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Community health Flashcards

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1
Q

What is the primary cause of polycythaemia?

A

Polycythaemia vera - JAK2 gene mutation

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2
Q

What are the secondary causes of polycythaemia?

A

Obstructive sleep apnoea
COPD
Chronic heart disease
EPO/anabolic steroids

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3
Q

What can cause apparent polycythaemia?

A

Diuretics
Alcohol
Obesity

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4
Q

What is polycythaemia?

A

High concentration of red blood cells
Makes blood thicker and less able to travel through blood vessels

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5
Q

What are the causes of macrocytosis?

A

B12 folate deficiency
Alcohol
Drugs
Haematological disorders
Liver disorder
Smoking
Pregancy

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6
Q

What drugs may cause macrocytosis?

A

Methotrexate
Azathioprine

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7
Q

What haematological disorders may cause macrocytosis?

A

Myelodysplastic syndrome
Aplastic anaemia
Myeloma

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8
Q

What are the potential causes of hypocalcaemia?

A

Decreased PTH
Low Vit D
CKD
Liver disease
Sclerotic (blastic) bone metastases

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9
Q

What are the potential causes of raised GGT?

A

Alcohol
Obesity
Pancreatic disease
MI
Renal failure
Diabetes

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10
Q

Which 2 liver enzymes may demonstrate cholesystitis?

A

ALP and GGT

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11
Q

What are the potential causes of raised ALT?

A

Statins
NSAIDs
Hep B&C
Coeliac disease
Alcohol
Fatty liver disease
Haemochromotosis
Alpha-1 antitrypsin deficiency

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12
Q

What are the causes of low phosphate?

A

GI - reduced absorption/intake (anorexia)
Alcoholism
DKA
Hyperparathyroidism
Renal disease - increased excretion

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13
Q

What are bisphosphonates?

A

Analogues of pyrophosphate
Potent inhibitors of osteoclast medicated bone resorption

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14
Q

What are bisphosphonates used for?

A

Paget’s disease
Hypercalcaemia
Osteolytic bone disease of malignancy
Primary and secondary hyperparathyroidism
Osteoporosis

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15
Q

What must you look out for in someone on bisphosphonates?

A

Osteonecrosis of the jaw

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16
Q

What BP range is a stage 1 hypertension?

A

130-139 systolic
80-89 diastolic

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17
Q

What BP range is a stage 2 hypertension?

A

140 of higher systolic
90 or higher diastolic

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18
Q

What BP range is a stage 3 hypertension?

A

Higher than 180 systolic
Higher than 110 diastolic

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19
Q

Name 5 risk factors of hypertension

A

Heart disease/angina
MI
Strokes
HF
PAD
Aortic aneurysms
Kidney disease
Vascular dementia
Aortic valve disease
Vision loss/choroidopathy
Sexual dysfunction
Brain aneurysms
Arrhythmias
Arterial thrombosis

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20
Q

How does hypertension damage blood vessels?

A

Increased shearing pressure due to increased BP
Therefore damage to arterial walls, then plaque formation and athlerosclerosis

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21
Q

What is choroidopathy?

A

Build up of fluid in eye due to burst blood vessels

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22
Q

Name 3 methods of lifestyle management for hypertension

A

Weight loss
Making sure weight not carried around abdomen
Regular exercise
Healthy diet - lots of fruit and veg
Reduce salt intake
Reduce alcohol consumption
Quit smoking

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23
Q

What examination may you do in an initial consultation for someone newly diagnosed with hypertension?

A

BP
Fundoscopy
Auscultate heart

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24
Q

What further investigations may you do for someone newly diagnosed with hypertension?

A

Urine albumin:creatinine
HbA1c
Electrolytes
Fundoscopy
ECG
Ambulatory blood pressure (if not already done for diagnosis)
Further tests to identify secondary cause of hypertension if signs

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25
Which 3 further investigations are the most important for someone with a new diagnosis of hypertension?
Urine albumin:creatinine Fundoscopy ECG
26
Why do you need further tests for someone recently diagnosed with hypertension?
Checking for signs of end organ damage
27
Name 3 secondary causes of hypertension
Renal disease Conn's disease Phaeochromocyotoma Cushing's disease Acromegaly Hyperthyroidism Alcohol Corticosteroids NSAIDs
28
Name 2 renal causes of hypertension
Chronic pyelonephritis Diabetic nephropathy Glomerulonephritis PKD Obstructive uropathy Renal cell carcinoma
29
Name 3 types of antihypertensives available
ACEi ARBs Diuretics CCBs Beta-blockers Alpha-blockers
30
Name an ACEi
Ramipril
31
Name 3 S/E of an ACEi
Bradykinin cough Hyperkalaemia (ramipril) Angioedema
32
What is a benefit of ACEis?
Protective for kidneys
33
What should you look out for with kidneys in using ACEis?
Some may get damage if atherosclerosis in renal arteries so do U&E 2 weeks after starting
34
Name 2 S/E of ARBs
Dizziness Headaches Fatigue
35
Name an ARB
Candesartan
36
Name a loop diuretic
Furosemide
37
Name 3 S/E of loop diuretics
Hyperuricaemia Hypomagnesaemia Hypocalcaemia Hypokalaemia Alkalosis Urinating a lot
38
Name a thiazide like diuretic
Indapamide
39
Name 3 S/E of thiazide like diuretics
Hypokalaemia Alkalosis Hypercalcaemia Hyperuricaemia Hyperglycaemia Hyperlipidaemia
40
Name a potassium sparing diuretic
Spironolocatone
41
Name 2 S/E of spironolactone
Hyperkalaemia Gynaecomastia
42
Name a CCB
Amlodipine
43
What are the S/E of CCBs?
FIGHTED Fatigue/flushing Increase in glucose levels and uric acid GI upset (nausea/constipation), gingival hyperplasia Headache Tachycardia, palpitation, angina Edema (pedal, peripheral, facial) - dose dependent Dizziness
44
Name a beta-blocker
Bisoprolol
45
Why may bisoprolol be preferable in the treatment of hypertension?
Cardio selective - less likely to get some of the S/E
46
What are the S/E of beta-blockers?
BALD FISH Bronchoconstriction/bradycardia Arrythmias Lethargy Disturbance in glucose metabolism Fatigue Insomnia Sexual dysfunction Hypotension
47
Name an alpha blocker
Doxazocin
48
What are the S/E of alpha blockers?
Postural hypotension Nausea Drowsiness/fatigue Swollen ankles/legs
49
What tests might you do for someone with erectile dysfunction?
History - psychological? External genitalia exam PSA and prostate Bloods - testosterone, LH if low testosterone, diabetes, cholesterol, FBC
50
What combination of 4 drugs is classically given to patients post-MI?
ACEi Amlodipine/beta-blocker Aspirin Statin
51
Name 5 risk factors for heart failure
Coronary heart disease MI Hypertension Valvular heart disease Infection Myocarditis Heavy alcohol usage Illegal drug usage Chemotherapy Congential heart defects Arrythmias Hyperthyroidism Phaeochromocytoma NSAIDs Sleep opnoea Smoking Obesity Family history - cardiomyopathies, hyperlipidaemia Chronic lung disease Pregnancy Anaemia Sarcoidosis
52
What are the different types of heart failure?
Left sided heart failure - Reduced EF - Preserved EF RHF Congestive HF
53
What is the difference between reduced EF and preserved EF left sided HF?
Reduced - ventricle not contracting properly Preserved - ventricle not relaxing properly
54
What is BNP?
Made by heart and tends to be raised in HF Used to diagnose/rule out HF
55
What is a normal BNP?
< 400
56
What is eGFR?
Estimated glomerular filtration rate
57
What is a healthy eGFR?
90ml/min
58
What does an eGFR of 60-90 mean?
G2
59
What does an eGFR of 45-59 mean?
Ga3
60
What does an eGFR of 30-44 mean?
G3b
61
What does an eGFR of 15-29 mean?
G4
62
What does an eGFR of <15 mean?
G5
63
What is the prognosis of heart failure?
50% die within 5 years
64
How does a loop diuretic work in heart failure?
Inhibits Na-K-Cl cotransporter in the thick ascending limp of loop of henle Helps kidneys remove excess water and salt so that your heart has less fluid to pump around the body
65
What is a loop diuretic used for in heart failure?
Symptomatic relief
66
Which is the only medication used in preserved EF HF?
Loop diuretic
67
What is the second line diuretic for HF?
Spironalactone
68
What are the S/E of loop diuretics?
Needing to wee more often Electrolyte imbalances
69
How does an ACEi work?
Prevents the formation of angiotensin II Angiotensin II causes narrowing of blood vessels therefore raising BP and resistance within arteries
70
How does an ACEi help in HF?
Reduces pressure so heart doesn't have to work as hard
71
How do beta-blockers help in HF?
Slows down HR to prevent heart from overworking Prevents heart responding to stress hormones therefore preventing the heart from overworking
72
What monitoring do you need to do for someone with HF?
Annual ECG BP - BB HR - BB U&Es - diuretics
73
What might you see on a chest x-ray in someone with HF?
Alveolar oedema (bat wings when acute) Kerley B lines - interstitial oedema Cardiomegaly - >50% oedema Dilated upper lobe vessels - pulmonary venous hypertension Pleural effusion
74
What bloods should you do for someone with suspected HF?
FBC U&E TFT LFT Lipid profile HbA1c NT-proBNP
75
What is the gold standard investigation for HF diagnosis?
ECHO
76
What LVEF suggests HF?
< 50%
77
What are the symptoms of measles?
CCCK - Cough - Coryza - Conjunctivitis - Koplik spots
78
What does the fever pain score assess and ?
The likelihood of an infection being caused by strep and when to prescribe antibiotics
79
What answers on the fever pain score would suggest strep?
Fever in past 24 hours - yes Absence of cough or coryza - yes Symptoms of onset
80
When is strep less likely?
As you get older. Much more common in children
81
What is the centor score?
Likelihood of a fever being strep
82
What answers would suggest that an infection is strep on the centor score?
Exudate or swelling on tonsils - yes Tender/swollen anterior cervical lymph nodes - yes Temp > 38 - yes Cough - no
83
What is the NICE traffic light guidance?
Guidance that you can use to assess how serious an infection is
84
What is assessed in the NICE traffic light guidance?
Colour, activity, respiratory, hydration and circulation, other
85
What colour would a child be if they were green on the NICE traffic light guidance?
Normal colour of skin, lips and tongue
86
What would the activity of a child be like if they were green NICE traffic light guidance?
Responding normally to social cues, content, smiling, stays awake or awakens quickly, strong normal cry/not crying
87
What respiratory symptoms would a child have if they were green on the NICE traffic light guidance?
None
88
What hydration and circulation symptoms would a child have if they were green on the NICE traffic light guidance?
Normal skin turgor and eye, moist mucus membranes
89
What is also important to note in order for a child to be green on the NICE traffic light guidance?
None of amber or red S&S
90
What colour might a child be if they are amber on the NICE traffic light guidance?
Pallor of skin, lips, or tongue reported by parent or carer
91
What activity might a child be showing if they are amber on the NICE traffic light guidance?
Not responding normally to social cues, waking only with prolonged stimulation, decreased activity, not smiling
92
What respiratory symptoms would a child have if they are amber on the NICE traffic light guidance?
Nasal flaring Tachypnoea 6-12m RR > 50 >12m RR > 40 O2 < 95% in air Crackles on chest auscultation
93
What hydration and circulation symptoms might a child have if they are amber on the NICE traffic light guidance?
Poor feeding Dry mucous membranes CRT > 3s Reduced urine output Tachycardia < 1 yr > 160 1-2 yrs > 150 2-5 yrs > 140
94
What other symptoms may be present if a child is amber on the NICE traffic light guidance?
Fever for 5 days or more Rigors Temp > 39 if 3-6m Swelling of limb/joint Non-weight bearing/not using a limb
95
What colour may a child be if they are red on the NICE traffic light guidance?
Pale, mottled, ashen, blue skin, lips, or tongue
96
What activity level may a child be at if they are red on the NICE traffic light guidance?
No response to social cues Appears ill to a healthcare professional Unable to rouse, of if roused doesn't stay awake Weak, high-pitched or continuous crying
97
What respiratory symptoms may a child have if they are red on the NICE traffic light guidance?
Grunting Tachypnoea RR > 60 Moderate/severe chest indrawing
98
What hydration and circulation symptoms may a child have if they are red on the NICE traffic light guidance?
Reduced skin turgor
99
What other symptoms may children have if they are red on the NICE traffic light guidance?
Temperature > 38 in 0-3m Non-blanching rash Bulging fontanelle Focal neurological signs Focal seizures Status epilepticus
100
What safety netting may you give a parent of a child that presents with a fever?
Breathless, drowsy, stop drinking, don't pass urine for more than 6 hours, fever for more than 5 days, or if worried about anything or think they're worse - bring them back or A&E
101
How many stages are there to delivery vaccines in babies under 1?
3
102
When do babies under the age of 1 get vaccines?
8 weeks 12 weeks 16 weeks
103
What vaccines do babies get at 8 week?
6-in-1 vaccine Rotavirus MenB
104
What vaccines do babies get at 12 weeks?
6-in-1 vaccine (2nd) Pneumococcal Rotavirus (2nd)
105
What vaccines do babies get at 16 weeks?
6-in1 vaccine (3rd) MenB (2nd)
106
How many times are primary children given vaccines?
2 times
107
When are primary school children vaccinated?
1 year 3 years 4 months
108
What vaccines are 1 year olds given?
HiB (4th)/MenC (1st) MMR (1st) Pneumococcal (2nd) MenB (3rd)
109
What vaccines are 3 year olds given?
MMR (2nd) 4-in-1 pre-school booster
110
How many times are teenagers vaccinated?
Twice
111
When are teenagers vaccinated?
12/13 14
112
What vaccines do 12/13 year olds get?
HPV
113
What vaccines do 14 year olds get?
3-in-1 teenage booster MenACWY
114
What is given in the 6-in-1 vaccine?
DPT - diptheria, tetanus, polio HepB HiB Whooping cough
115
What is in the 4-in-1 vaccine?
DTP Whooping cough (lose the two H's)
116
What is in the 3-in-1 vaccine?
DTP
117
What are the risk factors for developing dementia?
Hypertension Smoking Diabetes Obesity Sedentary life Poor diet Lots of alcohol Low levels of cognitive engagement Depression Traumatic brain injury Hearing loss Social isolation Air pollution Increasing age Female Down's syndrome and other learning disabilities Hypothyroidism
118
Which dementia is more common in down's syndrome?
Alzheimers - higher levels of Tau in Downs
119
How can the presentation of dementia differ in those with learning disabilities?
Earlier onset Reduced interest in being sociable Decreased enthusiasm for usual activities Decline in ability to pay attention Sadness, fearful, anxiety Irritability, uncooperative, aggression Restlessness, sleep disturbances Sleeping a lot
120
How can you diagnose dementia?
Needs referral to memory clinic Demonstrate decline in baseline cognition, functioning, and changes in personality across 3 longitudinal assessments Confusion screen
121
How can you diagnose dementia in individuals with learning disabilities?
Screen for dementia from 30 - annual review Comprehensive baseline assessment at 30 - memory, executive functions, praxis, visual spatial skills, language (written and verbal), attention, processing speed Special psychiatrist referral DSQIID - Dementia Screening Questionnaire for Individuals with Intellectual Disability
122
What does a confusion screen entail?
Bloods ECG Urinalysis CT head CXR Sputum culture?
123
What bloods are done in a confusion screen? What causes of confusion are they looking for?
FBC - infection, anaemia, malignancy U&E - hyponatraemia, hypernatraemia LFTs - liver failure, secondary encephalopathy Coagulation/INR TFTs - hypothyroidism Calcium - hypercalcaemia B12 + folate/haematinics - B12/folate deficiency Glucose - hypo/hyperglycaemia Blood cultures
124
What can B12 deficiency cause?
Subacute combined degeneration of spinal cord
125
Why do you do a confusion screen?
To ensure no reversible cause of dementia
126
What other confusion tests are there?
4AT - alertness, cognition, attention, acute change/fluctuating course 10-point cognitive screener 6-item cognitive impairment test Memory impairment screen Mini-cog
127
What are the 5 main points of the mental capacity act?
1. Presumption of capacity 2. Support individuals to make their own decisions 3. Unwise decision do not mean lacking in capacity 4. Best interests 5. Less restrictive option - must consider whether possible to act in a way that would interfere least with person's rights/freedoms
128
What questions do you need to answer when assessing capacity?
1. Does the person have an impairment of their mind or brain, whether because of an illness, or external factors such as alcohol or drug use? 2. Does the impairment mean a person is unable to make a specific decision when they need to? 3. Can they understand the information relevant to the decision? 4. Can they retain that information? 5. Can they use or weigh up that information as part of the process in making that decision? 6. Can they communicate that decision back to you?
129
What is normal pressure hydrocephalus?
Blockage to outflow of CSF with no raised ICP
130
What can cause normal pressure hydrocephalus?
SAH Head trauma Infection Tumour Surgical complications
131
What is hydrocephalus?
Raised intracranial pressure due to increased fluid in the brain
132
What can cause hydrocephalus?
Genetics Strokes Meningitis Tumours Head injury
133
What is multimorbidity?
People with multiple health conditions Often long-term and complex conditions requiring ongoing care
134
What can affect multimorbidity?
Increases with age and poorer socioeconomic status Individual lifestyle factors and combined effect of lifestyle factors associated with likelihood of simultaneous presence of three or more chronic conditions in the same subject
135
What is polypharmacy?
Concurrent use of multiple medications in an individual
136
What is appropriate polypharmacy?
Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to the best evidence
137
What is problematic polypharmacy?
Prescribing of multiple medications inappropriately or where intended benefit of the medication is not realised
138
Name 5 anti-cholinergic side effects
Can't see, can't pee, can't climb a tree Eyes - blurred vision, dry eyes Brain - drowsiness, dizziness, confusion, hallucinations Heart - rapid heart rate Bladder - urine retention (unable to empty your bladder) Skin - skin-flushing, unable to sweat, overheating Bowel - constipation Mouth - dry mouth
139
What can anti-cholinergics be used to treat?
Asthma Cardiovascular disease COPD Mydriasis Parkinson's disease Urge incontinence
140
What are the risks of stopping statins?
Associated with 33% increased risk of admission for a cardiovascular event in 75-year-old primary prevention of patients Lower relative risk of cardiovascular event following discontinuation of statins in a diabetic patient
141
In whom are hypoglycaemic events be more common in?
Incidence of serious hypoglycaemia higher in insulin users Recent hospital discharge was strongest predictor of subsequent hypoglycaemia in older persons with diabetes
142
What can increase risk of orthostatic hypotension including specific medications?
Age (10% over 85s) Number of medications Hydrochlorothiazide (65%) Lisinopril (60%) Furosemide (56%) Trazodone (58%) - antidepressant Terazosin (54%) - alpha blocker
143
What are the effects of multimorbidity?
Higher risk of safety issues Poor medication adherence and adverse drug events - polypharmacy Complex management More frequent and complex interactions with health care services Greater susceptibility to failure of care delivery and coordination Need for clear communication and patient-centred care due to complex needs Demanding self-management and competing priorities Vulnerability to safety issues Possible diagnostic overshadowing
144
What are the effects of appropriate polypharmacy?
Potential to improve QOL, longevity and minimise harm from medications
145
What are the effects of problematic polypharmacy?
Hazardous interactions Pill burden unacceptable to patient Demands make difficult to achieve clinically useful medication adherence Medicines prescribed to treat S/E of other medicines where alternative solutions are available to reduce number of medications prescribed
146
What does the mnemonic SAD PERSONS stand for and what is it used for?
Used for assessing suicide risk S - sex (male) A - age (< 19 and > 45) D - depression P - previous attempt/parasuicide E - excess alcohol or substance usage R - rational thinking loss S - social supports lacking O - organised plan N - no spouse S - sickness
147
What is a disability?
Related to anyone with a physical, sensory, or mental impairment which seriously affects their daily activities
148
What is a visual impairment?
Small percentage see nothing Some differentiate between light and dark No peripheral vision No central vision Patchwork of blanks and defined areas Some can see enough to read text, although may have difficulty crossing roads
149
What is macular disease?
Disease causing damage to the retina
150
What does the macular do?
Central part of retina which we use for detail (reading/writing)
151
How is age related macular degeneration treated?
No cure Can be slowed/halted in some cases with medical treatment, drug therapy, or laser treatment Most common eye condition in the UK
152
What are retinitis pigmentosas?
Inherited diseases of the retina
153
What happens in retitinitis pigmentosa?
Leads to gradual reduction in vision - night and peripheral vision affected first followed by difficulties in reading and colour vision 1 in 3000 affected in the UK
154
What is glaucoma?
Disease affecting optic nerve Irreversible
155
What are the dangers of glaucoma?
In early stages no obvious symptoms 40% optic nerve can be damaged before vision loss noted
156
How common is glaucoma?
2 in 100 over 40
157
What is diabetic retinopathy?
Damage to blood vessels due to high glucose If caught early can be successfully treated with laser treatment Stops it progressing but cannot restore loss Leading cause of blindness in adults over 65
158
What is Charles Bonnet Syndrome?
When people live with sight loss, brain not receiving as many pictures New fantasy pictures or old pictures stored in brains released and experienced as though seen Generally affects people who lost sight later in life but can affect someone of any age
159
How common is sight loss?
> 2000 children in UK 1 in 5 > 75 visually impaired 1 in 2 > 90 visually impaired 8% born with impaired vision 2% see nothing at all Older visually impaired 3x more likely to experience depression
160
What is the law around age to consent?
Under 16 - cannot consent to sex with someone over the age of 16 Under 13 - statutory rape even if have sex with someone of the same age If 14/15 can have sex with someone who is no more than 2 years older than them
161
What might the symptoms of gonorrhoea be?
Deep dispareunia Green discharge
162
What might the symptoms of chlamydia be?
Silent Deep dispareunia White discharge
163
What might the symptoms of trichomonas vaginalis be?
Green/yellow frothy discharge Vaginal itching and irritation
164
What might the symptoms of bacterial vaginosis be?
White discharge Soreness/irritation Smelly discharge
165
What questions should you ask about last sexual contact?
Timing Consent Relationship Sex and country of origin Types of sex - don't forget oral! Contraception Other sexual partners HIV risk factors Paid for sex/been paid for sex
166
What amount of time needs to have elapsed for a vaginal/cervical swab to be accurate?
2 weeks (chlamydia and gonorrhoea)
167
What amount of time needs to have elapsed for a STI blood test to be accurate?
12 weeks (3m) (syphilis and HIV)
168
What are the Fraser Guidelines?
Part of Gillick Competency Young person cannot be persuaded to inform their parents/carers that they are seeking this advice/treatment Young person understands advice being given Young person's physical/mental health or both is likely to suffer unless receive the advice/treatment Young person's best interests to receive the advice, treatment, or both without their parent/carers consent Young person likely to continue having sex with or without contraceptive treatment
169
What are the child protection concerns with children under 16 having sex and what could be signs of this?
Possible indicator of child exploitation/grooming Presenting repeatedly with STIs or TOP Partner > 18 Feeling uncomfortable with having sex Isolated from partners family/friends Partner in a position of power eg teacher, scout leader Being given lots of gifts from partner as rewards for certain behaviours
170
What are some of the CIs for prescribing the COCP according to the UKMEC guidelines?
Pregnant > 35 and smoker/stopped smoking less than 1 year ago BMI > 35 Hypertension Migraine with aura Breastfeeding up to 6 weeks CVS and VTE risk factors FHx or personal hx breast cancer
171
What is ectropion?
Columnar epithelium coming out of cervical os Normal May cause spotting or bleeding after sex
172
What are the components of chronic pain?
Physical Psychological Environmental Sensitisation - Allodynia - Hyperalgesia
173
What are the 3 different classifications of opioids?
Naturally occurring compounds Semi-synthetic Synthetic
174
Name 2 naturally occurring opioids
Morphine Codeine Thebaine Papaverine
175
Name 2 semi-synthetic opioids
Diamorphine (heroin) Dihydromorphine Buprenorphine Oxycodone
176
Name 2 synthetic opioids
Pethidine Fentanyl Methadone Alfentanil Ramifentanil Tapentadol
177
What are the 3 opioid receptors and where are they?
MOR, KOR, DOR Distributed throughout the CNS and to a lesser extent the periphery Also in the vas deferens, knee joint, GI tract, heart and immune system
178
How do opioids work?
Presynaptic inhibition of neurotransmitter release
179
What are the GI S/E of opioids?
Constipation N&V Weight gain
180
What are the respiratory S/E of opioids?
Sleep disordered breathing Respiratory depression
181
What are the CVS S/E of opioids?
Increased CVD risk
182
What are the CNS S/E of opioids?
Dizziness Sedation Falls (fracture risk) Respiratory depression
183
What are the endocrine S/E of opioids?
Hypogonadism Opiate induced androgen deficiency Sexual dysfunction - erectile dysfunction Infertility/reduced fertility Fatigue Decreased testosterone Osteoporosis Oligomenorrhoea Galactorrhoea
184
What are the immune S/E of opioids?
Pneumonia Reduced immunity
185
What do you need to look out for in long term opioid prescribing?
Addiction and misuse Tolerance Withdrawal Hyperalgesia Depression
186
What non-pharmacological ways are there of treating pain?
Physical - weight loss, smoking cessation, exercise (stretching, physio, yoga, pilates), joint injections Psychological - counselling, CBT, music, meditation, relaxation Complementary therapy - massage, reflexology Occupational - work place based review
187
What pharmacological ways are there of treating pain?
Non-opioid analgesics - intermittent usage, slow/low Adjuvant analgesics - anti-convulsant, anti-depressants, lidocaine patches
188
What are the potential signs of abuse and dependency of opioids?
Use of pain medications for things other than treatment Impaired control (of self or medication use) Compulsive use of medication Continued use of medication despite harm or lack of benefit Craving or escalation of medication use Selling or altering prescriptions Stealing or diverting medications Calls for early refills/losing prescriptions Reluctance to try non-pharmacological interventions
189
What are the key associations with opioid dependency?
Age - higher in younger, decreases as age increases Marital status - highest in those cohabiting but not married Employment - highest in those unemployed Strong association with very bad health Higher association between buying on the internet and dependency
190
What is the definition of a total anterior stroke from the Bamford criteria?
All 3 of... 1. Unilateral weakness/numbness 2. Homonymous hemianopia 3. Higher function impairment eg dysphasia
191
What is the definition of a partial anterior stroke from the Bamford criteria?
2/3 of... 1. Unilateral weakness/numbness 2. Homonymous hemianopia 3. Higher function impairment eg dysphasia
192
What is the definition of a posterior circulation syndrome from the Bamford criteria?
One of 1. Ipsilateral CN and contralateral body deficit 2. Bilateral deficit 3. Isolated homonymous hemianopia 4. Gaze paresis 5. Cerebellar symptoms - vertigo, ataxia, nystagmus
193
What is the definition of a lacunar stroke from the Bamford criteria?
Pure motor/sensory symptoms Sensorimotor Ataxic hemiparesis
194
Name 3 posterior circulation syndromes
Weber's Wallenberg's Lateral pontine
195
What is Weber's syndrome?
PCA Affects midbrain, cerebral peduncles, oculomotor nucleus Ipsilateral oculomotor palsy + contralateral weakness
196
What is lateral pontine syndrome?
AI cerebellar, lateral pons, pontine tracts, CN7 nucleus, cerebellum Ipsilateral facial spinothalamic - loss + contralateral body spinothalamic loss + facial nerve palsy + vertigo/ataxia/nystagmus
197
What is wallenberg's syndrome?
PI cerebellar Lateral medulla, medullary tracts, cerebellum Ipsilateral facial spinothalamic loss + contralateral body spinothalamic loss + vertigo/ataxia/nystagmus
198
What is the treatment for hypertension in haemorrhagic stroke?
If S>150 then labetol
199
What reversal of coagulopathy can be given for warfarin?
Prothrombin complex concentrate + vitamin K
200
What reversal of coagulopathy can be given for dabigatran?
Idaracizumab
201
What is the secondary prevention for stroke?
Aspirin 300mg for 2 weeks post stroke 1st line - clopidogrel 75mg lifetime 2nd line - aspirin + dipyriamole Statin
202
What is a severe SDH?
> 10mm or > 5mm with midline shift/neurological dysfunction
203
How is a severe SDH treated?
Surgery Anti-epileptics (phenytoin/keppra)
204
What is a moderate SDH?
< 10mm or <5mm midline shift and no neurological dysfunction
205
How is a moderate SDH treated?
Antiepileptics FU CT 2-3 weeks
206
How is a chronic SDH treated?
Same as severe but elective surgery
207
What is nimodipine used for?
Preventing vasospasm
208
What are the indications for a CT within 1 hour?
1. GCS < 13 at time of injury 2. GCS < 15 2hrs post injury 3. Depressed/open skull fracture 4. Basal skull fracture signs 5. Focal neurological deficit 6. Post-traumatic seizures 7. > 1 episode vomiting
209
What are the signs of a basal skull fracture?
1. Haemotympanum 2. CSF rhinorrhoea 3. Battle's sign (mastoid bruising) 4. Panda eyes
210
What are the causes of bacterial meningitis?
Explaining Big Hot Neck Stiffness 0-1 month = E coli, group B strep 1 month-6 years = Hib, Neisseria meningitidis, Strep pneumoniae 6 years + = N meningitidis, Strep pneumoniae 60+/immunocompromised = N meningitidis, Strep pneumoniae, LISTERIA monocytogenes
211
What is the treatment if there is suspected bacterial meningitis?
IM benpen
212
What is the treatment for bacterial meningitis by age group?
< 3 months = IV cefotaxime + IV ampicillin/amoxicillin > 3 months = IV ceftriaxone +/- IV dex > 60/immunocompromised = IV ceftriaxone and IV amoxicillin +/- dex
213
When should you give steroids in meningitis treatment?
1. Purulent CSF 2. Protein > 1g/L 3. CSF WCC > 1000/mL 4. Bacteria visible on gram stain
214
What are the scores for the motor section of the GCS score?
6 - obeying commands 5 - localising to pain 4 - withdrawing from pain 3 - flexing 2 - extending 1 - no response
215
What are the scores for the voice section of the GCS score?
5 - orientated 4 - confused 3 - words 2 - sounds 1 - no response
216
What are the scores for the eyes section of the GCS score?
4 - spontaneously opening 3 - open to voice 2 - open to pain 1 - no response
217
What are the symptoms of normal pressure hydrocephalus?
Wacky Wobbly Weeing
218
What are the differentials of dementia?
Depression NPH Hypothyroidism Addison's B12/folate/thiamine deficiency Syphilis Brain tumour SDH Chronic drug/alcohol use
219
What is Alzheimer's associated with?
FHx, Caucasian Down's syndrome Slow, steady decline Memory, understanding, learning
220
What is Lewy body dementia associated with?
Old men with FHx Hallucinations, falls, REM sleep disorder, fluctuating, parkinsonism
221
What is the first line treatment for Alzheimer's and Lewy body dementia?
Acetylcholine esterase inhibitors - rivastigmine, donepezil, galantamine
222
What is the second line treatment for Alzheimer's and Lewy body dementia?
NMDA receptor antagonist - memantine Anti-psychotics for hallucinations
223
What is vascular dementia associated with?
Stepwise, focal neurological deficits Low mood, depression, slowed thinking and reasoning
224
How is vascular dementia treated?
Aspirin 300mg + clopidogrel 75mg
225
What is frontotemporal dementia associated with?
FHx Personality change < 65 Gambling, memory preserved, lack of insight, speech
226
What is mild cognitive impairment?
No significant life impact/progression
227
What drugs can cause falls?
Opioids Antihypertensives SSRIs Drug interactions Polypharmacy
228
What are the peripheral causes of dizziness/vertigo?
Ear causes - BPV - Acute labyrinthitis - Meniere's disease - Acoustic neuroma
229
What causes BPV and what are the symptoms?
Debris in semicircular canal Head movement Vertigo for a few seconds
230
What are the symptoms of acute labyrinthitis?
Vertigo + N&V No hearing loss/tinnitus Vascular/virus
231
What are the symptoms of Meniere's disease?
Vertigo > 20 mins + deafness + tinnitus Bed rest
232
What are the symptoms of acoustic neuroma?
Unilateral hearing loss then vertigo +/- raised ICP
233
What can cause central vertigo?
MS, stroke, migraine, trauma, motion sickness, alcohol
234
What are the symptoms of pre-eclampsia?
Severe frontal headache Epigastric pain N&V Visual disturbances Swelling of hands and feet Liver tenderness
235
How is pre-eclampsia diagnosed?
Over 20 weeks Hypertension > 140/90 with proteinuria
236
How can you treat pre-eclampsia?
Antihypertensives - labetol (1st line), methyldopa, nifedipine Monitor foetal growth Fluid restriction If BP uncontrollable - deliver with MgSO4 before
237
What is eclampsia?
Tonic-clonic seizures due to uncontrolled pre-eclampsia Placental distress causing vasospasm widespread in body leading to hypertension that can lead to vasospasm in the brain causing seizures
238
What is HELLP syndrome?
H - haemolysis EL - elevated liver enzymes LP - low platelets Typically occurs in 3rd trimester Blood transfusions, platelets, MgSO4
239
How can you diagnose gestational diabetes?
Fasting > 5.6 2hr plasma glucose > 7.8
240
What can you do to reduce the risks of pre-term labour?
Tocolytic drugs - slow down contractions (nifedipine) MgSO4 to promote brain development Steroids (dexamethasone) to promote lung and brain development
241
What are the 4 Ts of PPH?
Tone - uterine atony Trauma - lacerations during birth Tissue - retained POC Thrombin - coagulopathy
242
What is foetal hydrops?
Abnormal fluid accumulation in 2 or more foetal components
243
When are anti-D injections given during pregnancy?
28 and 34 weeks
244
What can cause intrauterine growth restriction?
Extremes of maternal age Interpregnancy gap < 6 months Previous SGA baby Placental insufficiency Substance abuse/medications (warfarin) Maternal starvation Maternal infection Foetal chromosomal/genetic/congenital anormalities Placental dysfunction
245
What is a first degree peroneal tear?
Fourchette and vaginal mucosa damaged Underlying muscles exposed but not torn
246
What is a second degree peroneal tear?
Posterior vaginal wall and perianal muscles. Sphincter intact
247
What is a third degree peroneal tear?
Anal sphincter torn but rectal mucosa intact
248
What is a fourth degree peroneal tear?
Anal canal opened, tear may spread to rectum
249
What can cause foetal distress during labour?
Cord prolapse Pre-eclampsia Placental abruption Low levels of amniotic fluid Breech Hypoxia Maternal sepsis Should dystocia
250
What is cord prolapse?
When cord prevents out of cervix before uterus Contractions cause cord compression so cuts off O2 supply to foetus
251
What are the different types of cord prolapse?
Overt - happens after sac burst Abdo - ill fitting or non-engaged presenting part Vaginal - can be felt within vagina, if pulsating baby still alive
252
Name a GnRH receptor antagonist
Zolotex injections Degarelix Goserelin
253
What are the risk factors of fibroids?
Obesity Early menarche 1st degree relative(s) with fibroids Hypertension Alcohol Poor diet
254
What are the protective factors for fibroids?
Exercise Increased parity Smoking
255
Name 4 other causes of vaginal bleeding
Endometrial polyps Ectopic pregnancy Endometrial hyperplasia Endometrial cancer (post-menopausal) POP IUCD Anticoagulant treatment
256
When should you offer antihypertensives with stage I hypertension?
If < 80 and any of the following - Target organ damage - Established CVS disease - Renal disease - Diabetes - QRISK > 10%
257
What HbA1c suggests diabetes and pre-diabetes?
Diabetes > 48 Pre-diabetes 42-47
258
What is the 1st line treatment for T2DM?
Metformin
259
When should you add an SGLT2 inhibitor to metformin as first line for diabetes treatment?
If CVD, high risk for developing CVD (QRISK > 10%), HF eg empagliflozin Have CVS benefits (protective)
260
What are the S/E of SGLT2 inhibitors and why?
UTI Inhibits glucose reabsorption in kidney so glucosuria
261
What can you give if metformin is not tolerated due to S/E (gastric)?
Modified-release metformin
262
What can you give if metformin is CI?
If risk of CVD/HF - SGLT2 monotherapy If not at risk - DPP4 inhibitor or pioglitazone or sulphonylurea
263
What is the 2nd line treatment for T2DM?
Add one of - DPP4 inhibitor - Pioglitazone - Sulphonylurea
264
What is the 3rd line treatment for T2DM?
Add another drug Start insulin therapy
265
What is the FEVERPAIN score?
FEVER lasting 24 hours Pus on tonsils Attend rapidly (ie symptoms onset < 3 days) severely Inflamed tonsils No cough or coryza If >4 then antibiotics
266
What antibiotics would you give for strep throat?
Phenoxymethylpenicillin Clarithromycin if penicillin allergic 7/10 days
267
What is the most common cause of bacterial tonsilitis?
Strep pyogenes (gram positive coccus)
268
What FEV1/FVC suggests asthma and what improvement with a SABA is required?
< 70% predicted 12% improvement with SABA
269
What are the symptoms of a moderate asthma attack?
PEFR 50-75% best/predicted Speech normal RR < 25 HR < 110
270
What are the symptoms of a severe asthma attack?
PEFR 33-50% Can't complete sentences RR > 25 HR > 110
271
What are the symptoms of a life threatening asthma attack?
PEFR < 33% Sats < 92% Normal pCO2 4.6-6.0 Silent chest, cyanosis, feeble resp effort Bradycardia, dysrhythmia, hypotension Exhaustion, confusion, coma
272
What treatment can be given for regular migraines?
Beta blockers CI in asthma - topiramate
273
What are the problems with topiramate?
May be teratogenic Reduces effectiveness of oral contraceptives
274
What are the red flags of a headache?
Thunder clap - SAH Immunocompromised Triggered by cough, valsalva, sneeze, exercise - raised ICP until proven otherwise Impaired level of consciousness + vomiting (> 1) - CT Progressively worsening + higher functioning impaired - CT Hx current cancer - ?mets Worsening with fever Change in personality Orthostatic GCA signs Meningitis symptoms
275
When are NSAIDs CI?
NSAID Nursing and pregnancy Serious bleeding Allergic asthma Impaired renal function - incl renal artery stenosis Drugs (anticoags)
276
Name 3 cyanotic congenital heart defects
R -> L shunt - Truncus arteriosus - Transposition of the great vessels - Tricuspid atresia - ToF - Total anomalous pulmonary venous return Hypoplastic L heart syndrome
277
Name 3 acyanotic congenital heart defects
L -> R shunt - ASD - VSD - AVSD - PDA Outflow tract obstructions - Aortic stenosis - Pulmonary stenosis - Coarctation of the aorta
278
What is Eisenmenger's syndrome?
Increased flow L -> R through shunt increases pressure R hypertrophy Eventually shunt reversal -> cyanotic
279
What are the S&S of acyanotic heart defects?
Tachycardia, tachypnoea Faltering growth Sweating Pulmonary hypertension leading to HF -> oedema, fatigue, frequent chest infections
280
When will i) ASDs close? ii) VSD close?
i) By 1 ii) By 10
281
How do babies with cyanotic lesions survive?
Also need acyanotic lesion to counteract cyanotic
282
What does TGA look like on a CXR?
Egg on a string
283
What are the RF for TGA?
Male Maternal age > 40 Maternal diabetes Rubella Alcohol
284
How do you keep acyanotic lesions open?
Prostaglandin E1
285
What is tricuspid atresia?
No tricuspid valve RV hypoplasia as underdeveloped
286
What does ToF look like on CXR?
Boot shaped heart
287
What are the RF for ToF?
Male 1st degree relative Hx CHD Teratogens - alcohol, warfarin VACTERL CHARGE DiGeorges
288
What does VACTERL stand for?
Vertebral defects Anal atresia Cardiac defects Tracheo-Esophageal fistula Renal abnormalities Limb abnormalities
289
What does CHARGE stand for?
Coloboma Heart defects Atresia choanae Retardation of growth/development Genital/urinary abnormalities Ear abnormalites/deafness
290
What is the new most common causes of epiglottitis?
Strep pneumoniae (was Hib)
291
What are the 4 D's of epiglottitis?
Dyspnoea Dysphagia Drooling Dysphonia (hot potato voice) + tripod
292
How is epiglottitis treated?
Do not examine throat Secure airway - ENT/ anaesthetics O2 Nebulised adrenaline IV fluids Cefotacime/ceftriaxone
293
What antibiotic can you give for whopping cough and when can you give it?
Clarithromycin If cough present < 3 weeks
294
What is CF?
Autosomal recessive genetic disease of CFTR gene In caucasian population
295
What is the role of the CFTR protein?
Chloride channel in epithelial tissue Affects both Cl- and Na+ Reduces water in secretions therefore thickened
296
What are the problems with thickened fluids in CF?
Lungs - thick mucus, increased risk infection Pancreas - duct damaged in utero, pancreatic insufficiency, CF-related diabetes, require creon and vitamin ADEK supplements GI - liver and bowel problems Reproductive - men infertile (absent vas deferens), women must time pregnancy as causes deterioration of lung health
297
What signs can you get in CF?
Delayed meconium ileus Recurrent chest infections Steatorrhoea - frothy, pale stools Nasal polyps Clubbin
298
What medications can be used to treat OCD?
Clomipramine (TCA) SSRIs
299
What are the 3 core symptoms of depression?
Sustained low mood Reduced energy Anhedonia
300
What are the other symptoms of depression?
Reduced libido Poor sleep - early morning waking Diurnal mood variation - worse in morning Agitation, anxious Poor appetite Worthlessness, hopelessness, guilt Poor concentration, memory Thoughts + speech slowed Suicidal ideation/attempt
301
What are the symptoms of psychotic depression?
Derogatory auditory hallucinations Delusions of guilt Nilhilistic delusions Persecutory delusions
302
How is psychosis diagnosed?
1 or more - thought alienation - passivity phenomena - 3rd person auditory hallucinations - delusional perception 2 or more - delusions - 2nd person auditory hallucinations - other hallucinations - thought disorder - catatonia - -ve symptoms - amotive - poverty of speech - self neglect - lack of insight
303
What are the positive symptoms of psychosis?
Delusions Hallucinations Disorganised speech/behaviour
304
What are the negative symptoms of psychosis?
Lack of emotion Monotone, one-syllable answers Few gestures Difficulties thinking/coming up with ideas Decreased ability to initiate tasks Decreased motivation/drive Lack of interest in other people Inability to feel pleasure Lack of spontaneity
305
What are the S/E of lithium?
LITHIUM Leukocytosis Interstitial nephritis/insipidus Tremor (fine) Hydration decreased Increased skin/GI and memory problems Underactive thyroid Mum's beware (Ebsteins anomaly)
306
What are the symptoms of lithium toxicity?
Coarse tremor Hyperreflexia Acute confusion D&V Coma Death
307
What is in the cluster A of personality disorders?
Paranoid Schizoid Schizotypal
308
What is the difference between the cluster A personality disorders?
Paranoid - distrust and suspicious towards others without adequate reason to be suspicious Schizoid - avoiding social situations, limited range of emotional expression (Matt) Schizotypal - intense discomfort with close relationships and social interactions (Tim)
309
What is in the cluster B of personality disorders?
Antisocial EUPD Histrionic Narcissistic
310
What is the difference between the types of cluster B personality disorders?
Antisocial - impulsive, irresponsible, criminal behaviour EUPD - fluctuating emotions (period) Histrionic - uncomfortable if not centre of attention, feel constantly have to seek attention (Joe) Narcissistic - self-centred arrogant behaviour, lack of empathy and consideration towards others (G)
311
What is in cluster C of personality disorders?
Avoidant Dependant OCD/anakastic
312
What is the difference between the cluster C of personality disorders?
Avoidant - chronic feelings of inadequacy, highly sensitive to being negatively judged by others (me) Dependant - anxious, feel helpless, submissive, incapable of taking care of themselves, trouble making simple decisions (Soph) Anankastic - obsession with orderliness, rigidity and stubbornness (Ellie)

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