GENERAL PRACTICE 2 - Sexual Health, Contraception, Infect Dis, Derm, MSK Flashcards

Question

What are the contraindications of the COCP?

Answer 1

Uncontrolled hypertension Migraine with aura History of VTE **Aged 35 and smoking 15 cigarettes a day** Surgery Vascular disease IHD Liver cirrhosis SLE **Having just given birth as they will already in a prothrombotic state**

Answer 2

**If started on day 1-5 of menstrual cycle then protection is immediate** If started after this then it takes 7 days to have protection

Answer 3

Dianette and other COCPs containing cyproterone acetate (i.e. co-cyprindiol) can be considered in the treatment of acne and hirsutism. Cyproterone acetate has anti-androgen effects, helping to improve acne and hirsutism. Greater risk of VTE though

Answer 4

theoretically women will be protected if they perfectly take the pill in a cycle of 7 days on, 7 days off. This will prevent ovulation. Missing one pill is when the pill is more than 24 hours late (48 hours since the last pill was taken). Missing one pill (less than 72 hours since the last pill was taken): Take the missed pill as soon as possible (even if this means taking two pills on the same day) No extra protection is required provided other pills before and after are taken correctly

Answer 5

Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day) Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight

Answer 6

If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period. Theoretically, additional contraception is not required if more than one pill is missed between day 8 – 21 (week 2 or 3) of the pill packet and they otherwise take the pills correctly, although it is recommended for extra precaution. 7 days on, 7 days off xx

Answer 7

The traditional progestogen-only pill ( Norgeston or Noriday ) cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”. The desogestrel-only pill (Cerazette) can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”. Postpartum women (breastfeeding and non-breastfeeding) can start the progestogen-only pill at any time postpartum Contraception is not required before day 21 postpartum

Answer 8

Traditional progestogen-only pills work mainly by: Thickening the cervical mucus Altering the endometrium and making it less accepting of implantation Reducing ciliary action in the fallopian tubes *taken 3 hours or later = missed pill*

Answer 9

Desogestrel works mainly by: **Inhibiting ovulation** Thickening the cervical mucus Altering the endometrium Reducing ciliary action in the fallopian tubes 12 hours late = missed pill

Answer 10

Active Breast Cancer

Answer 11

Both can be started within the first 5 days of the menstrual cycle and work immediately, as it is very unlikely a woman will ovulate this early in the cycle. Postpartum women (breastfeeding and non-breastfeeding) can start the progestogen-only pill at any time postpartum Contraception is not required before day 21 postpartum

Answer 12

It can be started at other times of the cycle provided pregnancy can be excluded. **Additional contraception is required for 48 hours**. It takes 48 hours for the **cervical mucus to thicken enough** to prevent sperm entering the uterus. The POP can be started even if there is a risk of pregnancy, as it is not known to be harmful in pregnancy. However, the woman should do a pregnancy test 3 weeks after the last unprotected intercourse. POPs are only effective on the day taken - missing even one day reduces effectiveness. Patient should be advised to use condoms for the next two days

Answer 13

Changes to the bleeding schedule is one of the primary adverse effects of the progestogen-only pill. Unscheduled bleeding is common in the first three months and often settles after that. Approximately: 20% have no bleeding (amenorrhoea) 40% have regular bleeding 40% have irregular, prolonged or troublesome bleeding Other side effects include: Breast tenderness Headaches Acne Increased risk of depression

Answer 14

depot medroxyprogesterone acetate (a type of progestin). DMPA Women need to have injections every 12 – 13 weeks. Delaying past 13 weeks creates a risk of pregnancy. The FSRH guidelines say it can be given as early as 10 weeks and as late as 14 weeks after the last injection where necessary, but this is unlicensed.

Answer 15

The main action of the depot injection is to inhibit ovulation. It does this by inhibiting FSH secretion by the pituitary gland, preventing the development of follicles in the ovaries. Additionally, the depot injection works by: Thickening cervical mucus Altering the endometrium and making it less accepting of implantation

Answer 16

Changes to the bleeding schedule is one of the primary considerations with progestogen-only contraception. Reduced bone mineral density (osteoporosis) = Oestrogen helps maintain bone mineral density in women, produced by the follicles in the ovaries. Weight gain is also a key side effect ***Only form of contraception that causes weight gain and osteoporosis*** - so wouldnt be first choice in a young woman, long term

Answer 17

The progestogen-only implant is a small (4cm) flexible plastic rod that is placed in the upper arm, beneath the skin and above the subcutaneous fat. It slowly **releases progestogen into the systemic circulation**. It lasts for **three years and then needs replacing**. The primary mode of action of the contraceptive implant is inhibition of ovulation The only UKMEC 4 criteria for the implant is active breast cancer.

Answer 18

1/3 have infrequent bleeding 1/4 have frequent or prolonged bleeding 1/5 have no bleeding The remainder have normal regular bleeds Problematic bleeding is managed similarly to the progestogen-only implant. The FSRH guidelines suggest the combined oral contraceptive pill **(COCP) in addition** to the implant for three months when problematic bleeding occurs, to help settle the bleeding (provided there are no contraindications). *(med school mock said POP)* The primary mode of action of the contraceptive implant is inhibition of ovulation

Answer 19

There are two types of intrauterine device (IUD): Copper coil (Cu-IUD): contains copper and creates a hostile environment for pregnancy Levonorgestrel intrauterine system (LNG-IUS): contains progestogen that is slowly released into the uterus

Answer 20

Screen for Chlamydia and Gonorrhoea before insertion of the coil in women at risk of STD (ie under 25 years old) Perform Bimaniaul (pelvic) exam beforehand, to check postion and size of uterus Record BP and heart rate before and after

Answer 21

When the coil threads cannot be seen or palpated, three things need to be excluded: Expulsion Pregnancy Uterine perforation Before the coil is removed, women need to abstain from sex or use condoms for 7 days, or there is a risk of pregnancy.

Answer 22

It can cause heavy or intermenstrual bleeding (this often settles) Some women experience pelvic pain It does not protect against sexually transmitted infections Increased risk of ectopic pregnancies Can fall out Related to the IUS There can be systemic absorption causing side effects of acne, headaches, or breast tenderness

Answer 23

There are four types of IUS you may come across, all containing levonorgestrel: Mirena: effective for 5 years for contraception, and also licensed for menorrhagia and HRT The IUS to remember is the Mirena coil. It is commonly used for contraception, menorrhagia and endometrial protection for women on HRT. It is licensed for 5 years for contraception, but only 4 years for HRT.

Answer 24

The LNG-IUS works by releasing levonorgestrel (progestogen) into the local area: Thickening cervical mucus Altering the endometrium and making it less accepting of implantation Inhibiting ovulation in a small number of women

Answer 25

Copper: Reliable contraception It can be inserted at any time in the menstrual cycle and is effective immediately It contains no hormones, so it is safe for women at risk of VTE or with a history of hormone-related cancers It may reduce the risk of endometrial and cervical cancer IUD: Can make periods lighter No effect on bone mineral density (unlike the depo injection) No increase in thrombosis risk (unlike the COCP) No restrictions for use in obese patients (unlike the COCP) The Mirena has additional uses (i.e. HRT and menorrhagia)

Answer 26

IUD - Copper coil is most effective and should be offered first, but in practise most women tend to go for one of the 2 oral hormonal methods. Cant have copper coil if receiving treatment for a STI! Coil can be used within 120 hours of UPSI, OR up to 5 days after the likely ovulation date 2 types of hormone contraceptives = levonorgestrel and ulipristal,

Answer 27

both levonorgestrel and ulipristal (sold as EllaOne) are **progesterone receptor modulators.** Ulipristal may **reduce the effectiveness of hormonal contraception.** Contraception with the pill, patch or ring should be **started, or restarted, 5 days after having ulipristal.** Barrier methods should be used during this period caution should be exercised in patients with severe asthma There are no such restrictions on the use of levonorgestrel Levonorgestrel should only be given up to 3 days after UPSI. After this, it is not as effective

Answer 28

Diseases of malabsorption (eg. Crohns), Allergy, **Severe hepatic dysfunction**, patient taking rifampicin, **Breast feeding, Asthma**, drugs increasing gastric pH (omeprazole, ranitidine)

Answer 29

single dose of levonorgestrel 1.5mg (a progesterone) the dose should be doubled for those with a BMI >26 or weight over 70kg ulipristal - 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse

Answer 30

Contraceptives - time until effective (if not first day period): instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS

Answer 31

Widespread muscle pain of >3 months Pain Pain worse with stress, cold weather activity Morning stiffness <1 hour Non-restorative sleep Headache/diffuse abdominal pain

Answer 32

Neurocognitive features Poor sleep Fatigue Mood disorder Poor concentration Memory

Answer 33

Problems with pain signals **Low serotonin – inhibits pain signals** **Raised substance P and nerve growth factor** – increased pain signals

Answer 34

**Diagnosis of fibromyalgia is based on clinical features:** - **Chronic pain** that has been present for at least 3 months - **Widespread pain** - involved left and right sides, above and below waist, and the axial skeleton. - **Palpate tender point sites** - severe pain in 3 to 6 different areas of your body, or you have milder pain in 7 or more different areas **- No other reason for symptoms has been found**

Answer 35

TFTs – rule out hypothyroidism ANAs and dsDNA – to exclude SLE ESR and CRP – to exclude Polymyalgia rheumatica (PMR) Calcium and electrolytes – to exclude high calcium Vitamin D – to rule out low vitamin D Examine patient and CRP – to rule out inflammatory arthritis

Answer 36

MDT approach *advise there is not one specific treatment that will defo work* **Regular exercise for CV fitness** eg fast walking, biking, swimming, or water aerobics can help by reducing pain and fatigue. - **Relaxation techniques and good sleep hygiene** can also help. - **Physiotherapy and rehabilitation** - **CBT**

Answer 37

- **Amitriptyline** - tricyclic antidepressant - **Serotonin-norepinephrine reuptake inhibitors (SNRIs)** e.g. duloxetine Anticonvulsants like pregabalin and gabapentin which slow nerve impulses *Steroids or NSAIDS are not recommended because there is no inflammation (if it does respond, reconsider your diagnosis!)*

Answer 38

Otitis externa is a condition that causes inflammation (redness and swelling) of the external ear canal, which is the tube between the outer ear and eardrum.

Answer 39

Ear pain Discharge Itchiness Conductive hearing loss (if the ear becomes blocked) Examination can show: Erythema and swelling in the ear canal Tenderness of the ear canal Pus or discharge in the ear canal

Answer 40

advise analgesia, e.g. paracetamol 9 ibuprofen * prescribe ear drops—options are: **aluminium acetate drops (as effective as antibiotics)**; and antibiotic and/or steroid drops Avoid going in water/inserting things into your ear Skin of the pinna adjacent to the ear canal is often affected by eczema. Treat with topical corticosteroid cream/ointment—avoid prolonged use

Answer 41

The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull. Diabetes Immunosuppressant medications (e.g., chemotherapy) HIV

Answer 42

- Infection of the middle ear which is the space that sits between the tympanic membrane and the inner ear - This is where the nerves are found

Answer 43

- Bacteria enter from the back of the thorat through the eustachian tube - Strep pneumoniae is most common - A Viral URTI often precedes otitis media

Answer 44

- **Ear pain** - Reduced hearing - Feeling unwell - Signs of URTI

Answer 45

- Otoscope tympanic membrane will look bulging red and perforation will show discharge and hole in tympanic membrane

Answer 46

Most otitis media cases will resolve without antibiotics within around three days, sometimes up to a week. Antibiotics make little difference to symptoms or complications. Amoxicillin for 5-7 days first-line Clarithromycin (in pencillin allergy) Erythromycin (in pregnant women allergic to penicillin)

Answer 47

Its inflammation and accumulation of fluid in the middle ear, without any symptoms of acute inflammation Earache/hearing loss may not be present Behavioural problems should alert the GP to assess a child for OM with effusion

Answer 48

Ringworm is a fungal infection of the skin and **also known as tinea** Fungal infections have specific names depending on the area they affect: Tinea capitis refers to ringworm affecting the scalp (caput meaning head) Tinea pedis refers to ringworm affecting the feet, also known as athletes foot (pedis meaning foot) Tinea corporis refers to ringworm on the body (corporis meaning body) Onychomycosis refers to a fungal nail infection

Answer 49

Ringworm presents as an itchy rash that is erythematous, scaly and well demarcated. Tinea capitis can present with well demarcated hair loss. There will also be itching, dryness and erythema of the scalp. This is more common in children than adults. Tinea pedis (athletes foot) presents with white or red, flaky, cracked, itchy patches between the toes. The skin may split and bleed. Onychomycosis (fungal nail infections) presents with thickened, discoloured and deformed nails. TOM TIP: Check the toenails in someone presenting with ringworm, you may find they have a fungal nail infection that has spread to the skin.

Answer 50

Treatment of ringworm is with anti-fungal medications: Anti-fungal creams such as clotrimazole and miconazole Anti-fungal shampoo such as ketoconazole for tinea capitis Oral anti-fungal medications such as fluconazole, griseofulvin and itraconazole

Answer 51

Scabies are tiny mites called Sarcoptes scabiei that burrow under the skin causing infection and intense itching. They lay eggs in the skin, leading to further infection and symptoms. It can take up to 8 weeks for any symptoms or rash to appear after the initial infestation.

Answer 52

Scabies presents with incredibly itchy small red spots, (papular rash) possibly with track marks where the mites have burrowed. The classic location of the rash is between the finger webs, but it can spread to the whole body. Itching tends to be worse at night.

Answer 53

Treatment is with **permethrin cream.** This needs to be applied to the whole body, completely covering skin. It is best to do this when the skin is cool (i.e. not after a bath or shower) The cream should be left on for 8 – 12 hours and then washed off. This should be repeated a week later to kill all the eggs that survived the first treatment and have now hatched. When one person is diagnosed, all household and close contacts should also be treated in exactly the same way, even if asymptomatic. This is because they may be infected and not yet have symptoms.

Answer 54

Warts are non-cancerous viral growths usually occurring on the hands and feet but can also affect other locations, such as the genitals or face. Warts are caused by the human papillomavirus (HPV). There are about 130 known types of human papillomaviruses. HPV infects the squamous epithelium, usually of the skin or genitals

Answer 55

Salicylic acid (wart paints), or cryotherapy

Answer 56

Mumps is a viral infection spread by respiratory droplets. Taking a vaccination history is essential when considering a diagnosis of mumps. The MMR vaccine offers around 80% protection against mumps.

Answer 57

Patients experience an initial period of flu-like symptoms known as the prodrome. These occur a few days before the parotid swelling: Fever Muscle aches Lethargy Reduced appetite Headache Dry mouth Parotid gland swelling, either unilateral or bilateral, with associated pain is the key feature that should make you consider mumps.

Answer 58

The diagnosis can be confirmed using PCR testing on a saliva swab. The blood or saliva can also be tested for antibodies to the mumps virus. Mumps is a notifiable disease, meaning you need to notify public health of any suspected and confirmed cases. Management is supportive, with rest, fluids and analgesia. Mumps is a self limiting condition. Management of complications is also mostly supportive.

Answer 59

It can also present with symptoms of the complications, such as: Abdominal pain (pancreatitis) Testicular pain and swelling (orchitis) Confusion, neck stiffness and headache (meningitis or encephalitis)

Answer 60

B burgdorferi

Answer 61

- Tick bite with rash called **erythema migrans** - *(resembles a bulls eye)* - Fever - Headache - Myalgias - Stiff neck - Facial palsy

Answer 62

**Doxycycline**, unless there is just a rash that can't be distinguished from cellulitis then use **amoxicillin**

Answer 63

nfection with the Epstein Barr virus (EBV). It is commonly known as the “kissing disease”, “glandular fever” or “mono” This virus is found in the saliva of infected individuals. Infection may be spread by kissing or by sharing cups, toothbrushes and other equipment that transmits saliva.

Answer 64

Features Fever Sore throat Fatigue Lymphadenopathy (swollen lymph nodes) Tonsillar enlargement Splenomegaly and in rare cases splenic rupture Virus targets circulating B lymphocytes (lifelong latent infection) and squamous epithelial cells of oropharynx

Answer 65

In infectious mononucleosis, the body produces something called heterophile antibodies, which are antibodies that are more multipurpose and not specific to the EBV antigens *(takes 6 weeks for them to be produced)* We can test for these heterophile antibodies using two tests: Monospot test: this introduces the patient’s blood to red blood cells from horses. Heterophile antibodies (if present) will react to the horse red blood cells and give a positive result. Paul-Bunnell test: this is similar to the monospot test but uses red blood cells from sheep. These tests are almost 100% specific for infectious mononucleosis, however not everyone who has IM produces heterophile antibodies, and it can take up to six weeks for the antibodies to be produced. Therefore they are only 70 – 80% sensitive.

Answer 66

- Is usually self-limiting and lasts 2-3 weeks but can cause fatigue for several months

Answer 67

Mononucleosis causes an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins. *Look out for the exam question that describes an adolescent with a sore throat, who develops an itchy rash after taking amoxicillin*

Answer 68

- Avoid alcohol as EBV impacts the livers ability to process it - Avoid contact sports due to risk of splenic rupture

Answer 69

Splenic rupture Glomerulonephritis Haemolytic anaemia Thrombocytopenia Chronic fatigue EBV infection is associated with certain cancers, notable Burkitt’s lymphoma.

Answer 70

Aged 65 and over Young children Pregnant women Chronic health conditions, such as asthma, COPD, heart failure and diabetes Healthcare workers and carers

Answer 71

Delay between exposure/Sx typically ~2d **Fever** Lethargy and fatigue Anorexia (loss of appetite) Muscle and joint aches Headache Dry cough Sore throat Coryzal symptoms

Answer 72

Flu tends to have an abrupt onset, whereas a common cold has a more gradual onset. Fever is a typical feature of the flu but is rare with a common cold. Finally, people with the flu are “wiped out” with muscle aches and lethargy, whereas people with a cold can usually continue many activities.

Answer 73

Point-of-care tests using swabs are available, giving a rapid result. They detect viral antigens Viral nasal or throat swabs can be sent to the local virology lab for polymerase chain reaction (PCR) analysis

Answer 74

For complications * Oral oseltamivir (BD for 5d) Inhaled zanamivir (BD for 5d) PEP * Oral oseltamivir 75mg OD for 1od Inhaled zanamivir 10mg OD for 10d

Answer 75

Otitis media, sinusitis, bronchitis Viral pneumonia 2y bacterial pneumonia Worsening chronic health conditions - COPD, HF Febrile convulsions (young children) Encephalitis

Answer 76

A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy

Answer 77

ypically starts after the chancre has healed, with symptoms of: Maculopapular rash **Condylomata lata** (grey wart-like lesions around the genitals and anus) Low-grade fever Lymphadenopathy Alopecia (localised hair loss) Oral lesions

Answer 78

Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test or Samples from sites of infection can be tested to confirm the presence of T. pallidum with: Dark field microscopy Polymerase chain reaction (PCR)

Answer 79

. As with all sexually transmitted infections, patients need: Full screening for other STIs Advice about avoiding sexual activity until treated Contact tracing Prevention of future infections A single deep **intramuscular dose of benzathine benzylpenicillin (penicillin)** is the standard treatment for syphilis.

Answer 80

MC cause is a viral infection Rhinovirus Coronavirus Adenovirus In tonsillitis associated with infectious mononucleosis, MC is EBV

Answer 81

bacterial tonsillitis = group A streptococcus pyogenes 2nd MC cause bacterial = streptococcus pneumoniae Other bacterial causes: H.influenzae M.catarrhalis S.aureus

Answer 82

Waldeyer's tonsillar ring * In pharynx at back of throat = ring of lymphoid tissue * 6 areas of lymphoid tissue in Waldeyer's ring (adenoids, tubal tonsils, palatine tonsils + lingual tonsil) * Palatine tonsils typically infected & enlarged in tonsillitis = tonsils at either side at back of throat

Answer 83

O/E - throat red, inflamed, enlarged tonsils ± exudates (small white patches of pus on tonsils) Tonsillar erythema + enlargement Also may be **anterior cervical lymphadenopathy (swollen, tender lymph nodes in anterior triangle of neck)** ==> Tonsillar lymph nodes just behind angle of mandible Sore throat (sudden onset) Fever (above 38º) Pain on swallowing Headache Abdo pain

Answer 84

- Used to estimate the probability that the tonsillitis is due to a bacterial infection Fever over 38 Exudate on tonsils Absence of cough Tender cervical lymph nodes **FEAT** A score of 3 or more indicates a 40-60% likelihood it is bacterial

Answer 85

A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 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 86

Mostly self limiting and resolve spontaneously Analgesia, fluids Admission if: * Immunocompromised * Systemically unwell * Dehydrated * Has stridor * Respiratory distress Evidence of peritonsillar abscess or cellulitis

Answer 87

Throat culture Rapid streptococcal antigen test (+ve for GABHS) Other serological testing WBC count - raised neutrophil ± lymphocyte count HIV viral load assay to rule out

Answer 88

Consider ABX prescription if CENTOR score 3+ or feverPAIN 4+ **Penicillin V (phenoxymethylpenicillin)** 10 day course = 1st line (relatively narrow spectrum + effective against **S.pyogenes**) **Clarithromycin** 1st line in penicillin allergy *Clarithromycin interacts with atorvastatin and increases the risk of rhabdomyolysis, so it is advised to stop atorvastatin during courses of clarithromycin.* For recurrent episodes of tonsillitis -> tonsillectomy

Answer 89

Sinusitis refers to inflammation of the paranasal sinuses in the face. This is usually accompanied by inflammation of the nasal cavity and can be referred to as rhinosinusitis.

Answer 90

The paranasal sinuses are hollow spaces within the bones of the face, arranged symmetrically around the nasal cavity. They produce mucous and drain into the nasal cavities via holes called ostia. Blockage of the ostia prevents drainage of the sinuses, resulting in sinusitis.

Answer 91

Acute (less than 12 weeks) Chronic (more than 12 weeks) Inflammation of the sinuses can be caused by: Infection, particularly following viral upper respiratory tract infections Allergies, such as hayfever (with allergic rhinitis) Obstruction of drainage, for example, due to a foreign body, trauma or polyps Smoking Patients with asthma are more likely to suffer from sinusitis.

Answer 92

The typical presentation of acute sinusitis is someone with a recent **viral upper respiratory tract infection presenting with**: Nasal congestion Nasal discharge Facial pain or headache Facial swelling over the affected areas Loss of smell Fever Tenderness to palpation of the affected areas

Answer 93

Chronic sinusitis involves a similar presentation but with a duration of more than 12 weeks. Chronic sinusitis may be associated with nasal polyps, which are growths of the nasal mucosa.

Answer 94

In most cases, investigations are not necessary. In patients with persistent symptoms despite treatment, investigations include: Nasal endoscopy CT scan *Functional endoscopic sinus surgery (FESS) involves using a small endoscope inserted through the nostrils and sinuses. Instruments are used to remove or correct any obstructions to the sinuses. Obstruction may be caused by swollen mucosa, bone, polyps or a deviated septum (surgery to correct a deviated septum is call septoplasty).*

Answer 95

Systemic infection/sepsis -> hospital Most viral cases self resolve Supportive therapy, analgesics, antipyretics Sx for 10+ days: **high dose steroid nasal spray for 14d e.g. mometasone** Delayed ABX prescription if worsening/not improving within 7d **(phenoxymethylpenicillin 1st line)**

Answer 96

**Flat**, nonpalpable lesion with color change (hyper- or hypopigmented, erythematous) less than 5-10mm

Answer 97

**Raised lesion less than 5-10 mm** (wart, actinic keratosis)

Answer 98

Well circumscribed **fluid-filled lesion up to 5-10mm** - *seen in herpes, Varicella*

Answer 99

small (< 5mm) hemorrhagic (red-purple) non-blanchable discolorations meningococcemia, DIC, viral exanthem

Answer 100

Changes with size Macules => patches Papules => plaques (or nodules) Vesicles => bullae Petechiae => Purpura

Answer 101

A maculopapular rash is a mix of macules (flat discolored areas of skin) and papules (small raised bumps) that usually cover a large area of skin. scarlet fever, measles, secondary syphilis, rubella, HIV,

Answer 102

fever, *(high, whereas rubella tends to be a lower fever)* Resp Symptoms - 3Cs (only mild or absent in rubella) conjunctivitis, coryza, cough diarrhea, Koplik spots (white spots on the red buccal mucosa, like small grains of sand) Then generalized, maculopapular rash, classically face/neck->trunk->limbs - ***(lasts 5-7 days, Rubella rash tends to last about 3)***

Answer 103

Supportive. Isolate children in hospital. In immunocompromised patients, antiviral drug ribavirin can be used. Vitamin A, which may modulate the immune response should be given in low-income countries. Prevention by **immunization is the most successful strategy** for reducing the morbidity and mortality of measles.

Answer 104

Scarlet fever infectious disease caused by Streptococcus pyogenes, a Group A streptococcus The infection is a type of Group A streptococcal infection (Group A strep). It most commonly affects children between five and 15 years of age

Answer 105

Erythematous 'pinhead' Sandpaper rash, spares the face, desquamates around the fingers and toes + ‘Strawberry tongue’ Fever, Malaise, headache, nausea. Scarlet fever usually follows from a group A streptococcal infection

Answer 106

Swab throat Prescribe a 10-day course of phenoxymethylpenicillin (penicillin V) first-line. Azithromycin if allergic

Answer 107

It is a mild disease in childhood caused by the rubella virus. More common in winter and spring, it is spread by the respiratory route, frequently from a known contact. The prodrome is usually mild with a low-grade fever or none at all.

Answer 108

The maculopapular rash is often the first sign of infection, appearing initially on the face and then spreading centrifugally to cover the whole body. It fades in 3 days to 5 days. Lymphadenopathy, particularly the suboccipital and postauricular nodes, is prominent. May have low grade fever There is no effective antiviral treatment, so **immunisation is key**

Answer 109

Complications are rare but include thrombocytopenia and encephalitis. Rubella is dangerous in pregnancy and can lead to congenital rubella syndrome, which is a triad of deafness, blindness and congenital heart disease.

Answer 110

one of several possible manifestations of infection by parvovirus B19. It typically presents as a rash and is more common in children **Also known as Erythma Infectiosum, or fifth disease**

Answer 111

HPV-B19 infects the erythroblastoid red cell precursors in the bone marrow. asymptomatic infection – common; about 5% to 10% of preschool children and 65% of adults have antibodies * erythema infectiosum – the most common illness, with a viraemic phase of fever, malaise, headache, and myalgia followed by a characteristic rash on the face (slapped-cheek) a week later, progressing to a maculopapular, ‘lace’-like rash on the trunk and limbs; arthralgia or arthritis can be common in adults

Answer 112

In Pregnant women, as can be transfered to foetus Miscarriage or fetal death Severe fetal anaemia Hydrops fetalis (fetal heart failure) Maternal pre-eclampsia-like syndrome In those with sickle cell anaemia or Thalassaemia - **Can send them into a aplastic crisis** Treatment is supportive

Answer 113

Roseola infantum is also known as just roseola or sixth disease. This is caused by human herpesvirus 6 (HHV-6) and less frequently by human herpesvirus 7 (HHV-7).

Answer 114

It presents 1 – 2 weeks after infection with a high fever (up to 40ºC) that comes on suddenly, lasts for 3 – 5 days and then disappears suddenly. There may be coryzal symptoms, sore throat and swollen lymph nodes during the illness. When the fever settles, the rash appears for 1 – 2 days. The rash consists of a mild erythematous macular rash across the arms, legs, trunk and face and is not itchy. The main complication to be aware of is febrile convulsions, due to high temperature

Answer 115

Psoriasis is a chronic autoimmune condition that causes recurrent symptoms of psoriatic skin lesions.

Answer 116

Plaque psoriasis Guttate psoriasis Pustular psoriasis Erythrodermic psoriasis

Answer 117

Thickened erythematous plaques (1-10cm diameter) Silver scales Commonly seen extensor surfaces and scalp MC form in adults Skin changes caused by rapid generation of new skin cells Results in abnormal build up/thickening of skin

Answer 118

2nd MC form, commonly occurring in children Many small raised papules (mildly erythematous, scaly) Across trunk and limbs Over time papules -> plaques Often triggered by streptococcal throat infection/stress/meds Often spontaneously resolves 3-4mths

Answer 119

Both rare, and medical emergency Pustular - Pustules form under skin, pts can be systemically unwell erythrodermic -Extensive erythematous inflamed areas, covering a large SA of skin - skin comes away in large patches

Answer 120

Typically erythematous, circumscribed scaly papules and plaques on elbows, knees, extensor surfaces of limbs, scalp, and, less commonly, nails, ears, and umbilical region. Pruritus Also associated with: Nail psoriasis (pitting, thickening, discolouration, ridging & onycholysis) Psoriatic arthritis Psychosocial implications - depression, anxiety **Plaques, erythematous**, painful regions Bottom right - Gauatte psoriasis, and rest - plaque psoriasis

Answer 121

Auspitz sign refers to small points of bleeding when plaques are scraped off Koebner phenomenon refers to the development of psoriatic lesions to areas of skin affected by trauma (psoriasis on scars) Residual pigmentation of the skin after the lesions resolve

Answer 122

topical corticosteroids **(eg hydrocortisone topical) and a topical vitamin D analogue **(eg calcipotriol topical)** for 4 weeks Topical corticosteroids may cause depigmentation in patients who have darker skin types. Dithranol - non steroidal, slows growth of plaques review every 4 weeks Should use topcial steroids for more than 8 weeks in a row acitretin - a retinoid (vit a derritiavte)

Answer 123

For moderate Phototherapy **Methotrexate**, as a folic acid antagonist that works as an antiproliferative and anti-inflammatory agent cyclosporine - an immunosuppressant, or infliximab

Answer 124

Phototherapy Ciclospoin Methotrexate acitretin

Answer 125

Folliculitis is the infection and inflammation of one or more hair follicles. Manifests clinically as erythematous papules or pustules around hair follicles

Answer 126

Bacterial, fungal, viral and parasitic micro-organisms MC cause superficial folliculitis = S.aureus Trauma, including shaving and extraction Tight clothes causing friction Profuse sweating (hyperhidrosis) Recent Hx immersion in spa water: hot tub, whirlpool, swimming pool, water slides etc

Answer 127

Other interventions: can resolve spontaneously, warm compress w/ antiseptic use, loose fitting clothing, avoid shaving Topical antibiotics:clindamycin Oral antibiotics: tetracycline, cephalosporin (used in extensive involvement) Fungal: fluconazole, itraconazole

Answer 128

Urticaria are also known as hives. They are small itchy lumps that appear on the skin. They may be associated with a patchy erythematous rash. Urticaria are caused the release of histamine and other pro-inflammatory chemicals by mast cells in the skin. This may be part of an allergic reaction in acute urticaria or an autoimmune reaction in chronic idiopathic urticaria.

Answer 129

Acute urticaria is typically triggered by something that stimulates the mast cells to release histamine. This may be: Allergies to food, medications or animals Contact with chemicals, latex or stinging nettles Medications Viral infections Insect bites Dermatographism (rubbing of the skin)

Answer 130

Chronic urticaria is an autoimmune condition, Can be idiopathic Chronic inducible urticaria describes episodes of chronic urticaria that can be induced by certain triggers, such as: Sunlight Temperature change Exercise Strong emotions Hot or cold weather Pressure (dermatographism)

Answer 131

Antihistamines are the main treatment for urticaria. Fexofenadine is usually the antihistamine of choice for chronic urticaria. Oral steroids may be considered as a short course for severe flares. In very problematic cases referral to a specialist may be required to consider treatment with: Anti-leukotrienes such as montelukast Omalizumab, which targets IgE Cyclosporin

Answer 132

A non-inflammatory degenerative joint disorder characterised by joint pain and functional limitation. It commonly affects the synovial joints Disease of bone and joint cartilage "wear and tear of the joints"

Answer 133

It appears inflammatory cytokines interrupt normal repair of cartilage damage. **(IL-1) (TNF-alpha) stimulate metalloproteinase** production which degrade the collagen and proteoglycans, and inhibits collagen production As **cartilage is lost, the joint space narrows**. Bone on bone interaction may occur, leads to stress and over time subchondral sclerosis (via a process called eburnation) seen on x-ray. Essentially, cartilage is lost and chondroblasts are unable to replace and repair the lost cartilage, this leads to abnormal bone repair.

Answer 134

Joint pain - exacerbated by movement and relieved by rest Worse as the day goes on Joint Stiffness Swelling **OFTEN ASSYMETIRCAL** Joint Locking - inability to straighten joints

Answer 135

Hands: Bouchard's Nodes Heberden's Nodes Thenar Muscle wasting First CMC Joint affected most Weak grip Knees: Crepitus Hips: Antalgic gait Restricted internal rotation All affected Joints: Joint tenderness

Answer 136

Bouchard's - Bony swelling at PIP - (tom has this on his deformed finger) Heberden's Bony swelling at the DIP Remember B before H and proximal before distal

Answer 137

Knees Hips Sacro-ileac joints Cervical spine Wrist base of thumb (carpometacarpal) finger joints (interphalangeal)

Answer 138

Joint X rays show OA hallmarks: LOSS: Loss of Joint space Osteophytes Subarticular Sclerosis Subchondral Cysts

Answer 139

Bloods - normal in OA ESR/CRP - inflammatory markers to distinguish between RA or Gout Negative anti-nuclear antibodies

Answer 140

Weight loss if overweight to reduce the load on the joint Physiotherapy to improve strength and function Occupational therapy to support activities and function improved diet anti-inflammatory foods (basically less processed foods: fewer ingredients = less processed), Orthotics to support activities and function (e.g., knee braces)

Answer 141

Analgesics to control pain and Sx: 1st. Oral paracetamol / topical NSAIDs 2nd. Add oral NSAIDs 3rd . Consider Opiates - Codeine If these fail: Inter-articular steroid injections Joint replacement

Answer 142

If someone is over 45 and has typical activity related pain with **no morning stiffness or stiffness lasting less than 30 minuets**

Answer 143

Chronic systemic inflammatory disease due to **deposition of immune complexes in synovial joints** which causes symmetrical, deforming polyarthritis Can progress to involve larger joint and other organs such as the skin and lungs

Answer 144

- Female gender - Smoking - Family history - Infections - Hormones: increased risk post-menopause, potentially due to a reduction in oestrogen levels

Answer 145

enter the circulation and reach the joints. Here, T cells secrete cytokines (e.g. Interferon-gamma and IL-17) = recruits macrophages. Macrophages also produce cytokines (TNF, IL-1 and IL-6) These makes the Synovial cells proliferate, making a Pannus.

Answer 146

- Rheumatoid factor - IgM antibody that targets altered IgG - **Anti-CCP** anti-cyclic citrullinated peptide - targets citrullinated proteins. = forms an immune complexes, **that activate complement system,** **Chronic inflammation can also cause angiogenesis,** allowing more inflammatory cells to arrive.

Answer 147

*Inflammatory cytokines can also escape the joint space and affect multiple organ systems* Brain Lungs Heart Eyes Liver Blood vessels

Answer 148

**fever in brain**, Peripheral neuropathy Lungs - **Plural Effusions/ pulmonary fibrosis** Heart - Increased IHD risk, **Pericarditis**, MI Eyes -**Episcleritis** Liver - **Increase in Hepcidin**, which leads to less iron absorption in the blood - **Anaemia** Blood - Atherosclerotic Plaque deposition, **Vasculitis** Renal - **Glomerulonephritis** Oral - **Sjogrens Syndrome** Rheumatoid skin nodules

Answer 149

- **Symmetrical polyarthritis: (on both sides of body)** - Swollen, warm and tender small joints of the hands and feet (MCP, PIP, MTP) - Progresses to larger joints (shoulder, elbow, knee, ankle) - **Boutonniere deformity:** - **Swan-neck deformity:** - **Z-thumb deformity:** - **Ulnar deviation** of the fingers - **Popliteal cyst**: synovial sac bulges posteriorly to the knee - **Rheumatoid nodules** -

Answer 150

- **Boutonniere deformity:** PIP flexion and DIP hyperextension - **Swan-neck deformity:** PIP hyperextension and DIP flexion *B before S, so in Boutonniere - F before H, and Swan Neck - H before F* - **Z-thumb deformity:** hyperextension of the thumb IP joint with flexion of the MCP joint.

Answer 151

- Morning stiffness: > 30 mins and improves throughout the day - Malaise - Myalgia - Low-grade fever

Answer 152

Serology - Rheumatoid factor (RF) anti-cyclic citrullinated peptide (anti-CCP) antibody ESP and CRP will be elevated May show anaemia of chronic disease - Low Hb Count Joint x-rays - Do baseline Kidney and liver functions, as will need to monitor these if on DMARDs

Answer 153

can see X-ray – LESS Loss of joint space Erosions (peri-articular) Soft tissue swelling Soft bones (osteopenia)

Answer 154

- **NSAID**: low dose NSAID (e.g. ibuprofen) to cover the period between symptom onset and rheumatology referral - **Refer to specialist care** - **Physiotherapy and occupational therapy**

Answer 155

**Disease-Modifying Anti-Rheumatic Drugs (DMARDs)** Any one of methotrexate, leflunomide or sulfasalazine. Hydroxychloroquine can be considered in mild disease, *mildest anti rheumatic drug* ***METHOTREXATE - TAKE ONCE A WEEK, SUPPLEMENTING FOLIC ACID AS WELL***

Answer 156

Gout can be precipitated by methotrexate use Methotrexate can also cause liver damage Haemolytic anaemia is a side effect of sulphasalazine,

Answer 157

**Biologics**: **Abatacept** - Suppress T Cells **Rituximab** - Suppress B Cells *T cell drug ends in T, B cell drug ends in B* Infliximab, or etanercept - Suppress TNF a Anakinra - Suppress IL-1

Answer 158

Methotrexate Must give folate supplements as methotrexate inhibits folic acid synthesis **Contraindicated in pregnancy** S/E – can lead to malignancy, most commonly skin Both men and women should stop taking methotrexate for at least 6 months before they want to start conceiving

Answer 159

measure ESR and CRP levels

Answer 160

Monitor FBC every 3 months, looking at white cell count as can cause abrupt bone marrow suppression Can be toxic to liver, so need to monitor LFTs Can be GI toxic, so need to ask about any diarrhoea or stomatitis, and stop it if a patient gets any symptoms w it Can also cause pulmonary toxicity need to be vigilant for any sore throat/tonsilitis/illness - so do urgent same day bloods for anyone ill on a DMARD!

Answer 161

osteoarthritis Morning stiffness <30mins Affects older people more Cartilage loss Degenerative disease Asymmetrical Can affects DIP joint Rheumatoid Arthritis Morning stiffness >60 mins Joints hot and red affects younger people **Symmetrical** Inflamed Synovium Autoimmune disease **rarely effects DIP joint**

Answer 162

Malignancy - increased cell turnover Cytotoxic drugs Purine rich diet - seafood and alcohol, red meat Obesity Psoriasis **Increased production of purines - seen in high fructose corn syrup drink** like tango, fanta

Answer 163

CKD Diuretics e.g., thiazide and loop Dehydration, Alcohol intake Lead toxicity High fructose intake **Low dose asprin**

Answer 164

Uric acid is formed as a breakdown product if purines Uric acid has a limited solubility in the blood If too much urate accumulates, it'll turn into **urate ion and bind to sodium, forming monosodium urate crystals** This forms urate crystals which deposit in areas with slow blood flow the joints and kidney tubules

Answer 165

Lifestyle – calorie-restriction, modify diet, weight loss, reduce alcohol, hydration Foods =Dairy – protective, Also, cherries and vitamin C

Answer 166

Rapid onset severe joint pain Joint stiffness Commonly swollen red big toe which is painful you cannot put weight on i

Answer 167

Gout tophi are deposits of uric acid Ears **Most common site in gout is 1st MTP joint** Base of big toe **Podagra** - ***gout of the foot*** Wrists Base of thumb

Answer 168

Can be made on just clinical presentation but **excluding septic arthritis is key** Joint aspiration and analysis of **Synovial fluid** will show: no bacterial growth, Needle shaped crystals, displaying Negative bifringement under polarised light *undergoing polarised microscopy* Monosodium urate crystals Measure serum urate levels 4-6 weeks after attack as they can be low at time of attack

Answer 169

1st line - **NSAIDs – naproxen, ibuprofen** 2nd line - **Colchicine** (if NSAIDs contraindicated i.e. peptic ulcer, diabetes, renal disease) - **Inhibits WBC migration** 3rd line - **Steroids** *remember that colchicine was also seen in treatment for pericarditis?*

Answer 170

Lifestyle management and a **Xanthine oxidase inhibitor** First-line Allopurinol, w NSAID or colchicine cover NICE recommend 4 weeks of NSAID or colchicine cover with allopurinol Diarrhoea will likely precede pain relief is a key side effect of colchicine 2nd line prevention of gout - Second line prevention of gout after Allopurinol is Febuxostat, a non-purine selective xanthine oxidase inhibitor that reduces the production of uric acid

Answer 171

Known as **Calcium Pyrophosphate Arthropathy**, it's the Deposition of Calcium Pyrophosphate crystals in the synovium Calcium pyrophosphate crystals are deposited in the joint causing joint problems. Can lead to calcium around the hyaline cartilage - **chondrocalcinosis**

Answer 172

- **Increasing age**: the greatest known risk factor for pseudogout - Previous joint trauma - Hyperparathyroidism - **Haemochromatosis** - Acromegaly - **Wilson's disease** - Diabetes - **Hypomagnesaemia** -**Hypophosphataemia**

Answer 173

Deposition of calcium pyrophosphate triggers synovitis with the knee, shoulder and wrist most commonly being affected Produces the **radiological appearance of chondrocalcinosis** (linear calcification parallel to the articular surfaces) Can be acute or chronic

Answer 174

***Very similar to gout and usually indistinguishable until joint aspiration is performed.*** - Signs - Joint inflammation: pain, erythema and swelling - Signs can be monoarticular (1 joint) or polyarticular (several joints) - Symptoms - Rapid onset severe joint pain: knee, shoulder and wrist are most commonly affected - Joint stiffness

Answer 175

Joint aspiration: **weakly-positively birefringent rhomboid-shaped crystals under polarised microscopy** confirm the diagnosis. ***If any bacterial growth, then patient is likely to have septic arthritis*** - MEDICAL EMERGENCY Joint X-ray: **chondrocalcinosis (calcification of articular cartilage)** is seen in 40% of cases and is highly suggestive of pseudogout but is not diagnostic; the absence of chondrocalcinosis does not exclude pseudogout FBC – raised WBCs Pseudogout - **positive birefringent crystals**

Answer 176

Acute - **Anti-inflammatory:** NSAIDs or colchicine, particularly in polyarticular disease - **Corticosteroid:** **intra-articular** steroids can be used in monoarticular disease or **systemic** steroids in polyarticular disease - **Cool packs and rest** - **Aspiration of the joints -** relieves pain

Answer 177

- **DMARDs:** e.g. methotrexate and hydroxychloroquine may be considered in chronic pseudogout - **Joint replacement**: only indicated in chronic, recurrent cases with severe joint degeneration

Answer 178

a complex skeletal disease characterised by low bone density and micro-architectural defects in bone tissue, resulting in increased bone fragility and susceptibility to fracture. **Bones become more porous due to increased breakdown**

Answer 179

Osteopenia refers to a less severe reduction in bone density than osteoporosis. **Defined as bone mineral density 1-2.5 standard deviations below young adult mean value**

Answer 180

Primary – menopause and age, as Oestrogen protects bones Secondary – to disease or drugs rememeber as SHATTERED S – steroid use (prednisolone) H – hyperthyroidism/hyperparathyroidism A – alcohol/smoking T – thin (low BMI) T – testosterone low E – early menopause R– renal or liver failure E – erosive/inflammatory bone disease e.g. RA, myeloma D – dietary calcium low

Answer 181

Joint disease e.g. RA, SLE Hyperthyroidism and hyperparathyroidism – increased bone turnover High cortisol – Cushing’s (increases bone resorption and induces osteoblast apoptosis) Low oestrogen/testosterone e.g. hypogonadism, anorexia, menopause Renal disease – decreased vitamin D Previous fracture Anorexia

Answer 182

As we age, the activity of osteoclasts increases and is not matched by osteoblasts. As such bone mass decreases. Oestrogen is key to the activity of bone cells with receptors found on osteoblasts, osteocytes, and osteoclasts. The mechanisms are still being understood, but it appears **osteoclasts survive longer in the absence of oestrogen,** and there is arrest of osteoblastic synthetic architecture.

Answer 183

FRAX = fracture risk assessment tool Predicts the risk of a fragility fracture over the next 10 years. Usually the first step of assessment and is done on patients at risk of osteoporosis **BMI, co-morbidities, smoking, alcohol and family history +/- bone mineral density** - It gives results as a percentage 10 year probability of a: - Major osteoporotic fracture - Hip fracture

Answer 184

DEXA Scan (dual-energy xray absorptiometry) Measures bone mineral density by measuring how much radiation is absorbed by the bones **Scanning Hip is best** Gives **T score (main one)** - number of standard deviations below the mean for a healthy young adult their bone density is. **and Z score** - represent the number of standard deviations the patients bone density falls below the mean for their age.

Answer 185

T-score **>0 BMD** = is better than the reference. **0 to -1** = BMD is in the top 84%: no evidence of osteoporosis. **-1 to -2.5** = Osteopenia. Risk of later osteoporotic fracture. Offer lifestyle advice. **-2.5 or worse** = Osteoporosis. Offer lifestyle advice and treatment Repeat DEXA in 2yrs.

Answer 186

Activty and exercise Weight control Reduce alcohol/stop smoking NICE recommend calcium supplementation with vitamin D - eg **Calcihew-D3** vitamin D supplementation.

Answer 187

Bisphosphonates- they interfere with osteoclast activity reducing their activity. **Alendronate** 70mg once weekly

Answer 188

Oesophagitis/Reflux and oesophageal erosions. GI distress Renal Toxicity Hypocalcaemia Oesophageal ulcers Osteonecrosis *(death of bone tissue)* of the jaw and external auditory canal

Answer 189

Hormone replacement therapy should be considered in women that go through menopause early. **Raloxifene** - Selective oestrogen receptor **Teriparatide** - recombinant PTH, increases bone formation

Answer 190

Joint aspiration, microscopy Gout - **Negatively birefringent crystals** Pseudogout - **positive birefringent crystals** *note - most commonly affected joint in gout is 1st MTP of the big toe, most commonly affected joint in pseudogout is the knee joint*

Answer 191

Take **once a week in the morning** and at least **30 minutes before any food** the **patient should remain upright** for at least half an hour after taking

Answer 192

Main symptom is **headache that us unilateral and around forehead and temple.** Irreversible painless complete sight loss Jaw claudication Scalp tenderness may be noticed when brushing hair

Answer 193

1st line: **INCREASED ESR** - ELEVATED IN 83% OF CASES ANCA Negative Temporal Artery biopsy - diagnostic Fundoscopy Picture - diagnostic criteria

Answer 194

1st Line: Corticosteroids - Oral Prednisolone If you stop steroid doses abruptly, could cause an **Adrenal crisis**

Answer 195

Amaurosis Fugax: Sudden painless vision loss of one eye (optic neuropathy) Must be dealt with ASAP via high dose IV METHYL PREDNISOLONE

Answer 196

Chronic inflammatory rheumatic condition causing chronic pain in the shoulders, pelvic girdle and neck. This condition affects both muscles and joints Often **associated with and occurs alongside Giant cell arteritis**

Answer 197

Large cell vasculitis presenitng as chronic pain syndrome *(similar to fibromyalgia)* Patients are ALWAYS OVER 50. Wil have Raised ESR and CRP, temporal artery biopsy may show giant cell arteritis

Answer 198

A chronic progressive inflammatory arthropathy. It mainly affects the spine and cause progressive stiffness and pain. Ankylosis= abnormal stiffening and immobility of a joint due to the fusion of a bone

Answer 199

Inflammation destroys the intervertebral joints, facet joints and sacroiliac joints Fibroblasts replace the destroyed joints **with fibrin 🡪 formation of tough fibrin band around joints** which limits range of motion **Ossification occurs (fibrous tissue turns to bone)** and makes spine immobile **Syndesmophytes** – new bone formation and **vertical growth from anterior vertebral corners**

Answer 200

Weight loss Fever Fatigue - Pain and stiffness of joints - Lower back pain - Sacroiliac pain (buttock region) Pain worst with rest and improves with movement Neck or back pain/stiffness – cervical/thoracic region - Can lead to SOB **Acute, anterior uveitis** *think - kind of similar to Rheumatoid arthritis for the spine?*

Answer 201

- **CRP and ESR** - elevated - **Genetic testing** - HLA-B27? - Early stages - **MRI of spine** if x-ray is normal - can show early changes which show up as bone marrow oedema **(red arrows)** as well as erosions, sclerosis and ankylosis

Answer 202

Physio and hydrotherapy Long term high dose NSAIDs e.g. ibuprofen or naproxen DMARDs e.g. methotrexate – treat peripheral arthritis but not the disease Biologics– Anti-TNF e.g. etanercept or monoclonal antibodies against TNF e.g. infliximab, Monoclonal antibodies targeting IL-7 - e.g. secukinumab

Answer 203

An arthritis that is triggered following an infection (probs by molecular mimicry) Also known as Reiter syndrome Its a type of Seronegative spondyloarthropathy - RF is absent

Answer 204

- **Gastroenteritis** - Salmonella - Shigella - Camplobacter - **Sexually transmitted infections** - Chlamydia trachomatis. - Gonorrhea (may also cause gonococcal septic arthritis, so this must be considered)

Answer 205

Thought that the lipopolysaccharide ***(Endotoxin)*** on the gram negative bacteria produces a particularly strong response from immune system. This response also results in antibodies or inflammation that also affect the joints. In reactive arthritis, there are no actual joint infections (as seen in septic arthritis). The infection is at another site!

Answer 206

Acute, asymmetrical monoarthritis typically in lower leg (knee). Can also present with triad of: Urethritis, arthritis and conjunctivitis **Can’t see, pee or climb a tree** THIS TRIAD IS KNOWN AS REITER'S SYNDDROME

Answer 207

- **ESR and CRP** - elevated - **Infectious serology** ask about history of infection - Genetic testing for **HLA-B27** - If diarrhoea - **culture stool** Aspirate joints to rule out septic arthritis/Gout - should be sterile in RA Sexual health review

Answer 208

Management Treat cause of infection – antibiotics NSAIDs ± steroid joint injections Consider use of methotrexate and sulfasalazine as steroid sparing agents if >6 months - Recurrent/ persistent reactive arthritis - DMARDs e.g. methotrexate or sulfasalazine - Anti-TNF

Answer 209

Septic arthritis is defined as the infection of 1 or more joints caused by pathogenic inoculation of microbes. It occurs either by **direct inoculation** or via **haematogenous spread.** It is a medical emergency!- **CAN AFFECT ANY JOINT, MOST COMMONLY KNEE**

Answer 210

Gonococcal Arthritis- - **Neisseria gonorrhoeae** - young, sexually-active adults Non Gonococcal Arthritis - *(more common)* - **Staphylococcus aureus** - the most common cause in all age groups - **Staphylococcus epidermidis** - prosthetic joints - **Streptococcus pyogenes** - children under 5 years old - **Escherichia coli** - immunosuppressed, eldery and IV drug abuse Due to vaccine against haemophilus influenzae, it is now a rare cause of septic arthritis

Answer 211

Normally only one joint is affected. Most commonly the knee. Hot tender and swollen joint Limited range of movement Difficulty weight bearing Fever

Answer 212

- **FBC**: leukocytosis - **CRP and ESR**: elevated due to inflammation and used for monitoring response to treatment - **Blood cultures**: should be performed on **all** patients before commencing antibiotics Joint aspiration (arthrocentesis): definitive investigation ideally prior to commencing antibiotics; synovial fluid should be sent to the lab for microscopy and culture **having a prosethitci joint is a CI for aspiration**

Answer 213

- IV **antibiotics** - **Empirical therapy**: flucloxacillin is first-line - **Penicillin allergy**: clindamycin - **Suspected or confirmed MRSA**: vancomycin - **Gonococcal arthritis or gram-negative infection**: cefotaxime or ceftriaxone - **Joint drainage** - Aspiration - Arthroscopic drainage - Open drainage

Answer 214

Inflammation of the bone marrow (infection localised to bone) caused by an infecting organism, most commonly Staphylococcus aureus.

Answer 215

- **Staphylococcus aureus**: A gram-positive cocci. Includes MRSA - MOST COMMON - ***Pseudomonas aeruginosa*:** A gram-negative rod. More commonly seen in IV drug users. - ***Salmonella* spp.:** Gram-negative rods. Most commonly seen in patients with sickle cell anaemia.

Answer 216

Diabetes mellitus - vascular compromise due to high blood sugar Trauma – bone exposed to outside environment (open fractures) Surgery Peripheral vascular disease Malnutrition Inflammatory arthritis Debilitating disease Immunosuppression – HIV or immunosuppressive drugs Sickle cell disease Prosthetic material **RISK FACTORS FOR OSTEOMYELITIS ARE THE SAME AS THOSE FOR SEPTIC ARTHRITIS**

Answer 217

Onset – several days Dull pain at site of OM Fever Weakness Redness/Swelling May be aggravated by movement

Answer 218

**Systemic** - Fever, Rigors, Sweats, Malaise **Local** Acute OM Tenderness, warmth, erythema and swelling **Chronic OM** Tenderness, warmth, erythema and swelling Draining sinus tract **Deep/large ulcers that fail to heal** despite several weeks’ treatment

Answer 219

Bloods - **FBC - elevated WCC** - **CRP and ESR - elevated** Microbiology - **Urine MSU** - **Blood cultures** - **Wound swabs** Imaging - **X-ray of suspected area** - Local osteopenia - Areas of bone lysis - Cortical loss - Periosteal reaction - Sequestrum and involucrum may be seen in advanced disease **GOLD STANDARD** - MRI - **MRI** - Good visualisation of bone and surrounding soft tissue - Bone marrow oedema can be seen early on

Answer 220

6 weeks for acute OM 3 months for chronic OM Abx: IV Flucloxacillin/Or Vancomycin for MRSA cover Immobilise Surgery can remove any abscess, or necrotic bone/sequestrum

Answer 221

Bamboo spine **calcification of all the ligaments** of the spine **squaring of the vertebral bodies** subchondral sclerosis **Syndesmophytes** - bony outgrowths from the spinal ligaments as they attach to adjacent vertebral bodies fusion of joints (facet / sacroiliac / costovertebral)

Answer 222

SCP are clinically focused and provide the info required to support safe and effective shared care for specified medicines, have standardised lists and protocols - So GP can prescribed on the behalf of the specialist, and prompts you when to seek advice eg Methotrexate, Sulfasalazine Amiodarone, Ciclosporins

Answer 223

- **Broad spectrum antibiotics (e.g. co-amoxiclav)** , **and Cefalexin for 7 to 10 days** until culture and sensitivities are avaliable - **Hydration** - Other/ adjuncts - **Admission** if systemically unwell or complicated - **IV rehydration** - **Analgesia** - **Antipyretics**

Answer 224

First line: Antibiotic course for 3 days - **nitrofurantoin or trimethoprim** Second line: Antibiotic course for 3 days - nitrofurantoin or pivmacillinam or fosfomycin single-dose sachet

Answer 225

First line: Antibiotic course for 7 days - nitrofurantoin **but avoid nitrofuratnoin in third trimester, give a penicllin instead** Second line: Antibiotic course for 7 days - amoxicillin or cefalexin (1st Gen Cephalosporin)

Answer 226

First line: Trimethoprim 200 mg twice a day for 7 days Second line - Nitrofurantoin: If not resolving, consider an alternative diagnosis !

Answer 227

Trimethoprim carries a teratogenic risk in the first trimester as it inhibits folate synthesis. - **avoid throughtou all pregancy** Methotrexate is listed as a severe interaction with trimethoprim in the BNF, due to the increased risk of haematological side effects that can be fatal. Trimethorprin - can cause transient raise in creatine, so can lead to an eGFR based on creatine levels to look falsely low. Pivmecillinam 400mg initial dose, if both CI

Answer 228

Although Nitrofurantoin is first line in pregnant women with lower urinary tract infections, it should be **avoided in third trimester as it may cause neonatal haemolysis** also Nitrofurantoin is contraindicated in patients with an **eGFR of less than 45 G6PD deficiency is listed as a contra-indication to nitrofurantoin in the BNF. Pivmecillinam 400mg initial dose, if both CI

Answer 229

confer resistance to both penicillin and cephalosporin-based antibiotics Give nitrofurantoin or fosfomycin if systemically well or Carbapenems like meropenem IV if systemically unwell

Answer 230

reduced effectiveness of bronchodilator reduce exercise tolerance asthma attack within the last two years history of waking up at night with wheeze/cough/chest pain or daytime asthma symptoms (three times a week or more)

Answer 231

NRT (stop smoking cigarettes), Champix/Varenicline (reduce cravings), Bupropion/Zyban (reduce pleasure Bupropion can lower the seizure threshold, so CI in epilepsy

Answer 232

Nicotine replacement therapy is the only pharmacological therapy which is safe to prescribe during pregnancy

Answer 233

CRB-65 out of hospital and CURB-65 in hospital. The only difference is that out of hospital you do not count urea. C – Confusion (new disorientation in person, place or time) U – Urea > 7 R – Respiratory rate ≥ 30 B – Blood pressure < 90 systolic or ≤ 60 diastolic. 65 – Age ≥ 65

Answer 234

Score 0/1: Consider treatment at home Score ≥ 2: Consider hospital admission Score ≥ 3: Consider intensive care assessment 0 = Low risk (<1% mortality) 1-2 = Intermediate risk (1-10% mortality) 3-4 = High Risk (>10% mortality) requires in-patient admission and IV antibiotics. Normally a CAP is treated with Co-Amox and Clarithromycin (to cover for atypicals). HAPs are treated with Tazocin, however this may change depending on trust guidelines.

Answer 235

HAP - strep pneumoniae, H. Influenzae, someitmes mycoplasma, legionella CAP - Pseudomonas argeunoisa, staph aureus, klebsiella pneumonia

GENERAL PRACTICE 2 - Sexual Health, Contraception, Infect Dis, Derm, MSK Flashcards

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