General Practise/Primary Care

Question 1

What is acute bronchitis?

Answer 1

self limiting LTRI

inflammation of bronchi and trachea.

Question 2

Risk Factors of Acute Bronchitis

Answer 2

Smoking

Winter months

Contact with patients with RTI

Question 3

Pathophysiology of Acute Bronchitis

Answer 3

Acute bronchial wall inflammation

causes increased mucous production and oedema = productive cough.

damage caused to the wall may take weeks to repair so the cough might last a little.

50% lasts over 2 weeks and 25% over a month. - post bronchitis syndrome.

Question 4

Aetiology of Acute Bronchitis

Answer 4

Viral: same as urti’s

RSV
CORONAVIRUS
RHINOVIRUS
ADENOVIRUS

Question 5

Presentation of Acute Bronchitis

Answer 5

Productive Cough - clear, discoloured or white sputum. cough usually less than 1 month.

Sore throat

Rhinorrhoea

Wheeze - not always. maybe on forced expiration

Low grade fever - systemic features should be absent

Question 6

Bronchitis vs Pneumonia

Answer 6

Systemic features and dysnpoea, wheeze and productive cough - pneumonia

dullness, bronchial breathing and crepitations - pneumonia

if crackles for bronchitis will clear with cough

Question 7

Criteria for Acute Bronchitis

Answer 7

None in stone by Macfarlane helps with diagnosis:

Acute : less than 21 days
Cant be explained otherwise
At least 1 of LTRI symptoms like sputum, chest pain or wheeze.
Cough main symptom.

Question 8

Ix of Acute Bronchitis

Answer 8

Clinical diagnosis

CXR - RULE OUT PNEUMONIA IF UNSURE.

USE CRP TO GIVE BACK UP ABX

LESS THAN 20 MG/L - NO ABX
20-100 - DELAYED ABX
OVER 100 - IMMEDIATE ABX

PROCALCITONIN - new test for bacterial and viral infections. more effective for bacterial though.

Question 9

Management of Acute Bronchitis

Answer 9

Self - limiting - doesnt require anything other than symptom mx.

Adequate fluid and analgesia (para/ibuprofen) - maybe honey cough syrup?

ABX - BE CAREFUL BC ITS SELF LIMITING AND YOU DONT WANT OVERUSE.

ONLY GIVE ABX IF :

PRE-EXISTING CO MORBID ISSUES OR IMMUNOSUPPRESSED.
OVER 65 WITH 2/ OVER 80 WITH 1 :

HOSPITAL IN LAST YR
T1DM/T2DM
CCF
ORAL CORTICOSTEROID USE CURRENTLY

CRP OVER 100 MG/L

Question 10

What abx do you give in Acute Bronchitis ( if you give them)?

Answer 10

over 18 :

Doxycycline : 5 days - 1st day 200mg then 100mg OD for 4 days. NOT TO PREGNANT WOMEN.
ALTERNATIVE: AMOXICILLIN (PREGNANT) , ERYTHROMYCIN/CLARITHROMYCIN

12-17:
AMOX: 500MG 3*DAILY FOR 5 DAYS

ALTERNATIVE: ERYTHROMYCIN/CLARITHROMYCIN

Question 11

What is Acute Stress Disorder? (ASD)

Answer 11

acute stress reaction within first 4 weeks after traumatic event.

something abnormal like sexual assault or car accident or robbery.

Question 12

diff between asd and ptsd

Answer 12

asd is first 4 weeks and ptsd is after 4 weeks

Question 13

asd vs adjustment disorder

Answer 13

adjustment disorder - state of stress inferring with social function after having to adjust your life due to life change maybe a death or seperation. not an abnormal thing though

asd - abnormal stressor (physical/mental) that shouldnt be experienced by human.

Question 14

Presentation of ASD - ACUTE STRESS DISORDER

Answer 14

dsm-v criteria

1. disassociation - feel out of it. out of time
2. intrusive thoughts - nightmares/flashbacks
3. negative mood
4. avoidance - of like distressing memories or thoughts/feelings
5. arousal - hypervigilant, insomnia, cant concentrate

Question 15

Mx of acute stress disorder (ASD)

Answer 15

trauma - based CBT - 1st line - given to people with asd that affects daily function.

benzodiazepine - sometimes for acute symptoms like sleep disturbance or agitated. NOT LONG TERM (addictive)

nice recommends you don’t prevent PTSD

Question 16

What is contact dermatitis?

Answer 16

allergic or irritant reaction - 2 types

irritant contact (ICD) OR allergic (ACD)

Question 17

What is irritant contact dermatitis caused by?

Answer 17

direct toxicity to skin.
anyone in contact with irritant of sufficient conc for sufficient time. severity depends on this too.

can range from acute to chronic (single to repeated exposure)

metals
solvents
detergents
weak acid/alkalis
cement ( alkaline) - can even cause ACD because of dichromates presence.

Question 18

What is allergic contact dermatitis caused by ?

Answer 18

type 4 hypersensitivity reaction
dont need prior sensation.

rarer than icd

allergens typically haptens cause it. cause immune response when they bind to protein complex. they then move to epidermis and bind to langerhans cells in epidermis which are antigen presenting cells.

they also travel to regional lymph node sites to present cd4+ t cells which give a response in 48-96 hrs of re-exposure.

poison ivy
fragrance
metals - nickel
jewellery
hair dye
latex
dichromates - cement and leather
preservatives - hygiene and cosmetic product

Question 19

risk factors of contact dermatitis

Answer 19

occupational exposure - labourer, dry cleaner, janitor, dry cleaner, farmer, food-industry worker, machine operator, cook

atopic dermatitis (excema)

Question 20

Presentation of irritant contact dermatitis

Answer 20

presents minutes - hours of exposure to irritant. mild irritant days-weeks

commonly of face and hands. limited to site of exposure:

erythema
burning
pustules/acneiform lesions
ulceration (severe irritant)

Question 21

Presentation of allergic contact dermatitis

Answer 21

prevents 24-72 hours after re-exposure (previous sensitised)

commonly dominant hand but can be anywhere.
often margin of hairline.

erythema
pruritis
bullae and vesicles
urticaria - with latex or certain food exposure.

Question 22

Ix of contact dermatitis

Answer 22

Patch testing - present allergen to skin. will show inflammation - grade within 2-7 of application if +ve.

repeat open application test (ROAT)/ proactive use test (PUT) - 2* daily for 1 week.
stimulates contact dermatitis for leave on products like moisturisers or sunscreen or cosmetics

Question 23

Mx of contact dermatitis

Answer 23

1st line - avoid irritant/allergen

emolient = icd - applied to affected area

hydrocortisone - only ACD - topical corticosteroid

Question 24

How do insect bites affect you?

Answer 24

mosquitos, bed bugs and fleas have mouth piercing parts that pierce the skin.
horseflies lacerate the skin.

they have antigenic components in saliva cause local, systemic reactions. first time bite no reaction but after type 4 hypersensitivity reaction and after repetitive leads to inflamed and itchy maculopapules.

More concerningly, a type 1 hypersensitivity reaction may develop with a typical wheal and flare presentation. This develops within 20 minutes of the bite, and can sometimes lead to anaphylaxis.

Question 25

how do insect stings affect you? bees wasps hornets

Answer 25

inject venom from a sac attached to a stinger into the skin directly. - has allergen and histamine cause reaction. Local - no more than 10cm from the site of exposure. Redness, swelling and pain are limited to the soft tissue solely. Systemic - these are distant from the site, such as widespread redness, itching, uriticaria, angioedema. It is more likely to lead to anaphylaxis if there is airways and haemodynamic compromise.

Question 26

presentation of insect stings and bites

Answer 26

local - swelling erythema pain systemic - Uriticaria, rhinitis, wheeze, abdo pain, vomit, dizzi, angioedema, anaphylaxis

Question 27

ix of insect stings and bites

Answer 27

clinical diagnosis test for venom allergies in any pt with systemic reaction or anaphylaxis (skin-prick or venom specific IgE testing)) and if these are positive venom immunotherapy (VIT) need to be given.

Question 28

Mx of insect bites and stings

Answer 28

remove stinger if you see it small local reaction - nothing other than analgesia for pain and chlorphenamine (antihistamine) for itching or hydrocortisone cream. large local reaction - oral antihistamine and/or oral corticosteroids ( be careful of steroid bc wound could be infected) systemic reaction - admit to a+e - treat for anaphylaxis in meantime. allergy specialist referral.

Question 29

what do you mean by food allergy?

Answer 29

adverse reaction to proteins in food. common is peanuts, tree nuts, milk, eggs, fish , wheat, soya can be genetic and environmental factors and can be IgE mediated (acute) or non ige (subacute/chronic)

Question 30

presentation of food allergy

Answer 30

IgE mediated: minutes to 2 hrs of ingestion Uriticaria Angioedema Acute rhinoconjunctivitis Acute asthma Anaphylaxis Nausea and vomiting Abdominal pain Non IgE mediated: Contact dermatitis Dermatitis herpetiformis Coeliac disease Heiner syndrome (cow milk induced pulmonary disease)

Question 31

Ix of Food Allergy

Answer 31

Skin Prick - 1st line. reproducible quick 15 mins, fast and cheap good sensitivity (only 50% specificity). positive allergens produce wheal over 3 mm compared to control is +ve Serum Specific IgE immunoassay - expensive and longer for results Food Challenges - best test but longer expensive and difficult bc you need staff to manage anaphylaxis if necessary

Question 32

Mx of Food Allergy

Answer 32

Anaphylaxis treat accordingly. Allergy action plan and avoidance.

Question 33

What is an anal fissure?

Answer 33

tear in the squamous mucosal lining of the anal canal. occur most common on posterior (90%) aspect of anal canal. anterior fissures often follow parturition in females. lateral anal fissure suggests secondary cause.

Question 34

tell me the 2 types of anal fissures and how they come about

Answer 34

High-pressure fissures - ischaemia due to high pressure in anal sphincter causes the fissure. Low-pressure fissures - tends to happen in postpartum women.

Question 35

classify anal fissures

Answer 35

acute - less than 6 weeks chronic - over 6 weeks primary - no underlying disease present secondary - underlying disease like IBD

Question 36

Risk Factors of anal fissures

Answer 36

main causes: inflammation and trauma. major rf: 1. constipation 2. dehydration 3. IBD 4. chronic diarrhoea

Question 37

Clinical Features/symptoms of anal fissures

Answer 37

Intense post-defecatory pain - most common. disproportionate to size of fissure. Bleeding of fresh, bright red blood on wiping or after defecation. Itching fissures visible on dre but pt may refuse. can give anaesthetic. possible sentinel pile at 6 and 12 o clock. small external lump with tear.

Question 38

DD of anal fissure

Answer 38

haemorroids CHRONS/UC ANAL CANCER

Question 39

Mx of Anal Fissure

Answer 39

medical : analgesia, topic anaesthetic, diet management (increase fluid and fibre intake if less than 1 week), laxative if this dont work, gtn cream or diltiazem cream (CCB). increases blood flow to region and relaxes internal anal sphincter - promotes healing and reduces pain, applies less pressure on sphincter. diltiazem is better tolerated by gtn cream is cheap. use for high pressure fissures. CHRONIC: Topical glyceryl trinitrate is first-line treatment surgical: chronic with medical mx not working after 8 weeks. LATERAL SPINCTERECTOMY - DIVISION OF INTERNAL ANAL SPHINCTER RELIEVE PRESURE

Question 40

What is acne vulgaris?

Answer 40

chronic inflammation of hair follicles and sebaceous glands in the dermis. 12-25 - resolves in mid 20's

Question 41

Risk Factors of Acne Vulgaris

Answer 41

Teenage - peak is 14 girl, 16 boy Fhx Genetics - hyperkeratosis can run in family. PCOS is increased androgen=increased sebum Medication - androgens, corticosteroids Physical Product - moisturiser, cosmetics block pores Contact Acne - headband irritate skin Excessive washing of skin - irritate skin Stress - increased cortisol cause increased sebum secretion NOT DIET

Question 42

Ix and Diagnosis of Acne Vulgaris

Answer 42

Clinical consider: endocrine screen test testosterone, LH, FSH if hyperandrogenism is suspected: PCOS

Question 43

Pathophysiology of Acne Vulgaris

Answer 43

Obstruction of the pilosebaceous follicle factors that contribute: keratin plugs, sebum and bacterial overgrowth KERATIN PLUGS - tiny clumps of dead keratinocytes,keratin and melanin. when keratinocytes produce to much keratin in hair follicles= hyperkeratosis. more keratin plugs = block hair follicle opening SEBUM - RELEASED BY SEBACEOUS GLANDS RESPONDING TO INCREASED ANDROGEN PRODUCTION IN PUBERTY. CLOG UP FOLLICLES AND CAUSE BLOCKAGE LIKE KERATIN PLUGS. Excess keratin plugs/sebum or both , fills hair follicle but not full thing. Hair can come thru as its open to skin surface. = open comedome – black appearance – blackhead. – melanin in keratin plug gets oxidised when exposed to air = dark BACTERIAL OVERGROWTH: Bacteria live in follicles – Propionibacterium. If hair follicle gets plugged up = closed comedone. Bacteria grows, feasts overgrowth. Immune cells attack bacterial cells. This mix is white pus with red inflammation = whitehead/pimple If follicle bursts, inflammatory lesions like papules/pustules form. Excessive inflammation = nodules, cysts. You can get inflammatory scarring (ICE-PICK/HYPERTROPHIC SCARS)

Question 44

Clinical Manifestations of Acne Vulgaris

Answer 44

generally face neck and upper trunk mild - mostly non inflamed lesions - open and closed comedones with few inflammatory lesions. whiteheads and blackheads. moderate - more widespread. inflammatory papules and pustules severe - widespread inflammatory pustules and papules and nodules, cysts . scarring potentially

Question 45

what is a macule, papule , pustule?

Answer 45

macule - flat mark papule - small lump pustule - small lump with yellow pus

Question 46

describe different types of scars icepick hypertrophic rolling

Answer 46

icepick - after acne lesion heals small indentation in the skin hypertrophic - after acne lesion heals small lump in the skin rolling - irregular wave-like irregularity after acne heals

Question 47

Mx of Acne Vulgaris

Answer 47

1st line - if mild/moderate do one of : topical retinoid (slows sebum production) +/- benzoyl peroxide (reduce inflammation, unblock skin and is toxic to P.acnes bacteria) topical abx - clindamycin. give benzoyl peroxide or topical retinoid (if no ci) prevent abx resistance topical azelaic acid 20% 2nd line - oral tetracycline (doxycycline,limecycline, oxytetracycline) - with topical retinoid or benzoyl peroxide (prevent abx resistance) Combined oral contraceptive to women - alternative to oral abx - co-cyprindiol (danette) . increased risk of VTE so only use when other failed . use with topical therapy. stop after acne controlled for 3 months. 3rd line - Accutane - isotretinoin oral - vit A analogue if scarring or pt unresponsive to 2 courses of Abx .

Question 48

function of accutane

Answer 48

Reduce production of sebum – reduce inflammation and bacterial growth . Ci: pregnancy to both topic and oral retinoids – TERATOGENIC

Question 49

rules for abx use in acne vulgaris

Answer 49

dont use same abx longer than 3 months if inneffective move onto another erythromycin in pregnancy no tetracycline in pregancy/breastfeeding/under 12 minocycline avoid - irreversible pigmentation always co-prescribe benzoyl peroxide and topic retinoid to avoid resistance. dont give both oral and topical abx

Question 50

comps of acne vulgaris

Answer 50

Acne fulminans – severe acne – systemic upset. Hospital admin – steroid tx Post inflammatory change – hyperpigmentation/scarring Retinoid SE – dry skin, photosensitivity,depression, teratogencicity Depression and anxiety Gram-negative folliculities – long term abx – tx with high dose oral trimethoprim Other meds SE – isotretinoin and tetracycline cause intracranal HTN so don’t give both

Question 51

What is anaphylaxis

Answer 51

type 1 hypersensitivity reaction. igE activation causes mast cells to degranulate and release histamine and other pro-inflammatory mediators and you have ABC compromise. non-anaphylactic allergy doesnt have ABC compromise

Question 52

common allergens for anaphylaxis

Answer 52

food - nuts meds - b-lactams - pencillin and nsaids. general anaesthetics too. wasp and bee stings could be idiopathic

Question 53

Presentation of anaphylaxis

Answer 53

confusion, headache and loss of consciousness swollen lips , tongue, eyes fast heart rate abdo pain, vomit hives wheezing,cough, difficulty getting air rapid onset of allergy symptoms urticaria itching angioedema abdo pain

Question 54

ABC impact from anaphylaxis