Case management Flashcards
(126 cards)
1
Q
Colleague has made a mistake - name the 5 steps you’d take?
A
1) Patient safety - any clinical need to review patient now
2) Encourage them (and me to document what happened)
3) Inform patient, apologies and share next steps
4) Report (locally or wider) to practice manager, line manager, SEA form
5) Arrange chance to reflect and debrief and learn, individual or team
Make sure to support colleague in all of this!
2
Q
With regards to HRT - when oestrogen only/ continuous and when sequential?
A
No uterus: Ostrogen only (if subtotal or done for severe endometriosis will still need progesterone)
Perimenopause: Sequential combined
Menopause (>12m since last period) = Continuous
3
Q
Name 5 contraindications to HRT therapy?
A
Breast cancer hx
Endometrial ca/ hyperplasia
Arterial/ venous or thromboembolic disorder
Uncontrolled HTN
Severe liver disease
Undiagnosed bleeding
Note migranes not CI but would go with transdermal application for reducing VTE risk
4
Q
Age cut off’s - when is contraception not needed with HRT?
A
Stop over 55
If > 50yrs - When ammenorrhoea for 1 year
If <50yrs - When ammenorrhoea for 2 years
5
Q
What are contraception and HRT combined options?
A
IUS + oestrogen only
Sequential combined HRT + POP or implant
Combined continous if ammenorrheic with progesterone only contraception
NOT depot over age 40 as osteoporosis risk
6
Q
A 48 year old attends 2 months after starting continuous combined HRT with irregular bleeding - mx options?
A
Assess for underlying risks of endometrial ca - if absent:
If started in first 3-6months, likely due to HRT, can trial:
- Stopping for 4 weeks to check if it is due to HRT
- Going back to sequential for 12m (likely bleeding with continuous due to breakthrough bleed)
7
Q
Troubleshooting heavy bleeding on sequential HRT - what are the options?
A
Increase dose or duration of progesterone
(usual is 14d of progesterone, can go anywhere from 10d (note increase unopposed ostrogen) to 21 days) - Need to combine different packs
8
Q
What is the safest way to give HRT/ comes with least side effects?
A
Safest: Oestrogen patch + micronised progesterone tablet
Least SE progesterone: Medroxyprogesterone
(not levonogestrel or norethisterone as these come from testosterone so higher SE)
9
Q
Name 3 common progesterone side effects and how to manage them?
A
Acne
Mood/ PMS/ depression
- Manage by reducing HRT progesterone dose
Fluid, bloating, weight, breast tender, headaches can be oestrogen or progesterone
10
Q
Hot flushes with HRT - name drug managment options? (4)
A
HRT - If no contraindications
SSRI (Citalopram best, note paroxitine/ fluoxetine CI with tamoxifen)
Clonidine (only licenced option)
Pregabalin/ gabapentin - also not licenced
11
Q
Herbal suppliments in HRT. What are the key breast cancer considerations?
A
Tamoxifen - Do not take black cohosh or st johns wort
Hx breast Ca - Do not use any soy or red clover products
“Lots of herbal products can increase risk for those who have had breast cancer, so if there’s a specific one you want me to check let me know and I can look it up - don’t start without discussing with us”
12
Q
Menopause symptoms, name 5 non pharma/ suppliment options?
A
CBT
Accupuncture
Mindfullness
Exercise/ weight loss
Avoid alcohol, caffeine, spicy foods and smoking
13
Q
Topical oestrogen for urogential atrophy symptoms - key considerations?
A
Generally safe
However if any breast etc cancer - then specialist advice only - not to be prescribed in primary care
14
Q
FHx of breast cancer and HRT consideration?
A
Generally safe as long as not higher risk
High risk all reasons for secondary care referrals (so FHx <40, bilateral, orthodox Jew, BRCA gene, multiple relatives, male relative etc)
15
Q
Unscheduled HRT bleed - general management principles?
A
If low risk endometrial ca and within 6 months, or 3 months of dose change
Management options
- Switch back to sequential
- Offer IUS
- Offer oral if current transdermal (and no VTE risks)
- Increase progesterone dose or duration
If endometrial RF’s, or over the 3/6 month cut offs then urgent TVUS within 6 weeks to look at endometrial thickness
16
Q
New hyperthyroidism - how to manage?
A
Screen thyrotoic crisis (fever, hypertension, delirum, jaundice, heart failure)
Refer for carbimazole
Assess and examine
Start propanolol for symptoms
- Consider CRP/ ESr if thyroiditis (transient) is suspected
17
Q
3 circumstances where subclinical hyperthroid should be treated?
A
If TSH over 10
If symptomatic
If pregnant or planning pregnancy need to refer to consider tx
18
Q
Gout
a) Acute tx
c) Long term mx
A
a) NSAID, colchicine or steroid (5/7 or 1-2 days after attack has resolved)
b) Start 4 weeks after acute episode
Allopurinol or febuxostat - use colchicine when starting for 6months, lifelong need to counsel
Also discuss general healthy diet (nil specific), alcohol, weight etc
19
Q
Assessment of bradycardia - what to consider?
A
Urgent assessment if: Shock, MI, syncope etc
Drugs
Physiological
Signs or symptoms heart failure
Arrythmia’s (heart block)
Electorlyte or thyroid etc causes
20
Q
Management of hyperhidrosis
A
Trigger identification and management
www.sweathelp.org
Loose clothes, white or black colours
1st line: 20% aluminium chloride hexahydrate available OTC in roll on or spray antiperspirant (safe long term)
- Referral to derm if this doesn’t help - a few medicines they can try, or Iontophoresis/ botox and surgery all options
21
Q
What risk factors in ChadsVAC are listed?
A
Congestive heart failure
Hypertension
Age over 75 = 2pts
Diabetes
Stroke or TIA
Vascular disease
Age 65-74 = 1pt
Sex = female 1pt
22
Q
When should rate control not be offered for new AF?
A
New onset within 48hr - refer to hospital now
Heart failure primarily cause by AF
Reversible cause thought
23
Q
New AF requiring DOAC - already on clopidogrel - what considerations?
A
If PCI/ ACS or Stroke within last 12 months occasionally need DOAC and clopidogrel
- Otherwise DOAC along
(Always reference consultant connect)
24
Q
How is coeliac disease diagnosed?
A
Bloods igA TTG - Indicative but not diagnostic (need gluten in diet for at least 6 weeks)
Then refer gastro and diagnosed with small bowel biopsy
25
What website is offered to coeliacs for support on diet management?
www.coeliac.org.uk
Has a gluten free checklist for food groups and information on labelling
26
Patient presents with memory concerns - list 5 possible differentials?
Dementia
Depression/ anxiety
Stress or sleep disorders
Thyroid or B12 deficiency
Head injury/ stroke
Substance misuse (alcohol especially)
27
Which organisation is responsible for managing gun licences?
Police
28
Managing school refusal in a child? - Key points/ what agencies
Explore ICE, impact, reasons - manage this
- Ensure support for parents
Social services if needed
School pastoral team
29
Carer for patient with LD and lacks capacity wants to make a decision against your advice? Management?
Explore ICE etc
If pt lacks capacity and all on same page - ok
If disagreement - Need to think about best interests meeting (MCA) - i.e. for flu jab etc
30
Patient demanding medications (i.e. out of prison, says on CD's, no record) - how to manage?
Offer to contact prison doctors to clarify script
Acute withdrawal and concern about safety - A+E
Threatening withdrawal - Offer drug services like turning point, speak to c
Negotiate plan but don't prescribe CD's etc without evidence, can offer to see to discuss sleep or pain etc
31
Managing a drunk colleage/ colleague who has made a mistake, what key considerations?
1) Patient safety
2) Check in with colleague, are they ok, do they need support?
3) If serious or concerns, do you need to talk to their line manager or occupational health etc?
32
Patient discloses criminal activity - when do you have to disclose?
Risk to selves or risk to others (active)
- I.e. victim and other victims could be hurt (prostitue, slavery, children in home)
- Serious communicable disease
- Not fit to drive and won't tell DVLA
If historical risk and severe (i.e. previously abused children) is serious enough
Note - always tell them that you are going to break
33
Endometriosis - management options? (4)
Ix - USS, swabs etc
Refer to gyane - if significant impact on QoL
Non hormonal - 3 months paracetamol +/- mefanamic acid/ other NSAID
- Can add neuropathic
Hormonal - IUS/ COCP or progesterones (pill, depo, implant)
- Hormonal may improve symptoms and do not reduce fertility
34
Fibroids - Management (3)
If <3cm, no pressure symptoms or heavy bleeding, fertility issues - in primary care
Treat as mennorhagia (IUS, cocp, cyclical progesterone) OR non-hormone (NSAIDS, TXA)
Specialist - GnRH, surgery
(Don't need routine follow up or treatment if asymptomatic)
35
What should women be advised if they have fibroids and want to start HRT?
HRT may make fibroids bigger, safetynet on symptoms
If already symptomatic consider specialsit advice before starting
36
A patient with fibroids presents with a concern RE infertility - what should be done RE the fibroid?
This is one of the referral criteria to discuss fibroids with gynaecology
37
Vasectomy request - counselling?
Effective
Considered permenant (not easily reversed and not routine on NHS)
Risks: Haematoma, chronic pain (10%), can fail (rare)
- Need contraception for 3 months before check semen
Must always assess risk of regret (<30, recent relationship drama etc)
38
Management of acute exacerbation COPD?
Breathlessness - 30mg oral prednisolone for 5/7
Sputum/ prev infective/ high risk - Add ABx
- Amox 5/7 500mg TDS
- Doxy 5/7 100mg BD
- Clari 5/7 500mg BD
39
Managing exacerbation of COPD where treatment failure or higher risk?
Sputum culture
Alternative first choice Abx (Amox/ clari/ doxy) or if high risk consider TDS co-amox for 5/7
Safetynet and arrange follow up once stable (6 weeks) to review therapy
40
Management of (at home) mild/ moderate asthma exacerbation?
Pregnisolone 40mg daily for 5/7
Can also consider quadrupling ICS or ICS/ LABA
Safetynet and review within 2 working days!
41
Management considerations for recurrent UTI's?
Cancer ref indications (NVH, dysuria, raised WCC over 60)
- Non urgent referral for anyone with recurrent infections over 60
MSU/ STI screen
DDx: Urogential atrophy, STI's
42
Post coital UTI's recurrent - how to manage?
Encourage early voiding of bladder
- Always wipe front to back
- Keep well hydrated
Can consider Abx prophylaxis with single dose trimethorpim or nitrofurantoin before sex
43
Male with urethritis (dysuria and discharge) refusing STI clinic and wanting primary care management or needed urgently - how to treat?
Chlamydia
Doxycycline 100mg BD for 7/7
Azithromycin single dose 1g then 500mg OD for 2 days
(Advise no sex for 14 day)
44
Managing balanitis in children?
Hygeine - wash daily, don't retract foreskin if still fixed
Start topical hydrocortisone and antifungal for 14 days
If severe/ recurrent - do swab, consider other tx (may need bacterial etc)
- If persistent or recurrent refer to paeds urology in preimary care
45
Managing balanitis in adults?
Wash daily, keep foreskin retracted until glans dry then replace
Topical steroid/ antifungal for 14 days
If severe/ recurrent consider STI/ diabetes/ HIV testing and also swab
Refer if persistent and recurrent after this
46
Management primary bedwetting?
Fluid intake/ night avoid fluid caffeine etc/ toilet before sleep/ positive reward behaviours
Short term control needed trip/ sleepover - desmopresesion
OVER 5's
Otherwise 1st line enuresis alarm
(if <2/wk watch and wait also option)
2nd; Desmopressin sublingual before bed
(3 months trial then stop for 1 week to see response)
- Seek advice if behavioural, attentional, emotional disorders
47
How to manage secondary bedwetting?
Assess underlying cause
- UTI, constipation, T1DM
Assess stressesors etc
Refer secondary care
48
Insomnia management?
Assess underlying cause (mood, stress)
1st sleep hygeine
Short term <3m - Ok to offer short term 3-7days sleeping to reset cycle
>3m - CBTi (Sleepio app) +/- adjunt of short term 3-7days zopiclone
49
Management of ACS when in primary care?
Any suspected ACS or pain in last 12 hours - hospital
Whilst ambulance wait:
- GTN spray
- Morphine (5mg)
- Aspirin (300mg)
50
TOP request management? (5)
Explore feelings
Gestation of pregnancy, partner (do they know)? >24wks needs more counselling
Any coercision? Do you feel safe?
Refer to local abortion clinic, explain medical (2 tablets - upto 10wks) vs. surgical
Discuss contraception going forward
51
Chronic cough and differential diagnosis - options for Mx?
Asthma - ?trial inhaled ICS
Smokers cough
GORD - as GORD
Post-nasal drip - antihistamine/ decongestant
COPD / sleep apnea / heart failure / lung cancer/ ACEI induced
52
You are considering starting apixaban - what ORBIT screening questions may you want to ask?
Low HB (<130M, <120F)
Previous bleeds
Over 74
eGFR <60
Antiplatlets
53
Starting a new beta blocker for AF - when to review?
What is target HR when starting BB?
Review in 1 week after new beta blocker, assess heart rate
HR target - <80 resting is ideal
54
Who should have the genetic test for haemochromotosis?
New diagnosis haemochromotosis
Relatives (1st degree - parents, children, siblings) and partners of individuals with haemochromotosis or carriers
For children under 18 - Let them make their own decision (unless treatment would start in childhood - not the case for haemochromotosis)
55
New atrial fibrillation - counsel points?
DG: New onset/ signs heart failure etc / Chadsvasc and ORBIT / IMPACT and home situation
CM: Explain diagnosis (funny rhythm - dizzyness/ SOB + CLOTS)
Management (apixaban) +/- bisoprolol/ referral/ echo/ BNP
56
Recurrent UTI's in children - criteria and next steps
Criteria:
- 2 or more if any upper UTI
- 3 or more lower UTI
Treat current UTI then refer for assessment (USS and consider prophylaxis)
Under 6m - USS during acute infection
Over 6m - USS within 6 weeks
57
ABx choices for UTI in children?
Under 3m - admission
Lower- Trimeth/ nitro
Upper - Cefalex
If no improvement within 48 hours then consider USS and
2nd line - amox/ cefalexin
All should improve within 48hours
58
Which children should be referred for USS of kidneys with regard to UTI? (3 groups)
All children with UTI under 6months
All recurrent (3 lower/ 2 upper)
All with atypical (sepsis, doesn't respond in 48hrs, non-e.coli organisms)
59
Allergic rhinitis - (mx)
F- If struggling with primary care management can refer to allergy clinic for testing (they can give immunotherapy)
Ca- Shower or wash hair after exposure to allergen (i.e. pollen) exposure, nasal barriers like N95 masks
M- 1) Intranasal (mins to work)/ oral antihistamine 2) Instranasal steroids (takes days to work)
3) Combination steroid/ antihistamine
- Short term decongestant
- If severely affecting QoL - 5/7 low dose oral steroids
- LTRA if asthma also
S-
60
Gout
a) What urate to confirm diagnosis? When do you do this blood test?
b) What causes? What lifestyle things to cut out?
Do urate 4-6 weeks after flare up
- Over 360 needs treatment
b) Cause: Largely genetics + comorbid (CKD, HTN, diabetes etc)
Alcohol, sugar drinks, meat and seafood - no specific diet recommended but cut down on those things
61
Follow up management after episode of angioedema?
Assess obvious triggers
- Urgent referral/ discussion with allergy team
With anaphylaxis/ airway:
- Prescribe epiPen
Without airway/ anaphylaxis:
- Prescribe 6 weeks oral antihistamine
- EpiPen only on specialist advice
62
Management of urge incontience (3)
Rule out UTI/ red flags/ prolapse etc
1- 6 weeks bladder training, reduce evening fluids. alcohol and caffeine
2- Oxybutynin/ tolteridone (anticholinergic) OR mirabegron (less SE in elderly so choose if frail)
3- Refer (botox, urogynae input)
63
Management of stress incontience?
1- Physio guided pelvic floor muscle training for 3 months
2- Duloxetine (SE's nausea and fatigue)
3- Refer for surgery
64
Patient who has concerns about care for a relative coming out of hospital - what options to support?
Check if care needs assessment has been done by the social worker/ hospital discharge team
- Reablement package (temp support)
- Care package
Carers can speak to social services to request carers assessment
Ideal to support patient in managing with the hospital - ageUK also another good resource
65
Palliative care in Islam considerations? (5)
Normal key bits - advance planning/ DNACPR/ SOI so quick 24hr burial
Managing meds - morphine/ diazepam may be seen as intoxicants - discuss with Imam but should be permitted
Same gender carers where possible,
66
Managing a patient who needs onward care but has a moving address?
Focussed care practitioners
- Register at practice address
- FCW can contact pt by mobile phone
67
What to offer to make coil insertion less painful?
Most people will experience some short and temporary discomfort
Paracetamol/ ibuprofen an hour before
Can offer local anaesthetic or in some cases sedation if very concerned
68
Name 5 screening elements within pregnancy?
ID screening at booking (HIV, syphillis, hepatitis etc)
- Sickle cell and thalassemia screening for mum
Dating scan (11-14wks) - note this can be part of downs screen combined with blood test
(Other quadruple blood test 14-20wks)
Anomaly scan (18wk) - 11 conditions including some fatal
69
Management of ED? (3)
Conservative (weight loss, exercise, alcohol/ smoking, cycling)
Medical - Sildenafil if no major CVS risk
(trial each different type 4-8x before saying don't work, might need to switch between)
Ix- Causes (diabetes, CVD etc) - bloods and QRISK
70
What are the rules around gender and bridging endocrine prescriptions?
Children - send urgent advice
Adults - GP can do bridging prescription if on wait list and pt is already buying illegally, at high risk of suicide and with specialist advice
71
Managing new genital herpes in GP? (5)
Refer to GUM for full STI screen
If refusing:
- Viral swabs
- Aciclovir 5x/daily for 5 days
- Paracetamol/ ibuprofen for pain
- Vaseline for topical relief
(Advise could have been aquired a long time ago and new episdoe doesn't indicate recent infection)
Avoid sex whilst lesions present
72
Managing new gynaocomastia - key elements?
Rule out red flags (focal lump, nipple discharge, skin changes, weight loss, testicular lumps, new double vision)
Bloods (hormones, prolactin, thyroid, liver, kidneys etc)
DDx: Overweight, hormone changes, medications (incl alcohol, cannadbis)
73
New intermenstrual or postcoital bleeding - DDX and next steps?
DDx: Hormone changes (contraception or life stages), ectropion or polyp, STI's, fibroids, malignancy
Next steps: Examination
Speculum to view cervix
Swabs for STI's
Pregnancy test
Bloods/ USS occasionally helpful
74
How do you manage Parvovirus/ slapped cheek syndrome?
Children - self limiting/ paracetamol
- Can go to school
Need to inform at risk people (pregnant, immunocomp) for urgent discussion with virology lab
75
Management options for premature ejactulation?
Conservative: Thick condoms, condoms with anaestheic, masturbation before sex, take breakes
Sexual therapy - squeeze technique
Meds- SSRI's off lable (Dapoxetine - as and when)
Assess for ED and other pyschological factors
76
Managing needle stick injuries in the community?
Within 72 hours - refer to ED for PEP etc
After 72 hours - Discuss with GUM/ ID
77
Recurrent UTI over age 60 - considerations?
Any urgent 2ww (dysuria + raised WCC over age 60)
Non urgent referral for suspected cancer?
Topical estorgen if vaginal atrophy (no breast cancer check)
78
HOCM - pt presents with FHx - how to advise?
Autosomal dominant so if sibling or parent affect have 50% chance
ECG, Echo + general cardiac risk assessment (BP, lipids, diet etc)
Refer to cardiology if unsure - note genetic testing not usually done
79
Trigeminal neuralgia - management?
Red flags - tumours, sensory loss, new under 40 etc > refer urgently
1st - Carbamazepine QDS - titrate up dose - review again in a week
Can manage in GP unless red flags, severe
80
Vaginismus - mx?
UTI/ STI etc screens - consider alternative
Relaxation techniques
Vaginal trainers
Sexual counselling (relate is the organisation)
Treat physical (topical oestrogen if atrophy etc)
81
Influenza - when to give oral antivirals (and what to give)?
Oral oseltamvir
- If rapid Covid/ influenza unavailable then treat if all of:
1) influenza is circulating/ close contact
2) At risk (over 65, frail, pregnancy, <6m)
3) Can be started within 48hrs of symptoms
82
Acitinic/ Solar Keratosis - what features would prompt 2ww for SCC? (4)
New raised lesion
Recent growth
Bleeding/ ulceration
New surround inflammation
83
Bell's palsy - how to distinguish from stroke and mx? (3)
Bells forehead is affected (would be spared in stroke)
If within 72hours - prednisolone for 10 days
- Lubricating eye drops
Refer if concern (i.e. UMN signs, gradual onset symptoms, pain, hearing loss, infection)
84
How does De-Quervains tenosynovitis present? How to manage? (3)
Thumb tendons - Painful thumb movements, gripping and maybe snapping feeling)
1) NSAIDS, ice, gels
2) Modify activity
3) Physio - gradually increase movements and then strengthen
- Consider thumb splints in initial phase to settle down
(usually takes a few weeks to settle)
85
Presenting next day after first siezure - mx?
Urgent neuro referral (seen within 2 weeks)
First aid for further seizures (on side, move things away) - video episode
> STOP DRIVING 12 months after unprovoked seizure
(meds usually started after 2nd but sometimes after 1st)
86
Glandular fever - how to manage? (3)
Sore throat syx + ?rash/ ?enlarged spleen
(Don't bed rest or exclude from school - deconditioning)
- Avoid contact sports for 4 weeks
> Don't give ABX
Usually settles within 3-4 weeks
- Could do bloods - 2nd week illness (FBC and monospot)
87
New hyperthyroid - symptomatic - mx (3)
Whilst awaiting specialist assessment
- Prescribe BB
- Discuss consultant connect RE carbimazole
TSH receptor antibodies (Graves)
88
Management of new hepatitis A?
Hospital if unwell, dehydrated etc
Paracetmol for pain
Metoclopramide or cyclizine for nausea
Chlorphenamine for itch
Notify local health protection unit
(Avoid alcohol, school, nursery etc for at least 7 days)
89
Mx of whopping cough? (3)
Suspect if cough >14 days and inspiratory whoop
Notify public health
- Off school or nursery until 48hrs after ABx
- ABx if within 21 days - Clarithromycin
90
AMD - (1) common features and (2) management?
Blurry vision/ straight lines look wavy/ loss central vision
Urgent 1 week opthalmologist
- Especially if rapid changes think WetAMD
91
Tonsilectomy referral guidance (3)
No longer routine, risks outweight benefits
Seven episdodes in 1 year
5/yr for 2 years
3/yr for 3 years
92
TIA - GP management?
If last 7 days
- Refer to be seen within 24 hours
- Aspirin 300mg
(unless already on antiplatlet, then don't change)
If over 7 days
- Refer to be seen within 7 days
93
Patient on TC who suspected ACS - doesn't want to leave disabled son before - practical considerations? (4)
Is aspirin at home - take 300mg
- Communicate risk
- Support at home (family, friends - rapid response social work team)
- Arrange ambulance myself, don't let patient drive
94
Lipids - management steps (4)
Diet and lifestyle
1) Atorvastatin (20mg primary, 80mg secondary)
2) Ezetimibe 10mg OD
3) Lipid clinic (bempedoic acid or new s/c injections like Inclisiran (Leqvio)
95
What are the lipid targets for primary/ secondary CVD prevention?
Starting statin - want to see 40% reduction in non-HDL cholesterol
Aim LDL < 1.8mmol/ L
Aim non-HDL < 2.5mmol/ L
96
HRT - breakthrough bleeding after being on for over 6 months - mx?
If low risk can trial stopping HRT for 4 weeks to see if resolves
+ urgent USS scan for uterine lining
If higher risk woman needs 2ww for ix of uterine cancer first
97
Lewy body dementia - auditory and visual hallucinations - mx options?
Discuss old age pyschiatry donepazil or antipyschotics
Validation (talk to them about the hallucination to calm them down)
SAFETY - Need for carer input
- Use GPA care coorinator
- Need eyes and hearing test as well - can contribute
98
BP targets in pregnancy?
Labetalol - start over 140/90
Target 135/85
99
New HF diagnosis - drug management?
HEART FAILURE GROUP REHAB
- Add furosemide if symptomatic
- Consider aspirin if CHD/ atherosclerosis disease
- Consider statin
1st: Add ACEI and BB (start with ACEI if diabetes/ symptomatic HF)
2nd: Add spironolactone (if K<4.5)
---REFER SPECIALIST---
3rd: Ivabradine/ hydralazine/ digoxin/ valsartan
100
In which group of HF patients does drug management change - how?
Preserved ejection fraction
- No ACEI or BB
(But still furosemide/ aspirin/ statin
+ group exercise etc)
101
New LUTS in men - red flags (3) and next steps (3)
Red flag - Weight loss, back pain, haemturia (plus closed dysuria, erectile dysfunction)
Next steps
- DRE/ PSA/ urine dip
102
How do you manage new suspected peripheral vertigo?
BPPV - Epley manourve
Vestibular neuronitis/ labrynthitis - Gets better after days and then eases with time
Menieres - episodic, + tinnitus
All - Buccal stematil max 1 week
Review again in a week, consider referral need
103
Mx otitis media (3)
Consider admitting if under 6 months with fever
Advise usually 3 days, up to 1 week
- Paracetamol/ ibuprofen/ phenazone + lidocaine ear drops (OTIGO)
- Continue normal activites, avoid swimming if perf
ABx for - systemically unwell, otorrhoea or under 2 with bilateral infection
104
TB - when to suspect and how to manage?
Weight loss, fever, night sweats, anorexia, malaise + RF's
Initial:
CXR + sputum sample
- Discuss with ID if syx are highly suggestive
105
James key rule of thumb in managing eye conditions?
If acute vision change OR any pain will need urgent same day assessment
106
Rickets - presentation (3) and management (3)?
Present - Abnormal ALP, leg bowing, abnormal pains or x-ray findings
Mx - Paeds advice and start vitD/ calcium
107
UK - teenager vaccinations schedule?
12 to 13 years- HPV vaccine
14 years
- Td/IPV vaccine (3-in-1 teenage booster)
- MenACWY vaccine
108
Gambling disorder - mx options?
CBT
Gambler’s Anonymous (12 step programme)
Signpost to financial support
Manage co-morbit anxiety etc
109
Hoarding disorder - mx?
Subset OCD
- FCW and connecting to community support
- CBT and hoarding/ OCD specific
- Sertraline (up to 200mg - higher doses)
110
Management of Ehlers-Danlos (4)
Pacing etc
- Physio/ OT
-Pain mx (simple, pyschological)
- Nutrition/ excercise
111
Low libido not improving with HRT - mx options? (3)
Trial increased oestrogen (up to max) - convert to transdermal
Stop contributing meds (SSRI's) etc
Consider testosterone (up to 5mg) daily, higher can give irreversible effects - get specialist input
112
Post-partum thyroiditis - progression and mx?
Hyperthyroid for 3m > hypothyroid 6m - most recover in 12m but some remain hypothyroid
Do TPO antibodies (and TSH to exclude graves)
All endocrine referrals - urgent - consider BB treatment if no CI
113
Managing NVH in young male, no UTI - differentials and mx?
Differential - trauma, exercise, UTI/ STI, nephritis, PKD, cancers, stones, BPH
Next steps - MSU, STI screen, bloods (renal, PSA), blood pressure and renal USS
- Next steps refer
2ww if over 45 and NVH without UTI
114
Thrombocytopenia - differentials (7)
Haem malignancies
Chemo
ITP (diagnosis exclusion)
Drug induced
Infectious (HIV, any viral/bac/ fungal)
Autoimmune (i.e. SLE)
Alcohol
Chronic liver disease
115
New thrombocytopenia - next steps?
Work through differentials:
Hx- Alcohol, infections
Syx: Bleeding/ bruising/weight loss/ fever/ night sweats
Ex: Liver/ bleeding etc
Ix: FBC/ clotting/ liver/ renal/ HIV and infections screen
116
Thrombocytosis differentials (5)
Cancers - LEGO-C
CML/ myelodisplastic sydromes
Infection
Autoimmune (RA/ SLE / coeliac/ GCA etc)
COPD
IBD
Iron deficiency
117
New thrombocytosis- next steps? (3)
Hx: Screen for LEGO-C cancers, bone pain + IBD/ COPD/ RA etc syx
Examine as above
Full set bloods
118
Platlet count cut offs for thrombocytosis referral?
Over 1000 - urgent
600-1000 - urgent if over 60, any bleeding or neuro or recent arterial or venous thrombous
Over 450 for more than 3 months - routine referral
119
Platlet count cut offs for thrombocytopenia referral?
<50 - Urgent referral
50-100 - Urgent if any bleeding, pancytopenia, splenomegaly or lympadenopathy, pregnancy or upcoming surgery
Otherwise routine if <100 persistently and unexplained for 6 weeks
120
Management of 1st degree relative of index sudden cardiac death case?
Start echo and ECG
- Manage other CVD risks
Refer onwards if still concern after this
121
Mx of incontience in MS - options?
Common problem (50% stress and 70% urge - often co-exist)
Stress - pelvic floor
Urge - bladder training, oxybutanin or mirabegron
Consider ref for intermittent self-catheter, botox etc
122
How do you manage suspected Ovarian Ca?
Pelvic/ abdo mass or ascites - 2ww
Otherwise:
- Urgent CA-125 and abdo/pelvic USS
123
Suspected myeloma - initial mx?
Bloods - FBC, calcum, ESR - urgent
If syx of or then leukopenia or raised calcium:
- Serum electrophoresis, light chains
+ Urine bence jones protein
Then haematology 2ww
124
AKI - Indications for admission? (5)
AKI stage 3
Hyperkalaemia
No known cause
Urinary obstruction
Can't take fluids
Or systemic unwell, sepsis etc
125
Management AKI2? Not needing admission?
Hydration advice
- Stop nephrotoxics
- Rpt renal function in 1 week
Safetynet strongly
126
Management of optic neuritis in suspected MS?
Same day opthalmology
