General Practice Flashcards
(141 cards)
1
Q
Target INR for patients on Warfarin?
A
2-3
2
Q
What two questions are SUPER important to ask someone presenting with a headache?
A
Foreign Travel (can be the first presentation of Malaria) Pregnancy (pre-eclampsia)
3
Q
How do you manage Cluster headaches in primary care?
A
Acutely: 100% Oxygen for 15 mins + Sumatriptan.
Prevention: Cut out smoking and drinking, Steroids + Lithium + Verapamil are all associated with reducing attacks, unclear mechanism.
4
Q
Features of an aura?
A
Last 15-30 minutes, followed within the hour by migraines.
Visual: Chaotic distortion and blending of lines, dots, zig zags.
Sensory: Paraesthesia.
Motor: Ataxia, Dysarthria, Hemiparesis.
Speech: Dysphagia, Paraphasia.
5
Q
How do you manage Migraines?
A
Acutely: NSAIDs + Paracetemol + Oral Triptan +/- Anti-Emetic.
Prevention: Avoid triggers, avoid pain medications as could trigger rebound, PROPANOLOL.
6
Q
What do you do if a woman is getting COCP related migraines?
A
Switch to POP
7
Q
How do you manage tension headaches?
A
Acutely: NSAIDs and Aspirin.
Prevention: Destress, Hydration, Alcohol avoidance. If all else fails comsider TCAs.
8
Q
How do you manage Trigeminal Neuralgia?
A
First thing, refer to neuro for MRI. Must check TN isnt secondary to nerve compression due to another underlying pathology e.g. malformation, herpes zoster…
Medical = Carbamazepine, Phenytoin or Gabapentin. Surgical = When drugs have failed. Decompresses.
9
Q
What do Strains and Sprains affect?
A
Strain = T for Tendon (or Muscle)
Sprain = P for Pligament
10
Q
When should an X Ray be offered to a patient with an ankle injury?
A
Following Ottowa rules:
If pain in malleolar zone and any one of-
- Inability to weight bear
- Bony tenderness along the distal 6 cm of either the fibula or tibia or either malleolus.
11
Q
How do you grade sprains and strains?
A
Grade 1-3
Depending either on extent of damage or Stability (sprains)/ Loss of Function (strains).
12
Q
When should you refer a sprain?
A
If ligament is totally torn, if joint is unstable or if it hasnt healed in 6 weeks (will need further imaging, may have missed bony pathology).
Worsening pain, deformity, NV compromise are obvious concerns.
13
Q
Which analgesics are used in sprains amd strains?
A
Paracetemol initially.
NSAIDs going forward-
- Oral (Naproxen or Ibuprofen)
- Topical (Diclofenac or Ibuprofen)
14
Q
How do you distingiush Scleritis and Episcleritis?
A
Scleritis is frankly tender whereas Episcleritis is only uncomfortable or gritty.
Episcleritis has well defined inflammed blood vessels, Scleritis has a generalised pinkish hue.
15
Q
What should you think if you see Scleritis?
A
Rheumatology (RA, SLE, Sjogrens, GPA, Scleroderma) or TB
16
Q
What should you think if you see Uveitis?
A
Seronegative SAs.
IBD.
Sarcoidosis.
Infections e.g. Herpes, TB, Syphilis.
17
Q
How do you distinguish Scleritis and Uveitis?
A
Uveitis you see more obvious pupil changes, such as irregular shape and a cloudy cornea.
May be visual changes or a hypopyon.
18
Q
How do you treat Uveitis?
A
Steroids and CYCLOPLEGICS (drugs that paralyse the muscles of the eye and allow for healing)
19
Q
How do you manage a corneal abrasion?
A
Chloramphrenicol (combined lubricant and antibiotic), Oral analgesics, Stop wearing contact lenses.
Refer if:
- Large abrasion
- Visual disturbance
- Not resolving
- Penetrating injury
- Embeded foreign body
- Chemical injury
20
Q
What organisms cause corneal ulcers? How do they present?
A
Secondary to a corneal abrasion: Pseudomonas, Resp infection species.
Able to penetrate eye without abrasion: Neiseria
Will probably present as an abrasion that has gotten worse over time. May see a hazy epithelia defect with fluffy, irregular borders.
21
Q
What causes Viral Keratitis?
A
Herpes Simplex
Varicella Zoster
22
Q
How does Acute Angle Closure Glaucoma present?
A
Idiopathic, however DM is a risk factor.
Closure happens suddenly and asymptomatically, but it leads to a slow rise in intra-ocular pressure causing; Pain, Headache, Nausea, Vomiting, Photophobia, Reduced visual acuity. (Unilaterally)
Mid-dilated, unreactive pupil.
23
Q
How do you manage Acute Angle Closure Glaucoma?
A
First step is to lie patient flat on their back, as this can spontaneously open up the angle.
Next refer to opthalmology. Management usually involves:
- Acetozolamide (systemic pressure reducing agent)
- Topical Beta-blockers (reduce IOP)
- Pilocarpine (myotic that opens up the angle)
Surgical management = Peripheral Iridotomy (laser bores hole in iris to allow for drainage)
24
Q
How do you investigate corneal abrasions and foreign body injuries?
A
Fluorescein Stain under a Cobalt Blue light
25
What are the causes of a sub-conjuntival haemorrhage?
Normally over rubbing, minor trauma or minor exertion (lofting weights or going for a poo).
HOWEVER can be indicative of deranged coagulopathy or blood pressure.
26
3 Features of Anaphylaxis?
- Rapid onset
- Life threatening dysfunction of the Airway, Breathing and Circulation
- Skin changes (Flushing, Urticaria, Angioedema)
27
What antibiotic is given for high fever pain sore throat
Pen V or Clari
Also give Paracetemol and Ibuprofen to tackle muscle aches and fever.
28
How do you treat a Quinsy?
Refer for Lavage, Antibiotics, Surgical drainage and Pain relief.
29
What are the risk factors for UTIs?
Incontinence and sexual activity (lead to increased bacterial inoculation)
Menopause and low oestrogen (make the vagina dry and easy to colonise)
Dehydration and obstruction (reduced urine flow)
DM, Immunosuppression... (increased bacterial growth)
30
Causes of Hospital Aquired UTIs?
Most common is still E.Coli
Klebsiella, Staph, Proteus Mirabillis are also common
31
How do you treat Prostatitis?
Ciprofloxacin for 4 weeks.
Its a Fluroquinolone which are the only antibiotics able to penetrate prostatic fluid.
32
What is sterile pyuria and what causes it?
The presence of WBCs in urine that doesnt grow anything when cultured.
Infectious Causes = Urinary tract TB, Appendicits, Prostatitis, Chlamydia
Non-Infectious = Stones, Cancer, Nephritis, PCKD, Cystitis, SLE, Steroid use, Pregnancy
33
When should you give antibiotics im conjunctivitis?
Not resolving over 3 days, or need rapid resolution.
Give chloramphenicol.
34
What are the 3 common organisms behind Atypical pneumonia, and what antibiotics do you give for them?
Legionella = Cipro and Clary
Chlamydia = Tetracycline
Pneumocytis = Co-Trimoxalone (given as prophylactic in HIV patients)
Screen for all 3 if non resolving pneumonia or high curb score.
35
What are the possible causative organisms for HAP and what do you give to cover them?
Organisms: E. Coli, Pseudomonas, Anaerobes
Antibiotics: Aminoglycoside and Pen V
36
Worrying side effects of Aminoglycosides?
Sensorineural hearing loss, visual loss through nerve damage.
37
What so you give in Aspiration pneumonia?
IV Cephalosporin and Metronidazole.
38
How do you manage Acute Sinusitis?
Most will spontaneously resolve within 7-10 days, until then manage with P&I, steam inhalation and plenty of fluids.
Decongestants and Nasal Steroid Spray (Beclometasone can be given in severe cases)
Amoxicillin is rarely used, but given if Frontal Sinusitis, IMS, CF or mot resolving after 3 weeks.
39
How do you define Chronic Sinusitis?
Sinusitis symptoms, either non-stop for 3 months or 3 times in a year.
Management is the same as severe acute sinusitis.
More likely to present with a nasal drip, polyps and voice changes.
Refer to ENT if aymptoms getting in the way of everyday life.
40
How do you distinguish Sinusitis from Rhinitis?
Sinusitis causes frontal headache and face pain.
| Rhinitis has more discharge and sneezing.
41
When should you refer a Rhinitis patient and what for?
If severe, which is to say:
- Troublesome symptoms
- Interfeering with work or school
- Difficulty sleeping
- Impacts AoDL
Refer for allergy testing, Rhinitis almost always has a trigger.
42
How do you manage Rhinitis?
- Decrease allergen exposure.
- Nasal steroids are safe and effective long term.
- Oral steroids for rescue therapy.
- Oral or Topical antihistamins.
- Montelukast.
- Topical or Oral decongestants.
43
What is a Furunculosis?
Staph Aureus boil within the outer ear.
Treat with pain relief and referal to ENT for drainage.
44
What can cause refered pain to the ear?
- Dental issues like carries, abscess, impacted molars.
- HSV infection
- Ramsay-Hunt
- Tumours in the Larynx
- Tonsilitis, Quinsy
- Cervical Spondylosis
45
What are the two worrying things to exclude in a patient with ear discharge?
1) CSF Leakage. Will have history of head injury, fluid will test positive for glucose.
2) Perforated ear drum, possibly due to Cholesteatoma (a cyst caused by an ingrowing hair due to repeated infections)
46
When would you refer Otitis Externa to an ENT?
If Diabetic or Immunosuppressed. At risk of developing an aggresive form of inner ear necrotising fascitis.
47
How do you manage Otitis Externa in primary care?
ALUMINIUM ACETATE.
Can give antibiotic drops but AA is as effective.
Consider steroids if cause is eczema or oral antibiotics if canal is blocked.
48
What works for Pseudomonnas infection pretty much anywhere in the body (GI, RTI, Pinna Perichondritis)?
Ciprofloxacin
49
What are the two forms of Otitis Media and how do you manage both?
Acute Suppurative Otitis Media (the infection one): Delayed antibiotics, only if havent healed in 4 days. AMOXICILLIN.
(N.B. Can also get a chronic form that is the same except drum has perforated and infection has continued, unless perforation is central and they are symptomless, refer to ENT)
Otitis Media with Effusion (the one caused by Eustachian tube disfnction): Usually resolves within a couple of months, if not refer to ENT for Grommet insertion and excusion of a tumour.
50
How might Acute Suppurative Otitis Media present?
- Ear pain
- Perhaps systemically unwell
- May have sudden hearing loss, discharge and spike in pain. This would be caused by the drum perforating.
51
What part of the ear drum is safe when perforated?
Central part.
If attical or marginal, refer to ENT.
52
How do you manage Mastoiditis?
Vancomycin and Ceftriaxone, IV, in hospital
53
List some causes of Comductive Hearing Loss?
```
Impacted Wax
Foreign Bodies
Drum Perforation
Middle Ear Effusion
Otosclerosis
```
54
List some causes of Sensorineural Hearing Loss?
```
Presbyacusis
Measles
Meningitis
Meniere’s
Drugs e.g. Furosemide and Aminoglycosides
Acoustic Neuroma
Noise induced deafness
```
55
What are the symptoms of an acoustic neuroma?
Unilateral SN hearing loss
Tinnitus
Facial Palsy
56
What causes Tinnitus?
Often unknown.
Can be:
- Natural with hearing loss
- Loud noises
- Head injury
- Anaemia
- Hypertension
- Meniere’s
- Loop diuretics
- TCAs
- NSAIDs and Aspirin
- Aminoglycosides
57
How do you manage Tinnitus?
- Refer to ENT for investigation of a sinister cause
- If comes back clear focus is on hearing aids +/- white noise to drown out whine, masking the sound with radio or music, support groups, managing depression and sleeping issues.
- Can refer for TROCHLEAR NERVE SEVERING if really not managing well.
58
What is Labyrinthitis?
Inflammation of the inner ear, likely resulting from a viral illness.
Causes Nystagmus, Vertigo, Hearing Loss, Tinnitus, Nausea, Vomiting.
59
What are the two manouvres associated with BPV?
Hallpike = Diagnostic
Epley’s = Curative (potentially, may not work and most patients dont require it as condition is self limiting. Teaching the patient to avoid rapid movements and vestibular rehab may be better options)
60
What are the symptoms of Meniere’s?
Clustered attacks of Vertigo lasting minutes to hours, Tinnitus and Nausea.
Sensation of fullness in the ear.
SN Hearling loss.
61
How do you manage a patient with a Meniere’s flare up?
- Cyclizine. Sedates the labyrinthine system. Can be given rectally if patient is vomiting but cannot be used as long term therapy.
- Early remobilisation after an attack is crucial.
Next step is to focus on acoidance:
- Stress avoidance (can trigger attacks)
- Support groups
- Consider dietary changes, can be helpful
- Surgical option = Labyrinthectomy. Causes unilateral deafness.
62
How does Eczema present?
Waxing and Waining itchyness, predominently affecting the hands and antecubital/popliteal fossa (face in babies) in a person with a personal or family history of asthma/hay fever/eczema. May be a clear trigger.
Often see sleep disturbance as well.
63
Management of Eczema?
- Emollients
- Topical Steroids
- Consider Antibiotics, consider bandaging.
- Consider offering a sedating anti-histamine if issues with sleep anditchiness
- Severe cases may require oral Steroids or Tacrolimus (specialist)
- If contact dermatitis, avoiding trigger and emphasising hand hygiene is important.
- If venous eczema (haemosiderin staining, lipodermatosclerosis, ulceration), treat venous disease
64
When should you refer an Eczema patient?
- Herpes Infection (as an emergency)
- Resistant to treatment
- Requiring large amounts of steroids
- Severe social or psychological issues
- Patch testing
65
How do you treat Cradle Cap (infantile seborrhoeic dermatitis)?
- Emollients
- Hydrocortisone
- OTC Cradle Cap creams
66
How do you spot and treat Seborrhoeic Dermatitis?
Form of dermatitis that affects sebum producing areas, so look for involvement of the scalp, face, nose.
Mx:
- Ketoconazole shampoo if scalp affected.
- Imidazole and Hydrocortisone for other areas.
- If recurrent, can give prophylactic antifungals bimonthly.
67
What are some potential causes of acne, aside from puberty?
- PCOS
- Cushing’s
- Squeezing
- Cosmetics use
- Steroids
- Androgens
- Physical Occlusion (e.g. violinists chin’
68
What oral antibiotic is given for moderate acne?
Tetracycline
69
What advise do you give patients regarding acne cream?
- Can take weeks to work properly
- Reassess at 3 month intervals
- Continue treatment until new lesions stop appearing
- Watch out for side effects at all times
- Skin may dry and acne may get worse in initial stages
70
What are the two worrying forms of Psoriasis?
- Erythroderma
- Generalised Pustular Psoriasis
Refer to dermatology
71
Management options for Psoriasis?
- Salicylic acid is very effective
- Coal Tar works as an anti-inflammatory and is bery effective, if a bit smelly.
- Vit D Analogues.
- Topical Rerinoids and Steroids
72
What causes Moluscum Comtagiosum?
DNA Pox virus infection, spread by towel.
73
What causes Pyoderma Grangrenosum?
3 groups of conditions:
- GI: Crohn’s and UC
- Arthritis: RA and Seronegative As
- Cancers: Leukaemia and Myeloma both can
Mx = Systemic Corticosteroids and Ciclosporin. Can also give Topical Tacrolimus.
74
What causes Dermatitis Herpetiformis?
Skin manifestation of Coeliacs Disease
75
How do you manage Impetigo?
Localised: Fusidic Acid Cream
Widespread: Oral Flucloxacillin
Good general advise for bacterial skin infections (usually Staph Aureus and these are excellent vs SA)
76
How do you manage Erysipelas and Cellulitis?
Same thinf really, cellulitis goes a bit deeper into the SC Fat.
- If stable: Oral Fluclox or Clari
- If systemically unwell: Admit and give IV ABs
- If facial infection, Pen V
77
What is the difference between a Boil and a Carbuncle?
Both are staph aureus infections involving hair follicles. Boil = 1, Carbuncle = A group.
Manage the same:
- Most resolve with moist heat
- Large, localised, painful lesions require incision and drainage
- If Fever/Cellulitis/Face lesion, require Fluclox or Clari
78
Risk factors for Bacterial skin infections?
- Any existing lesion
- Fat
- DM
- HIV
- Immunocompromise
- Use of topical steroids
79
How do you decide which antibiotics to give for a wound infection?
If localised to the wound = Staph Aureus = Fluclox or Clari
If spreading beyond wound = Strep = Pen V
If strong, unusual odour = Possibly anaerobe = Metronidazole
80
What causes warts?
HPV infection
81
How do you treat warts?
- Try and avoid it, unless immunocompromised in which case refer.
- Can give Salicylic acid if patient is very insistent (psych effects etc..)
82
How do you manage Herpes?
- Initial Mouth Herpes: Supportive unless seen within first 48 hours, in which case Aciclovir. Can give analgesic mouth wash.
- Recurrent Mouth infection: Aciclovir
- Genital Herpes: Aciclovir if seen within first 5 days
83
Where can Candidia present?
- Genitals = Thrush
- Intertrigo, skin folds
- Oral Thrush
- Nappy area
- Systemic in immunosuppressed individuals
84
Where can Dermatophytes present?
- Tinea Corporis = Ringworm
- Tinea Cruris = Jock Itch
- Tinea Pedis = Athletes foot
- Tinea Capitis = Head and scalp
85
How do you manage a Fungal skin infection?
- Prevention: Keep skin folds dry and apart as much as possible, minimise hot and humid conditions.
Topical options:
- Nystatin for mouth lesions
- Imidazole for skin or genital lesions
Systemic options:
- Fluclonazole for Candidiasis
- Itraconazole for Tinea Cruris/Pedis
86
At what point would you refer a suspected malignant melanoma and what for?
- Score of 3+
- Excission biopsy, best optiin for cure and diagnosis.
- 5-Fluorouacil is only valid chemo option
87
What are general risk factors for skin cancer?
- Sun exposure
- Sunbed use
- Severe sunburns (esp if at a young age)
- Radiation exposure
- Immunosuppression
- Caucasian < Fair Skinned < Ranga
- Wart viruses
- Pipe smoking
- Certain industrial exposures
88
Distinguishing a BCC from an SCC?
BCC:
- Shiny, pearly
- Telangiectasia
- Umbilicated center
SCC:
- Hyperkeratotic
- Crusting
- Ulceration
- Grow more aggresively
89
What to say when assessing a lesion?
- How many are there
- Where on the body
- Size
- Border (is it well defined? Is it regular?)
- Colour (level of pigmentation + erythema)
- Morphology (papule, pustule....)
- Any secondary characteristics
If looks like MM go ABCDEEF.
Consider checking other parts of the body e.g. Nails, Scalp, Hands, Elbows, Local lymph nodes
90
What are the Green Signs in Paediatrics?
- Normal colour (skin, lips, tongue)
- Responds to social cues, is happy and smiley
- Wakes up quickly and stays awake
- Not crying or strong normal cry
- Well hydrated; Moist mucous membranes and normal skin turgor.
91
What are the Amber Signs in Paediatrics, indicating a moderate risk the child is unwell?
- Pale but NOT MOTTLED OR ASHEN
- Decreased response to social cue, not smiling
- Wakes only with excessive stimulation
- Signs of respiratory distress; Nasal flaring, High RR, Sats below 95%
- Crackles in chest
- Tachycardia or delayed capillary refill time
- Poor feeding
- Dehydration; fewer wet nappies, dry mucous membranes
- Temperature above 39 (if older than 3 months, if temperature raised in someone younger than that RED sign)
- Rigors
- Swelling or lack of weight bearing in a limb
92
What are the Paediatric Red Signs, indicating a high risk the child is unwell?
- Mottled or Ashen skin
- Unresponsive to social cues
- Grunting
- Does not wake, or cant stay awake
- Weak, high pitched, continuous crying
- Very high RR (above 60)
- Chest indrawing
- Non-blanching rash
- Bulging fontanelle
- Temp above 38 in a child under 3 months
- Neck stiffness
- Seizures and Status Epilepticus
- Focal neuro signs
93
How do you interpret the flag system?
Green: Supportive care
Amber: Primary care
Red: Immediate referal to paediatrics, with a review within 2 hours.
94
What are the common causes of PUO in kids?
FEVER AND NO LOCALISING SIGNS IN KID, TEST FOR UTI.
- Infection (UTIs are very common, TB, Endocarditis, Malaria are also quite common)
- Malignancy (leukaemia and lymphoma)
- Liver or Renal disease can present as PUO in kids
- Drug reactions, commonly to antibiotics
- Juvenile Idiopathic Arthritis
- Kawasaki disease (look for Strawberry tongue, Swollen Lymph nodes across the body, fever not responding to medication in a child under the age of 5. Resolves spontaneously).
95
Signs of Respiratory Distress in children?
- Raised HR and RR
- Colour changes
- Grunting
- Tracheal tug
- Head bobbing
- Nasal flaring
- Intercostal and subcostal recessions
- Sweating
- Wheezing
- Stridor
96
What is the differential diagnosis for neonatal jaundice?
2 Benign:
- Neonatal jaundice. Comes and goes in first week.
- Breast-feeding jaundice. Develops soon after birth and resolves itself.
2 Serious:
- Biliary Tree Atresia. Narrowing, lack of opening, or total absence of the biliary tree. Leads to high levels of conjugated bilirubin therefore no immediate risk of brain damage but eventual risk of cirrhosis. Management is surgical, various ways of reopening the biliary system.
- Haemolytic Disease of the New Born. Raised unconjugated bilirubin at birth, due to autoimmune reaction. High levels of UCB puts the child at risk of Kernicterus, brain damage caused by B. Test via Coombs test, manage via blood transfusions and phototherapy to break down the B.
Rarer ones: Sepsis, Thalaseamia, Sickle Cell, G6DP Deficiency, Subgaleal haemorrhage
97
What should a child be able to do at 6 weeks?
- Tummy time
- Follow moving objects by turning their head
- Startled by loud noises but not necesarily making any
- Smiles responsively
98
What should a child be able to do at 6 months?
- Sit without support
- Palmar grasp
- Make cooing noises/begin to make polysylabic noises like bababa
- Put food in their own mouth
99
What should a child be able to do at 1 year?
- Walk unsteadily
- Mature pincer grip
- Two or three words other than Mama and Dada
- Drink from a cup held in two hands
100
What should a child be able to do at 2 years?
- Walk less unsteadily, begin to run and jump
- Be able to draw a line and build a tower of 6 blocks
- Simple sentences like “give me teddy”
- Playing with others, beginning to toilet train
101
What are the 4 areas of childhood development?
- Gross Motor
- Fine Motor
- Hearing, Speech and Language
- Social, Emotional and Behavioural
102
How would you manage a baby with a sticky eye?
- Swab for potential STI conjunctivitis, and ask mother about UPSI during pregnancy.
- Reassure its probably just a blocked tear duct, bath with boiled water during nappy changes.
103
What would you suspect in a baby who is posseting large amounts and failing to thrive?
GORD.
Management:
- Test for cows milk allergies, can present similarly
- Feeding baby sat up should go most of the way to resolving the symptoms
- If not, thickening agents such as Carobel can be added to food.
- Finally, Gaviscon and Ranitidine can be used
Refer if:
- Still failing to thrive
- Suspected complication (Aspiration pneumonia and Oesophageal stricture are common)
- Anaemic
- Chesty
104
Baby comes in with repeated bouts of intense, inconsolable crying, mostly in the early evenings. Body goes entirely rigid, face goes red, knees draw up. Eventually settles.
What are you thinking and how do you manage?
Colic.
Management is Colid drops/Gripe water. Refer to paeds if not resolving easily.
105
How do you safely diagnose a URTI?
Patient comes in with coryza
- Check chest, not pneumonia
- Check throat, not strep throat
- Check ears and mastoid, no spreading
- Check systemic health, not sepsis
If all clear tell them to jog on.
106
How do you manage a child with Pneumonia?
If any of:
- Sats below 92
- Cyanotic
- RR > 70
- Difficulty breathing (grunting)
- Dehydration
- Not feeding
- Not responding to intial antibiotics
ADMIT TO PAEDS.
If none of the above:
- Amoxicillin is first line
- Add a Macrolide (e.g. Azithromycin) if concerned/allergic
- Co-Amox is better if associated with flu symptoms
107
What is Bronchiolitis?
Inflammation and blockage of the small airways of the lungs secondary to infection by Respiratory Syncitial Virus, mostly affecting children below the age of 6.
Coryza, Fever, Cough, Breathing Difficulty, Eating Difficulty
Creps and wheeze on examination
Management depends on severity:
- Moderate illness can be managed at home, fluids and paracetemol suspensions. Must avoid other kids as contagious.
- Severe illness, ADMIT TO PAEDS FOR ANTIVIRALS.
108
How do you diagnose and treat constipation in kids?
Any 2 of:
- History of Constipation
- Abnormal Stool Pattern (less than 3 a week, overflow soiling, hard rabbit dropping stools)
- Symptoms of Constipation (e.g. pain, straining, anorexia...)
Eliminate any serious causes:
- Hirschsprung’s
- Coeliacs
- Hypothyroidism
- Anorectal disease
- Neuro conditions
Management:
- Check tTG and Thyroid
- Refer if abnormal anus, ribon stools, asymetrical gluteal muscles or neuro signs, gross distention
- MACROGOL
109
What are the causes of pituitary dwarfism and how is it managed?
Idiopathic, Genetic, Midline defect (e.g. Cleft Palate), Pituitary adenoma.
Need to see specialist, will likely go on a mixture of hormonal replacement therapies. GH, Cortisol and TH are common.
110
How is delayed puberty defined?
- No changes by aged 13 in girls or 14 in boys OR
| - No prgression in two years
111
What causes delayed puberty?
80% Normal in boys, 80% Abnormal in girls.
Usually either:
- Hypergonadotrophic Hypogonadism (primary ovarian/testes failure)
- Hypogonaditrophic Hypogonadism (secondary ovarian/testes failure)
112
What are some complications of coeliacs?
- Osteomalacia
- Dermatitis Heroetiformis
- Failure to thrive or weight loss
- Mouth ulcers
- Angular stomatitis
113
Diagnosis and management of Coeliac’s?
- TTG IgA while on a gluten diet
- Duodenal biopsy while on a gluten diet is next step if highly suspicious but unclear diagnosis
- Anaemia, B12 deficiency, low Feritin are all secondary findings.
114
What are the managemer options for Coeliacs?
- Life long gluten free diet.
- Rice, Maize, Soy, Potatoes, Sugar are all okay
- Gluten free foods are available on the NHS as they are very expensive, require proof obviously.
115
When is anxiety considered abnormal?
- If it occurs in the absence of a stimulus
- It impairs physical/occupational/social function
- It is excesively severe
- It is excesively prolongued
116
What are some physical signs of anxiety?
Can affect all systems: CNS, PNS, CVS, Resp, GI, Urinary, Reproductive
- Dry mouth
- Tremor
- Dizzyness
- Paraesthesiae
- Stomach upset
- Chest discomfort and constriction
- Palpitations
- Urinary frequency or urgency
- Sexual dysfunction
- Hyperventilation and SoB
117
What time frames are needed to diagnose anxiety and depression?
- Anxiety: Symptoms must be present on most days for 6 months
- Depression: Symptoms present 50% of the time over the last 3 weeks
118
What diagnostic questionnaires are available for Depression and Anxiety?
```
Depression = PHQ-9
Anxiety = GAD Score, Hamilton Anxiety Scale can be used by the patient at home to assess their own levels.
```
Basically ask screening questions and if they answer any positively, consider asking them to fill out the questionnaires.
119
What are some medical differentials for Anxiety?
- Hyperthyroidism
- Hypocalcaemia
- Phaechromocytoma
- Temporal lobe epilepsy
- Drug and Alcohol abuse and withdrawal
120
Management options for anxiety?
- Always start with low intensity interventions. Mindfullness, education, self-help guides and support groups.
- Similarly, avoiding caffeine alcohol and drugs has known benefits.
- Consider more intensive therapies like CCBT, CBT proper.
- Medication: Sertraline first line. If fails consider Citalopram, Duloxetine or Pregabalin (best if they cant handle SSRIs).
- Benzodiazepines work for short term acute relief.
121
How do you distinguish anxiety from panic disorders?
Panic is associated with intense, sudden increases in anxiety with accompanied sensation of impending doom and physical symptms more consistent with cardio-resp distress.
Management is similar:
- CANNOT USE BENZOS LIKE YOU CAN IN ANXIETY
- SSRIs first line: Citalopram and Paroxetine
- TCAs are second line.
- Refer much earlier as more likely to benefit from specialist intervention
122
How do you manage a panic attack?
- Exclude asthma/epilepsy/anaphylaxis/hypoglycaemia
- Talk the patient down. Discuss their symptoms with them and start counting breaths in and out.
- Rebreathing. Increases CO2 in blood and can solve some symptoms.
- Propanolol 10-20mg stat can be useful.
123
How do you manage mixed depression and anxiety?
- Treat whichever feature is more dominant.
- Refer to psych. These patients are at massive risk of deterioration and chronicity, so benefit from early initiation of secondary care.
124
What are the two main features of OCD?
Obsessional thinking: Persistent intrusive thoughts that generate anxiety
Compulsive behaviour: Rituals and repeated behaviours done to try amd get rid of the anxiety
Also depression/anxiety/indicisiveness.
125
Why is Fluoxetine so useful?
Best for OCD and only SSRI that works on young people.
126
What therapies are best for OCD?
- CBT, Exposure-response prevention therapy and Group therapy initially
- Fluoxetine and CBT if not effective.
- If still not working, try a different SSRI or refer
127
What drugs can cause symptoms like depression?
- Anticonvulsants and Antipsychotics
- Beta blockers
- CC blockers
- Corticosteroids
- OCP
- Levodopa
128
What are the key questions to ask in a depression history?
- Ask around current symptoms (sort of SQITARS)
- Family and personal history of depression
- Quality of relationships and support
- Living conditions
- Employment and finances
- Alcohol or other substances
- SUICIDE
- Past experiences with therapy
+ Any mental and physical co-morbidities
129
What are the core and non-core symptoms of depression?
Core = Low mood, Low energy, Lack of interest in things they normally enjoy.
Non-Core =
- Sleep disturbance and fatigue (especially important to look out for. Has a very high predictive value for depression). This includes both hypo and hypersomnia.
- Changes in appetite and weight.
- Poor concentration.
130
How do you relate PHQ-9 score to management?
- Less than 5 = Sub-clinical Depression = Education, Sleep improvement, Exercise, Watchful waiting
- 5-9 = Mild Depression = CCBT, Group therapy
- 10-19 = Moderate-Severe Depression = Interpersonal therapy, CBT, SSRIs.
- 19+ = Severe depression = High suicide and neglect risk, refer to psych.
Obviously if you dont get a response at one level, move on to the next.
131
How do you distinguish Anorexia from Bulimia?
Actually not that simple.
Anorexia patients tend to have lower BMIs and Bulimia patients tend to be more prone to gorging and purging but neither is diagnostic. Both show undue influence of body shape on self-image.
Managed by regular electorlyte monitoring, and psychotherapy. Family therapy is very effective in adolescents.
132
What advise would you give a patient who purges?
- Avoid brushing your teeth after vomiting, as it can cause further damage. Non-acidic mouth wash would be better.
- Do not use laxatives, has no effect on how many calories are absorbed and can cause electrolyte disturbances.
- However dont stop them right away as will lead to comstipation.
133
What is the management pathway for a suspected alcoholic patient?
1) Are they an alcoholic? Assess how much they drink and their behaviour around the drinking.
2) Are they willing to change? If no, document. If yes, consider options.
3) Are they dependant on alcohol?
- YES: Provide advise and refer to community alcohol team so they can help with safe detox.
- NO: Provide advise and manage yourself. Keep a diary, agree on targets and follow up.
134
What drugs are used to get a patient to stop drinking?
- Chlordiazepoxide can help treat the symptoms of anxiety attatched to withdrawal.
- Pabrinex and over Vitamin supplements can help avoid the serious effects of withdrawal.
- Disulfiram cam help avoid relapse.
135
What are some SSRIs and what are common side effects.
Fluoxetine, Sertraline, Citalopram
First 2 weeks issues, GI disturbance, GI bleed (may be worth prescribing a PPI), Hyponatraemia
136
What are some SNRIs and when are they used?
Used when SSRIs are unnafected. Venlafaxine is most common. Cant give if arrythmia or hypertension
137
How should you monitor patients starting on antidepressants?
Review every 1-2 weeks until stable. Give it at least 6 weeks until deciding treatment has failed.
Asking about 4 things: Symptoms, Compliance, Side effects, SUICIDE RISK.
138
What is a discontinuation reaction?
Set of symptoms seen about 5 days after patients whove been on them for longer than 8 weeks stop taking antidepressants. More pronounced in SNRIs than SSRIs.
Common symptoms include: GI disturbance, headache, nausea, vomiting, insomnia, restlessness, paraesthesia, anxiety, flu symptoms.
Avoid by tapering off symptoms over the course of about 4 weeks.
139
What is Carcinoid syndrome?
Paraneoplastic syndrome of carcinoid tumours.
Caused by oversecretion of Serotonin and Kallikrein.
Symptoms include: Flushing, Diarrhoea, Vomiting, Abdo Pain. In severe cases, bronchoconstriction and heart failure can occur.
140
What are the common symptoms affecting terminal patients and how do we treat them?
- Pain: Morphine
- Nausea and Vomiting: Either Cyclizine or Haloperidol
- Anxiety: Either Medazolam or Haloperidol
- SoB: Oxygen, Morphine or Lorazepam
- Respiratory Secretions: Hyoscine
141
What is involved in a HRQoL? What are its components?
FPS SCOPE
Functional
Psychological
Symptomatic
```
Social
Cognitive
Overall
Personal Constructs
Emotional
Satisfaction with care
```
(Aspects to a health intervention)
