitis - chloramphenicol
* Urethritis - tetracycline if chlamydial
source likely
* Arthritis - rest, NSAID / steroids if severe
A
- Jarisch-Herxheimer reaction
* Can happen with any antibiotic
treatment
* Occurs in ~15% of patients with
Lyme disease treated with
antibiotics
* Occurs within 24 hours of treatment
* Caused by release of toxins following
death of bacteria
* Causes worsening of fever, chills,
muscle pains, and headache.
* Additional features can include
tachycardia, hyperventilation,
vasodilation with flushing, and mild
hypotension
medica
15
Q
- eGFR - creatinine
* The standard method of assessing
estimated glomerular filtration rate
* Need 4 metrics to calculate:
* Creatinine
* Age
* Sex
* Ethnicity
* NICE recommends use of CKD-EPI
equation for calculation
* Calculation inaccurate in patients
with abnormal muscle mass or skin
surface area
* Avoid meat for 12 hours before
testing
A
- Bell’s Palsy
* Unilateral, idiopathic, acute facial
nerve paralysis
* Maximum facial weakness usually
develops within 2 days
* Earache, discomfort or facial pain may
precede the palsy
* Most people make a full recovery
within 9-12 months - protecting the
affected eye is important
* If onset was <72 hours ago then
consider prednisolone
* Refer if there are doubts, if the
condition is recurrent or if it is bilateral
16
Q
- Whooping cough management
* Arrange admission if:
* 6 months old or younger and acutely
unwell
* Significant breathing problems
* Significant complications e.g. seizures
or pneumonia
* If admission not needed, prescribe
antibiotics if onset of cough within 21
days:
* Clarithromycin if aged <1 month
* Azithromycin or Clarithromycin if
1m+
* Erythromycin for pregnant women at
36 weeks+ gestation
* Complete form for notifiable disease
A
- Impetigo
* Typical features - golden coloured, crusting
lesions
* Non bullous infection
* Localized + low risk - hydrogen peroxide 1%
cream or topical fusidic acid - (5 days)
==
Widespread + low risk - topical OR oral
antibiotic
* Severe infection + high risk - oral flucioxacillin
(7 days)
-=
Clarithrorycin or erythromycin if penicillin
allerzy
* Treat underlying cause if applicable (eg,
Eczema, scabies, head lice)
¿ Bullous infection - oral antibiotics as above
• Advise time off school
# Until lesions crusted over or 43 hours from
start of antibiotics
17
Q
- Lipid therapy ~ primary prevention
* Offer medication to patients 84 years or
younger with 10 year CVD risk of 10%+
* Use ORISK2 to assess CVD risk
* Offer medication without need for
formal risk assessment to patients with:
* Type 1 diabetes
* Chronic kidney disease
* Familial hypercholesterolaeria
* Consider offering medication to patients
85 years+ after considering risks and
benefits based on individual
circumstances
* 1= line medication is atorvastatin 20mg
unless contraindicated (e.g. in
pregnancy)
A
- Lipid therapy - CVD prevention
* For primary and secondary prevention:
* Address other modifiable risk factors e.g.
smoking, obesity
* Identify and manage secondary causes of
dyslipidaemia e.g. hypothyroidism
* Arrange follow up to monitor treatment
and adverse outcomes
* Baseline bloods before medication:
* Non-fasting lipid profile
* Liver function tests (transaminases)
* Renal function (including eGFR)
* HBA1C
* 1st line treatment: atorvastatin
* 20mg daily for primary prevention
* 80 mg daily for secondary prevention
medica
18
Q
- CHA,DS,VASc score
* For assessing stroke risk in patients with AF
* C - Congestive heart failure
1
* H - Hypertension
1
* A, - Age 75+
2
* D - Diabetes
1
* S, - Stroke / TIA / thromboembolism
2
* V- Vascular disease (MI, PAD etc.)
1
* A- Age 65-74
1
* Sc - Sex category - female
1
* Score 1+ for males, 2+ for females: consider
anticoagulant treatment to reduce stroke risk
* Use ORBIT bleeding risk scoring tool to assess
risk of bleeding when considering
anticoagulants
A
- For assessing bleeding risk for patients
with AF - more accurate than HAS-BLED
Criterion Score
Males: haemoglobin <130 g/L or 2
haematocrit<40%
Females: haemoglobin <120 g/L 2
or hematocrit <36%
Personal history of bleeding e.g. 2
Gl / intracranial bleeding,
hemorrhagic stroke
Age > 74 years. 1
eGFR < 60 mL/min/1.73m2. 1
On antiplatelets. 1 - ORBIT score:
- 0-2: Low risk
*3:
Medium risk - 4-7: High risk
19
Q
- Chronic Plaque Psoriasis: Management
* Offer topical emollients to reduce scale
* Offer topical potent steroid + Vitamin D
preparation
* Steroid and vitamin D preparation
should be applied at different times of
day
* Advise on risks of topical steroids
* Refer for second and third-line
treatments (e.g. phototherapy or
systemic therapy) at the same time as
offering topical treatments where
topical is unlikely to control psoriasis:
* Extensive disease (>10% body surface
affected)
* A score of moderate or worse on static
PGA
* Psoriasis unlikely to respond (e.g. nail
involvement)
A
J. Hirsutism: Reterral guidelines * Refer urgently (2WW) to rule out androgen-secreting tumors in patients with: * Sudden onset or rapid progression of hair growth * Severe hirsutism * Signs of virilization * Pelvic or abdominal mass * Refer to endocrinology if features of Cushing' syndrome: * Weight gain (moon face) * Weight gain in the neck, upper back, torso * Stretch marks (new onset) * Easy bruising * Proximal muscle weakness * Refer if initial investigations abnormal: * Serum total testosterone >4 nmol/L * Refer urgently (2WW) if testosterone >6 nmol/L * Elevated 17-hvdroxvorogesterone levels
20
Q
39. Genetic conditions - modes of inheritance Autosomal dominant * Marfan syndrome, achondroplasia, neurofibromatosis, Huntington's disease Autosomal recessive * Albinism, cystic fibrosis, phenylketonuria, sickle cell anemia, Tay Sachs disease X linked dominant * Alport syndrome, Rett syndrome, Vitamin D resistant rickets, Fragile X X linked recessive * MD, haemophilia, G6PD deficiency, Hunter syndrome, colour blindness Polygenic / multifactorial * Neural tube defects, pyloric stenosis @medica
A
40. Chromosomal genetic disorders Error in number: * Down syndrome Trisomy 21 * Edwards syndrome Trisomy 18 * Patau syndrome Trisomy 13 * Turner syndrome 45X0 (× missing) * Klinefelter syndrome 47XXY (Extra X) Deletions: * Cri-du-chat syndrome * Missing short arm on chromosome 5 * Prader-Willi syndrome * Deletion on chromosome 15
21
Q
Test Positive result
Fractional exhaled nitric 40 ppb (Age oxide (FeNO) 17+)
35 ppb (Age
5-16)
Spirometry: FEV./FVC. Ratio <70% ratio. or be below the lower limit of normal Bronchodilator FEV1: 12%+ improved + reversibility (BDR) test Volume: 200ml+ increase Peak flow variability 20%+ variability
A
- Frozen shoulder
* Shoulder pain / stiffness on elevation and
external rotation
* Incidence higher in diabetic patients
* Usually self-limiting but can take months to
years to resolve
* Consider the following in management:
* Regular analgesia - paracetamol +/- NSAID /
codeine
* Physiotherapy for 6 weeks+
* Joint injection (glenohumeral) with steroids
* Refer to secondary care:
* If no response after 3 months
* If symptoms or impact on patient is severe
* If there is diagnostic uncertainty
* If steroid injection cannot be done in primary
care
22
Q
43. Infertility - early referral criteria FemaleMale Age 36+ Previous genitalpathology Amenorrhoea or oligomenorrhoea Previous urogenital surgery Previous abdominal or pelvic surgery Varicocele Previous pelvic inflammatory disease Significant systemic illness Abnormal pelvic examination Abnormal genital examination Previous sexually transmitted infection Known reason for infertility (e.g. prior treatment for cancer)
A
- Infertility - Investigations (females)
* Regular unprotected sex for 1 year, test
earlier if identified as less likely to conceive
* Screen for chlamydia
* Confirm ovulation with serum progesterone
on 7 days prior to 1st day of period (e.g. day
21 of 28 day cycle)
* Offer additional testing if:
* Prolonged cycles - repeat serum
progesterone weekly after initial sample
(adjust sample day e.g. day 28 of a 35 day
cycle) until next cycle
Irregular cycles - measure gonadotrophins
(follicle-stimulating and luteinizing hormones)
* Symptoms of thyroid disease - measure TFTs
* Ovulatory disorder, galactorrhoea or
suspected pituitary tumour - measure
prolactin
23
Q
- Infertility - investigations (males)
* Arrange semen analysis
* Collect after 2-7 days sexual abstinence
* Sample should be at lab within 1 hour of
production
* If first result normal, no need to
repeat
* If 1st test is abnormal, repeat after 3
months for confirmation
* Repeat sooner (2-4 weeks) if azoospermia
or severe oligospermia detected
* If repeat test normal, no need for 3rd
test
* 2 abnormal results - refer
* Screen for chlamydia
A
- Infertility - semen analysis
* WHO reference values should be used:
* Semen volume: 1.5 ml+
* pH: 7.2+
* Sperm concentration: 15 million+ per ml
* Total sperm count: 39 million+ per
ejaculate
* Total motility: 40%+ motile or 32%+ with
progressive motility
* Vitality: 58%+ live spermatozoa
* Morphology: 4% + normal forms
* If 1st test is abnormal, repeat after 3
months for confirmation
* Repeat as soon as possible if azoospermia
or severe oligospermia detected
medica
24
Q
- Influenza vaccination groups
* Age 65+ or 6 months+ in clinical risk
groups
* Chronic respiratory disease
* Chronic heart disease
* Chronic kidney disease
* Chronic liver disease
* Chronic neurological disease
* Diabetes mellitus
* Immunosuppression
* Asplenia or splenic dysfunction
* Pregnant women
* Morbid obesity (BMI 40+)
* Healthcare workers / carers
A
- Anaphylaxis management
* IM Adrenaline 1:1000
* Adults:
500 micrograms (0.5 mL)
* Children:
* Age 12 years+:
500 micrograms (0.5 mL)
* Age 6-12 years:
300 micrograms (0.3 mL)
* Age 0 - 6 years: 150 micrograms (0.15 mL)
* Repeat after 5 minutes if not improving
* Oxygen if available - highest concentration
* Additional drugs that may be used:
* Chlorphenamine
* Hydrocortisone
* Salbutamol
25
```
49. Safeguarding: maltreatment
Factors associated with neglect / maltreatment
Parental/family
* Previous social services involvement
* Parental mental health problems
* History of domestic abuse
* Poor housing/frequent moves
* Parental substance misuse
* Parental criminal convictions
* Parental learning difficulty
Child
* Age <1 year
* Low birth weight / SCBU admission
* Known disability
Child
* Age <1 year
* Low birth weight / SCBU admission
* Known disability
```
50. Obesity Related Health Problems
* Type 2 diabetes
* Coronary heart disease
* Hypertension and stroke
* Asthma
* Depression / psychological distress
* Metabolic syndrome
* Dyslipidaemia
* Cancer
* Gastro-oesophageal reflux disease
* Gallbladder disease
* Reproductive problems
* Osteoarthritis and back pain
* Obstructive sleep apnoea
* Breathlessness
26
51. Alcohol withdrawal symptoms
* Think of someone falling down the
stairs and hitting the door - STAIRS
HD
Sweating
Tremor
Anxiety
Insomnia
Rapid heart rate
Seizures
Hallucinations
Disorientation
52. Hypertension: risk factors
* Remember SAFESAL
* S- Sex
*@(Males) & risk if age <65 years
* (Females) & risk if age 65+ years old
* A - Age - BP rises with age
* F- Family history
* E - Ethnicity - African / Caribbean risk
* S- Social deprivation - most deprived
30% have increased risk
* A - Anxiety / stress - due to raised
adrenaline and cortisol levels
* L- Lifestyle - smoking, alcohol, excess
salt, obesity, lack of exercise
medica
27
53. Generalised Seizures: Features
* Tonic - impairment of consciousness
and stiffening. Trunk flexed or straight
* Conic - jerking and impairment of
consciousness
* Tonic-clonic - stiffening, jerking,
impairment of consciousness
* Absence - sharp onset, no residual
symptoms. Normal activity is
interrupted.
* Myoclonic - brief shock like
contractions of the limbs, no apparent
impairment of consciousness
* Atonic - brief attacks of loss of tone,
falls and impaired consciousness
54. Differential Diagnosis - seizures
* Syncope
* Postural chances, pain, prolonged standing
* Cardiac arrhythmias
* More common with structural heart
disease or ischemic heart disease
* Panic attacks with hyperventilation
* Non-epileptic attack disorders
* More common in women - 3:1 ratio
* Thrashing, side to side head / limb
movements, prolonged motionless
collapse
* In children between 6 months and 5
years
* Night terrors, breath holding attack,
behavioral phenomena
28
55. Seizure management: <5 minutes
* Look for epilepsy identity card /
jewellery
* Protect them from injury
* Cushion head, move harmful objects away
* Do not restrain or put anything in the
mouth
* When seizure stops check airway and
put in recovery position
* Observe until fully recovered
* Examine for and manage injuries
* Arrange for emergency admission if it
is a first seizure
```
56. Seizure management:
>5 minutes or >3 in 1 hour
* Follow usual seizure protocol AND
* Treat with
* Buccal midazolam as 1st line in the
community
* Rectal diazepam if preferred or 1st line
unavailable
* IV lorazepam if IV access already
established
* Call ambulance for urgent admission if
seizures do not respond promptly to
treatment OR if seizures were
prolonged or status epileptics has
developed
* Arrange for specialist review
* Provide carers with buccal midazolam
/ rectal diazepam in case of future
events
```
29
57. Polycystic Ovary Syndrome
* Suspect PCOS is woman has ≥ 1 of:
* Infrequent or no ovulation (infertility,
oligomenorrhoea, amenorrhoea)
* Hyperandrogenism (hirsutism, acne
vulgaris after adolescence, alopecia)
* Women over 18 with 2 years of irregular
cycles (>35 or <21 days)
* Indirect evidence of insulin resistance
is suggestive of PCOS (not diagnostic)
* Obesity - especially central obesity
* Acanthosis nigricans
* Increase suspicion if there is FH
* Exclude other conditions with similar
clinical presentations
58. Polycystic Ovary Syndrome: Tests
* Total testosterone
* Sex hormone-binding globulin
* Free androgen index
* To rule out other causes of
oligomenorrhoea and amenorrhoea
* LH and FSH
* Prolactin
* Thyroid-stimulating hormone
* Exclude pregnancy
* Pelvic ultrasonography - if the
diagnosis of POS can't be certain on
clinical and biochemical grounds
30
59. Higher risk pregnancies
* Multiple pregnancy
* Aged <18 or >40
* BMI >35 kg/m? or <18 kg/m?
* Recurrent miscarriage or preterm birth
* Family history of genetic disorder
* Problems in a previous pregnancy or
delivery:
* Severe pre-eclampsia, eclampsia, HELLP
syndrome, 2+ episodes of antenatal or
postpartum hemorrhage or retained
placenta, puerperal psychosis, uterine
surgery, rhesus isoimmunization, stillbirth
or neonatal death etc.
* Ongoing health problem or disease:
cancer, CF, HIV, sickle cell, thalassaemia etc.
60. Uncomplicated pregnancy: 1st Trimester
* Height, weight and BMI
* Blood pressure and proteinuria
* Offer scans: dating 10-13 weeks &
anomaly scan: 18-20 weeks
* Offer foetal screening for Down
Syndrome
* Blood typing
* Maternal screening for anemia, red cell
alloantibodies and
haemoglobinopathies, Hep B, HIV,
asymptomatic bacteriuria, syphilis
* Immunity to rubella
* Do NOT offer chlamydia screening
routinely
* Offer influenza vaccination
* Lifestyle advice - diet, exercise, alcohol,
smoking
31
o_. Uncomplicated pregnancy: 2na rimester
*16 weeks
* Check Hb levels.
* Offer vaccination against pertussis and
influenza
* 25 weeks - for nulliparous women
* Screen for hypertension, safety net about
pre-eclampsia
* Offer vaccination against influenza
* Measure fundal height
* 28 weeks
* Screen for hypertension / pre-eclampsia
* Offer vaccination against influenza
* Screen for anaemia
* Measure fundal height
62. Uncomplicated pregnancy: 3rd Trimester
* 31 weeks for nulliparous women
* Offer vaccination against pertussis
* 34 weeks
* Give specific information on preparation for
labour and birth
* 36 weeks
* Information about breastfeeding
* 38 weeks (40 weeks for nulliparous
women)
* Discuss options for managing prolonged
pregnancy
* After 41 weeks - membrane sweep,
offer induction
32
63. Alopecia areata - diagnosis
* Hair loss is usually patchy with sudden
onset
* Patches are usually round and well
circumscribed
* Skin is normal coloured
* Exclamation mark hairs (short broken
hairs) around the margins
* Usually asymptomatic - occasionally
may have itch or tingling
* Nail changes - pitting, onycholysis,
splitting, ridging, red lunula,
koilonychia, leukonychia
64. Alopecia areata - differentials
* Tinea capitis - fungal skin infection
* Trichotillomania
- psychiatric
condition
* Traction alopecia - caused by hair
styling
* Androgenetic alopecia (shown below)
* Scarring (cicatricial) alopecia
inflammatory disorders which destroy
the hair follicle
* Secondary syphilis
* Telogen effluvium - hair loss after
significant emotional or health event
* Anagen effluvium - drug induced
33
65. Alopecia areata: management
* Regrowth (short, fine, tapered,
depigmented) - no need for treatment
* No regrowth and <50% hair loss
consider watchful wait
* No regrowth and >50% hair loss
discuss medical treatment
* Trial of potent corticosteroid (not for facial
areas such as beard and eyebrows)
* Hair regrowth may not be seen for at least
3 months
* Hair regrowth is initially fine and
depigmented
* Refer if - uncertain diagnosis, in child
or pregnant / breastfeeding woman
66. Suspected Lung / Pleural cancers
* Suspected cancer pathway (2WW) if:
* CXR suggestive of lung cancer /
mesothelioma
* Aged 40+ with unexplained haemoptysis
* Urgent chest x-ray (within 2 weeks) if
40+ with 2 or more of the following
(1+ if a smoker or ex-smoker)
* Cough
* Fatigue
* Shortness of breath
* Chest pain
* Weight loss
* Appetite loss
34
67. Febrile Seizure - diagnosis
* Exclude differentials such as rigors,
syncope, breath-holding
* Take temperature of patient (or accept
parental perception / measurement)
* Identify any underlying cause of the fever
* Exclude meningitis / meningococcal disease
* Encephalitis
* Typical features of a febrile seizure
* Child aged 6 months - 5 years
* Last no longer than 3 - 6 minutes
* Generalised tonic-clonic type
* Complete recovery of consciousness within
1 hour
```
68. Febrile Seizure: Management
Urgently admit any child with
suspected meningitis, meningococcal
disease or encephalitis
* Immediate hospital assessment by a
pediatrician if:
* 1st seizure or a subsequent seizure but the
child has not previously been assessed by a
specialist
* There is diagnostic uncertainty about the
cause of the seizure
* Any of the following features
• Seizure lasted for >15 minutes
•Focal features during the seizure
• Recurrence in the same illness or within
24 hours
• Incomplete recovery within a hour
•Child <18 months
• Anxious parents
```
35
69. Analgesia: opioid strengths
* The following doses of opioids are
roughly equivalent to morphine 10mg
PO:
* Codeine:
100mg PO
* Dihydrocodeine: 100mg PO
* Tramadol:
100mg PO
* Oxycodone:
6.6mg PO
* Morphine:
5mg IM, SC, IV
* Diamorphine:
3mg IM, SC, IV
* Hydromorphone: 2mg PO
* Patient response can be variable:
monitor response and titrate
accordingly
```
70. Managing Pain - WHO ladder
Adjuvants may be added for
* Step 3:
specific pain types at any step e.g.
severe pain
Gabapentin (neuropathic pain),
Zoledronic acid (bone pain) etc.
*
Strong opioid
such as
* Step 2:
morphine,
oxycodone,
moderate
fentanyl +/-non-
pain
opioid analgesic
*
Weak opioid
* Step 1:
mild
pain
* Non opioid
analgesic
such as
paracetamol
or NSAIDs
such as
codeine,
dihydrocodein
e or tramadol
+/- non-opioid
analgesic
```
36
71. Achilles Tendinopathy
* Achilles tendon rupture - sudden
intense pain in the back of the leg,
inability to walk
* Typical symptoms:
* Pain in back of leg or heel - usually
intermittent, worse in the morning,
aggravated by activity
* Stiffness in the tendon
* Examine both legs for swelling,
deformity, signs of inflammation.
* Exclude tendon rupture
* Achilles tendinopathy is a clinical
diagnosis and imaging is not routinely
recommended
72. Addison's Disease - investigations
* Test serum cortisol (ideally at 8am
9am), urea and electrolytes
* Seek specialist advice if the patient
works shifts, is receiving long term
corticosteroid treatment or oestrogen
treatment
* Serum cortisol levels - check local
reference ranges but as a general
guide:
* <100 nanomol/L - admit to hospital.
Adrenal insufficiency is highly likely
* 100 - 500 nanomol/L- refer to an
endocrinologist for further investigations
including a Synacthen test. Urgency
depends on severity of symptoms.
37
73. Addison's Disease - management
* Initiated and adjusted by a specialist
* Androgen replacement not routinely
prescribed in the UK
* Glucocorticoid replacement - usually
hydrocortisone - but prednisolone and
dexamethasone are sometimes used
as they're longer acting.
* Glucocorticoid replacement should
resemble natural cycle of corticosteroid
release e.g. 3 divided doses at waking,
noon and early evening.
** Mineralocorticoid replacement -
fludrocortisone is usually used
74. Allergic rhinitis
* Inflammatory disorder where the
membranes of the nose become
sensitised to allergens
* Associated with the development of
allergic conjunctivitis, eczema and
asthma
* Seasonal - if caused by pollen it is
known as hay fever
* Perennial - where symptoms occur
throughout the year - often from
house dust mites / pets
* Occupational - exposure to allergens
at work
38
75. Allergic rhinitis - assessment
* Assess for asthma
* Try to identify most likely allergen
causing symptoms
* Ask about factors which may
influence choice of drug treatment:
* Frequency, severity, persistence of
symptoms
* Adverse effect on quality of life
* Associated conjunctivitis
* Previous treatments tried
* Preference - oral or nasal treatments
* Signs of chronic nasal congestion
breathing through mouth, cough,
halitosis
* Examine nose for polyps, deviated
septum, mucosal swelling
```
•AllergIC n- prescriin
* Antihistamine
* Oral non sedating - cetirizine, fexofenadine,
loratadine
* Intranasal - Azelastine
* Intranasal corticosteroid
* Triamcinolone (aged 2+), budesonide (aged
12+) or beclomethasone (aged 6+) or
betamethasone
* If nasal polyps / blockage then mometasone
furoate is indicated in adults
* Short course of oral corticosteroid
* Intranasal decongestants
* Ephedrine and xylometazoline
* Intranasal sodium cromoglicate
* Intranasal ipratropium
```
39
77. Amenorrhoea
* Absence or cessation of menses - due
to physiological, pathological, iatrogenic
cause
* Primary - failure to establish
menstruation by 16 years of age in
women with normal secondary sexual
characteristics, or by 14 in women with
no secondary characteristics
* Secondary - no consensus but absence
of menstruation for >6 months in
women with previously normal menses,
or >12 months in women with
oligomenorrhoea is a common
definition
* Oligomenorrhoea
- menses occurring
less frequently than every 35 days
78. Amenorrhea - assessment
* Exclude pregnancy
* Enquire about lower abdominal pain;
stress, depression, weight loss;
headache; sexual history; FH; drug
use.
* Measure BMI
* Examine for
* Turner's syndrome (short, web neck,
shield chest)
* Hirsutism (PCOS)
* Signs of thyroid or other endocrine
disease
* If appropriate: clitoromegaly,
galactorrhoea, haematocolpos,
androgen insensitivity, pelvic exam to
look for absent uterus
40
79. Amenorrhoea - investigations
* Usually done by a specialist
* Pelvic ultrasonography (if the presence
of a vagina and uterus cannot be
confirmed by a physical examination
or in young girls who are not sexually
active)
* Serum prolactin. Do not examine
breasts before taking blood, wait 48
hours after breast exam.
* >1000 mIU/L warrants further investigation
* TSH, FSH, LH
* Total testosterone if there are features
of androgen excess
80. Amenorrhea - management
* Primary amenorrhoea - refer there
is parental / patient concern or if
abnormality is suspected
* Most referrals to a gynaecologist
* Refer to endocrinologist for thyroid
disease, hyperprolactinaemia, androgen
excess
* Secondary amenorrhoea
* Manage POS, hypothyroidism,
menopause in primary care
* Refer to gynaecology; premature
ovarian failure, where there has been
surgery or infection
* Refer to endocrinology; hormonal cause
* Manage weight related, exercise
related or stress related
41
81. Iron deficiency anemia - signs
* Symptoms depend on speed of onset
* Very common: dyspnoea, fatigue,
alopecia.
* Common: cognitive dysfunction,
restless leg, vertigo
* Rare: dysphagia, haemodynamic
instability, syncope
* Other symptoms: dizziness,
weakness, dysgeusia, irritability,
palpitations, pica, pruritus, sore
tongue, tinnitus, impairment of body
temperature regulation; angular
cheilosis, nail changes, tachycardia.
```
82. Iron deficiency anemia - treatment
Iron Salt
Dose
Equivalent dose
of elemental iron
Ferrous fumarate
Ferrous gluconate
Ferrous sulfate
Ferrous sulfate, dried
Ferrous feredetate
200mg
65mg
300 mg
35mg
300 mg
60mg
200mg
65mg
190mg /
27.5mg/5mL
5mL elixir
elixir
* Adverse ettects
- constipation, diarrhoea,
epigastric pain, faecal impaction, nausea
* Adverse effects are directly related to
levels of iron absorbed
* Adverse effects are common cause of non-
compliance - 10-20% of people discontinue
* Supplements better tolerated with food
but this decreased absorption by 40-66%
```
42
83. Angina management - new diagnosis
* Information and support
* Factors that can provoke angina,
managing cardiovascular risk, advice
about driving, flying and work
* Prescribe sublingual glyceryl
trinitrate (GTN) for rapid relief of
symptoms
* Advise on how to use GTN and when
to call for extra help
* Prescribe a beta-blocker or calcium
channel blocker
* Review 2-4 weeks
* Drug treatment for secondary
prevention - antiplatelet, ACE
inhibitor, statin, anti-hypertensive
84. Angina management: poor control
* Ensure that maximum licensed /
highest tolerated dose is being taken
* If patient is taking a beta-blocker
switch to or add CCB. Do not combine a
beta-clocker with a rate limiting CB as
severe bradycardia / heart failure can
Occur
* If a dihydropyridine CB can't be used
consider adding a nitrate, Nicorandil,
Ivabradine or Ranolazine
* If patient is taking a CCB - switch to or
add a beta-blocker
* If patient is on dual therapy refer to
cardiologist for assessment for
revascularisation
* Consider starting a 3rd anti-anginal drug whilst waiting
43
```
85. Analgesics in children
(Age <16 years)
* Either paracetamol or ibuprofen
alone as 1st line for mild - moderate
pain
* If no response:
* Check adherence, switch to other choice
* If response is still insufficient:
*Consider alternating (paracetamol every 6
hours, ibuprofen every 8 hours) but care
must be taken not to exceed maximum
24hr dose.
* Not recommended in primary care
* Paracetamol / ibuprofen doses at the
same time
* Naproxen
* Diclofenac
* Aspirin (risk of Reye's syndrome)
* Weak opioids
```
86. Body Mass Index
* Calculation: Weight / height squared
* Units: (kg/m2)
* Below 18.5: Underweight
* 18.5-24.9:
Healthy
* 25.0-29.9: Overweight
* 30.0-34.9:
Obesity I
* 35.0-39.9:
Obesity Il
* 40.0+:
Obesity Ill
* Consider waist circumference in
addition to BMI in patients with a BMI
<35 kg/m2
*
#(Males): 94cm+ (90cm+ if Asian) or
© (Females): 80cm+ = increased risk of
obesity related health problems
* #(Males): 102cm+ or ?(Females): 88cm+
= very high risk of obesity related health
problems
44
87. Angioedema
* Swelling of deep dermis,
subcutaneous, or submucosal tissue
* Often affects the face, genitalia,
hands and feet
* Most commonly occurs with urticaria
* Chronic (>6 weeks) or acute
* Mechanism the same as anaphylaxis
- histamine and/or bradykinin
*Causes: ANCI
* Allergic reaction
* Non-allergic drug reaction
* C1 esterase inhibitor (C1-INH) deficiency
(can be hereditary or acquired)
* Idiopathic
88. Angioedema - management
* Rapidly developing angio-oedema
without anaphylaxis - Rapid admission
for slow IV or IM chlorphenamine and
hydrocortisone
* Stable angio-oedema without
anaphylaxis
* Identify underlying cause
* Stop any ACE inhibitor
* Treatment may not be needed for mild
symptoms
* Non-sedating antihistamine
* For severe symptoms - short course of oral
corticosteroid
* Safety netting - in case of anaphylaxis
* Refer to dermatologist or immunologist
45
89. Ankylosing Spondylitis - diagnosis
* Suspect Ankylosing spondylitis where
there is chronic / recurrent low back
pain, fatigue and stiffness +:
* Aged <45
* Pain present >3 months
* Stiffness is inflammatory (not mechanical)
* Buttock pain, arthritis is asymmetric and
in lower limbs
* Enthesitis, costochondritis or epicondylitis
* Psoriasis or inflammatory bowel disease;
infective diarrhoea, STI (esp. chlamydia)
* Remember the 4As (associated with AS):
* Anterior uveitis
* Apical fibrosis
* Aortic regurgitation
* Achilles tendonitis
90. Ankylosing Spondylitis - tests
* Confirm inflammation with ESR/
CRP and FBC
* Refer (according to protocols) for
imaging of joints / spine
*X-rays - may only detect abnormalities i7
disease is well established
* MRI - can detect early changes in
sacroiliac oints
* Ultrasound - can confirm enthesitis
* Rheumatoid factor and anti-nuclear
antibodies
* HLA-B27 - secondary care
*IEA
- may be raised but not useful in
diagnosis
46
91. Migraine: Prophylactic Treatment
* Consider prophylaxis if having
significant impact on quality of life +
daily function
*E.g. occurring more than once a week or
prolonged and severe despite taking
optimal acute treatment
* At risk of medication overuse headache
* Standard analgesia and triptans
contraindicated / ineffective
* Uncommon type e.g. hemiplegic or
prolonged aura - consider referral or
seeking expert advice
92. Prescribing Migraine Prophylaxis
* Topiramate
* 25mg at night for 1 week and increase
weekly by 25mg to effective dose - max
200mg daily
* Usual dose 50 - 100 mg in divided doses
* Increased risk of fetal malformation and
impaired effectiveness of hormonal
contraceptives
* Propranolol
* Initially 80mg daily - 40mg twice a day or
modified release 80mg once daily
* Can be increased to 160mg or max 240mg
* Suitable if co-existing hypertension /
anxiety
* Not suitable if asthma, COPD, PVD or
uncontrolled heart failure
* Amitriptyline
* BF dose range for migraine prophylaxis
is 25-75mg at night
47
93. Medication Overuse Headache
* Existing headache disorder AND
* Headache on 15+ days a month AND
* Overuse of medication for 3+ months
* Overuse defined as use on
* 10+ days a month for ergots, triptans,
opioids or combination analgesics
* 15+ days a month for simple analgesics
* Management - withdrawal of all
overused acute drugs for at least 1 month
* If overuse involves opioids / tranquilizers,
discuss with neurology - may need
referral
* Review symptoms after 4-8 weeks
* Consider restarting overused medication
after 2 months with clear restrictions on
frequency of use
94. Cluster Headache
* Typically unilateral peri-orbital pain
associated with ipsilateral cranial
autonomic symptoms
* Conjunctival injection
* Lacrimation
* Eyelid oedema
* Attacks can last 15 - 180 minutes
* Timing of attacks often predicatable
*Consider neuroimaging for first bout
* Acute treatment = 100% oxygen
and/or MAX DOSE
subcutaneous/nasal triptan
* NOT paracetamol, NSAIDS, ergots,
opioids or oral triptans
* Prophylaxis = verapamil under
specialist supervision
48
95. When to suspect AF
* Irregular pulse with or without
* Breathlessness or palpitations
* Chest discomfort
* Syncope / dizziness
* Reduced exercise tolerance
* Malaise or polyuria
* Potential complications of AF - stroke,
TIA, heart failure
* Suspect paroxysmal AF if symptoms
last <48 hours and come and go
* Relevant PMH:
* Cardiac disease: valvular heart disease,
coronary artery disease, hypertension,
pericarditis, cardiomyopathy, other
arrhythmias, recent cardiothoracic
surgery
* Non-cardiac conditions: diabetes, thyroid
disease, cancer, alcohol misuse
96. Rate-control for new AF
* If onset within last 48 hours and
pulse >150 or systolic BP <90 /
patient unwell / haemodynamically
unstable - urgent admission for
cardioversion
* For other patients with new AF,
consider rate control
* Beta blocker OR rate-limiting
calcium-channel blocker
* Digoxin monotherapy ONLY for non-
paroxysmal AF with sedentary
lifestyle
* Follow up in 1 week
* AVOID:
* Beta-blockers if patient has asthma
* Calcium-channel blockers if patient
has heart failure
* Sotalol in primary care
49
97. Aphthous Ulcers
* Typically small, round or ovoid, oral
ulcers with circumscribed margins
present first in childhood or adolescence
and not associated with systemic disease
* Often recurrent, spontaneous resolution
with age
* Minor ulcers (less than 1cm diameter,
85% of cases) health spontaneously
within 14 days/
* Major ulcers 1-3cm diameter, deeply
indurated. Can last up to 6 weeks. 10% of
recurrent benign oral ulcers
* Herpetiform are very small grouped
lesions. 5% of cases, persist for up to 10
days. Very painful. May coalesce into
larger erosive plagues
98. Aphthous Ulcers - Management
* If an underlying causes is suspected
refer for specialist assessment with
urgency determined using judgement
* Advise to avoid trigger factors - oral
trauma, certain foods and drinks
* Appropriate dental treatment for
people with local trauma
* Treatment may not be needed
* Topical corticosteroid
* Topical anaesthetic
* Short course of systemic prednisolone
for severe, recurrent ulceration
* Vitamin B12 supplement
50
99. Appendicitis
* Classic symptoms
* Abdominal pain - peri umbilical or epigastric, worsens in the first 24 hours, migrates to the right iliac fossa; worsened by movement.
* Anorexia - almost always present
* Nausea
* Constipation
* Vomiting
* Physical examination
* Tenderness on percussion, guarding, rebound tenderness
* Facial flushing, dry tongue, halitosis, low-grade fever, tachycardia
* Consider testing for peritoneal signs:
* Roving's sign - increased pain in the right lower quadrant on palpation of the left lower quadrant
* Psoas sign
- passive extension of the right thigh with the person in the left lateral position elicits pain in the right lower quadrant
* Obturator sign
passive internal rotation of
the flexed right thigh elicits pain in the right lower quadrant
100. Appendicitis - atypical presentations
* Classic presentation of appendicitis
appears in only about 50% of people
* Older age - pain may be minimal and
fever absent. May present with
confusion / shock.
* Young age - infants and young
children may show only vague
abdominal pain and anorexia
* Pregnancy - in 3rd trimester right
upper quadrant or right flank pain
* Atypical anatomical position of the
appendix
51
```
101. Attention Deficit Hyperactivity
Disorder
* Persistent pattern of inattention and /
or hyperactivity-impulsivity which
interferes with functioning or
development
* Usually starts <12 years
* Occur in 2 or more settings
* Present for at least 6 months
* Interfere with / reduce quality of
functioning
* Not better understood by another
mental disorder
* Inattention - wandering off task
* Hyperactivity - excessive motor activity
when inappropriate
* Impulsivity - hasty actions without
forethought
```
102. ADHD: management
*Before formal diagnosis by a specialist:
* Assess social and educational impact
* Watchful wait for up to 10 weeks, encourage self-help and simple behaviour management
* Refer to a CAMS professional, specialist
pediatrician or child psychiatrist using clinical judgement
* After formal diagnosis management
should be coordinated by specialists
* Effectiveness and adverse effects of drug treatments may be monitored in primary care alongside other observations such as height, weight and BP / HR.
* Watch out for sustained resting tachycardia
* Non drug treatments include CBT, group support
52
103. Autism in children: risk factors
* Born before 35 weeks gestation
* With following conditions:
* Birth defects associated with central nervous system malformation (e.g. cerebral palsy)
* Intellectual disability
* Neonatal or epileptic encephalopathy
* Chromosomal disorders (e.g. Downs)
* Muscular dystrophy
* Neurofibromatosis
* Tuberous sclerosis
* Sibling with ASD - 10-20% risk of siblings being affected
* Parent with schizophrenia like psychosis or an effective disorder
* Mother who received sodium valproate
in pregnancy
104. Autism in children: history
* Language delay or regression
* Reduced or negative response to others
» Reduced or absent interaction
* Reduced eye contact, pointing and other gestures
* Reduced or absent imagination or variety of pretend play
* Unusual or restricted interests /
behaviour
* Over or under reaction to sensory stimuli
* Caution:
* With development delay assess according to developmental age, not chronological age
* Deprived background - features of ASD vS caused by maltreatment / deprivation
53
105. Baker's Cyst
* Also known as a popliteal cyst
* Primary - idiopathic, not associated with
disease, found mainly in children
* Secondary - associated with underlying
disease, main found in adults
* Causes: in children - trauma, juvenile
idiopathic arthritis, osteochondritis
dissecans
* Causes: in adults - osteoarthritis,
meniscal tears, anterior cruciate
ligament damage
* Rarer causes: septic arthritis,
pigmented villonodular synovitis,
psoriatic arthritis, gout, tuberculosis,
lymphoma, connective tissue diseases
106. Baker's Cyst: diagnosis
* Swelling - asymptomatic swelling behind the knee may be the only feature.
* Pain and tightness - non specific
posterior knee pain, may be aggravated
by walking
* Knee joint - range of movement may be restricted
* Red flags:
* Baker's cysts are usually chronic but can present with acute symptoms with dissection /rupture
* Sudden 'pop' with 1 pain, redness
* Sudden increase or change in lump may indicate serious alternative cause
* Examination - round, smooth, fluctuant
swelling in medial popliteal fossa
54
107. Cataracts
* Most commonly caused by ageing
* May be secondary to another eye disease
* Traumatic cataract after injury / exposure
* Systemic disease - diabetes, myotonic
dystrophy, neurofibromatosis, atopic
dermatitis
* Congenital / developmental in children
* Risk factors
* Family history
* Corticosteroid treatment
* Tobacco smoking
* Cumulative exposure to UVB light
108. Cataracts: diagnosis
In adults:
* Gradual painless reduction in visual acuity
* With an ophthalmoscope: opacity can be seen in the lens, red reflex is reduced
In children:
* All babies in UK screened at birth and 6-8 weeks
* Poor vision, white / grey pupil, involuntary eye movements, squint
* With an ophthalmoscope: opacity can be seen in the lens, red reflex is reduced
55
109. Meniere's Disease: Diagnosis
* Refer to ENT to confirm
* Definite diagnosis requires all of the
following:
* 2+ spontaneous episodes of vertigo
lasting 20mins - 12 hours
* Fluctuating hearing, tinnitus, and/or
feeling of aural fullness
* Sensorineural, low-to-mid
frequency hearing loss confirmed
by audiometry
* No more likely vestibular diagnosis
* Probable diagnosis = all of the above
except audiometry
110. Meniere's Treatment
* Severe attack
* Consider admission for IV labyrinthine
sedatives and fluids
* Consider administration of buccal
prochlorperazine OR deep IM
prochlorperazine / cyclizine for rapid relief
*Everyone else
* Consider short course prochlorperazine,
OR an antihistamine
* Suitable antihistamines = cinnarizine,
cyclizine, or promethazine teoclate
* Check diagnosis if no better after 5-7 days
56
111. Meniere's Prophylaxis
* Consider trial of betahistine to
reduce frequency / severity of
attacks
* Initially 16mg TDS with food
* Maintenance dose 24 - 48mg daily
* Contraindicated if
phaeochromocytoma
* Caution if asthma or history of
peptic ulcer
* Refer to ENT if recurrent attacks
despite compliant use of
betahistine
112. Benign paroxysmal positional vertigo
* Discuss option of watchful waiting - most
patients recover over several weeks
* Advise on safety issues
* Not to drive while dizzy or if likely to have an
attack while driving
* Most patients with BPPV can continue to drive
* They should inform their employer if vertigo
might cause a risk in the workplace
* Discuss risks of falling at home
* If treatment preferred, offer Epley
manoeuvre.
* Repeat after 1 week if symptoms not settled
* Suggest Brandt-Daroff exercises at home as
an alternative
* Drug treatment not usually helpful for BPPV
