General Practice Flashcards

Question

Secondary prevention for ACS

Answer 1

6As - Aspirin 75mg once daily - Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months - Atorvastatin 80mg once daily - ACE inhibitors (e.g. ramipril) - Atenolol (or other beta blocker) - Aldosterone antagonist for those with clinical heart failure

Answer 2

- Stop smoking - Reduce alcohol consumption - Mediterranean diet - Cardiac rehabilitation (a specific exercise regime for patients post MI) - Optimise treatment of other medical conditions (e.g. diabetes and hypertension)

Answer 3

Heart Failure (DREAD) - D – Death - R – Rupture of the heart septum or papillary muscles - E – “Edema” (Heart Failure) - A – Arrhythmia and Aneurysm - D – Dressler’s Syndrome (pericarditis secondary to injury)

Answer 4

Refers to the clinical features of impaired heart function, specifically the function of LV to pump blood out of the heart and around the body. This impaired LV leads to a chronic backlog of blood waiting to flow into the left side of the heart. The left atrium, pulmonary veins and lungs experience increased volume and pressure, and start to leak fluid, resulting in pulmonary oedema

Answer 5

Ejection fraction is the % of blood in the LV squeezed out with each ventricular contraction EF > 50% = normal HFrEF = EF < 50% HFpEF = EF > 50% - issues with LV filling during diastoles

Answer 6

- Ischaemic heart disease - Valvular heart disease (commonly aortic stenosis) - Hypertension - Arrhythmias (commonly atrial fibrillation) - Cardiomyopathy

Answer 7

- Breathlessness, worsened by exertion - Cough, which may produce frothy white/pink sputum - Orthopnoea, which is breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use) - Paroxysmal nocturnal dyspnoea (PND) sudden night waking with severe SOB, cough and wheeze) - Peripheral oedema - Fatigue

Answer 8

- Tachycardia - Tachypnoea - Hypertension - Murmurs on auscultation indicating valvular heart disease - 3rd heart sound on auscultation - Bilateral basal crackles (sounding “wet”) on auscultation of the lungs, indicating pulmonary oedema - Raised jugular venous pressure (JVP),

Answer 9

- Clinical assessment (history and examination) - N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test - ECG - Echocardiogram Others: - Blood - CXR

Answer 10

- Class I: No limitation on activity - Class II: Comfortable at rest but symptomatic with ordinary activities - Class III: Comfortable at rest but symptomatic with any activity - Class IV: Symptomatic at rest

Answer 11

RAMPS - R – Refer to cardiology - A – Advise them about the condition - M – Medical treatment - P – Procedural or surgical interventions - S – Specialist heart failure MDT input, such as the heart failure specialist nurses, for advice and support Urgency of referral dpedns on NT-proBNP results: 400 - 2000ng/L = specialist and echo < 6 weeks > 2000ng/L = specialist and echo < 2 weeks

Answer 12

- Flu, covid and pneumococcal vaccines - Stop smoking - Optimise treatment of co-morbidities - Written care plan - Cardiac rehabilitation (a personalised exercise programme)

Answer 13

ABAL A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone) L – Loop diuretics (e.g., furosemide or bumetanide)

Answer 14

A type of supraventricular tachycardia (SVT), characterised by a chaotic irregular atrial arrhythmia.

Answer 15

SMITH S – Sepsis M – Mitral valve pathology (stenosis or regurgitation) I – Ischaemic heart disease T – Thyrotoxicosis H – Hypertension Alcohol and caffeine = lifestyle causes

Answer 16

Normally, the SA node produces electrical activity that coordinates the contraction of the atria and heart. In AF, atrial contractions are uncoordinated and irregular because the uncoordinated electrical discharges produced in the atria override the regular impulses produced in the SA node.

Answer 17

Often asymptomatic and diagnosed after a stroke (5x risk of stroke with AF) - Palpitations - Shortness of breath - Dizziness or syncope (loss of consciousness) - Symptoms of associated conditions (e.g., stroke, sepsis or thyrotoxicosis)

Answer 18

- Irregularly irregular pulse

Answer 19

ECG - Irregularly irregular ventricular rhythm - Absent P waves - Narrow QRS complex (<120ms) tachycardia

Answer 20

Episodes of AF that reoccur and spontaneously resolve back to sinus rhythm. Lasts between 30s to 48 hours If normal ECG but suspected paroxysmal AF: - 24-hour ambulatory ECG (Holter monitor) - Cardiac event recorder lasting 1-2 weeks

Answer 21

- Rate or rhythm control - Anticoagulation Complex but remember from zero to finals Most patients = beta blocker for rate control, often bisoprolol, and a DOAC for anticoagulation. If you remember one thing about the treatment of atrial fibrillation, remember this combination.

Answer 22

Hypertension is defined as a blood pressure reading of ≥140/90 mmHg (ambulatory blood pressure monitoring ≥135/85 mmHg).

Answer 23

ROPED R – Renal disease O – Obesity P – Pregnancy-induced hypertension or pre-eclampsia E – Endocrine D – Drugs (e.g., alcohol, steroids, NSAIDs, oestrogen and liquorice)

Answer 24

- Ischaemic heart disease (angina and acute coronary syndrome) - Cerebrovascular accident (stroke or intracranial haemorrhage) - Vascular disease (peripheral arterial disease, aortic dissection and aortic aneurysms) - Hypertensive retinopathy - Hypertensive nephropathy - Vascular dementia - Left ventricular hypertrophy - Heart failure

Answer 25

1) Stage 1 Hypertension Clinic Reading: >140/90 Ambulatory / Home Readings >135/85 2) Stage 2 Hypertension Clinic Reading: >160/100 Ambulatory / Home Readings >150/95 3) Stage 3 Hypertension Clinic Reading: >180/120 Ambulatory / Home Readings: >180/120

Answer 26

Clinic BP: 140/90 mmHg - 180/120 mmHg = 24-hour ambulatory blood pressure or home readings to confirm the diagnosis. White-coat syndrome involves more than 20/10mmHg difference in clinic and home/ambulatory reading

Answer 27

NICE guidelines: every 5 years if no end organ damage, consider more often if clinical readings are near 140/90

Answer 28

- Urine albumin:creatinine ratio (proteinuria) and dipstick for microscopic haematuria to assess for kidney damage - Bloods for HbA1c, renal function and lipids - Fundoscopy for hypertensive retinopathy - ECG for LVH - Calculate QRISK (risk of stroke or MI in next 10 years) if above 10% = statin

Answer 29

Healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.

Answer 30

A – ACE inhibitor (e.g. ramipril 1.25mg up to 10mg once daily) B – Beta blocker (e.g. bisoprolol 5mg up to 20mg once daily) C – Calcium channel blocker (e.g. amlodipine 5mg up to 10mg once daily) D – Thiazide-like diuretic (e.g. indapamide 2.5mg once daily) ARB – Angiotensin II receptor blocker (e.g. candesartan 8mg to up 32mg once daily) ARB is used if ACEi is not tolerated or the patient is of Afro-Caribbean or African descent.

Answer 31

There are slightly different guidelines for younger patients and those aged over 55 or black: Step 1: Aged less than 55 and non-black use A. Aged over 55 or black of African or African-Caribbean descent - use C. Step 2: A + C. Alternatively A + D or C + D. If black then use an ARB instead of A. Step 3: A + C + D Step 4: A + C + D + additional (see below) For step 4, if the serum potassium is ≤ 4.5 mmol/l then consider a potassium-sparing diuretic such as spironolactone. If the serum potassium is > 4.5 mmol/l, consider an alpha blocker (e.g. doxazosin) or a beta blocker (e.g. atenolol). Specialist mx if the blood pressure remains uncontrolled despite treatment at step 4.

Answer 32

< 80 years Systolic Target: < 140 Diastolic Target: < 90 > 80 years Systolic target: < 150 Diastolic target: < 90

Answer 33

1) IHD 2) Cerebrovascular accident (hypertension is biggest risk factor) 3) Heart failure 4) Chronic kidney disease

Answer 34

Asthma is a chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity. One of the atopic conditions: eczema, hay fever and food allergies

Answer 35

- History of other atopic conditions - Family history - Viral URTI - Other triggers: cold weather and exercise - Occupational exposure (10-15%): e.g. spray paint, flour (bakers) - requires specialist referral

Answer 36

- Episodic - periods where symptoms are better or worse - Diurnal variability Typical symptoms: - SOB - Chest tightness - Dry cough - Wheeze Improve with bronchodilators

Answer 37

- Normal if patient is well - Key finding = widespread "polyphonic" expiratory wheeze TOM TIP: a localised monophonic wheeze is not asthma, differentials include inhaled foreign body, tumour = CXR

Answer 38

- Infection - Nighttime or early morning - Exercise - Animals - Cold, damp or dusty air - Strong emotions Non-selective beta-blockers e.g. propranolol and NSAIDs can worsen asthma

Answer 39

- Spirometry - FEV1:FVC ration < 70% = obstructive disease e.g. asthma or COPD - Bronchodilator reversibility testing - > 12% increase in FEV1 indicates asthma - Fractional exhaled nitric oxide (FeNO) - measures concentration of NO exhaled, marker of inflammation (> 40ppb = positive) - Peak flow variability - peak flow diary, variability of > 20% = positive

Answer 40

NICE guidelines recommends the following in patients with suspected asthma: - Fractional exhaled nitric oxide (FeNO) - Spirometry with bronchodilator reversibility - If diagnostic uncertainty = peak flow variability by keeping peak flow diary, twice a day, for 2 to 4 weeks

Answer 41

1) SABA (short-acting beta-agonist); e.g. salbutamol 2) ICS (inhaled corticosteroid); e.g. beclomethasone. 3) LTRA (leukotriene receptor antagonist); e.g. montelukast (reduces inflammation, not a steroid) 4) LABA (long-acting beta-agonist); e.g. salmeterol 5) MART (maintenance and reliever therapy); combined fast-acting LABA and ICS for symptomatic relief and maintenance in a single inhaler.

Answer 42

Occupational exposure = they should be referred to a specialist. Occupational asthma = symptoms and reduced PEFR during the working week and improvement when not at work. Step 1: Newly-diagnosed asthma: SABA (PRN) Step 2: If symptoms not controlled through SABA: SABA + low-dose ICS Step 3: SABA + low dose ICS + LTRA Step 4: SABA + low dose ICS + LABA +/- LTRA dependent on response Step 5: consider MART regime 6. Increase ICS to moderate dose 7. High dose ICS 8. Specialist management (e.g. oral corticosteroids)

Answer 43

- Progressively shortness of breath - Use of accessory muscles - Raised respiratory rate (tachypnoea) - Symmetrical expiratory wheeze on auscultation - The chest can sound “tight” on auscultation, with reduced air entry throughout

Answer 44

Initially respiratory alkalosis as tachypnoea causes decrease in CO2 Normal pCO2 or low pO2 (hypoxia) = concerning as it means patient is getting tired - life-threatening asthma Respiratory acidosis due to high pCO2 is very bad sign

Answer 45

Peak flow 50 – 75% best or predicted

Answer 46

- Peak flow 33-50% best or predicted - Respiratory rate above 25 - Heart rate above 110 - Unable to complete sentences

Answer 47

- Peak flow less than 33% - Oxygen saturations less than 92% - PaO2 less than 8 kPa - Becoming tired - Confusion or agitation - No wheeze or silent chest - Haemodynamic instability (shock)

Answer 48

Involve seniors Mild exacerbations - SABA (e.g., salbutamol) via a spacer - 4x dose of their inhaled corticosteroid (for up to 2 weeks) - Oral steroids (prednisolone) if ICS ineffective Follow-up within 48 hours Moderate exacerbations may additionally be treated with: - Consider hospital admission - Nebulised beta-2 agonists (e.g., salbutamol) - Steroids (e.g., oral prednisolone or IV hydrocortisone) Severe exacerbations may additionally be treated with: - Hospital admission - Oxygen to maintain sats 94-98% - Nebulised ipratropium bromide - IV magnesium sulphate - IV salbutamol - IV aminophylline Might need: - Admission to HDU or ICU Intubation and ventilation

Answer 49

Salbutamol can cause potassium to be absorbed from blood to cells, resulting in hypokalaemia

Answer 50

Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible obstructive lung disease characterised by airflow limitation that is not fully reversible. It encompasses both emphysema and chronic bronchitis.

Answer 51

Loss of alveolar integrity due to an imbalance between proteases and protease inhibitors (e.g. alpha-1 antitrypsin). Elastase breaks down elastin, which decreases surface area fir gaseous exchange. Triggered by chronic inflammation, such as smoking.

Answer 52

Bronchitis involves excessive mucus secretion secondary to ciliary dysfunction and increased goblet number and size → lung parenchymal destruction → impaired gas exchange. Chronic bronchitis is long-term bronchitis.

Answer 53

Typical presentation of COPD is a long-term smoker with persistent symptoms of: - Shortness of breath - Cough - Sputum production - Wheeze - Recurrent respiratory infections, particularly in winter

Answer 54

- Tachypnoea - Barrel chest (bulging of the chest) - Hyperresonance on percussion - Tar staining of fingers with peripheral cyanosis

Answer 55

- Age: usually diagnosed > 45 - Tobacco smoking: greatest risk factor - Occupational exposure: dust, coal, cotton - Alpha-1 antitrypsin deficiency: younger patients that present with COPD features

Answer 56

- Grade 1: Breathless on strenuous exercise - Grade 2: Breathless on walking uphill - Grade 3: Breathlessness that slows walking on the flat - Grade 4: Breathlessness stops them from walking more than 100 meters on the flat - Grade 5: Unable to leave the house due to breathlessness

Answer 57

Clinical diagnosis and spirometry results Spirometry: - FEV1:FVC < 70% - No response to bronchodilator testing with beta-2 agonists (e.g., salbutamol). Severity - Stage 1 (mild): FEV1 > 80% of predicted - Stage 2 (moderate): FEV1 50-79% of predicted - Stage 3 (severe): FEV1 30-49% of predicted - Stage 4 (very severe): FEV1< 30% of predicted

Answer 58

- BMI - Chest x-ray to exclude lung cancer - CT thorax to rule out fibrosis or bronchiectasis - FBC for polycythaemia (raised haemoglobin due to chronic hypoxia), anaemia and infection - Sputum culture - ECG and echocardiogram - Serum alpha-1 antitrypsin

Answer 59

FEV1: forced expiratory volume; the volume of air exhaled in the first second of forced exhalation FVC: forced vital capacity; the volume exhaled after maximal expiration following full inspiration Normal FEV1/FVC = above 0.75-85

Answer 60

1) SABA: short-acting beta-adrenoceptor agonist (e.g. salbutamol) - leads to bronchodilation 2) SAMA: short-acting muscarinic antagonist (ipratropium) - inhibits smooth muscle contractions 3) LABA: long-acting beta-adrenoceptor agonist (e.g. salmeterol) - leads to bronchodilation 4) LAMA: long-acting muscarinic antagonist (e.g. tiotropium) - inhibits smooth muscle contraction 5) ICS: inhaled corticosteroid (e.g. beclomethasone

Answer 61

- Smoking cessation - Annual flu and pneumococcal vaccine Step 1: SABA or SAMA (e.g. ipratropium bromide) Step 2: if no asthmatic or steroid-responsive features = combination inhalers containing LABA and LAMA If asthmatic or steroid-responsive features = LABA and ICS combination inhalers Step 3: LABA, LAMA and ICS combination inhalers Long-term oxygen for severe COPD with O2 sats < 92%

Answer 62

Rapidly worsening symptoms - Cough - SOB - Sputum - Wheezing Triggers: viral or bacterial infection

Answer 63

Permanent dilatation of the bronchi, the large airways that transport air to the lungs. Sputum collects and organisms grow in the wide tubes, resulting in a chronic cough, continuous sputum production and recurrent infections.

Answer 64

Results from damage to the airways - Idiopathic (no apparent cause) - Pneumonia - Whooping cough (pertussis) - Tuberculosis - Alpha-1-antitrypsin deficiency - Connective tissue disorders (e.g., rheumatoid arthritis) - Cystic fibrosis - Yellow nail syndrome

Answer 65

Triad of yellow fingernails, bronchiectasis and lymphoedema

Answer 66

- Shortness of breath - Chronic productive cough - Recurrent chest infections - Weight loss

Answer 67

- Oxygen therapy (if needed) - Weight loss (cachexia) - Finger clubbing - Signs of cor pulmonale (e.g., raised JVP and peripheral oedema) - Scattered crackles throughout the chest that change or clear with coughing - Scattered wheezes and squeaks

Answer 68

Sputum culture, most common infective organisms are: - Haemophilus influenza - Pseudomonas aeruginosa CXR findings: - Tram-track opacities (side-view of the dilated airway) - Ring shadows (dilated airways seen end-on) - Gold standard: high-res CT (HRCT) to establish diagnosis

Answer 69

- Vaccines (e.g., pneumococcal and influenza) - Respiratory physiotherapy to help clear sputum - Pulmonary rehabilitation - Long-term antibiotics (e.g., azithromycin) for frequent exacerbations - Inhaled colistin for Pseudomonas aeruginosa colonisation - Long-acting bronchodilators if SOB - Long-term oxygen therapy if low sats Surgery: - Surgical lung resection - Lung transplant for end-stage disease

Answer 70

- Sputum culture (before antibiotics) - 7–14 days antibiotics - Ciprofloxacin if Pseudomonas aeruginosa

Answer 71

- Finger clubbing - Diagnosis by HRCT - Pseudomonas colonisation - Extended 7 - 14 days course of antibiotics

Answer 72

Pneumonia is an infection of lung tissue, causing inflammation in the alveolar space CAP develops in the community It is a lower respiratory tract infection - the lower the infection, the more likely it is bacterial

Answer 73

- Cough - Sputum production - Shortness of breath - Fever - Feeling generally unwell - Haemoptysis (coughing up blood) - Pleuritic chest pain (sharp chest pain, worse on inspiration) - Delirium (acute confusion)

Answer 74

- Bronchial breath sounds (harsh inspiratory and expiratory breath sounds) due to consolidation around the airways - Focal coarse crackles caused by air passing through sputum in the airways - Dullness to percussion due to lung tissue filled with sputum or collapsed

Answer 75

CRB-65 is a scoring system used in community to assess the severity + mortality risk of pneumonia - C – Confusion (new disorientation in person, place or time) - U – Urea > 7 mmol/L (only in hospital) - R – Respiratory rate ≥ 30 - B – Blood pressure < 90 systolic or ≤ 60 diastolic. - 65 – Age ≥ 65 Consider hospital assessment when CRB-65 score is > 0

Answer 76

- Streptococcus pneumoniae (most common) - Haemophilus influenzae

Answer 77

In community, CRB 0 or 1 pneumonia = don't always need investigations. Point of care test for CRP levels used to guide diagnosis and abx in primary care

Answer 78

- Chest x-ray - seen as a consolidation - Full blood count (raised white cell count) - Renal profile - CRP Moderate/severe infection - Sputum cultures - Blood cultures - Pneumococcal and Legionella urinary antigen tests WBCC and CRP levels roughly = severity of infection, used to monitor patient progress to recovery

Answer 79

Mild - abx according to local guidelines, usually: - Amoxicillin - Doxycycline - Clarithromycin Moderate/severe = hospital for IV abx

Answer 80

- Sepsis - Acute respiratory distress syndrome - Pleural effusion - Empyema - Lung abscess - Death

Answer 81

An autoimmune disease that causes the destruction of beta cells in the islets of Langerhans in the pancreas, so it is unable to produce adequate insulin. This leads to chronic hyperglycemia due to insulin dysfunction.

Answer 82

Autoantibodies attack beta cells in the Islets of Langerhans leading to Insulin deficiency = chronic hyperglycaemia As the body cannot use glucose as fuel, cells think the body is starved. So continuous breakdown of glycogen from liver (gluconeogenesis) > glycosuria (glucose in urine)

Answer 83

- Northern European ancestry - Genetic susceptibility - Certain viral infections (e.g. coxsackie B virus or enterovirus)

Answer 84

- Polyuria (excessive urine) - Polydipsia (excessive thirst) - Weight loss (mainly through dehydration) Or Diabetic ketoacidosis

Answer 85

- Random plasma glucose >11.1 mmol/L (along with symptoms, this alone is enough for a diagnosis) - Fasting plasma glucose >7 mmol/L - HbA1c (glycated haemoglobin) > 6.5% / 48mmol/mol.

Answer 86

In type 1 DM, cells cannot use glucose as fuel and think they are starving. They undergo ketogenesis so that they have usable fuel. - Over time the patient gets higher and higher glucose and ketones levels. - Initially, the kidneys produce bicarbonate to counteract the ketone acids in the blood and maintain a normal pH. - Over time the ketone acids use up the bicarbonate and the blood becomes acidic > metabolic acidosis (pH < 7.3). This is called ketoacidosis.

Answer 87

- Ketoacidosis - Dehydration - Potassium imbalance (serum K high or normal but total body K low as none stored in cells)

Answer 88

- Polyuria - Polydipsia - Nausea and vomiting - Acetone smell to their breath - Dehydration - Weight loss - Hypotension (low blood pressure) - Altered consciousness

Answer 89

- Hyperglycaemia (blood glucose > 11 mmol/L) - Ketosis (e.g., blood ketones above 3 mmol/L) - Acidosis (e.g., pH below 7.3)

Answer 90

FIG-PICK Fluid Insulin Glucose (monitor and add glucose when < 14mmol/L) Potassium Infection (treat underlying) Chart fluid balance Ketone (monitor ketones, pH and bicarbonate)

Answer 91

**Basal-bolus regime** - Basal (long-acting) insulin - once a day - Bolus (short-acting) insulin - injected 30mins before carb consumption **Insulin pumps** Small devices that continuously infuse insulin at different rates to control blood sugar levels

Answer 92

Some patients might not be aware until they are severely hypoglycaemic Hunger Tremor Sweating Irritability Dizziness Pallor Reduced consciousness Coma Death

Answer 93

**Macrovascular:** - Coronary heart disease = significant cause of death in diabetics - Peripheral ischaemia = poor skin healing and diabetic foot ulcers - Strokes - Hypertension **Microvascular complications** - Diabetic neuropathy leads to lack of sensation in feet > occult foot ulcers - Diabetic retinopathy - Diabetic nephropathy particularly glomerulosclerosis **Infections:** - UTI - Skin and soft tissue infection particularly in the feet

Answer 94

A disease characterised by abnormally low insulin secretions and peripheral insulin resistance, which leads to chronic hyperglycemia due to insulin dysfunction

Answer 95

Repeated exposure to glucose and insulin causes insulin resistance in the body. Increasing levels of insulin are required to stimulate cells to take up and use glucose. The pancreas eventually becomes fatigued and damaged from producing so much insulin, and insulin production is reduced. A high carb diet, insulin resistance and reduced pancreatic function leads to chronic hyperglycaemia Chronic hyperglycaemia leads to microvascular, macrovascular and infectious complications (see type 1 diabetes)

Answer 96

Non-modifiable - Older age - Ethnicity (Black African or Caribbean and South Asian) - Family history Modifiable - Obesity - Sedentary lifestyle - High carbohydrate (particularly sugar) diet

Answer 97

Consider type 2 diabetes in patients with risk factors - Tiredness - Polyuria and polydipsia - Unintentional weight loss - Opportunistic infections (e.g., oral thrush) - Slow wound healing - Glucose in urine (on a dipstick) Acanthosis nigricans - thickening and darkening of the skin (giving a “velvety” appearance), often neck, axilla and groin, associated with insulin resistance.

Answer 98

HbA1c ≥ 48mmol/L, repeated after a month to confirm diagnosis

Answer 99

- A structured education program - Low-glycaemic-index, high-fibre diet - Exercise - Weight loss (if overweight) - Antidiabetic drugs - Monitoring and managing complications

Answer 100

- 48 mmol/mol for new type 2 diabetics - 53 mmol/mol for patients if on more than 1 med - The HbA1c is measured every 3 to 6 months until under control and stable.

Answer 101

1st line: metformin SGLT-2 inhibitor (e.g. dapagliflozin) if CVD or HF (NICE says consider if QRISK > 10%) 2nd line: add sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor. 3rd line: - Triple therapy with metformin and two of the second-line drugs - Insulin therapy (initiated by the specialist diabetic nurses) If above ineffective and BMI above 35, change one medication to GLP-1 mimetic (e.g., liraglutide).

Answer 102

DKA Glycosuria and therefore increased UTIs

Answer 103

Pre-diabetes is an indication that the patient is heading towards developing T2DM. They do not fully fit the diagnostic criteria for T2DM but should be educated on diabetes and lifestyle changes Not recommended to start treatment - weight loss and lifestyle changes first

Answer 104

HbA1c of 42 – 47 mmol/mol

Answer 105

Rare but potentially fatal complication of type 2 diabetes Characterised by hyperosmolality (water loss = very concentrated blood), hyperglycaemia) and absence of ketones (different from DKA) Presents with polyuria, polydipsia, weight loss, dehydration, tachycardia, hypotension and confusion. Medical emergency, experienced seniors and treatment with IV fluids and monitoring

Answer 106

Hyperthyroidism is a disease characterised by the over-production of thyroid hormones T3 and T4 by the thyroid gland.

Answer 107

GIST G – Graves’ disease - most common, autoimmune disease where TSH receptor antibodies stimulate TSH receptors I – Inflammation (thyroiditis) S – Solitary toxic thyroid nodule - usually adenomas removed via surgery T – Toxic multinodular goitre - nodules on thyroid that produce excessive thyroid hormones

Answer 108

- Anxiety and irritability - Sweating and heat intolerance - Tachycardia - Weight loss - Fatigue - Insomnia - Frequent loose stools - Sexual dysfunction - Brisk reflexes on examination - Oligomenorrhea

Answer 109

- Diffuse goitre (without nodules) - Graves’ eye disease, including exophthalmos (bulging of the eyes) - Pretibial myxoedema - Thyroid acropachy (hand swelling and finger clubbing)

Answer 110

1st line: carbimazole (taken for 12 to 18m). Once levels stable after about 4 - 6 weeks, titrated to maintain normal levels

Answer 111

- Acute pancreatitis - look out for a patient in your exam taking carbimazole with severe epigastric pain radiating to the back - Agranulocytosis - dangerously low WCC - key presenting feature is a sore throat, urgent FBC and aggressive infection treatment

Answer 112

Insufficient thyroid hormones, triiodothyronine (T3) and thyroxine (T4). Primary hypothyroidism = thyroid produces inadequate hormones. Negative feedback is absent = raised TSH and low T3 and low T4. Secondary hypothyroidism (central hypothyroidism) is where the pituitary behaves abnormally and produces inadequate TSH. TSH, T3 and T4 will all be low.

Answer 113

Primary - TSH levels are high Secondary - TSH levels are low

Answer 114

- Hashimoto's thyroiditis, most common cause in developed world Autoimmune condition causing inflammation of the thyroid gland. Presence of anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (Anti-Tg) antibodies Iodine deficiency - most common in developing countries

Answer 115

Lack of other pituitary hormones e.g. ACTH (hypopituitarism) - Tumour (e.g. pituitary adenomas) - Surgery - Radiotherapy - Sheehan's syndrome (post-partum haemorrhage causes avascular necrosis of the pituitary gland) - Trauma

Answer 116

- Weight gain - Fatigue - Dry skin - Coarse hair, hair loss and thinning or loss of the outer third of the eyebrows - Fluid retention (including oedema, pleural effusions and ascites) - Heavy or irregular periods Constipation Iodine deficiency = goitre Hashimoto's thyroiditis - initially goitre then atrophy of the thyroid gland

Answer 117

Oral levothyroxine (synthetic version of T4 and metabolises to T3 in the body Dose is titrated based on TSH level - initially every 4 weeks TSH = high, increase levothyroxine TSH = low, decease levothyroxine levels

Answer 118

Acid from the stomach flows through the lower oesophageal sphincter and into the oesophagus and irritates the lining and causes symptoms

Answer 119

- Greasy and spicy foods - Coffee and tea - Alcohol - NSAIDs - Stress - Smoking - Obesity - Hiatus hernia

Answer 120

- Dyspepsia (non-specific term to describe indigestion): - Heartburn - Acid regurgitation - Retrosternal or epigastric pain - Bloating - Nocturnal cough - Hoarse voice

Answer 121

- Critical!!! Dysphagia at any age = immediate two week wait referral - Aged over 55 (urgent referral) - Weight loss - Upper abdominal pain - Reflux - Treatment-resistant dyspepsia - Nausea and vomiting - Upper abdominal mass on palpation - Low haemoglobin (anaemia) - Raised platelet count

Answer 122

Insertion of a camera through the mouth down to the oesophagus, stomach and duodenum to assess for: - Gastritis - Peptic ulcers - Upper gastrointestinal bleeding - Oesophageal varices (in liver cirrhosis) - Barretts oesophagus - Oesophageal stricture - Malignancy of the oesophagus or stomach

Answer 123

Lifestyle changes: reduce tea, coffee and alcohol, weight loss, avoid smoking, smaller, lighter meals, stay upright after meals - Review meds (stop NSAIDs) - Antacids (e.g. Gaviscon) - PPI (e.g. omeprazole) - Histamine H2-receptor antagonists (e.g. famotidine)

Answer 124

The usual medical strategy when someone presents for the first time is to exclude red flags, address potential triggers, offer a 1 month trial of a proton pump inhibitor and consider H. pylori testing.

Answer 125

- Gram-negative aerobic bacteria that can live the stomach - It causes damage to the epithelial lining, resulting in gastritis, ulcers and increased risk of stomach cancer - Offer test for H.pylori to patients with dyspepsia, need 2 weeks without PPI before testing for accurate result

Answer 126

- Stool antigen test - Urea breath test using radiolabelled carbon 13 - H. pylori antibody test (blood) - Rapid urease test performed during endoscopy (also known as the CLO test)

Answer 127

Triple therapy with PPI and two antibiotics e.g. amoxicillin and clarithromycin for 7 days.

Answer 128

When the lower oesophageal epithelium changes from squamous to columnar epithelium (metaplasia - change from one cell type to another) It is a pre-malignant condition and increases risk of oesophageal adenocarcinoma Histology of Barrett's is a common exam question

Answer 129

Small stones that form in the gallbladder Most are made of cholesterol

Answer 130

Intermittent right upper quadrant pain caused by gallstones irritating bile ducts

Answer 131

Blockage to the flow of bile

Answer 132

Presence of gallstones

Answer 133

Inflammation of the gallbladder

Answer 134

Gallstones in the common bile duct

Answer 135

Infection and Inflammation of the bile ducts. Surgical emergency, high mortality rate due to sepsis and septicaemia

Answer 136

Cholecystectomy: surgical removal of the gallbladder

Answer 137

Inserting a drain into the gallbladder

Answer 138

4Fs Fat Fair Female Forty

Answer 139

- Might be asymptomatic - Typical symptom: biliary colic - severe epigastric or RUQ pain - Often after meals especially if high in fat - 30 mins to 8 hours - Nausea and vomiting - Sometimes patients can present with the complications e.g. acute cholecystitis, acute cholangitis, obstructive jaundice , pancreatitis

Answer 140

Fat causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder = biliary colic Patients with gallstones and biliary colic told to avoid high fat meals Possible exam question

Answer 141

- Raised Alkaline phosphatase (ALP) is non-speific marker = biliary obstruction if alongside RUQ pain and/or jaundice - Raised ALT and AST = hepatocellular injury - Cholestasis (due to gallstones) = slight increase in ALT and AST with higher increase in ALP, known as "obstructive picture" - Raised bilirubin (jaundice) with pale stools and dark urine - biliary obstruction)

Answer 142

1st line = ultrasound scan, helps identify: - Gallstones in the gallbladder - Gallstones in the ducts - Bile duct dilatation (normally < 6mm diameter) - Acute cholecystitis 2nd line - magnetic resonance cholangio-pancreatography

Answer 143

- A condition resulting from a disturbance of the gut-brain interaction - Functional disorder - More common in women than menn j

Answer 144

IBS mnemonic I – Intestinal discomfort (abdominal pain relating to the bowels) B – Bowel habit abnormalities S – Stool abnormalities (watery, loose, hard or associated with mucus) Common symptoms (varies between individuals): - Abdominal pain - Diarrhoea - Constipation - Fluctuating bowel habit - Bloating - Worse after eating - Improved by opening bowels - Passing mucus

Answer 145

- Bowel cancer - Inflammatory bowel disease - Coeliac disease - Ovarian cancer (often presents with vague symptoms, particularly bloating in women over 50 years) - Pancreatic cancer

Answer 146

Investigations can be used to assess for underlying differentials (normal in IBS): - Full blood count for anaemia Inflammatory markers (e.g., ESR and CRP) - Coeliac serology (e.g., anti-TTG antibodies) - Faecal calprotectin for IBD - CA125 for ovarian cancer

Answer 147

- NICE recommends ruling out differentials before diagnosis and patient should have at least 6 months of abdo pain or discomfort with at least one: - Pain or discomfort relieved by opening the bowels - Bowel habit abnormalities (more or less frequent) - Stool abnormalities (e.g., watery, loose or hard) For a diagnosis, patients also require at least two of: - Straining, an urgent need to open bowels or incomplete emptying - Bloating - Worse after eating - Passing mucus

Answer 148

- Anxiety - Depression - Stress - Sleep disturbance - Illness - Medications - Certain foods - Caffeine - Alcohol

Answer 149

- Drinking enough fluids - Regular small meals - Adjusting fibre intake according to symptoms (more fibre if predominantly constipated, less with diarrhoea/bloating) - Limit caffeine, alcohol and fatty foods - Low FODMAP diet, guided by a dietician - Reduce stress where possible - Regular exercise

Answer 150

- Loperamide for diarrhoea - Bulk-forming laxatives (e.g., ispaghula husk) for constipation (lactulose can cause bloating and is avoided) Antispasmodics for cramps (e.g., hyoscine butylbromide (buscopan) or peppermint oil)

Answer 151

Usually refers to colorectal cancer, small bowel and anal cancers are less common.

Answer 152

- Family history of bowel cancer - Familial adenomatous polyposis (FAP) - Hereditary nonpolyposis colorectal cancer (HNPCC) (Lynch syndrome) - Inflammatory bowel disease (Crohn’s or ulcerative colitis) - Increased age - Diet (high in red and processed meat and low in fibre) - Obesity and sedentary lifestyle - Smoking - Alcohol

Answer 153

Autosomal dominant condition that involves dysfunction of the tumour suppressor genes called adenomatous polyposis coli (APC) Results in many polyps (adenomas) in the large intestines - potential to become cancerous. Patients have their entire large intestine removed prophylactically to prevent bowel cancer

Answer 154

Autosomal dominant conditions that results from mutations in DNA mismatch repair (MMR) genes - increases risk of colorectal cancer

Answer 155

- Change in bowel habit (usually to more loose and frequent stools) - Unexplained weight loss - Rectal bleeding - Unexplained abdominal pain - Iron deficiency anaemia (microcytic anaemia with low ferritin) - Abdominal or rectal mass on examination - Unexplained anaemia

Answer 156

- Over 40 years with abdominal pain and unexplained weight loss - Over 50 years with unexplained rectal bleeding - Over 60 years with a change in bowel habit or iron deficiency anaemia

Answer 157

- Faecal immunochemical tests (FIT) - looks for amount of human haemoglobin in stool Used for patients that do not fit the two-week-wait criteria - Over 50 with weight loss only - Under 60s with change in bowel habit Patients 60 to 74 do home FIT test every two years

Answer 158

Gold standard: colonoscopy, endoscope to visualise entire large bowel, and lesions biopsied for histology Staging CT - full CT thorax, abdomen and pelvis

Answer 159

**T for Tumour:** TX – unable to assess size T1 – submucosa involvement T2 – involvement of muscularis propria (muscle layer) T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa T4 – spread through the serosa (4a) reaching other tissues or organs (4b) **N for Nodes:** NX – unable to assess nodes N0 – no nodal spread N1 – spread to 1-3 nodes N2 – spread to more than 3 nodes **M for Metastasis:** M0 – no metastasis M1 – metastasis

Answer 160

- MDT involvement - Treatment depends on clinical conditions, general health, stage, histology, patient wishes - Surgical resection: laparoscopic preferred - Chemotherapy - Radiotherapy - Palliative care

Answer 161

- Difficulty in emptying the bowels, usually with hardened stools. - Primary: dysfunctions of regulation of colonic and anorectal neuromuscular function or brain-gut neuroenteric function. Causes slower transit of stool through the bowel - Secondary: results from certain medications (opiates, antipsychotics), metabolic disturbances (hypercalcaemia, hypothyroidism)

Answer 162

- Female - Age > 65 - Black ethnicity - Lower SES - Medications: opiates - Sedentary lifestyle - Reduced dietary fibre

Answer 163

- Difficult defecation - Infrequent stools: <3 per week - Hard stools - Excessive straining Signs: - Abdominal mass (stool palpable) - Anorectal lesions: haemorrhoids, fissures - PR exams: hard stools - Delirium (common in elderly)

Answer 164

- Abdominal examination: masses, distention, palpable colon - PR examination: masses, stool, fissures, haemorrhoids , prolapse, rectocele

Answer 165

Constipation (< 3 month) 1st line: - Investigate, exclude or treat secondary cause - Lifestyle advice: increase daily fibre intake, increase exercise, increase fluid intake - Bulk forming laxative: fybogel (ispaghula husk), methylcellulose - 2nd line for hard stool, difficult to pass: Osmotic laxative: macrogol, lactulose - Soft stool, inadequate emptying - stimulant laxatives: senna, bisacodyl Chronic constipation If above ineffective for at least 6 months then: - 1st line: Oral macrogol +/- stimulant laxative

Answer 166

A pouch or pocket in the bowel wall, usually ranging in size from 0.5 – 1cm.

Answer 167

Presence of diverticula, without inflammation or infection. Diverticular disease = symptomatic diverticulosis

Answer 168

Inflammation and infection of diverticula.

Answer 169

Circular muscle layer in the wall of the large intestine have gaps where blood vessels penetrate Increased pressure over time allow mucosa to herniate through the circular muscle layer and form pouches (diverticula) The colon (except rectum) has longitudinal muscles forming ribbons called teniae coli The areas that are not covered by teniae coli are vulnerable to the development of diverticula. Rectum - outer longitudinal muscle surrounds it completely > extra support protecting it from diverticula

Answer 170

- "Wear and tear" of the bowel - Most commonly affect sigmoid colon - Common with increased age, low fibre diets, obesity, use of NSAIDs - Incidental finding on colonoscopy or CT scans

Answer 171

Asymptomatic = no treatment But if left abdo pain, constipation or rectal bleeding then: - Increased fibre - Bulk-forming laxatives (e.g. ispaghula) - Avoid stimulant laxatives (e.g. senna)

Answer 172

- Pain and tenderness in the left iliac fossa / lower left abdomen - Fever - Diarrhoea - Nausea and vomiting - Rectal bleeding - Palpable abdominal mass (if an abscess has formed) - Raised inflammatory markers (e.g., CRP) and white blood cells

Answer 173

- Oral co-amoxiclav (at least 5 days) - Analgesia (avoiding NSAIDs and opiates, if possible) - Only taking clear liquids (avoiding solid food) until symptoms improve, usually 2-3 days - Follow-up within 2 days to review symptoms - Severe - hospital admission

Answer 174

- Perforation - Peritonitis - Ileus/obstruction

Answer 175

- Inflammation of the gallbladder, key complication of gallstones - Main presenting symptom: RUQ pain that might radiate to the right shoulder. Other symptoms: - Fever - Nausea - Vomiting - Tachycardia and tachypnoea - Right upper quadrant tenderness - Murphy’s sign (positive in acute cholecystitis) - Raised inflammatory markers and white blood cells

Answer 176

1st line: abdominal ultrasound scan: - Thickened gallbladder wall - Stones or sludge in gallbladder - Fluid around gallbladder Magnetic resonance cholangiopancreatography (MRCP) - visualise the biliary tree

Answer 177

- Emergency admission to hospitals - Nil by mouth - IV fluids - Antibiotics - NG tube if vomiting - ERCP can be used to remove stones in the common bile duct Surgery: - Cholecystectomy

Answer 178

- Inflammation of the appendix - Peak incidence between 10 to 20 years old

Answer 179

- Obstruction of appendix > build-up of mucus and resident bacteria > inflammation and infection. - Increasing pressure leading to engorgement and congestion of the appendix - Inflammation spreads to the parietal peritoneum (tissue covering the abdominal cavity) > classic LRQ pain Gangrene + rupture > bacteria and faecal matter leak out > peritonitis

Answer 180

- Key symptom: abdominal that starts centrally then moves down to the right iliac fossa (RIF) - Tenderness at McBurney's point Other features: - Anorexia - Nausea and vomiting - Low-grade fever - Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF) - Guarding on abdominal palpation - Rebound tenderness in the RIF + percussion tenderness = peritonitis

Answer 181

- Clinical presentation and raised inflammatory markers - CT scan to confirm diagnosis and exclude other pathology - USS in female patients to exclude ovarian and gynae pathology

Answer 182

- Ectopic pregnancy - consider in female of childbearing age. Pregnancy test to exclude pregnancy - Ovarian cyst - pelvic and iliac fossa pain, particularly if rupture or torsion

Answer 183

- Emergency admission to hospital for appendicectomy , usually laparoscopic surgery

Answer 184

Inflammation of the kidneys resulting from bacterial infection. It affects the renal pelvis (connects kidney and ureter) and parenchyma (tissue).

Answer 185

E.coli is the most common cause - gram-negative, anaerobic, rod-shaped bacteria

Answer 186

Usually clinical diagnosis with history and examination Similar presentation to lower UTI (dysuria, suprapubic discomfort and increased frequency) and triad of symptoms: - Fever - Loin or back pain (bilateral or unilateral) - Nausea / vomiting

Answer 187

- Urine dipsticks - infection (nitrites, leukocytes and blood - Midstream urine (MSU) for microscopy, culture and sensitivity - Blood tests - raised WCC and CRP

Answer 188

- Referral to hospital if there are features of sepsis or not safe to manage in the community - 1st line antibiotics for 7 to 10 days in the community: - Cefalexin - Co-amoxiclav (if culture results are available) - Trimethoprim (if culture results are available) - Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)

Answer 189

- Presents with recurrent episodes of infection in the kidneys - Recurrent infection leads to scarring of the renal parenchyma > CKD and then end-stage renal failure

Answer 190

Also known as renal calculi, urolithiasis and nephrolithiasis They are hard stones that form in the renal pelvis, where the urine collects before going down the ureters Asymptomatic until they obstruct the ureters - commonly at the vesico-ureteric junction

Answer 191

Calcium-based stones (~80%): calcium oxalate (more common) and calcium phosphate Hypercalcaemia and low urine output = key risk factors

Answer 192

- Can be asymptotic - Main presenting complaint = renal colic which is severe unilateral loin to groin pain (worse than childbirth) - Colicky (fluctuating in severity) as the stone moves and settles - Nausea and vomiting from the pain Look out for symptoms of sepsis

Answer 193

- Urine dipstick = haematuria (normal does not exclude stones) - Blood tests to assess for infection, hypercalcaemia as a cause and kidney function - Non-contrast CT KUB within 24 hrs = first line investigation

Answer 194

Remember: renal stones, painful bones, abdominal groans and psychiatric moans

Answer 195

- Calcium supplementation - Hyperparathyroidism - Cancer (e.g. myeloma, breast or lung cancer)

Answer 196

- NSAIDs particularly intramuscular or PR diclofenac - Antiemetics (e.g. metoclopramide) - Antibiotics if infection - Watchful waiting if <5mm as usually passes by themselves - Tamsulosin (alpha-blocker) to help passing stones - Surgery if > 10mm or does not pass spontaneously

Answer 197

More likely to recurrent if previous episode - Increase fluid intake (2.5 - 3L) - Add fresh lemon juice to water as citric acid binds to urinary calcium - Salt < 6g daily - Maintain normal calcium intake (low dietary calcium = increased renal stone risk)

Answer 198

- Potassium citrate - Thiazide diuretics (e.g. indapamide)

Answer 199

A chronic inflammatory skin condition characterised by clearly defined red and scaly plaques. There are several types

Answer 200

- Symmetrically distributed, red, scaly plaques with well-defined edges - Plaques often violet/purple in darker skin, the pinkness of early patches might be difficult to see - Silvery white plaques - Most common sites: scalp. elbows and knees - Auspitz sign - pinpoint bleeding upon removal of scaly layer in plaque psoriasis - Koebner phenomenon: new plaques at sites of skin injury - Residual pigmentation or hypopigmentation after lesions resolve

Answer 201

For pictures + info: https://dermnetnz.org/topics/psoriasis

Answer 202

Post-streptococcal (often after strep throat infection) acute guttate psoriasis Widespread small plaques Often resolves after several months https://dermnetnz.org/topics/psoriasis

Answer 203

- Often late age of onset (>50) - Plaques <3 cm

Answer 204

- Persistent and treatment-resistant - Plaques >3 cm - Most often affects elbows, knees, and lower back - Ranges from mild to very extensive

Answer 205

- Rapid extension of existing or new plaques - Koebner phenomenon: new plaques at sites of skin injury - Induced by infection, stress, drugs, or drug withdrawal

Answer 206

- Affects body folds and genitals - Smooth, well-defined patches - Colonised by candida yeasts

Answer 207

Scalp - first or only site

Answer 208

- Affecting the palms and/or soles - Keratoderma (thickening of epidermis) - Painful fissuring

Answer 209

Pitting, onycholysis (separation of nail from nailbed) , yellowing, and ridging Associated with inflammatory arthritis

Answer 210

- Streptococcal tonsillitis ('Strep throat') and other infections - Injuries such as cuts - Sun exposure in ~10% of psoriasis patients (sun exposure is more often beneficial) - Dry skin - Obesity, smoking, or excessive alcohol - Medications such as lithium, beta-blockers, NSAIDs - Stopping oral steroids or strong topical corticosteroids - Stress

Answer 211

- Diagnosis usually based on clinical appearance of lesions , history and examination - Tools such as psoriasis area and severity index are used (measures erythema, induration (thickness) and desquamation (scaling))

Answer 212

Depends on severity - Topical steroids - Topical vitamin D analogues (calcipotriol) - Topical dithranol - Topical calcineurin inhibitors (tacrolimus) are usually only used in adults - Phototherapy with narrow band ultraviolet B light for extensive guttate psoriasis - Psychological support, as it can be difficult to treat

Answer 213

Psoriatic arthritis in 10% to 20% patients

Answer 214

A rash in the flexures e.g. behind ears, under arms, groin, between buttocks, fingers, toe spaces

Answer 215

- Obesity - Genetic tendency to skin disease - Hyperhidrosis - Age - Diabetes - Smoking - Alcohol

Answer 216

- Infection or inflammatory but often overlap - Infections usually unilateral and asymmetrical - Atopic dermatitis (inflammatory) usually bilateral and symmetrical, and affect flexures of neck, elbow or knees

Answer 217

- Thrush: Candida albicans - Tinea (ringworm fugus): Tinea cruris (groin) and athletes foot (between toes) - Impetigo: staphylococcus aureus, streptococcus pyogenes - Boils: S. aureus

Answer 218

- Seborrheic dermatitis - Atopic dermatitis (eczema) - Contact irritant dermatitis e.g. napkin dermatitis in infants in the nappy area - Contact allergic dermatitis

Answer 219

- Swab for microscopy, culture and sensitivity - Scraping for fungal microscopy and culture

Answer 220

- Depends on underlying cause (covered under individual diseases) Conservative measures: - Bathing and completely drying after physical exertion - Reduce sweating with antiperspirant

Answer 221

Fungal infection of the foot (tinea pedis) Often results in peeling skin and fissures between the toes (toe clefts)

Answer 222

Proliferation of dermatophyte fungi of the genera Trichophyton rubrum, Trichophyton interdigitale, and Epidermophyton floccosum.

Answer 223

- More common in those who participate in sports because: - They may wear occlusive footwear - They sweat heavily - They may fail to dry their feet carefully after showering - They are exposed to fungal spores in communal areas.

Answer 224

- Moist, peeling skin between the toes - White, yellow, or greenish discolouration - Sometimes, thickened skin - Painful fissures - Unpleasant smell. Usually mild, severe inflammation indicates bacterial infection

Answer 225

Usually clinical

Answer 226

- Yeast infection - Bacterial infection (e.g. staphylococci)

Answer 227

- Dry carefully between the toes - Use a dusting powder e.g. talc to keep the affected area dry - Wear shoes that are loose around the toes or go bare foot - Topical antifungal agent e.g. Terbinafine

Answer 228

- Liver disease - Renal disease - Cancer

Answer 229

Urticaria is characterised by weals (hives) or angioedema or both Several different types For pictures: https://dermnetnz.org/topics/acute-urticaria

Answer 230

It is urticaria with or without angioedema that is present for < 6 weeks and often gone within hours to days 1 in 5 children More common in patients with atopy.

Answer 231

Weals result from the release of chemical mediators from tissue mast cells and circulating basophils, they include histamine and cytokines. Bradykinin release causes angioedema.

Answer 232

- Acute viral infection e.g. URTI - Food allergy (IgE mediated) - Drug-induced (e.g. penicillin) - Bee/wasp sting

Answer 233

For pictures: https://dermnetnz.org/topics/acute-urticaria Urticarial weals - few mm or cm diameter, white or red with or without red flare Angioedema is usually more localised, commonly affects the face, and can involve the tongue, uvula, soft palate and larynx (danger!!!)

Answer 234

- A patient with a short history of weals that last less than 24 hours with or without angioedema - Ask about medication and family hx - Physical examination to identify underlying cause - Skin prick or radioallergosorbent tests (RAST) might be requested in suspected drug, latex or food

Answer 235

- Adults and children: oral second-gen antihistamine e.g. cetirizine, loratadine or fexofenadine - Avoid triggers - IM adrenaline for life-threatening anaphylaxis or throat-swelling

Answer 236

Score of 0 - 3 Measures number of weals over 24 hours and itch Score: 0, weals: none, itch: none Score 1: weals: 20, itch: mild Score 2: weals: 20 - 50, itch: intense Score 3: weals: > 50, itch: intense

Answer 237

Daily or episodic occurrence of weals, angioedema, or both for at least 6 weeks Persists for 1 - 5 years or longer

Answer 238

Urticaria with no specific cause or trigger Clinical features: - White/red weals with red flare, lasting few minutes or hours - Rings, map-like or giant patches - Angioedema commonly affecting the face, hands, feet and genitalia Systemic symptoms: headache, fatigue, joint pain/swelling

Answer 239

- Careful history and examination

Answer 240

- Identify and eliminate any underlying causes - Avoid triggers - Pharmacological treatment e.g. antihistamines, if ineffective after 2 to 4 weeks, then refer to dermatologist, immunologist or medical allergy specialist Treatment overlaps with chronic inducible urticaria

Answer 241

Chronic urticaria that has an identifiable cause and classified according to the stimulus that provokes weals to develop e.g. scratching the skin (dermographism), exercise and emotional upset (cholinergic urticaria)

Answer 242

Medical term for a widespread rash that is usually accompanied by systemic symptoms such as fever, malaise and headache. Usually caused by a infection, and is either a reaction to toxin produced or damage to skin by the infective organism or immune response

Answer 243

Exanthems during children are very common and usually due to specific viral infections e.g.: - Chickenpox (varicella) - Measles (morbillivirus) - Rubella (rubella virus) - Non-specific viral Bacterial exanthem: - Staphylococcal toxin: toxic shock syndrome - Streptococcal toxin infection: scarlet fever

Answer 244

- Non-specific exanthems appear as spots or blotches with or without itch - Usually more extensive on trunk than extremities - Most cases, patients might have the following symptoms prior to rash: fever, malaise, headache, loss of appetite, muscular aches and pains

Answer 245

Diagnosis by distinct patterns and prodromal (pre-rash) symptoms which allow for clinical diagnosis If required, consider viral swab for culture and PCR, blood test for serology or PCR

Answer 246

Symptomatic: - Paracetamol to reduce fever - Moisturising emollients to reduce itch

Answer 247

Prodrome of persistent high fever (> 39) for at least 5 days Widespread erythematous maculopapular rash and desquamation (peeling) on palms and soles - Strawberry tongue (red tongue with large papillae - Cracked lips - Cervical lymphadenopathy - Conjunctivitis

Answer 248

Mild systemic symptoms and few or many pruritic papules, vesicles, pustules and crusted lesions that might scar Mainly on face and trunk Pictures: https://dermnetnz.org/cme/viral-infections/specific-viral-exanthems

Answer 249

Prodrome of fever, malaise, anorexia, then conjunctivitis, cough and coryza Then Kolpik spots (oral papules) appear 2 - 3 days into prodrome period 24 to 48 hours later, rash starts on cheeks and spreads to trunk and limbs within a day or two - Widespread "morbiliform" erythema (5 - 10mm macules), fades in a few days, might scar

Answer 250

Prodrome can be asymptomatic or with slight fever, sore throat, rhinitis and malaise - Pale pink erythematous rash that starts on the face and spreads to neck, trunk and extremities, lasts up to 5 days

Answer 251

Common viral infection that presents with localised blistering, very common. Aka cold sores, recurrences triggered by febrile illness e.g. flu

Answer 252

Type 1 HSV - oral and facial type 2 HSV - genital and rectal After primary episodes of infection, HSV remains dormant in spinal dorsal root nerves that supply the skin. Multiple= clinical lesion, rest and repeat.

Answer 253

Type 1 HSV - usually infants and children in underdeveloped countries and overcrowded places Type 2 HSV - after puberty and usually sexually transmitted

Answer 254

Primary type 1 HSV - gingivostomatitis (blisters on gums) and fever, usually resolves by 2 weeks Primary type 2 HSV - genital herpes - painful vesicles, ulcers, redness and swelling for 2 - 3 weeks.

Answer 255

Usually clinical diagnosis but if in doubt then confirm by culture or PCR via viral swab taken from fresh vesicles.

Answer 256

Mild, uncomplicated = no treatment Severe = aciclovir

Answer 257

Herpes zoster is a localised, blistering and painful rash caused by a reactivation of varicella-zoster virus (VZV)

Answer 258

Anyone who has had varicella ( chickenpox) Common in elderly patients and those with weak immunity e.g. active cancer

Answer 259

After primary infection, varicella (VZV) remains dormant in dorsal root ganglia in the spine for years before reactivation It migrates down sensory nerves to the skin and causes herpes zoster

Answer 260

- Pressure on affected nerve roots - Radiotherapy at the level of affected nerve root - Spinal surgery - Infection - Injury

Answer 261

- Early sign - localised pain without visible skin changes, fever, headache - Then 2 - 3 days later, blisters in dermatomal distribution - blisters confined to cutaneous distribution of one or two adjacent nerve roots - Unilateral, sharp cut-off at anterior or posterior midline

Answer 262

- Prevention = VZV vaccine for > 60 - Contraindicated in immunosuppressed patients - Usually supportive management with rest, pain relief, petroleum jelly on blisters - Abx if secondary infection - Aciclovir if severe - Recovery 2- 3 weeks for children and younger adults and 3 - 4 weeks if older

Answer 263

Common, superficial, highly contagious bacterial skin infection Pustules (lesions with pus) and honey-coloured crusted lesions

Answer 264

Non-bullous - Staphylococcus aureus and less commonly streptococcus pyogenes Bullous - always staphylococcus aureus

Answer 265

- Young children - Direct contact with infected person - Skin conditions e.g. eczema - Skin injury - Poor hygiene - Crowded environments

Answer 266

- Face or extremities are common sites - Starts as single erythematous macule (flat <5mm) then becomes pustule or vesicle (small blister < 0.5cm) - Dries into honey-coloured lesion

Answer 267

- S.aureus produces epidermolytic toxin that presents as bullae (blisters > 1cm) that rupture and ooze yellow fluid - Usually face, trunk, extremities, buttocks and perianal regions Associated with systemic symptoms of malaise, fever, and lymphadenopathy.

Answer 268

- Clinical diagnosis based on appearance of lesions, history and examination - Swabs of weeping bullae can confirm diagnosis, bacteria and antibiotic sensitivities

Answer 269

Localised non-bullous impetigo - - Wash affected areas with soap and water - Hygiene measures (wash hands, cover affected areas) - Stay off school or work until all blisters are healed - Antiseptic cream (hydrogen peroxide 1% cream) Widespread non-bullous impetigo - Topical fusidic acid - Antibiotics usually flucloxacillin Bullous impetigo: - Conservative measures as above and oral antibiotics usually flucloxacillin

Answer 270

An acute bacterial infection of the dermis and subcutaneous tissue

Answer 271

- Previous cellulitis - Fissuring of toes or heels (e.g. athlete's foot) - Trauma e.g. surgical wounds - Diabetes - Chronic kidney and liver disease

Answer 272

Streptococcus pyogenes and Staphylococcus aureus

Answer 273

- Most often affects the limbs - Unilateral - Malaise, fever, chills and rigor due to bacteraemia - Localised painful, red swollen skin Other signs: - Dimpled skin (peau d'orange) - Warmth - Blistering - Ulceration - Abscess formation - Purpura (discolouration of skin due to small vessel haemorrhage

Answer 274

- Primarily based on clinical features and physical examination If systemically unwell: - FBC: leukocytosis, raised CRP - Blood culture to identify causative organism - U + E - LFTs

Answer 275

Eron classification system - Class I - no signs of systemic toxicity + no uncontrolled comorbidities - Class II - systemically unwell or well with comorbidity - Class III - significant systemic upset e.g. acute confusion, tachycardia and tachypnoea - Class IV - sepsis or severe life-threatening infection e.g. necrotising fasciitis

Answer 276

- Unilateral redness or swelling: - Acute gout - DVT - Chronic allergic dermatitis

Answer 277

- Refer to hospital if sepsis or infection e.g. necrotising fasciitis - Consider hospital referral if severely unwell, frail or immunocompromised - Oral abx treatment usually flucloxacillin - Analgesia e.g. paracetamol - Identify risk factors and manage for cellulitis e.g. diabetes mellitus and weight management

Answer 278

Acne vulgaris is a chronic inflammatory skin conditions affecting the face, back and chest. Characterised by the blockage and inflammation of pilosebaceous unit (hair follicle) Presents with non-inflammatory, inflammatory lesions (or a mixture

Answer 279

- Non-inflammatory lesions (comedones) must be present for a diagnosis - Papules and pustules (< 5mm) - Nodules or cysts (> 5mm)

Answer 280

Advice: - Avoid over-cleaning the skin - Use non-alkaline synthetic detergent cleansing product - Avoid oil-based comedogenic products - Treatment might irritate the skin at the start

Answer 281

1st line: 12 week course of any 2 of the following in combination: - Topical benzoyl - Topical antibiotics (clindamycin) - Topical retinoids (tretinoin adapalene)

Answer 282

- 1st line: 12 week course of same medicines as above but different doses (NICE CKS) - Sometimes the combo topical creams are combined with oral tetracycline and doxycycline - COCP alternative to systemic abx for women

Answer 283

A chronic inflammatory skin condition predominantly affecting the central face (cheeks, chin, nose and central forehead) and starts usually between 30 to 60

Answer 284

Diagnosis if one diagnostic or two major clinical features - Diagnostic features — phymatous changes (skin thickening), persistent erythema. Major features — flushing/transient erythema, papules and pustules, telangiectasia, eye symptoms (ocular rosacea). Minor features — skin burning and/or stinging sensation, skin dryness, oedema.

Answer 285

- Increasing age. - Photosensitive skin types. - UV exposure. - Smoking, alcohol. - Spicy foods and hot drinks. - Heat or cold temperature. - Emotional stress and exercise.

Answer 286

- Dryness/discomfort - Foreign-body sensation - Photophobia - Tearing - Itching - Photophobia

Answer 287

- Acute vulgaris - Seborrheic dermatitis - Contact dermatitis - SLE

Answer 288

Advice: rosacea is chronic condition and relapse may occur Signpost to support and info: British skin foundation, patient leaflets - Avoid triggers and identify triggers with diary - Sunscreen - Gentle soap-free OTC cleanser

Answer 289

Persistent erythema - topical brimonidine 0.5% gel PRN once a day as temporary symptom relief

Answer 290

Parasitic insects that infest the hairs of the human head and feed on blood from the scalp. Head lice infestation is called pediculosis capitis

Answer 291

Detection combing (fine-tooth 0.2-0.3mm) Diagnosis of active head lice infestation only made if live head louse is found.

Answer 292

Depends on preference of the person and their parents/carers Affected members of the household should be treated the same day - A physical insecticide, such as dimeticone 4% lotion (Hedrin®). - A traditional insecticide, such as malathion 0.5% aqueous liquid (Derbac-M®). - Wet combing with a fine-toothed head louse comb (such as the Bug Buster® comb). - Advise children being treated for head lice can go school - Not possible to prevent head lice infestion, primary school children should be checked regularly

Answer 293

Scabies is an transmissible, intensely itchy skin infestation caused by the human parasite Saroptes scabiei Classical (typical) scabies is infestation with low numbers of mites (5 - 15 per host) Crusted (Norwegian) scabies is a hyperinfestation with thousands or millions of mites

Answer 294

- Close contact with an infested person. - High levels of poverty and social deprivation. - Crowded living conditions and institutionalization. - Winter months, probably due to increased crowding and prolonged survival of mites

Answer 295

- Classical itchy rash - occurs 4 - 6 weeks following initial infection - Lesions are symmetrical, mainly affecting the hands, wrists, axillae, thighs, buttocks, waist, soles of the feet, genitalia - Itch worse at night Rashes are erythematous papules, excoriated with haemorrhagic crusts on top Thin, linear line brown/grey in colour (pathogonomic sign)as the mites burrow

Answer 296

- Dermatitis, pubic lice and insect bites

Answer 297

- Seek specialist advice e.g. paediatric dermatologist if patient < 2months - Admission to hospital if crusted scabies suspected - Classical scabies: topical permethrin 5% cream - Patient info and education - Advise that close contacts must be treated with topical permethrin 5% cream - Bedding, clothing and towels decontaminated with hot wash cycle and drying - Itching may persist for up to 4 weeks after treatment

Answer 298

"Wear and tear" in the joints Occurs in the synovial joints and results from genetic factors, overuse and injury Due to imbalance between cartilage damage and chondrocyte response.

Answer 299

- Obesity - Age - Occupation - Trauma - Female - FHx

Answer 300

- Hips - Knees - Distal interphalangeal (DIP) joints in the hands - Carpometacarpal (CMC) joint at the base of the thumb - Lumbar spine - Cervical spine (cervical spondylosis)

Answer 301

LOSS - Loss of joint space - Osteophytes (bone spurs) - Subarticular sclerosis (increased density of the along the joint line) - Subchondral cysts (fluid-filled holes in the bone)

Answer 302

- Pain and stiffness in affected joints - Better first thing in the morning - Worse with activity and end of the day Patients might present with referred pain - e.g. OA of the hip might present as LBP or knee pain Leads to deformity, instability and reduced joint function

Answer 303

- Bulky, bony enlargement of the joint - Restricted range of movement - Crepitus on movement - Effusions around the joint

Answer 304

- Heberden’s nodes (in the DIP joints) - Bouchard’s nodes (in the PIP joints) - Squaring at the base of the thumb (CMC joint) - Weak grip - Reduced range of motion

Answer 305

NICE guidelines Diagnosis can be made without any investigations if: - Over 45 - Typical pain associated with activity - No morning stiffness or lasting <30 mins

Answer 306

Patient education and lifestyle changes: - Therapeutic exercise - improve strength and reduce pain - Weight loss - Occupational therapy (e.g. walking aids and adaptations at home

Answer 307

- Topical NSAIDs first-line for knee osteoarthritis - Oral NSAIDs where required and suitable (with PPI for gastroprotection)

Answer 308

Very effective for MSK pain, but best used intermittently, adverse effects: - GI side effects, such as gastritis and peptic ulcers (leading to upper GI bleeding) - Renal: AKI - Cardiovascular side effects, such as hypertension, heart failure, myocardial infarction and stroke - Exacerbating asthma Particular caution needed in older patients and those on anticoagulants e.g. aspirin or DOACs

Answer 309

NSAIDs block prostaglandins (prostaglandins cause vasodilation).

Answer 310

A type of crystal arthropathy associated with chronically high blood uric acid levels Urate crystals deposited in the joint cause it be inflamed.

Answer 311

Usually a single acute, hot, swollen and painful joint Typically affected joints are - Metatarsophalangeal joint (MTP) i.e. base of big toe - Carpometacarpal joint (CMC joint) i.e. base of thumb Critical differential is septic arthritis

Answer 312

Clinical diagnosis supported by raised serum urate levels on a blood test Analysis of aspirated joint fluid show monosodium urate crystals which are needle-shaped, negatively birefringent (yellow) under polarised light. This is in contrast to pseudogout where the calcium pyrophosphate crystals are rhomboid-shaped and positively birefringent

Answer 313

- Maintained joint space (no loss of joint space) - Lytic lesions in the bone - Punched out erosions - Erosions can have sclerotic borders with overhanding edges

Answer 314

- Weight loss - Hydration - Reduce alcohol and purine-based food consumption (meat, seafood)

Answer 315

Acute flares: - 1st line is NSAIDs co-prescribed with PPI - 2nd line is colchicine for patients that are unsuitable for NSAIDs e.g. renal impairment or heart disease

Answer 316

Xanthine oxidase inhibitors e.g. Allopurinol or febuxostat to reduce uric acid levels Prophylaxis started weeks after acute attack resolution Initially NSAIDs or colchicine may be given to prevent a gout attack Once allopurinol or febuxostat is started, continue during acute attack COMMON EXAM QUESTION

Answer 317

Lower back pain refers to pain in the lumbosacral area Non-specific or mechanical back pain is lower back pain not attributable to an underlying cause Accounts for 90 to 95% of low back pain cases in primary care

Answer 318

- Obesity - Physical inactivity - Heavy lifting - Stress - Depression

Answer 319

- Spinal fracture (e.g., major trauma) - Cauda equina (e.g., saddle anaesthesia, urinary retention, incontinence or bilateral sciatica) - Spinal stenosis (e.g., intermittent neurogenic claudication) - Ankylosing spondylitis (e.g., age under 40, gradual onset, morning stiffness or night-time pain) - Spinal infection (e.g., fever or a history of IV drug use)

Answer 320

- Muscle or ligament sprain - Herniated disc - Degenerative changes

Answer 321

- Muscle or ligament strain (e.g., poor posture or repetitive activities) - Whiplash (typically after a road traffic accident) - Cervical spondylosis (degenerative changes to the vertebrae)

Answer 322

The sciatic nerve is formed of spinal nerves L4 - S3 It supplies sensation to the lateral lower leg and foot, and motor function to posterior thigh, lower leg and foot Sciatica is unilateral pain from the buttocks to the back of the thigh to below the knee or feet, "electric" or "shooting" pain

Answer 323

- "Electric" or "shooting" pain unilaterally from buttocks to the back of the thigh to below the knee or feet - Paraesthesia - Numbness - Motor weakness

Answer 324

Lumbosacral nerve root compression by: - Herniated disc - Spondylolisthesis (anterior displacement of a vertebra out of line with the one below) - Spinal stenosis

Answer 325

Cauda equina syndrome

Answer 326

Any pain = SOCRATES Key symptoms in the history: - Major trauma (spinal fracture) - Stiffness in the morning or with rest (ankylosing spondylitis) - Age under 40 (ankylosing spondylitis) - Gradual onset of progressive pain (ankylosing spondylitis or cancer) - Night pain (ankylosing spondylitis or cancer) - Age over 50 (cancer) - Weight loss (cancer) - History of cancer with potential metastasis (cauda equina or spinal metastases) - Fever (spinal infection) - IV drug use (spinal infection)

Answer 327

- Localised tenderness to the spine (spinal fracture or cancer) - Bilateral motor or sensory signs (cauda equina) - Bladder distention might indicate urinary retention (cauda equina) - Reduced anal tone on PR (Cauda equina)

Answer 328

Sciatic stretch test

Answer 329

PoRTaBLe Po - prostate R - renal Ta - thyroid B - Breast Le - Lung

Answer 330

- Non-specific back pain - usually clinical diagnosis - X-ray or CT for spinal fractures - Emergency MRI if suspected cauda equina (within hours of presentation) Suspected ankylosing spondylitis: - Inflammatory markers (CRP and ESR) - Spinal X-ray - "bamboo" spine in later stages - Spinal MRI - bone marrow oedema

Answer 331

Stratify risk of a patient developing back pain 9 questions that assess a patient's function and psychological response to the back pain - Total score out of 9 - Subscore on 4 psychological questions (out of 4) Low risk: total score ≤ 3 and subscore ≤ 3 Medium risk: total score > 3 and subscore ≤ 3 High risk: total score > 3 and subscore > 3

Answer 332

- Exclude serious underlying pathology, if so, arrange appropriate specialist review Management of non-specific back pain based on StarT Back tool Low risk: - Self-management - Education - Reassurance - Analgesia (1st line is NSAIDs, and codeine as alternative, benzo for muscle spasms) - Staying active and continuing to mobilise as tolerated

Answer 333

- Physiotherapy - Group exercise - Cognitive behavioural therapy Safety netting for red-flag symptoms

Answer 334

Similar to acute back pain NICE states NOT to use meds such as gabapentin, pregabalin, diazepam or oral corticosteroids for sciatica. NOT to use opioids for chronic sciatica Use the following neuropathic meds if symptoms are persisting or worsening: - Amitriptyline - Duloxetine Referral to specialist if no improvement

Answer 335

Polymyalgia rheumatica is an inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck Strongly associated with giant cell arteritis and they often occur together

Answer 336

- More common in older white patients - Rapid symptom onset over days to weeks - Symptoms should be present for at least 2 weeks before diagnosis is considered - Core symptoms are pain and stiffness of: - Shoulders, might radiate to upper arm and elbow - Pelvic girdle (hip), might radiate to thigh - Neck

Answer 337

- Worse in the morning - Worse after rest or inactivity - Interfere with sleep - Take at least 45 minutes to ease in the morning - Somewhat improve with activity Associated symptoms: - Systemic symptoms (e.g., weight loss, fatigue and low-grade fever) - Muscle tenderness - Carpel tunnel syndrome - Peripheral oedema

Answer 338

The symptoms are not specific to PMR and there are a long list of differentials - Osteoarthritis - Rheumatoid arthritis - Systemic lupus erythematosus - Myositis (e.g., polymyositis) - Fibromyalgia - Lymphoma or leukaemia Myeloma

Answer 339

Based on clinical presentation, response to steroids and excluding differentials NICE recommends investigations before starting steroids - Full blood count - Renal profile (U&E) - Liver function tests - Calcium (abnormal in hyperparathyroidism, cancer) - Thyroid-stimulating hormone - Creatine kinase for myositis - Rheumatoid factor for rheumatoid arthritis - Urine dipstick Additional investigations to consider: SLE: Anti-nuclear antibodies (ANA) RA: anti-cyclic citrullinated peptide (anti-CCP) Myeloma: Urine Bence Jones protein

Answer 340

15mg prednisolone daily initially Follow up after one week Should be dramatic improvement after a week (70%) Steroids for 1 - 2 years, gradually reducing: - 15mg until the symptoms are fully controlled, then - 12.5mg for 3 weeks, then - 10mg for 4-6 weeks, then - Reducing by 1mg every 4-8 weeks

Answer 341

Don't STOP mnemonic Don't - steroid dependence occurs after 3 weeks of treatment, and abruptly stopping risks adrenal crisis S – Sick day rules (steroid doses may need to be increased if the patient becomes unwell) T – Treatment card – patients should carry a steroid treatment card to alert others that they are steroid-dependent O – Osteoporosis prevention (e.g., bisphosphonates and calcium and vitamin D) P – Proton pump inhibitors for gastro-protection (e.g., omeprazole)

Answer 342

- Tiredness - Shortness of breath - Headaches - Dizziness - Palpitations - Worsening of other conditions, such as angina, heart failure or peripheral arterial disease

Answer 343

- Pale skin - Conjunctival pallor - Tachycardia - Raised respiratory rate

Answer 344

- Anaemia of chronic disease often occurs with chronic kidney disease due to reduced production of erythropoietin by the kidneys, the hormone responsible for stimulating red blood cell production. - Treatment is with erythropoietin.

Answer 345

Non-specific - Fatigue - Fever - Pallor due to anaemia - Petechiae or bruising due to thrombocytopenia - Abnormal bleeding - Lymphadenopathy - Hepatosplenomegaly

Answer 346

- Full blood count for haemoglobin and mean cell volume - Reticulocyte count (indicates red blood cell production) - Blood film for abnormal cells and inclusions - Renal profile for chronic kidney disease - Liver function tests for liver disease and bilirubin (raised in haemolysis) - Ferritin (iron) - B12 and folate - Intrinsic factor antibodies for pernicious anaemia - Thyroid function tests for hypothyroidism - Coeliac disease serology (e.g., anti-tissue transglutaminase antibodies) - Myeloma screening (e.g., serum protein electrophoresis) - Haemoglobin electrophoresis for thalassaemia and sickle cell disease - Direct Coombs test for autoimmune haemolytic anaemia

Answer 347

A lack of B12 that leads to macrocytic anaemia (mean cell volume (MCV > 95fL), the key causes of low B12 are: - Pernicious anaemia (autoimmune disorder that impairs the adsorption of B12) - Insufficient dietary B12 - Medications that reduce B12 absorption (e.g. PPI and metformin)

Answer 348

Slowly progressing cancer of the lymphoid cell line There is neoplastic proliferation of mature B lymphocytes and underproduction of the other cell types

Answer 349

The parietal cells of the stomach produce intrinsic factor, which is needed for B12 absorption in the distal ileum. In pernicious anaemia, autoantibodies target either parietal cells or intrinsic factor = lack of intrinsic factor and lack of B12 absorption

Answer 350

- Peripheral neuropathy, with numbness or paraesthesia (pins and needles) - Loss of vibration sense - Loss of proprioception - Visual changes - Mood and cognitive changes

Answer 351

- Intrinsic factor antibodies (the first-line investigation) - Gastric parietal cell antibodies (less helpful)

Answer 352

1st line: IM hydroxocobalamin Maintenance: - Pernicious anaemia - 2 - 3 monthly injections for life - Dietary - oral cyanocobalamin or twice a year injections

Answer 353

- Important to treat B12 deficiency first! - Giving patients folic acid if they have a vitamin B12 deficiency > subacute combined degeneration of the cord with demyelination of spinal cord and severe neurological problems

Answer 354

- Age: more common in 60+ - Family History - Male sex x2 risk

Answer 355

- FBC within 48 hours for patients with suspected leukaemia - 1st line: FBC - Blood film: increased number of mature lymphocytes and smudge cells - Immunophenotype Immunoglobulins: hypogammaglobulinemia Genetic analysis: identify chromosomal deletions to guide treatment - Bone marrow biopsy

Answer 356

Urgent referral to oncology and haematology - MDT involvement - Chemo and targeted therapies e.g. tyrosine kinase inhibitors (e.g. ibrutinib)

Answer 357

- Referral to oncology and haematology specialist - MDT involvement - Chemotherapy and targeted therapies e.g. tyrosine kinase inhibitors (e.g. ibrutinib)

Answer 358

A form of cancer caused by a mutation in the myeloid cells in the bone marrow resulting in inadequate production of blood cells (ineffective haematopoiesis) It has the potential to transform into acute myeloid leukaemia

Answer 359

It causes low levels of blood components that originate from the myeloid cell line: - Anaemia (low haemoglobin) - Neutropenia (low neutrophil count) - Thrombocytopenia (low platelets) Known as pancytopenia

Answer 360

- Older age - Previous chemotherapy or radiotherapy

Answer 361

FBC abnormal (pancytopenia - low RBC, low WBC, low platelets), blasts on blood film

Answer 362

Depending on the symptoms, risk of progression and overall prognosis: - Watchful waiting - Supportive treatment (e.g., blood or platelet transfusions) - Erythropoietin (stimulates red blood cell production) - Granulocyte colony-stimulating factor (stimulates neutrophil production) - Chemotherapy and targeted therapies (e.g., lenalidomide) - Allogenic (donor) stem cell transplantation (risky but potentially curative)

Answer 363

- Storage symptoms: occurs when bladder should be storing urine - need to pee FUNI Frequency, Urgency, Nocturia, (urgency) Incontinence - Voiding symptoms - occurs when the bladder outlet obstructed SHID - Voiding: (poor) Stream, Hesitancy, Incomplete emptying, Dribbling Others: straining, terminal dribbling, intermittency (stop then start

Answer 364

Benign prostatic hyperplasia is a very common condition affecting men in older age (usually over 50 years). Cause = hyperplasia of the stromal and epithelial cells of the prostate.

Answer 365

- Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate - Abdominal examination to assess for a palpable bladder - Urinary frequency volume chart, recording 3 days of fluid intake and output - Urine dipstick - infection, haematuria (e.g., due to bladder cancer) - Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference

Answer 366

- Benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus - A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus

Answer 367

1st line: lifestyle advice and modification if the patient has mild (non-bothersome) symptoms: treat constipation, reduce caffeine and fluid intake, medication review, bladder retraining.

Answer 368

- Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms - 5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate

Answer 369

PSA is usually used to screen for prostate cancer. However, many things can also raise PSA levels, such as benign prostate hyperplasia, prostatitis or UTI. Therefore, it is not a specific test for prostate cancer as it can be raised even if the patient does not have prostate cancer.

Answer 370

AN infection that involves the bladder, causing cystitis (inflammation of the bladder). It can potentially spread up to the kidneys and cause pyelonephritis

Answer 371

Primary source of bacteria from faeces, and bacteria can easily move from anus to urethral opening E.coli is the most common causative organism

Answer 372

- Dysuria (pain, stinging or burning when passing urine) - Suprapubic pain or discomfort - Frequency - Urgency - Incontinence - Haematuria - Cloudy or foul smelling urine - Confusion is commonly the only symptom in older and frail patients

Answer 373

Fever Loin/back pain Nausea/vomiting Renal angle tenderness on examination Can potentially lead to sepsis and kidney scarring

Answer 374

- Nitrite present: bacteria present as gram-negative bacteria (e.g. E.coli) break down nitrates to nitrites - Leukocytes - normal to have a small amount in urine, but raised indicates infection - RBC= can detect microscopic haematuria UTI if presences of nitrites or leukocytes + red blood cells If not, UTI diagnosed only if nitrites are present

Answer 375

A MSU sample is sent for microscopy, culture and sensitivity to determine the infective organism and antibiotics Not all patients with uncomplicated UTI will need a MSU, more important in: - Pregnant patients - Patients with recurrent - UTIs - Atypical symptoms - If abx ineffective

Answer 376

- Trimethoprim (Avoid in first trimester) - Nitrofurantoin (avoided in patients with an eGFR <45 and third trimester) 3 days for simple UTI in women - 5 to 10 days in immunosuppressed women, abnormal anatomy or impaired kidney function - 7 days of abx for men, pregnant women

Answer 377

- 7 days of antibiotics - MSU for microscopy, culture and sensitivity Antibiotics: - Nitrofurantoin (avoid in the third trimester as risk of neonatal haemolysis) - Trimethoprim (avoid in first trimester as folate antagonist) - Amoxicillin (only after sensitivities are known) - Cefalexin

Answer 378

Most common cancer in men. 95% are adenocarcinomas

Answer 379

- Increasing age - Family history - Black African or Caribbean origin - Tall stature - Anabolic steroids

Answer 380

- Might be asymptotic - LUTS (similar to BPH) e.g. hesitancy, frequency, weak flow, terminal dribbling and nocturia - Haematuria - Erectile dysfunction - Weight loss, bone pain, cauda equina syndrome indicate advanced or metastatic disease

Answer 381

- Prostate cancer - Benign prostatic hyperplasia - Prostatitis - Urinary tract infections - Vigorous exercise (notably cycling) - Recent ejaculation or prostate stimulation It can lead to early detection of prostate cancer however, high rate of false positive (75%) and false negatives (15%)

Answer 382

Counselling a patient about whether to have a PSA test is a common OSCE scenario. Tests whether you understand the implications of false positives and negatives and whether you can explain this to a patient to allow them to make an informed decision. False positives might lead to further investigations. invasive prostate biopsies and lead to unnecessary diagnosis and treatment of prostate that would never have caused problems . False negatives might lead to false reassurances

Answer 383

Benign prostate = smooth, symmetrical and slightly soft, with maintained central sulcus (the dip in the middle between the right and left lobe) Cancerous prostate = firm or hard, asymmetrical, craggy or irregular with loss of central sulcus. There might be hard nodule. The above might indicate prostate cancer warrants a 2WW urgent cancer referral to urology.

Answer 384

- 1st line for suspected localised prostate cancer: multiparametric MRI, reported on a Likert scale (1- very low suspicion to 5 - definite cancer) - Next step = prostate biopsy (if Likert 3 or above) or clinical suspicion - Isotope bone scan to look for bony metastasis

Answer 385

Grading system for prostate cancer based on histology of prostate biopsies Made up of two numbers added up: the grade of the most prevalent pattern and grade of the second most prevalent pattern 6: low risk 7: intermediate risk 8 or above: high risk

Answer 386

T - Tumour, N (lymph node) and M (metastasis) T for Tumour: TX – unable to assess size T1 – too small to be felt on examination or seen on scans T2 – contained within the prostate T3 – extends out of the prostate T4 – spread to nearby organs N for Nodes: NX – unable to assess nodes N0 – no nodal spread N1 – spread to lymph nodes M for Metastasis: M0 – no metastasis M1 – metastasis

Answer 387

- Surveillance or watchful waiting in early prostate cancer - External beam radiotherapy directed at the prostate - Brachytherapy (implanting radioactive metal "seeds" into the prostate) - Hormone therapy e.g. androgen deprivation (surgery to lower testosterone levels) or blockade (drugs to block testosterone) - Surgery e.g. bilateral orchidectomy

Answer 388

Testicular cancer arises from the germ cells in the testes. Germ cells are cells that produce gametes (sperm in males). Two types: - Seminomas - Non0seminomas (mostly teratomas)

Answer 389

- Undescended testes - Male infertility - Family history - Increased height

Answer 390

Typical presentation: Painless lump that is: - Non-tender (or even reduced sensation) - Arising from testicle - Hard - Irregular - Not fluctuant - No transillumination

Answer 391

- 1st line: scrotal ultrasound Tumour markers: - Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas) - Beta-hCG – may be raised in both teratomas and seminomas - Lactate dehydrogenase (LDH) is a very non-specific tumour marker - Staging CT scans

Answer 392

Royal Marsden staging system: - Stage 1 – isolated to the testicle - Stage 2 – spread to the retroperitoneal lymph nodes - Stage 3 – spread to the lymph nodes above the diaphragm - Stage 4 – metastasised to other organs

Answer 393

- Lymphatics - Lungs - Liver - Brain

Answer 394

- MDT to decide best course of action for the patient Depending on the grade and stage of testicular cancer: - Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted - Chemotherapy - Radiotherapy - Sperm banking to save sperm for future use, as treatment may cause infertility

Answer 395

Significant as most patients are young and expect to live for a long time after treatment: - Infertility - Hypogonadism (testosterone replacement may be required) - Peripheral neuropathy - Hearing loss - Lasting kidney, liver or heart damage - Increased risk of cancer in the future

Answer 396

- Early testicular cancer - 90% cure rate - Metastatic disease can be curable - Patients will need follow-up to monitor for reoccurrence - tumour markers, imaging CT scans and CXR

Answer 397

A hydrocele is a collection of serous fluid between the layers of the membrane (tunica vaginalis) that surrounds the testis or along the spermatic cord. The tunica vaginalis is a sealed pouch of membrane that surrounds the testes.

Answer 398

- Patients will present with a testicular lump - The testicle is palpable within the hydrocele - Soft, fluctuant and may be large - Irreducible and has no bowel sounds (distinguishing it from a hernia) - Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)

Answer 399

- Idiopathic - Testicular cancer - Testicular torsion - Epididymo-orchitis - Trauma

Answer 400

- Ultrasound to confirm diagnosis - Exclude serious pathology (e.g. cancer) - Idiopathic or smaller hydrocele = conservative - Symptomatic/large - surgery, aspiration or sclerotherapy (injection technique to scar and resolve the hydrocele)

Answer 401

A varicocele occurs when the veins in the pampiniform plexus become swollen - common (15% men) It can impair fertility, likely due to impaired temperature control in the affected testicle. It can also lead to testicular atrophy

Answer 402

A network of veins in the spermatic cord and drains the testes into the testicular vein. Regulates temperature of blood entering the testes as the testicles need to be at an optimum temperature for producing sperm.

Answer 403

- Varicoceles are due to increased resistance in the testicular vein. - Right testicular vein drains directly into the IVC and the left testicular vein drains into the left renal vein, so increased resistance. - Left-sided varicocele may indicate obstruction of the left testicular vein due to renal cell carcinoma

Answer 404

- Throbbing/dull pain or discomfort, worse on standing - A dragging sensation - Sub-fertility or infertility

Answer 405

- A scrotal mass that feels like a “bag of worms” - More prominent on standing - Disappears when lying down - Asymmetry in testicular size if the varicocele has affected the growth of the testicle

Answer 406

- USS with Doppler imaging to confirm diagnosis - Semen analysis if concerns about fertility - Hormonal tests (e.g. FSH and testosterone) if concerns about function

Answer 407

- Uncomplicated = conservative management - Surgery or endovascular embolisation indicated for pain, testicular atrophy or infertility

Answer 408

Cysts that occur at the top of the tests (epididymis) Fluid-filled or sperm-filled (spermatocele) Very common - 30% of adult men

Answer 409

- Usually asymptotic - Examination findings: - Soft, round lump - Typically at top of testicle - Separate from testicle, associated with the epididymis - Large cysts - transilluminate (separate from testicle)

Answer 410

Usually harmless, not associated with infertility or cancer Occasionally might cause pain or discomfort and removal might be considered.

Answer 411

Diffuse inflammation of the skin and subdermis of the external ear canal. Might involve the pinna or tympanic membrane. Acute: inflammation < 6 weeks Chronic: inflammation > 6 weeks

Answer 412

Acute - usually bacterial staphylococcus aureus and pseudomonas aeruginosa Chronic - fungal cause e.g. Aspergillus or candida albicans

Answer 413

Acute otitis externa: underlying skin conditions e.g. contact dermatitis, otitis media, trauma to ear canal Chronic otitis externa: diabetes mellitus, immunocompromise, prolonged antibiotic or corticosteroid use

Answer 414

- Ear pain - Discharge - Itchiness - Conductive hearing loss

Answer 415

- Erythema and swelling in the ear canal that might extend to the tympanic membrane - Tenderness of the ear canal - Pus or discharge in the ear canal - Lymphadenopathy (swollen lymph nodes) in the neck or around the ear

Answer 416

Clinical diagnosis with examination of the ear canal using an otoscope Ear swab for causative organism but not usually required

Answer 417

Mild = acetic acid 2% (OTC EarCalm) - both antibacterial and antifungal Moderate = topical antibiotics and steroids: - Neomycin, dexamethasone and acetic acid (e.g., Otomize spray - most common, so REMEBER THIS) - Aminoglycosides (e.g. gentamicin or neomycin) = potentially ototoxic if pas the tympanic membrane, so rule out perforated eardrum before prescribing - Fungal = clotrimazole ear drops

Answer 418

Oral abx e.g. flucloxacillin Or discussion with ENT for admission and IV abx

Answer 419

Severe potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. Progresses to osteomyelitis of the temporal bone of the skull

Answer 420

- Diabetes - Immunosuppressant medications (e.g., chemotherapy) - HIV

Answer 421

Severe, unremitting pain, purulent ear discharge, fever, hearing loss, granulation tissue in the ear canal, possible facial nerve palsy. Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding.

Answer 422

- Emergency! - Admit to hospital under ENT team - IV antibiotics - CT/MRI to assess extent of infection

Answer 423

- Facial nerve damage and palsy - Meningitis - Intracranial thrombosis - Death

Answer 424

Inflammation of the tonsils Most common is viral infection If bacterial - most common cause is group A streptococcus (S. pyogenes)

Answer 425

- Sore throat - Fever (> 38) - Pain on swallowing Examination of the throat = red, inflamed and enlarged tonsils with/without exudates - small, white patches of pus on the tonsils

Answer 426

Estimates the probability that tonsillitis is due to bacterial infection and benefit from antibiotics score ≥ 3 = 40 - 60% possibility of bacterial tonsillitis and abx offered: 1 point for each: - Fever over 38ºC - Tonsillar exudates - Absence of cough - Tender anterior cervical lymph nodes (lymphadenopathy)

Answer 427

Alternative to Centor score Score 2 - 3 = 34 - 40% probability Score 4 - 5 = 62 - 65% probability of bacterial tonsillitis - Fever during previous 24 hours - P – Purulence (pus on tonsils) - A – Attended within 3 days of the onset of symptoms - I – Inflamed tonsils (severely inflamed) - N – No cough or coryza

Answer 428

- Consider admission if patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or peritonsillar abscess (quinsy) or cellulitis. - Calculate Centor or feverPAIN score - If viral: educate patients and give safety net advice - Management with simple analgesia with paracetamol and ibuprofen - NICE recommends that patients return if pain does not settle after 3 days or fever rises above 38.3 - consider antibiotics or alternative diagnosis - Antibiotics if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4. - Also, consider antibiotics if young infants, immunocompromised patients or significant co-morbidity - Delayed prescription - antibiotics for collection only if symptoms worsen or do not improve in next 2 - 3 days

Answer 429

1st line: penicillin V (phenoxymethylpenicillin) for 10 days Clarithromycin if penicillin allergy

Answer 430

- Peritonsillar abscess (quinsy) - Otitis media - Scarlet fever - Rheumatic fever - Post-streptococcal glomerulonephritis - Post-streptococcal reactive arthritis

Answer 431

Inflammation of the conjuctiva - a thin layer of tissue that covers the inside of the eyelids and sclera It can be caused by viruses, bacteria or allergy Unilateral or bilateral

Answer 432

- Red, bloodshot eye - Itchy or gritty sensation - Discharge Please note that conjunctivitis does not cause pain, photophobia or reduced visual acuity

Answer 433

- Purulent discharge - Usually worse in the morning when eyes are stuck together - Highly contagious

Answer 434

- Common and presents with a clear discharge - Associated with other symptoms of viral infection e.g. dry cough, sore throat and blocked nose, tender pre-auricular lymph nodes (in front of the ears) - Contagious

Answer 435

Causes of an acute painful red eye include: - Acute angle-closure glaucoma -Anterior uveitis - Scleritis - Corneal abrasions or ulceration - Keratitis (corneal infection) - Foreign body - Traumatic or chemical injury Causes of an acute painless red eye include: - Conjunctivitis - Episcleritis - Subconjunctival haemorrhage Pain or reduced visual acuity warrant an emergency same-day referral to ophthalmology

Answer 436

- Resolves in 1 -2 weeks (viral and bacterial) - Hygiene measures to reduce spread (e.g. avoid towel sharing and close contact and regular hand washing) - Clean eye with cool boiled water and cotton wool to clear discharge - Neonates < 1m need urgent ophthalmology assessment as it might be caused by gonococcal infection and can cause permanent vision loss

Answer 437

- Conjunctivitis that occurs due to contact with allergens - Causes swelling of conjunctival sac and eyelid with itching and watery discharge - Antihistamines to relieve symptoms - Topical mast-cell stabiliser can be used in patients with chronic seasonal symptoms

Answer 438

- Seasonal e.g. UK only has enough sunlight in spring and summer months (lol not even then) - Dietary deficiency - Skin colour - darker skin requires more sunlight exposure - Clothing cover - e.g. religious/cultural reasons - Malabsorption diseases e.g. coeliac - End-stage renal failure

Answer 439

Check vitamin D levels by measuring serum 25-hydroxyvitamin D (25[OH]D) only if symptomatic: - MSK symptoms: e.g. suspected osteomalacia, suspected osteoporosis - Less than 25 nmol/L – vitamin D deficiency - 25 to 50 nmol/L – vitamin D insufficiency

Answer 440

Colecalciferol (vitamin D₃) Example loading regime: - 50,000 IU once weekly for 6 weeks - Or 4000 IU daily for 10 weeks A maintenance dose of 800-2000 IU per day is continued following the loading regime (or as the initial treatment in patients that do not require rapid treatment.)

Answer 441

Colecalciferol (vitamin D₃) Example loading regime: - 50,000 IU once weekly for 6 weeks - Or 4000 IU daily for 10 weeks A maintenance dose of 800-2000 IU per day is continued following the loading regime (or as the initial treatment in patients that do not require rapid treatment.)