GP Flashcards

Question

What is the management of bacterial vaginosis in an asymptomatic patient?

Answer 1

If the woman is asymptomatic, treatment is not usually required Exceptions include if the patient is undergoing termination of pregnancy

Answer 2

Oral metronidazole for 5-7 days Single oral dose of 2g may be used if adherence is an issue

Answer 3

Topical metronidazole or topical clindamycin

Answer 4

Dermatophyte fungal infection of the scalp

Answer 5

Oral antifungal - terbinafine Topical ketoconazole shampoo for first two weeks to reduce transmission

Answer 6

Oral antifungal - griseofulvin Topical ketoconazole shampoo for first two weeks to reduce transmission

Answer 7

Dermatophyte fungal infection of the foot

Answer 8

Dermatophyte fungal infection of the groin

Answer 9

Dermatophyte fungal infection of the trunk, legs or arms

Answer 10

Oral fluconazole

Answer 11

Molluscum contagiosum is a common skin infection caused by molluscum contagiosum virus (MCV), a member of the Poxviridae family

Answer 12

Transmission occurs directly by close personal contact, or indirectly via fomites (contaminated surfaces) such as shared towels and flannels

Answer 13

Pinkish or pearly white papules with a central umbilication 5mm in diameter Children - typically trunk and flexures Adults - Genitalia, pubis, thighs, and lower abdomen

Answer 14

Treatment is not usually recommended Cryotherapy can be used or simple trauma

Answer 15

Types 6 and 11

Answer 16

Topical podophyllum - when multiple and non-keratinised Cryotherapy - when solitary and keratinised

Answer 17

Imiquimod which is a topical cream

Answer 18

An inflammatory process involving any part of the hair follicle; it is most commonly secondary to infection

Answer 19

Staphylococcus aureus

Answer 20

Clindamycin or Flucloxacillin

Answer 21

Topical benzoyl peroxide

Answer 22

A chronic skin disorder defined by red, scaly patches on the skin

Answer 23

The most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp

Answer 24

The same as plaque psoriasis but the skin is smooth

Answer 25

Transient psoriatic rash frequently triggered by a streptococcal infection.

Answer 26

Commonly occurs on the palms and soles

Answer 27

Trauma Alcohol Lithium Drugs: beta blockers, antimalarials, NSAIDs, ACEi and infliximab Withdrawal of systemic steroids

Answer 28

Potent topical corticosteroid OD + vitamin D analogue OD

Answer 29

Potent topical corticosteroid OD + vitamin D analogue BD If no improvement after 8 weeks

Answer 30

Potent topical corticosteroid BD + vitamin D analogue BD If no improvement after 8-12 weeks

Answer 31

Ultraviolet B light Ultraviolet A light + psoralen Oral methotrexate

Answer 32

Potent topical corticosteroids used once daily for 4 weeks

Answer 33

Mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks Due to pronity of steroid atrophy of skin

Answer 34

Calcipotriol (Dovonex) Calcitriol Tacalcitol

Answer 35

Decrease cell division and differentiation, therefore there is decreased epidermal proliferation

Answer 36

Impetigo is a superficial bacterial skin infection

Answer 37

Staphylcoccus aureus Streptococcus pyogenes

Answer 38

Areas not covered by clothes: Face Flexures Limbs

Answer 39

4 to 10 days

Answer 40

Golden crust to the skin Very contagious

Answer 41

First line - hydrogen peroxide 1% cream Topical fusidic acid

Answer 42

Oral flucloxacillin Oral erythromycin if allergy

Answer 43

Children should be excluded from school until the lesions are crusted and healed OR 48 hours after commencing antibiotic treatment

Answer 44

Urticaria describes a local or generalised superficial swelling of the skin. Most common cause is allergy.

Answer 45

Pale, pink raised skin. Variously described as 'hives', 'wheals', 'nettle rash' Pruritic

Answer 46

Non-sedating antihistamines - continued for up to 6 weeks are first line Sedating may be considered for night time use

Answer 47

Prednisolone

Answer 48

Non-sedating antihistamines (e.g. loratadine or cetirizine) Sedating antihistamines (e.g. chlorophenamine)

Answer 49

All People Need Oxygen: Aspirin Penicillins NSAIDs Opiates

Answer 50

Primary infection with varicella zoster virus

Answer 51

Reactivation of varicella zoster virus from dorsal root ganglion

Answer 52

Spread via the respiratory route Can be caught by someone with shingles infective from 4 days before rash until 5 days after rash appeared

Answer 53

10-21 days

Answer 54

Prodromal phase - fever initially Itchy, rash starting on head/trunk before spreading. Systemic upset is usually mild

Answer 55

Initially macular then papular then vesicular

Answer 56

Keep cool Trim nails School exclusion until all lesions are dry and have crusted over

Answer 57

Immunocompromised patients Newborns with peripartum exposure If chickenpox develops = IV aciclovir

Answer 58

Secondary bacterial infection particularly invasive group A streptococcal soft tissue infections may occur resulting in necrotising fasciitis NSAIDs

Answer 59

Acute bronchitis is a type of chest infection a result of inflammation of the trachea and major bronchi

Answer 60

Cough: may or may not be productive Sore throat Rhinorrhoea Wheeze

Answer 61

No other focal chest signs in acute bronchitis other than wheeze. No systemic symptoms

Answer 62

Analgesia Fluid intake CRP 20-100 = delayed prescription antibiotics CRP >100 = immediate antibiotics

Answer 63

Doxycycline if first-line Amoxicillin if pregnant or child

Answer 64

MacFarlane Criteria: An acute illness of <21 days Cough as the predominant symptom At least 1 other lower respiratory tract symptom, such as sputum production, wheezing, chest pain No alternative explanation for the symptoms

Answer 65

A diagnosis of acute bronchitis

Answer 66

A chronic inflammatory disorder of the airways secondary to type 1 hypersensitivity

Answer 67

It is common for young children to wheeze when they develop a virus ('viral-induced wheeze')

Answer 68

Other IgE-mediated atopic conditions such as: Atopic dermatitis (eczema) Allergic rhinitis (hay fever)

Answer 69

Aspirin Will most likely have nasal polyps if this is the case

Answer 70

Cough - worse at night Dyspnoea Expiratory wheeze Reduced peak expiratory flow rate

Answer 71

Forced expiratory volume - volume that has been exhaled at the end of the first second of forced expiration

Answer 72

Forced vital capacity - volume that has been exhaled after a maximal expiration following a full inspiration

Answer 73

FEV1 - significantly reduced FVC - normal FEV1% (FEV1/FVC) < 70%

Answer 74

Fractional exhaled Nitric Oxide OR Eosinophil count

Answer 75

Bronchodilator reversibility (BDR) with spirometry

Answer 76

Salbutamol

Answer 77

Short-acting-beta agonist (SABA)

Answer 78

Relaxation of the smooth muscles of the airways

Answer 79

Inhaled corticosteroids

Answer 80

Oral candidiasis Stunted growth in children

Answer 81

Beclometasone dipropionate Fluticasone propionate

Answer 82

Leukotriene receptor antagonist (LTRA) - Montelukast

Answer 83

Long-acting beta-agonist

Answer 84

They work by relaxing the smooth muscle of airways

Answer 85

SpO2 > 92% No clinical features of severe asthma

Answer 86

SpO2 <92% PEF - PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis

Answer 87

SpO2 < 92% PEF - 33-50% Too breathless to talk or feed Use of accessory neck muscles HR - >125 (>5 years), >140 (1-5 years) RR - >30 (>5 years), >40 (1/5 years)

Answer 88

Beta-2-agonist via a spacer (>3 years use close fitting mask) 1 puff every 30-60 seconds. Max 10 puffs If no symptom control refer to hospital Steroid therapy for 3-5 days 2-5 years - 20mg prednisolone OD >5 years - 30-40mg prednisolone OD

Answer 89

PEFR 50-75% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm

Answer 90

PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm

Answer 91

PEFR < 33% best or predicted Oxygen sats < 92% 'Normal' pC02 (4.6-6.0 kPa) Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma

Answer 92

Raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.

Answer 93

Admission to hospital 15L oxygen in non-rebreathe mask if 02 sats low (until spO2 94-98) Nebulised SABA (salbutamol) 40-50mg prednisolone PO - 5 days Ipratropium bromide in all life-threatening or whom have not responded to SABA / Steroids

Answer 94

Stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours Inhaler technique checked and recorded PEF >75% of best or predicted

Answer 95

Bronchiolitis is a condition characterised by acute bronchiolar inflammation

Answer 96

Respiratory syncytial virus (80%) Rhinovirus (20%)

Answer 97

Immunofluorescence of nasopharyngeal secretions may show RSV

Answer 98

If SpO2 persistently >92% - humidified oxygen Accessory: NG feeding Suction of secretions

Answer 99

Bronchopulmonary dysplasia (e.g. Premature) Congenital heart disease Cystic fibrosis

Answer 100

COPD is an umbrella term encompassing the older terms chronic bronchitis and emphysema

Answer 101

Cough: often productive Dyspnoea Wheeze RSHF -> peripheral oedema

Answer 102

Post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%

Answer 103

Hyperinflation Bullae: if large, may sometimes mimic a pneumothorax Flat hemidiaphragm

Answer 104

Post-bronchodilator spirometry Chest X-ray FBC - exclude secondary polycythaemia BMI calculation

Answer 105

FEV1/FVC < 0.7 FEV1 of predicted >80%

Answer 106

FEV1/FVC < 0.7 FEV1 of predicted 50-79%

Answer 107

FEV1/FVC < 0.7 FEV1 of predicted 30-49%

Answer 108

FEV1/FVC < 0.7 FEV1 of predicted <30%

Answer 109

C4-GAS: Cadmium Coal Cotton Cement Grain Alpha-1 antitrypsin deficiency Smoking - biggest risk factor

Answer 110

Smoking cessation Annual influenza vaccination One-off pneumococcal vaccination Pulmonary rehabilitation

Answer 111

SABA - Salbutamol OR SAMA - Ipatropium bromide

Answer 112

Whether the patient has 'asthmatic features/features suggesting steroid responsiveness'

Answer 113

Previous diagnosis of asthma / atopy Higher blood eosinophil count Substantial FEV1 variation over time (>400ml) Substantial diurnal variation in PEF (20%)

Answer 114

SABA - Salbutamol LABA - Salmeterol LAMA - Triotropium If already taking a SAMA, discontinue and switch to a SABA

Answer 115

SABA - Salbutamol OR SAMA - Ipatropium bromide Add the following: LABA - Salmeterol and ICS

Answer 116

SABA - Salbutamol Triple therapy: LAMA - Triotropium LABA - Salmetrol ICS If already taking a SAMA, discontinue and switch to a SABA

Answer 117

Mucolytics

Answer 118

Phosphodiesterase-4 (PDE-4) inhibitors E.g. roflumilast

Answer 119

Those who continue to smoke despite being offered smoking cessation advice and treatment

Answer 120

Haemophilus influenzae - most common cause overall Streptococcus pneumoniae Moraxella catarrhalis

Answer 121

Rhinovirus

Answer 122

Increase the frequency of bronchodilator use and consider giving via a nebuliser 30mg prednisolone for 5 days

Answer 123

If sputum is purulent or there are clinical signs of pneumonia

Answer 124

Amoxicillin or Clarithromycin or Doxycycline

Answer 125

Cough which is barking and seal-like, with symptoms worse at night.

Answer 126

Single dose of oral dexamethasone regardless of severity. Second line - Prednisolone

Answer 127

High-flow oxygen and nebulised adrenaline

Answer 128

Never perform a throat examination on a patient with croup due to risk of airway obstruction

Answer 129

Subglottic narrowing, commonly called the 'steeple sign'

Answer 130

Swelling of the epiglottis - the 'thumb sign'

Answer 131

Parainfluenza virus accounts for the majority of cases of croup

Answer 132

Children - Live Adult - Inactivated

Answer 133

An inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.

Answer 134

Facial pain - pressure when bending forward Nasal discharge Nasal obstruction - mouth breathing Post-nasal drip

Answer 135

Avoid allergen Intranasal corticosteroids Nasal irrigation with saline solution

Answer 136

Unilateral symptoms Persistent symptoms despite 3 months treatment Epistaxis - nose bleed

Answer 137

Whooping cough (pertussis) is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis

Answer 138

URTI symptoms

Answer 139

Cough increases in severity Worse at night or after feeding Inspiratory whoop Infants may have spells of apnoea

Answer 140

Cough will subside over weeks to months

Answer 141

Acute cough >14 days AND one of following: Paroxysmal cough Inspiratory whoop Post-tussive vomiting undiagnosed apnoeic attacks in children

Answer 142

An oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) Notify public health

Answer 143

Atrial flutter is a form of supraventricular tachycardia characterised by a succession of rapid atrial depolarisation waves

Answer 144

Sawtooth appearance (flutter waves / f wave)

Answer 145

Synchronised cardioversion with anticoagulant

Answer 146

Atrial fibrillation is the most common sustained cardiac arrhythmia in which there is an increased risk of stroke

Answer 147

First detected episode Recurrent episodes Permanent AF

Answer 148

Paroxysmal AF - Terminates spontaneously Persistent AF - Non-self terminating (>7 days)

Answer 149

Palpitations Dyspnoea Chest pain Irregularly irregular pulse

Answer 150

Rhythm control (preferred under certain criteria) Rate control

Answer 151

Try to get the patient back into, and maintain, normal sinus rhythm. This is termed cardioversion.

Answer 152

Haemodynamically unstable - electrical cardioversion E.g. hypotension, heart failure

Answer 153

Short duration of symptoms (less than 48 hours) OR Be anticoagulated for a period of time prior to attempting cardioversion - 3 weeks.

Answer 154

Amiodarone Flecainide (if no structural heart disease)

Answer 155

Accept that the pulse will be irregular, but slow the rate down to avoid negative effects on cardiac function

Answer 156

A beta-blocker or a rate-limiting calcium channel blocker (e.g. diltiazem) is used first-line

Answer 157

Combination therapy with any 2 of the following: Betablocker Diltiazem Digoxin

Answer 158

The moment a patient switches from AF to sinus rhythm

Answer 159

Calculates stroke risk for patients with atrial fibrillation

Answer 160

CHA2DS2-VSAc

Answer 161

C - congestive heart failure - 1 H - hypertension - 1 A2 - Age - Age >= 75 - 2, Age 65-74 - 1 D - diabetes - 1 S2 - Prior Stroke, TIA or thromboembolism - 2 V - Vascular disease (IHD, PAD) - 1 S - sex (female) - 1

Answer 162

0 - No treatment 1 - Male - consider coagulation, Female - no treatment 2 or more - Offer anticoagulation

Answer 163

ECHO to exclude valvular heart disease

Answer 164

DOACs: Apixaban Dabigatran Edoxaban Rivaroxaban

Answer 165

Warfarin due to requiring regular blood tests to check the INR

Answer 166

ORBIT score

Answer 167

To assess the patient's bleeding risk before anticoagulation is commenced

Answer 168

Atrioventricular nodal re-entrant tachycardia (AVNRT) Atrioventricular reentrant tachycardia (AVRT) e.g. Wolf-Parkinson White syndrome

Answer 169

Atrioventricular nodal reentrant tachycardia (AVNRT)

Answer 170

Valsalva manoeuvre: e.g. trying to blow into an empty plastic syringe Carotid sinus massage

Answer 171

Intravenous adenosine: Rapid IV bolus of 6mg → if unsuccessful give 12 mg → if unsuccessful give further 18 mg Verapamil if asthmatic

Answer 172

Radio-frequency ablation of the accessory pathway

Answer 173

A congenital accessory conducting pathway between the atria and ventricles leading to atrioventricular re-entry tachycardia (AVRT)

Answer 174

Short PR interval Wide QRS complex with slurred upstroke - Delta wave Left axis deviation - majority of cases

Answer 175

Short PR interval Wide QRS complex with slurred upstroke - Delta wave Right axis deviation Dominant R wave in V1

Answer 176

No QRS complex can be identified, ECG completely disorganised Patient is likely to be unconscious

Answer 177

Immediate Dc cardioversion

Answer 178

Monomorphic VT: most commonly caused by myocardial infarction Polymorphic VT: A subtype of polymorphic VT is torsades de pointes

Answer 179

Immediate cardioversion IV amioderone

Answer 180

Ventricular ectopics are premature ventricular beats

Answer 181

Reassurance in otherwise healthy people Beta blockers and Ca channel blockers for palpitations

Answer 182

IV magnesium sulphate

Answer 183

A clinic reading persistently above >= 140/90 mmHg, or: A 24 hour blood pressure average reading >= 135/85 mmHg

Answer 184

This is where there is no single disease causing the rise in blood pressure but rather a series of complex physiological changes which occur as we get older

Answer 185

Secondary hypertension may be caused by a wide variety of endocrine, renal and other causes

Answer 186

Glomerulonephritis Chronic pyelonephritis Adult polycystic kidney disease Renal artery stenosis

Answer 187

Primary hyperaldosteronism Phaeochromocytoma Cushing's syndrome Liddle's syndrome Congenital adrenal hyperplasia (11-beta hydroxylase deficiency) Acromegaly

Answer 188

Glucocorticoids NSAIDs Pregnancy Coarctation of the aorta Combined oral contraceptive pill

Answer 189

Blood pressure reading 24-hour blood pressure reading - more in recent years U&Es - renal disease HbA1c - co-existing diabetes mellitus Lipids - hyperlipidaemia ECG Urine dipstick

Answer 190

Fundoscopy: to check for hypertensive retinopathy Urine dipstick: to check for renal disease, either as a cause or consequence of hypertension ECG: to check for left ventricular hypertrophy or ischaemic heart disease

Answer 191

Angiotensin-converting enzyme (ACE) inhibitors

Answer 192

Inhibit the conversion angiotensin I to angiotensin II

Answer 193

Ramipril End in 'ipril'

Answer 194

Cough Angioedema Hyperkalaemia

Answer 195

Afro-Caribbean patients - less effective Pregnant women - due to risk of worsening renal function

Answer 196

Calcium channel blockers

Answer 197

Amlodipine

Answer 198

Block voltage-gated calcium channels relaxing vascular smooth muscle and force of myocardial contraction

Answer 199

Flushing Ankle swelling Headache

Answer 200

Inhibit sodium absorption at the beginning of the distal convoluted tubule

Answer 201

Angiotensin II receptor blockers (A2RB) - Block effects of angiotensin II at the AT1 receptor

Answer 202

Candesartan

Answer 203

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

Answer 204

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

Answer 205

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg

Answer 206

A low salt diet <6g per day, ideally >3g/day Reduced caffeine intake Stop smoking Less alcohol Balanced diet rich in fruit and vegetables More exercise

Answer 207

Treat if < 80 years of age AND any of the following apply; Target organ damage Established cardiovascular disease Renal disease Diabetes 10-year cardiovascular risk equivalent to 10% or greater OR >60 years old and QRICK under 10% can be considered for medication

Answer 208

Offer drug treatment regardless of age

Answer 209

ACE-i or ARB ARB should be used when ACE-i is not tolerated

Answer 210

Calcium channel blocker

Answer 211

If already taking ACE-i or ARB then add CCB or thiazide-like diuretic

Answer 212

Indapamide

Answer 213

If already taking CCB then add ACE-i or ARB or thiazide-like diuretic. In African or African-Caribbean origin then ARB would be preferred

Answer 214

Add a third drug treatment: ACE-i and CCB, then add thiazide-like diuretic ACE-i and thiazide-like diuretic then add CCB

Answer 215

Confirm elevated clinic BP with ABPM or HBPM Assess for postural hypotension. Discuss adherence

Answer 216

If potassium < 4.5 mmol/l add low-dose spironolactone If potassium > 4.5 mmol/l add an alpha- or beta-blocker

Answer 217

Clinic BP - 140/90 mmHg ABPM / HBPM - 135/85mmHg

Answer 218

Clinic BP - 150/90 mmHg ABPM / HBPM - 145/85 mmHg

Answer 219

A major circulatory disorder characterised by arterial obstruction, leading to reduced blood supply and ischaemia in the lower limbs

Answer 220

1 or more of the 6 P's Pale Pulseless Painful Paralysed Paraesthetic 'Perishing with cold'

Answer 221

Handheld arterial Doppler examination - if doppler signals are present then: Ankle-brachial pressure index

Answer 222

Suspect acute limb ischaemia

Answer 223

Abnormally calcified vessels

Answer 224

Normal - does not exclude diagnosis if clinically indicated

Answer 225

Intermittent claudication - mild-to-moderate arterial disease

Answer 226

Critical limb ischaemia - rest pain, ulceration, gangrene

Answer 227

Duplex ultrasound

Answer 228

Exercise + management of risk factors e.g. stop smoking

Answer 229

Established cardiovascular disease - 80mg Atrovostatin AND Clopidogrel 75mg (used to be aspirin 75mg)

Answer 230

Surgery: Endovascular revascularization Surgical revascularization

Answer 231

Dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart

Answer 232

Commonly occur in the legs due to reflux in the great saphenous vein and small saphenous vein

Answer 233

Increasing age Female Pregnancy - uterus compression on pelvic vein Obesity

Answer 234

Venous duplex ultrasound: this will demonstrate retrograde venous flow

Answer 235

Leg elevation Weight loss Regular exercise Graduated compression stockings

Answer 236

Significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling Previous bleeding from varicose veins Skin changes secondary to chronic venous insufficiency Active or healed leg ulcer

Answer 237

Endothermal ablation Foam sclerotherapy Surgery - stripping or ligation

Answer 238

Compression bandaging, four layer Oral pentoxifylline, a peripheral vasodilator, improves healing rate

Answer 239

Medial malleolus

Answer 240

A stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event

Answer 241

Acute stress reaction - <4 weeks PTSD - >4 weeks

Answer 242

Intrusive thoughts e.g. flashbacks, nightmares Dissociation e.g. 'being in a daze', time slowing Negative mood Avoidance Arousal e.g. hypervigilance, sleep disturbance

Answer 243

First line - trauma-focused cognitive-behavioural therapy (CBT) Benzodiazepines

Answer 244

Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both.

Answer 245

An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind.

Answer 246

Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one's mind.

Answer 247

Someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance

Answer 248

Low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) If this is insufficient or can't engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)

Answer 249

Offer a choice of either a course of an SSRI or more intensive CBT (including ERP) Consider clomipramine (as an alternative first-line drug treatment to an SSRI)

Answer 250

Fluoxetine is specifically given for body dysmorphic disorder

Answer 251

Can be considered as an alternative first-line drug treatment to SSRIs if the person has had a previous good response to it.

Answer 252

Refer to secondary care mental health team for assessment. Whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider Clomipramine

Answer 253

ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

Answer 254

Excessive worry about a number of different events associated with heightened tension.

Answer 255

Salbutamol Theophylline Corticosteroids Antidepression Caffeine

Answer 256

Education about GAD + active monitoring

Answer 257

Low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)

Answer 258

High-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.

Answer 259

Highly specialist input e.g. Multi agency teams

Answer 260

Sertraline is first-line

Answer 261

If sertraline is ineffective, an alternative SSRI or SNRI can be used. Duloxetine or Venlafaxine (SNRI examples)

Answer 262

If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin

Answer 263

For patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Answer 264

Cognitive behavioural therapy or drug treatment

Answer 265

If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Answer 266

Aged 35- 54 Being divorced or separated Living alone Being a lone parent

Answer 267

Aged 16 - 24 Being married or cohabiting

Answer 268

Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss - this is called pseudodementia

Answer 269

Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. It is thought to be secondary to reduced CSF absorption at the arachnoid villi.

Answer 270

Urinary incontinence Dementia and bradyphrenia Gait abnormality (may be similar to Parkinson's disease)

Answer 271

Normal pressure hydrocephalus

Answer 272

Hydrocephalus with ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement

Answer 273

Normal pressure hydrocephalus

Answer 274

Ventriculoperitoneal shunting

Answer 275

Around 10% of patients who have shunts experience significant complications such as seizures, infection and intracerebral haemorrhages

Answer 276

A range of activities to promote wellbeing that are tailored to the person's preference Group cognitive stimulation therapy for patients with mild and moderate dementia Group reminiscence therapy and cognitive rehabilitation

Answer 277

Acetylcholinesterase inhibitors

Answer 278

Donepezil, Galantamine and Rivastigmine

Answer 279

NMDA receptor antagonist

Answer 280

- For moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors. - As an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's. - Monotherapy in severe Alzheimer's

Answer 281

Bradycardia

Answer 282

Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.

Answer 283

Lewy-body dementia

Answer 284

Progressive cognitive impairment which typically occurs before parkinsonism, but usually both features occur within a year of each other. Cognition may be fluctuating (different to other dementias) Parkinsonism Visual hallucinations + dementia = lewy -body dementia

Answer 285

Lewy body dementia

Answer 286

Donepezil and Rivastigmine

Answer 287

Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. E.g, Risperidone and Haloperidol.

Answer 288

Frontotemporal lobar degeneration (FTLD) is the third most common type of cortical dementia after Alzheimer's and Lewy body dementia.

Answer 289

Frontotemporal dementia (Pick's disease) Progressive non fluent aphasia (chronic progressive aphasia, CPA) Semantic dementia

Answer 290

Onset before 65 Insidious onset Relatively preserved memory and visuospatial skills Personality change and social conduct problems

Answer 291

Characterised by personality change and impaired social conduct.

Answer 292

Hyperorality Disinhibition Increased appetite Perseveration behaviours

Answer 293

Focal gyral atrophy with a knife-blade appearance. Macroscopic - Atrophy of the frontal and temporal lobes Microscopic: Pick bodies - spherical aggregations of tau protein (silver-staining) Gliosis Neurofibrillary tangles Senile plaques

Answer 294

Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.

Answer 295

A fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer's memory is better for recent rather than remote events.

Answer 296

Alzheimer's disease (AD) is a progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK

Answer 297

Increasing age Family history Inherited autosomal trait Apoprotein E allele E4 Caucasian ethnicity Down syndrome

Answer 298

Mutations in: - The amyloid precursor protein (chromosome 21) - Presenilin 1 (chromosome 14) - Presenilin 2 (chromosome 1) genes

Answer 299

Down syndrome

Answer 300

Widespread cerebral atrophy, particularly involving the cortex and hippocampus

Answer 301

Cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein Hyperphosphorylation of the tau protein has been linked to AD

Answer 302

There is a deficit of acetylcholine from damage to an ascending forebrain projection

Answer 303

Motor symptoms will be present before dementia symptoms for PDD. PDD is diagnosed if a patient had a Parkinson's disease diagnosis for at least 1 year.

Answer 304

Creutzfeldt-Jakob disease (CJD) is rapidly progressive neurological condition caused by prion proteins.

Answer 305

Prion proteins induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases.

Answer 306

Dementia with rapid onset Myoclonus

Answer 307

MRI - hyperintense signals in the basal ganglia and thalamus.

Answer 308

Creutzfeldt-Jakob disease

Answer 309

It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease.

Answer 310

Vascular dementia

Answer 311

Stroke-related VD Subcortical VD Mixed dementia

Answer 312

Vascular dementia caused by a multi-infarct or single-infarct dementia

Answer 313

Vascular dementia caused by small vessel disease.

Answer 314

The presence of both VD and Alzheimer's disease

Answer 315

History of stroke or transient ischaemic attack (TIA) Atrial fibrillation Hypertension Diabetes mellitus Hyperlipidaemia Smoking Obesity Coronary heart disease A family history of stroke or cardiovascular

Answer 316

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopath)

Answer 317

Several months or several years of a history of a sudden or STEPWISE DETERIORATION of cognitive function.

Answer 318

Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms The difficulty with attention and concentration Seizures Memory disturbance Gait disturbance Speech disturbance Emotional disturbance

Answer 319

NINDS-AIREN criteria

Answer 320

For a diagnosis of vascular dementia

Answer 321

Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event Cerebrovascular disease defined by neurological signs and/or brain imaging A relationship between the above two disorders inferred by: - The onset of dementia within three months following a recognised stroke - An abrupt deterioration in cognitive functions fluctuating, stepwise - Progression of cognitive deficits

Answer 322

Include: cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy

Answer 323

A PHQ-9 score of < 16

Answer 324

A PHQ-9 score of ≥ 16

Answer 325

Less severe depression

Answer 326

More severe depression

Answer 327

- Guided self-help - Group cognitive behavioural therapy (CBT) - Group behavioural activation (BA) - Individual CBT - Individual BA - Group exercise - Group mindfulness and meditation - Interpersonal psychotherapy (IPT) - Selective serotonin reuptake inhibitors (SSRIs) - Counselling - Short-term psychodynamic psychotherapy (STPP)

Answer 328

- A combination of individual cognitive behavioural therapy (CBT) and an antidepressant - Individual CBT - Individual behavioural activation (BA) - Antidepressant medication - Selective serotonin reuptake inhibitor (SSRI), or - Serotonin-norepinephrine reuptake inhibitor (SNRI), or - Another antidepressant if indicated based on previous clinical and treatment history - Individual problem-solving - Counselling - Short-term psychodynamic psychotherapy (STPP) - Interpersonal psychotherapy (IPT) - Guided self-help - Group exercise

Answer 329

Five (or more) of the DSM-5 symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Answer 330

Citalopram Escitalopram Sertraline Paroxetine (only when to another SSRI)

Answer 331

Withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low dose of the alternative SSRI

Answer 332

Citalopram Escitalopram Sertraline Paroxetine

Answer 333

Cross-tapering is recommended (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)

Answer 334

- Citalopram (Cipramil) - Dapoxetine (Priligy) - Escitalopram (Cipralex) - Fluoxetine (Prozac or Oxactin) - Fluvoxamine (Faverin) - Paroxetine (Seroxat) - Sertraline (Lustral) - Vortioxetine (Brintellix)

Answer 335

- Desvenlafaxine (Pristiq, Khedezla) - Duloxetine (Cymbalta, Irenka) - Levomilnacipran (Fetzima) - Milnacipran (Savella) - Venlafaxine (Effexor XR)

Answer 336

They enhance the activity of the inhibitory neurotransmitter GABA in the CNS.

Answer 337

Diazepam (Valium) and Lorazepam, and Alprazolam (Xanax)

Answer 338

Flumazenil IV

Answer 339

Barbiturates act on GABA-A receptors by increasing the amount of time the chloride ion channel is opened, which increases the affinity of the receptor for GABA.

Answer 340

Pentobarbitone and Phenobarbitone

Answer 341

Opioids work via the endogenous opioid system by acting as a potent agonist to the μ receptor. This results in a complex cascade of intracellular signals resulting in dopamine release, blockade of pain signals, and a resulting sensation of euphoria.

Answer 342

Pinpoint pupils Respiratory depression Decreased level of consciousness

Answer 343

IV or IM Naloxone Activated charcoal can be given in 3 hour window instead of 1 hour due to slowing of gastric motility by opiates

Answer 344

Naloxone is a competitive opioid receptor antagonist

Answer 345

Amphetamines increase neurotransmission of dopamine (DA), serotonin (5-HT), and norepinephrine (NE) by entering neurons via the 5-HT and DA transporters and displacing storage vesicles.

Answer 346

Benzodiazepines for sedation and to control seizures Activated charcoal if within 1 hour of amphetamine ingestion

Answer 347

Benzodiazepines - These are CNS depressants and thus will counteract the effects of cocaine

Answer 348

N-acetylcysteine

Answer 349

Sodium bicarbonate

Answer 350

Methadone or buprenorphine

Answer 351

Diagnosed after at least 3 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease which may explain symptoms

Answer 352

Often described as a 'tight band' around the head or a pressure sensation. Symptoms tend to be bilateral

Answer 353

Aspirin, paracetamol or an NSAID are first-line

Answer 354

IgE mediated therefore type 1 hypersensitivity

Answer 355

House dust mite Pollen Mold Foods Drugs Latex Household chemicals

Answer 356

Clinical diagnosis first line Skin prick testing in children - wheal >2mm is positive result RAST testing - measures total and allergen specific IgE in blood

Answer 357

Avoid allergen Oral antihistamines Steroids e.g. prednisolone

Answer 358

Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction

Answer 359

Food (e.g. nuts) most common in children Drugs Insect venom (e.e. wasp sting)

Answer 360

Airway and/or Breathing and/or Circulation problems Airway - Swelling of throat and tongue Breathing - Wheeze and dyspnoea Circulation - Hypotension and tachycardia

Answer 361

<6 months - 100-150 μg adrenaline 6 months - 6 years - 150 μg adrenaline 6-12 years - 300 μg adrenaline >12 years - 500μg adrenaline Can be repeated every 5 minutes if necessary

Answer 362

Anterolateral aspect of the middle third of the thigh

Answer 363

Iron deficiency anaemia Thalassemia Sideroblastic anaemia

Answer 364

Sickle cell disease Hereditary spherocytosis G6PD deficiency Autoimmune haemolytic Malaria Haemolytic disease of the newborn

Answer 365

B12 deficiency Folate deficiency

Answer 366

Alpha-thalassaemia is a autosomal recessive condition due to a deficiency of alpha chains in haemoglobin

Answer 367

2 separate alpha-globulin genes are located on each chromosome 16

Answer 368

If 1 or 2 alpha globulin alleles are affected then the blood picture would be hypochromic and microcytic, but the Hb level would be typically normal

Answer 369

If are 3 alpha globulin alleles are affected results in a hypochromic microcytic anaemia with splenomegaly. This is known as Hb H disease

Answer 370

If all 4 alpha globulin alleles are affected (i.e. homozygote) then death in utero (hydrops fetalis, Bart's hydrops)

Answer 371

Regular Blood Transfusions to maintain normal haemoglobin levels in severe cases. Chronic transfusion therapy may lead to iron overload, hence iron chelation therapy with drugs like Deferasirox or Deferoxamine is necessary

Answer 372

Beta-thalassaemia trait is an autosomal recessive condition where there is deficiency in the production of the beta globulin chains of haemoglobin. characterised by a mild hypochromic, microcytic anaemia..

Answer 373

Chromosome 11

Answer 374

Where there is a reduced beta chain due to either promotor region mutations or splice sites.

Answer 375

Where there is absent beta chains due to either promotor region mutations or splice sites

Answer 376

Presents in the first year of life with failure to thrive and hepatosplenomegaly

Answer 377

Repeated blood transfusions Iron chelation therapy due to potential of iron overload

Answer 378

Also known as erythroblastosis fetalis, is a complex and potentially life-threatening condition arising from maternal-foetal blood group incompatibility.

Answer 379

Hb electrophoresis: HbA2 & HbF raised HbA absent FBC - Microcytic anaemia

Answer 380

Sickle-cell anaemia is a genetic condition that results for synthesis of an abnormal haemoglobin chain termed HbS

Answer 381

It is more common in people of African descent as the heterozygous condition offers some protection against malaria

Answer 382

Symptoms in homozygotes don't tend to develop until 4-6 months when the abnormal HbSS molecules take over from fetal haemoglobin

Answer 383

Polar amino acid glutamate is substituted by non-polar valine in each of the two beta chains (codon 6). This decreases the water solubility of deoxy-Hb causing them to polymerase and 'sickle' where they haemolyse and block small vessels

Answer 384

Autosomal recessive

Answer 385

Hb electrophoresis FBC Blood film

Answer 386

Sideroblastic anaemia is a condition where red cells fail to completely form haem

Answer 387

Delta-aminolevulinate synthase-2 deficiency

Answer 388

FBC - hypochromic microcytic anaemia Iron studies: ferratin, iron, transferrin saturation are all high

Answer 389

Iron deficiency anaemia

Answer 390

Preschool-age children

Answer 391

Fatigue SOB on exertion Pallor Palpitations Koilonychia - spoon shaped nails Angular stomtatitis

Answer 392

FBC - hypochromic microcytic anaemia: Low serum Ferratin Low serum Iron Low Transferrin Total iron binding capacity will be high Anti-Transglutaminase Antibody (TTG) antibodies to rule out Coeliac disease

Answer 393

Treat underlying cause Oral iron supplementation - ferrous sulphate or ferrous fumarate IV iron (ferric carboxymaltose) if cannot give above Blood transfusion in severe cases

Answer 394

Plasmodium protozoa: Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malariae

Answer 395

Female Anopheles mosquito

Answer 396

Plasmodium falciparum causes nearly all episodes of severe malaria. The other three types, of which Plasmodium vivax is the most common, cause 'benign' malaria.

Answer 397

Sickle cell disease G6PD deficiency HLA-B53 Absence of Duffy antigen

Answer 398

Paroxysms of fever - cyclical (48 hours) Chills Sweating

Answer 399

Artemisinin-based combination therapies (ACTs)

Answer 400

Chloroquine, if ineffective then give ACTs. Also give primaquine to destroy liver hypnozoites and prevent relapse.

Answer 401

A type of anaemia characterised by a defect in the red blood cell cytoskeleton. The normal biconcave shape of the red blood cell is replaced by a shpere-shaped blood cell. Red blood cell survival is reduced

Answer 402

Hereditary spherocytosis

Answer 403

Failure to thrive Jaundice, gallstones Splenomegaly Aplastic crisis precipitated by parvovirus infection Degree of haemolysis variable MCHC elevated

Answer 404

Supportive treatment Transfusion if necessary

Answer 405

Folate supplementation Splenectomy

Answer 406

EMA binding test

Answer 407

Autosomal dominant

Answer 408

The commonest red blood cell enzyme defect

Answer 409

X-linked recessive

Answer 410

It is more common in people from the Mediterranean and Africa

Answer 411

Neonatal jaundice is often seen Intravascular haemolysis Gallstones are common Splenomegaly may be present

Answer 412

Heinz bodies on blood films. Bite and blister cells may also be seen

Answer 413

G6PD enzyme assay - 3 months after an acute episode of haemolysis

Answer 414

Anti-malarials - Primaquine Ciprofloxacin Sulphonamides, Sulphasalazine, Sulfonylureas

Answer 415

Autoimmune haemolytic anaemia (AIHA) may be divided in to 'warm' and 'cold' types, according to at what temperature the antibodies best cause haemolysis

Answer 416

Anaemia Reticulocytosis Low haptoglobin Raised lactate dehydrogenase (LDH) and indirect bilirubin Blood film: spherocytes and reticulocytes

Answer 417

Positive direct antiglobulin test (Coomb's test)

Answer 418

Most common type. The antibody (usually IgG) causes haemolysis best at body temperature and haemolysis tends to occur in extravascular sites, for example the spleen.

Answer 419

The antibody in cold AIHA is usually IgM and causes haemolysis best at 4 deg C. Haemolysis is mediated by complement and is more commonly intravascular. Features may include symptoms of Raynaud's and acrocynaosis.

Answer 420

Steroids (+/- rituximab)

Answer 421

Used in the body for red blood cell development and also maintenance of the nervous system.

Answer 422

Pernicious anaemia - most common Post gastrectomy Vegan / poor diet Disorders of terminal ilium

Answer 423

If no neurological involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months If also folate deficient then treat B12 first.

Answer 424

Treat underlying cause e.g. stopping drugs or alcohol consumption Folic acid supplements: always give alongside B12 - 5mg PO OD for 3 months

Answer 425

Chlamydia trachomatis serovars D through K

Answer 426

The incubation period is around 7-21 days

Answer 427

70% of women and 50% of men

Answer 428

Cervicitis (discharge, bleeding) Dysuria

Answer 429

Urethral discharge Dysuria

Answer 430

Nuclear acid amplification tests (NAATs) are now the investigation of choice. Women: vulvovaginal swab is first-line Men: urine test is first-line

Answer 431

Gram-negative, anaerobic bacterium

Answer 432

Doxycycline (7 day course)

Answer 433

Azithromycin, erythromycin or amoxicillin may be used Azithromycin (1g od for one day, then 500mg od for two days)

Answer 434

Neisseria gonorrhoeae

Answer 435

Neisseria gonorrhoeae

Answer 436

Gram-negative diplococcus

Answer 437

Urethral discharge and dysuria

Answer 438

Cervicitis e.g. leading to vaginal discharge

Answer 439

IM ceftriaxone 1g

Answer 440

Oral ciprofloxacin 500mg

Answer 441

Oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose)

Answer 442

Tenosynovitis Migratory polyarthritis Dermatitis (lesions can be maculopapular or vesicular)

Answer 443

Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum

Answer 444

Lower abdominal pain Fever Deep dyspareunia Dysuria and menstrual irregularities may occur Vaginal or cervical discharge Cervical excitation

Answer 445

Chlamydia trachomatis - most common Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis

Answer 446

Pregnancy test - exclude ectopic pregnancy High vaginal swab - often negative Screen for Chlamydia and Gonorrhoea

Answer 447

Stat IM ceftriaxone + 14 days of oral doxycycline + oral metronidazole

Answer 448

Oral ofloxacin + oral metronidazole

Answer 449

Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls

Answer 450

Perihepatitis (Fitz-Hugh Curtis Syndrome) - 10% Infertility Ectopic pregnancy

Answer 451

Infants less than 3 months old should be referred immediately to a paediatrician. Children aged more than 3 months old with an upper UTI should be considered for admission to hospital.

Answer 452

Oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days

Answer 453

Urinary tract infection (UTI) in childhood should prompt an investigation for possible underlying causes and damage to the kidneys

Answer 454

E. coli (responsible for around 80% of cases) Proteus Pseudomonas

Answer 455

Advancing age Previous pregnancy and childbirth High BMI Hysterectomy Family history

Answer 456

Incomplete bladder emptying Vesicoureteric reflux Poor hygiene

Answer 457

UTI - found in 30% of patients that present with UTI

Answer 458

Urge incontinence Stress incontinence Mixed incontinence Overflow incontinence Functional incontinence

Answer 459

The urge to urinate quickly followed by an uncontrollable leakage ranging from a few drops to complete emptying. Due to detrusor muscle overactivity.

Answer 460

Leaking small amounts when coughing or laughing, due to a high abdominal pressure

Answer 461

Urge incontinence

Answer 462

Stress incontinence

Answer 463

A mixture of both stress and urge incontinence

Answer 464

AKA neurogenic bladder - the bladder doesn't empty completely which leads to an eventual leak e.g. prostate enlargement

Answer 465

Overflow incontinence - AKA neurogenic bladder

Answer 466

Damage to the peripheral nerves or nerves of the brain and spinal cord

Answer 467

Frequent urination, especially at night

Answer 468

Urge incontinence

Answer 469

Co-morbid physical conditions impair the patient’s ability to get to a bathroom in time

Answer 470

Dementia Sedating medication Injury / illness resulting in decreased ambulation

Answer 471

There is a weak or intermittent stream / hesitancy

Answer 472

Overflow incontinence

Answer 473

Bladder diaries for a minimum of 3 days Vaginal examination Kegel exercises Urine dipstick and culture Urodynamic studies

Answer 474

Bladder retraining for 6 weeks minimum

Answer 475

Oxybutynin (immediate release)

Answer 476

Antimuscarinics (anticholinergics)

Answer 477

Frail elderly women due to an increased risk of falls

Answer 478

Tolterodine or Solifenacin

Answer 479

Closed-angle glaucoma

Answer 480

Mirabegron

Answer 481

A beta-3-agonist

Answer 482

Pelvic floor retraining (Kegel exercises) 8 contractions performed 3 times per day for a minimum of 3 months

Answer 483

Surgical procedures: e.g. retropubic mid-urethral tape procedures

Answer 484

Duloxetine

Answer 485

A combined noradrenaline and serotonin reuptake inhibitor

Answer 486

Increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction

Answer 487

Re-establish a clear pathway for urine flow e.g. catheterisation or medications like alpha blockers, which relax smooth muscle e.g. Tamsulosin

Answer 488

Age: 50% of 50 year olds 80% of 80 year olds Ethnicity - Black > White > Asian

Answer 489

Voiding symptoms Storage symptoms Post-mictrition

Answer 490

Weak or intermittent urinary flow Straining Hesitancy Terminal dribbling Incomplete emptying

Answer 491

Urgency Frequency Urgency incontinence Nocturia

Answer 492

Urine dipstick U&Es PSA - if obstructive symptoms Urinary frequency-volume chart - at least 3 days IPSS

Answer 493

International Prostate Symptom Score (IPSS) - tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life

Answer 494

Score 20-35: severely symptomatic Score 8-19: moderately symptomatic Score 0-7: mildly symptomatic

Answer 495

Tamsulosin, alfuzosin

Answer 496

Alpha-1 antagonists

Answer 497

Dizziness Postural hypotension Dry mouth Depression

Answer 498

Decrease smooth muscle tone of the prostate and bladder

Answer 499

Finasteride

Answer 500

5 alpha-reductase inhibitor

Answer 501

Block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH Causes a reduction in prostate volume and hence may slow disease progression. Can take up to 6 months.

Answer 502

Erectile dysfunction Reduced libido Ejaculation problems Gynaecomastia

Answer 503

Combination therapy: Alpha-1 antagonist AND 5 alpha-reductase inhibitor

Answer 504

Tolterodine Darifenacin

Answer 505

Antimuscarinic (anticholinergic)

Answer 506

95% adenocarcinoma Peripheral zone

Answer 507

Gleason score

Answer 508

Increasing age Obesity Afro-Caribbean heritage Family history

Answer 509

Localised prostate cancer is often asymptomatic Bladder outlet obstruction: hesitancy, urinary retention Haematuria, haematospermia Pain: back, perineal or testicular DRE: asymmetrical, hard, nodular enlargement with loss of median sulcus

Answer 510

Prostate specific antigen. A serine protease enzyme produced by normal and malignant prostate epithelial cells

Answer 511

Considered in men with suspected prostate cancer Offered to men older than 50 years of age who request a PSA test

Answer 512

<40 - use clinical judgement 40-49 - >2.5ng/ml 50-59 - >3.5ng/ml 60-69 - >4.5ng/ml 70-79 - >5.5ng/ml >79 - use clinical judgement

Answer 513

BPH Prostatitis and UTI Ejaculation within 48 hours Vigorous exercise within 48 hours Urinary retention within 4 weeks

Answer 514

Transrectal ultrasound-guided (TRUS) biopsy It can cause: Sepsis Pain lasting over 2 weeks Fever Haematuric and rectal bleeding

Answer 515

Multiparametric MRI then a biopsy if indicated

Answer 516

Conservative: active monitoring & watchful waiting - preferred Radical prostatectomy Radiotherapy: external beam and brachytherapy

Answer 517

Hormonal therapy Radical prostatectomy Radiotherapy: external beam and brachytherapy

Answer 518

Erectile dysfunction

Answer 519

May develop proctitis Increased risk of colon, bladder, and rectal cancer

Answer 520

Combination of: Synthetic GnRH a(nta)gonist e.g. Goserelin + cyproterone acetate (anti-anrogen) Bicalutamide Bilateral orchidectomy Chemotherapy with docetaxe

Answer 521

Reducing androgen levels

Answer 522

Diabetic nephropathy Chronic glomerulonephritis Chronic pyelonephritis Hypertension Adult polycystic kidney disease

Answer 523

According to glomerular filtration rate

Answer 524

CAGE: Creatinine Age Gender Ethnicity

Answer 525

Pregnancy Muscle mass (e.g. amputees, body-builders) Eating red meat 12 hours prior to the sample being taken

Answer 526

Greater than 90 ml/min, with some sign of kidney damage on other tests (if all the kidney tests are normal, there is no CKD) I.e. normal U&Es and no proteinuria

Answer 527

60-90 ml/min with some sign of kidney damage (if kidney tests are normal, there is no CKD) I.e. normal U&Es and no proteinuria

Answer 528

Stage 3a - 45-59 ml/min, a moderate reduction in kidney function Stage 3b - 30-44 ml/min, a moderate reduction in kidney function

Answer 529

15-29 ml/min, a severe reduction in kidney function

Answer 530

Less than 15 ml/min, established kidney failure - dialysis or a kidney transplant may be needed

Answer 531

ACE inhibitors (or angiotensin II receptor blockers) All patients should be started on a statin

Answer 532

ACE inhibitors (or angiotensin II receptor blockers) regardless of if hypertension is present or not All patients should be started on a statin

Answer 533

SGLT-2 inhibitors

Answer 534

Primarily act by blocking reabsorption of glucose in the proximal tubule → lowers the renal glucose threshold → glycosuria By blocking the cotransporter, they also reduce sodium reabsorption → natriuresis reduces intravascular volume and blood pressure, but it also increases the delivery of sodium to the macula densa → normalises tubuloglomerular feedback and thereby reduces intraglomerular pressure

Answer 535

Renal ultrasound - most patients with CKD have bilateral small kidneys Autosomal dominant polycystic kidney disease Diabetic nephropathy (early stages) Amyloidosis HIV-associated nephropathy Other features that suggest CKD - hypocalcaemia (due to lack of vitamin D)

Answer 536

1-alpha hydroxylation occurs in the kidneys → CKD = low vitamin D Kidneys normally secrete phosphorous → CKD leads to high phosphate Increased phosphate drags calcium out of the bones. Low calcium due to lack of vitamin D and high phosphorous Low calcium, low vitamin D, high phosphorous = secondary hyperparathyroidism

Answer 537

First-line - reduce phosphate intake Vitamin D: alfacalcidol, calcitriol Parathyroidectomy in severe cases

Answer 538

Defecation that is unsatisfactory because of infrequent stools (< 3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation.

Answer 539

Ispaghula husk - a bulk forming laxative

Answer 540

Macrogol - an osmotic laxative

Answer 541

Ispaghula husk Methylcellulose

Answer 542

Lactulose Macrogol

Answer 543

Senna Bisacodyl

Answer 544

Docusate sodium

Answer 545

Glycerol Bisacodyl

Answer 546

Phosphate Sodium citrate Docusate

Answer 547

They increase the bulk of the stool, usually take 2-3 days to work. It is important to drink plenty of water alongside bulk laxatives

Answer 548

Stimulate the local nervous system within the gut wall which increase colonic contractility and secretions. They work in 6-12 hours. Better for those with difficulty emptying more so than infrequent motions

Answer 549

These are poorly absorbable molecules that cause an osmotic effect drawing water into bowel lumen. Very commonly used and very effective in faecal impaction and infrequent bowel motions

Answer 550

Lowers the surface tension, leading to water and fasts penetrating the stool.

Answer 551

Used to aid rectal emptying by stimulating the anal sphincter and initiating peristalsis. Used when there is an inadequate response to oral, incomplete emptying, incontinence, or altered rectal sensitivity. Causes more rapid evacuation

Answer 552

Include osmotic, softeners, and/or weak stimulants. A phosphate enema contains 128mL of liquid whereas other mini ones have 5mL. Act quickly to bring about a more rapid evacuation.

Answer 553

Diverticulosis is an extremely common disorder characterised by multiple outpouchings of the bowel wall

Answer 554

Most commonly in the sigmoid colon.

Answer 555

One of the diverticular become infected.

Answer 556

Left iliac fossa pain and tenderness Anorexia, nausea and vomiting Diarrhoea Features of infection (pyrexia, raised WBC and CRP)

Answer 557

Plain abdominal films and an erect chest x-ray will identify perforation A contrast enhanced CT will help identify inflammation and local complications.

Answer 558

Either a colonoscopy, CT cologram or barium enema

Answer 559

Increase dietary fibre intake

Answer 560

Mild - oral antibiotics Severe - hospital, nil by mouth, IV fluids, IV antibiotics Peri colonic abscesses should be drained

Answer 561

Cephalosporin + metronidazole

Answer 562

Haemorrhoidal tissue is mucosal vascular cushions found in the left lateral, right posterior and right anterior portions of the anal canal (3 o'clock, 7'o'clock and 11 o'clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic

Answer 563

Painless rectal bleeding - most common Pruritus Pain: not significant unless thrombosed Soiling may occur with third or forth degree piles

Answer 564

Soften stools - increase fibre and fluid Topical local anaesthetic and steroids Rubber band ligation Surgery is reserved for large symptomatic haemorrhoids which do not respond to above

Answer 565

Gastro-oesophageal reflux disease (GORD) may be defined as symptoms of oesophagitis secondary to refluxed gastric contents

Answer 566

Upper GI endoscopy Age >55 years Symptoms lasting more than 4 weeks Dysphagia Relapsing symptoms Weight loss

Answer 567

24-hr oesophageal pH monitoring

Answer 568

Full dose PPI 1-2 months - if response then low dose PRN No response double dose for one month

Answer 569

Full dose PI for 1 month - if response then low dose PRN If no response then H2RA or prokinetic for 1 month

Answer 570

The following for 6 months: (A)bdominal pain (B)loating (C)hange in bowel habit

Answer 571

Patient has abdominal pain relieved by defecation or associated with altered bowel frequency stool form, in addition to 2 of the following 4 symptoms: Altered stool passage Abdominal bloating Symptoms made worse by eating Passage of mucus

Answer 572

Rectal bleeding Unexplained weight loss Family history of bowel cancer Onset after 60 years old

Answer 573

FBC ESR / CRP Coeliac disease screen (TTG)

Answer 574

Pain: antispasmodic agents hyoscine butylbromide (Buscopan) Constipation: laxatives but avoid lactulose Diarrhoea: loperamide is first-line

Answer 575

Regular meal times Avoid missing meals / long gaps 8 cups of fluid per day Restrict tea and coffee Restrict alcohol and fizzy drinks Limiting high fibre foods Limit fresh fruit Increasing intake of oats and linseeds for wind and bloating

Answer 576

Hyoscine butylbromide (Buscopan)

Answer 577

Loperamide

Answer 578

Tricyclic antidepressant - Amitriptyline 5-10mg at night

Answer 579

The classic triad of sore throat, pyrexia and lymphadenopathy (98%)

Answer 580

A maculopapular, pruritic rash

Answer 581

Heterophil antibody test (Monospot test) in the second week of illness

Answer 582

Rest, fluid intake, avoid alcohol Simple analgesia Avoid contact sports for 4 week to reduce risk of splenic rupture

Answer 583

Paracetamol / Ibuprofen Antibiotics not routinely offered

Answer 584

Features of marked systemic upset secondary Unilateral peritonsillitis History of rheumatic fever Increased risk of acute infection (children / HIV) Centor criteria = 3 or more

Answer 585

Likelihood of strep pharyngitis, 1 for each of: Presence of tonsillar exudate Tender anterior cervical lymphadenopathy or lymphadenitis History of fever Absence of cough

Answer 586

Phenoxymethylpenicillin Clarithromycin (if the patient is penicillin-allergic

Answer 587

A chronic condition characterised by abnormally raised levels of blood glucose.

Answer 588

Abdominal pain Polyuria, polydipsia, dehydration Kussmaul respiration (deep hyperventilation) Acetone-smelling breath ('pear drops' smell)

Answer 589

Urine dip for ketones and glucose Fasting glucose and random glucose C-peptide levels (typically low) Diabetes specific antibodies

Answer 590

HbA1c is not as useful for patients with a possible or suspected diagnosis of T1DM as it may not accurately reflect a recent rapid rise in serum glucose

Answer 591

Anti-glutamic acid antibodies (anti-GAD) Islet cell antibodies (ICA) Insuline antibodies (IAA) Insulinoma-associated-2 autoantibodies (IA-2A)

Answer 592

Fasting glucose greater than or equal to 7.0 mmol/l OR Random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test) If asymptomatic then 2x positive tests on separate occasions

Answer 593

Every 3-6 months Target of HbA1c level of 48 mmol/mol (6.5%) or lower

Answer 594

Recommend testing at least 4 times a day, including before each meal and before bed More frequently during sports, illness, planning pregnancy, during pregnancy, while breastfeeding

Answer 595

5-7 mmol/l on waking and 4-7 mmol/l before meals at other times of the day

Answer 596

Multiple daily injection basal-bolus insulin regimens: Twice-daily insulin detemir OR Once-daily determir is alternative Rapid-acting insulin analogues injected before meals

Answer 597

NICE recommend considering adding metformin if the BMI >= 25 kg/m²

Answer 598

If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis Check their blood glucose more regularly

Answer 599

HbA1c of greater than or equal to 48 mmol/mol (6.5%) If asymptomatic must be repeated to confirm diagnosis

Answer 600

Metforim - should be titrated up slowly to avoid GI upset If standard release not tolerated, then use modified release

Answer 601

SGLT-2 inhibitors The patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%) The patient has established CVD The patient has chronic heart failure

Answer 602

If the patient has a risk of CVD, established CVD or chronic heart failure: SGLT-2 monotherapy If the patient does not have this risk: DPP-4 inhibitor or pioglitazone or a sulfonylurea

Answer 603

If the HbA1c has risen to 58 mmol/mol (7.5%) then further treatment is indicated

Answer 604

Metformin + DPP-4 inhibitor Metformin + pioglitazone Metformin + sulfonylurea Metformin + SGLT-2 inhibitor

Answer 605

Metformin + DPP-4 inhibitor + sulfonylurea Metformin + pioglitazone + sulfonylurea Metformin + pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 Insulin-based treatment

Answer 606

GLP-1 mimetic Particularly in those that are BMI ≥ 35 kg/m²

Answer 607

Lifestyle management = 48 mmol/mol (6.5%) Lifestyle = Metformin = 48 mmol/mol (6.5%) Drug which may cause hyperglycaemia = 53 mmol/mol (7.0%)

Answer 608

A relative deficiency of insulin due to an excess of adipose tissue The most common cause

Answer 609

Autoimmune disorder where the insulin-producing beta cells of the islets of Langerhans in the pancreas are destroyed by the immune system

Answer 610

Polydipsia Polyuria Due to water being 'dragged' out of the body due to the osmotic effects of excess blood glucose being excreted in the urine (glycosuria).

Answer 611

Cannot be used in patients with an eGFR of < 30 ml/min

Answer 612

Increases insulin sensitivity Decreases hepatic gluconeogenesis

Answer 613

Stimulate pancreatic beta cells to secrete insulin Examples - gliclazide and glimepiride

Answer 614

Increases incretin levels which inhibit glucagon secretion

Answer 615

Inhibits reabsorption of glucose in the kidney

Answer 616

Advise the patient to temporarily stop some oral hypoglycaemic Can be restarted when eating and drinking again If on insulin therapy do not stop

Answer 617

Ischaemic heart disease Heart failure Peripheral vascular disease Stroke

Answer 618

Diabetic neuropathy Diabetic nephropathy Diabetic retinopathy

Answer 619

There is a problem with the thyroid gland itself, for example an autoimmune disorder affecting thyroid tissue

Answer 620

Usually due to a disorder with the pituitary gland (e.g.pituitary apoplexy) or a lesion compressing the pituitary gland

Answer 621

Weight gain Lethargy Cold intolerance Constipation

Answer 622

Dry (anhydrosis), cold, yellowish skin Non-pitting oedema Dry, coarse scalp hair, loss of later aspect of eyebrows (Queen Anne's sign)

Answer 623

Menorrhagia

Answer 624

Decreased deep tendon reflexes Carpal tunnel syndrome

Answer 625

Prolonged neonatal jaundice Delayed mental/physical milestones Short stature Puffy face Hypotonia

Answer 626

Hashimoto's - autoimmune thyroiditis Most common in developing world - iodine deficiency

Answer 627

High TSH Low T3 Low T4

Answer 628

Levothyroxine

Answer 629

Hyperthyroidism: due to over treatment Reduced bone mineral density Worsening of angina Atrial fibrillation

Answer 630

Hashimoto thyroiditis - autoimmune Associated with IDDM, Addison's or pernicious anaemia 5-10x more common in women

Answer 631

BMI = weight (kg) / height (m) squared

Answer 632

30 - 35 - Obese class I 35 - 40 - Obese class II > 40 - Obese class III

Answer 633

Diet and exercise Medical - orlistat and liraglutide Bariatric surgery

Answer 634

Cessation of menses for at least 12 consecutive months

Answer 635

40-60 years old. Average age is 51 years.

Answer 636

Menopause before the age of 40 years.

Answer 637

Current or past breast cancer. Any oestrogen sensitive cancer. Undiagnosed vaginal bleeding. Untreated endometrial hyperplasia.

Answer 638

If they do not have a uterus.

Answer 639

Increased risk of VTE, no increased risk with transdermal

Answer 640

Ovarian and breast

Answer 641

Fluoxetine

Answer 642

Utrogestan (micronised progesterone)

Answer 643

12 months after the last period in women > 50 years 24 months after the last period in women < 50 years

Answer 644

Bursitis is an acute or chronic inflammatory condition of a bursa

Answer 645

Conservative management and analgesia Second-line is corticosteroid injection - Methylprednisolone acetate

Answer 646

A syndrome characterised by widespread pain throughout the body with tender points at specific anatomical sites

Answer 647

Women are around 5 times more likely to be affected Typically presents between 30-50 years old

Answer 648

Chronic pain: at multiple site, sometimes 'pain all over' Lethargy Cognitive impairment: 'fibro fog' Sleep disturbance, headaches, dizziness are common

Answer 649

Explanation Aerobic exercise: has the strongest evidence base Cognitive behavioural therapy Relaxation techniques

Answer 650

Pregabalin Duloxetine Amitriptyline

Answer 651

LOSS mnemonic: Loss of joint space Osteophytes forming at joint margins Subchondral sclerosis Subchondral cysts

Answer 652

Knee - most common Hip - second most common

Answer 653

Female Increasing age Obesity Hypermobility Developmental dysplasia of the hip

Answer 654

Carpometacarpal joints (CMCs), distal interphalangeal joints (DIPJs) are affected more than the proximal interphalangeal joints (PIPJs)

Answer 655

Inactivity stiffness Heberden's nodes at the DIP joints Bouchard's Nodes at the PIP joints Squaring of the thumbs

Answer 656

Usually diagnosed clinically X-ray can be done

Answer 657

Weight loss and advice with exercise Topical NSAIDs are first line Oral NSAIDs should be given with PPI Intra-articular steroid injections if above is ineffective

Answer 658

Characterised by muscle stiffness and raised inflammatory markers

Answer 659

Abrupt onset of bilateral early morning stiffness in over 60s Weakness is not a symptom

Answer 660

Raised inflammatory markers e.g. ESR > 40 mm/hr Note creatine kinase and EMG normal

Answer 661

Prednisolone e.g. 15mg/od Patients should respond dramatically - failure should prompt consideration of alternate diagnosis

Answer 662

A form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 0.45 mmol/l)

Answer 663

Drugs: diuretics + Aspirin Chronic kidney disease Lead toxicity

Answer 664

Myeloproliferative/lymphoproliferative disorder Cytotoxic drugs Severe psoriasis

Answer 665

Pain: this is often very significant Swelling Erythema

Answer 666

1st metatarsophalangeal (MTP) joint - 70% Ankle Wrist Knee

Answer 667

Measuring uric acid levels: A uric acid level ≥ 360 umol/L supports diagnosis Uric acid level < 360 umol/L during a flare - repeat 2 weeks after the flare has settled

Answer 668

Needle shaped negatively birefringent monosodium urate crystals under polarised light

Answer 669

NSAIDs - also PPI If peptic ulcer disease - colchicine

Answer 670

Urate-lowering therapy: Allopurinol (xanthine oxidase inhibitor) Febuxostat (also a xanthine oxidase inhibitor) is second-line

Answer 671

Reduce alcohol intake and avoid during an acute attack Lose weight if obese Avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products

Answer 672

A form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium.

Answer 673

Increasing age (>60 years) Haemochromatosis Hyperparathyroidism Low magnesium, low phosphate Acromegaly, Wilson's disease

Answer 674

Knee Wrist Shoulders

Answer 675

Weakly-positively birefringent rhomboid-shaped crystals

Answer 676

Chondrocalcinosis

Answer 677

Aspiration of joint fluid, to exclude septic arthritis NSAIDs or intra-articular, intra-muscular or oral steroids as for gout

Answer 678

A term which described a classic triad of urethritis, conjunctivitis and arthritis following an infection where the organism cannot be recovered from the joint

Answer 679

Arthritis is typically an asymmetrical oligoarthritis of lower limbs Dactylitis Symptoms of urethritis Conjunctivitis and/or anterior uveitis

Answer 680

Typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months

Answer 681

Analgesia - NSAIDS, intra-articular steroids Sulfasalazine and methotrexate are sometimes used for persistent disease

Answer 682

Osteoporosis is a disorder affecting the skeletal system characterised by loss of bone mass. WHO defines as presence of bone mineral density (BMD) of less than 2.5 standard deviations (SD) below the young adult mean density

Answer 683

Corticosteroid use Smoking Alcohol Low BMI Family history

Answer 684

FRAX score

Answer 685

Used to measure a patients 10-year risk of developing a fragility fracture

Answer 686

Dual-energy X-ray absorptiometry (DEXA)

Answer 687

Hip and lumbar spine.

Answer 688

Alendronate OR Risedronate OR Etidronate Vitamin D and calcium if deficient

Answer 689

Oral bisphosphonates

Answer 690

Step 1: Is a fragility fracture present? - No = move on to step 2 - Yes = Make clinical diagnosis of osteoporosis if age ≥ 75 OR perform DEXA scan if age > 50 Step 2: Perform Fragility fracture risk assessment - Low Risk = Repeat fragility fracture assessment in 5 years - Intermediate-High Risk = perform DEXA scan

Answer 691

Perform DEXA scan

Answer 692

Based on bone mass of young reference population

Answer 693

-1.0 means bone mass of one standard deviation below that of young reference population Osteopenia

Answer 694

-2.5 means bone mass of 2.5 standard deviations below that of young reference population Osteoporosis

Answer 695

Z score is adjusted for age, gender and ethnic factors

Answer 696

Bisphosphonates bind to hydroxyapatite in bone, inhibiting osteoclast-mediated bone resorption

Answer 697

Oral bisphosphonates should be taken with a full glass of water, on an empty stomach, and the patient should remain upright for at least 30 minutes afterwards

Answer 698

Denosumab injection every 6 months

Answer 699

Strontium ranelate Raloxifene Teriparatide Romosozumab

Answer 700

Human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts

Answer 701

Equivalent of prednisolone 7.5mg a day for 3 or more months.

Answer 702

Parkinson's disease Drug-induced e.g. antipsychotics, metoclopramide* Progressive supranuclear palsy Multiple system atrophy Wilson's disease Post-encephalitis Dementia pugilistica (secondary to chronic head trauma e.g. boxing) Toxins: carbon monoxide, MPTP

Answer 703

Parkinson's disease is a progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra.

Answer 704

The reduction in dopaminergic output results in a classical triad of features: bradykinesia, tremor and rigidity. The symptoms of Parkinson's disease are characteristically asymmetrical.

Answer 705

Poverty of movement also seen, sometimes referred to as hypokinesia Short, shuffling steps with reduced arm swinging Difficulty in initiating movement

Answer 706

Most marked at rest, 3-5 Hz Worse when stressed or tired, improves with voluntary movement Typically 'pill-rolling', i.e. in the thumb and index finger

Answer 707

Mast-like facies Flexed posture Micro-graphia Drooling of saliva Impaired olfaction REM sleep disturbance Fatigue Postural hypertension

Answer 708

Levodopa nearly always combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide)

Answer 709

This prevents the peripheral metabolism of levodopa to dopamine outside of the brain and hence can reduce side effects

Answer 710

Dry mouth Anorexia Palpitations Postural hypotension Psychosis

Answer 711

Glycopyrronium bromide

Answer 712

Midodrine - acts on peripheral alpha-adrenergic receptors to increase arterial resistance

Answer 713

Dopamine agonist (non-ergot derived) Levodopa Monoamine oxidase B (MAO-B) inhibitor

Answer 714

Bromocriptine Ropinirole Cabergoline Apomorphine

Answer 715

Echocardiogram ESR Creatinine Chest x-ray Due to being associated with pulmonary, retroperitoneal and cardiac fibrosis

Answer 716

Dopamine receptor agonists

Answer 717

Monoamine Oxidase-B inhibitors work by inhibiting the breakdown of dopamine secreted by the dopaminergic neurones. Selegiline

Answer 718

Entacapone Tolcapone

Answer 719

Catechol-O-Methyl Transferase inhibitors - an enzyme involved in the breakdown of dopamine, and hence may be used as an adjunct to levodopa therapy

Answer 720

Symptoms often worsen towards the end of dosage interval. This results in a decline of motor activity

Answer 721

Large variations in motor performance, with normal function during the 'on' period, and weakness and restricted mobility during the 'off' period

Answer 722

Dystonia, chorea and athetosis (involuntary writhing movements)

Answer 723

A severe, unilateral, throbbing headache associated with nausea, photophobia and phonophobia May be precipitated by aura

Answer 724

Offer combination therapy with: an oral triptan and an NSAID, OR an oral triptan and paracetamol

Answer 725

Nasal and not oral

Answer 726

Propranolol Topiramate Amitriptyline

Answer 727

Should be avoided in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives

Answer 728

If patients have migraine with aura then the COC is absolutely contraindicated due to an increased risk of stroke

Answer 729

Trigeminal neuralgia is a pain syndrome characterised by severe unilateral pain of the face

Answer 730

The pain is commonly evoked by light touch, including washing, shaving, smoking, talking, and brushing the teeth (trigger factors), and frequently occurs spontaneously

Answer 731

Carbamazepine is first-line

Answer 732

An acute, unilateral, idiopathic, facial nerve paralysis.

Answer 733

Oral prednisolone within 72 hours of onset of Bell's palsy

Answer 734

A type of syncope resulting from a failure in autoregulation of blood pressure, and ultimately, in cerebral perfusion pressure resulting in transient loss of consciousness.

Answer 735

Cardiovascular examination Postural BP and lying BP ECG

Answer 736

One of the most common causes of vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position.

Answer 737

Vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards) May be associated with nausea Each episode lasts for approximately 10-20 seconds

Answer 738

Dix-Hallpike manoeuvre - rapidly lower the patient to the supine position with an extended neck. Positive test recreates symptoms. There is also rotary nystagmus

Answer 739

Epley manoeuvre

Answer 740

Inflammation of the eyelid margins

Answer 741

Meibomian gland dysfunction (common, posterior blepharitis) OR Seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis)

Answer 742

Bilateral symptoms Grittiness and discomfort Eyes may be sticky in the morning Eyelid margins may be red Swollen eyelid - staphylococcal blepharitis Styes and chalazions are common

Answer 743

Softening of the lid margin using hot compresses 2x/day Lid hygiene - cooled boiled water and baby shampoo on cotton wool Artificial tears for symptomatic relief

Answer 744

Acute localised infection or inflammation of the eyelid margin

Answer 745

Cooled boiled water and baby shampoo on cotton wool

Answer 746

A chronic, non-infectious, inflammatory granuloma caused by blockage of meibomian gland duct(s)

Answer 747

Warm compress: apply a warm compress (for example, with a clean flannel rinsed with warm water) to the affected eye for 10–15 minutes, up to five times a day, to loosen meibomian gland content

Answer 748

Entropion is an inversion or inward turning of the eyelid margin

Answer 749

Ectropion is an outward turning of the eyelid margin

Answer 750

Infective conjunctivitis

Answer 751

Sore, red eyes Purulent discharge

Answer 752

Sore, red eyes Serous discharge Recent URTI

Answer 753

Usually self-limiting Topical antibiotic - Chloramphenicol drops Contact lenses should not be worn

Answer 754

Infection - bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal Seborrhoeic dermatitis Contact dermatitis (allergic and irritant) Recent swimming is a common trigger

Answer 755

Ear pain, itch, discharge Otoscopy: red, swollen, or eczematous canal

Answer 756

Topical antibiotic or a combined topical antibiotic with a steroid If tympanic membrane perforated = do not use amino-glycosides If debris consider removal

Answer 757

Oral antibiotics (flucloxacillin) if the infection is spreading Empirical use of antifungal agent - recurrent infection should warrant use of antifungal (Candida)

Answer 758

RNA paramyxovirus Spread via aerosol transmission Infective from prodromal phase until 4 days after rash starts

Answer 759

10-14 days

Answer 760

Irritable Conjunctivitis Fever

Answer 761

Koplik spots before the rash develops (white spots) Rash - behind ears then whole body Diarrhoea

Answer 762

Discrete maculopapular rash becoming blotchy & confluent desquamation that typically spares the palms and soles may occur after a week

Answer 763

IgM antibodies detected within a few days of rash onset

Answer 764

Supportive mainly Admission if immunocompromised or pregnant Notifiable disease so inform public health

Answer 765

Otitis media

Answer 766

Offer MMR vaccine Should be given within 72 hours

Answer 767

Mumps is a caused by RNA paramyxovirus and tends to occur in winter and spring Spread by droplets

Answer 768

14-21 days Infective 7 days before and 9 days after parotid swelling starts

Answer 769

Fever Malaise, muscular pain Parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70%

Answer 770

MMR vaccine (80%) efficacy

Answer 771

Rest Simple analgesia A notifiable disease

Answer 772

The spirochaete Treponema pallidum

Answer 773

Chancre - painless ulcer at the site of sexual contact Local non-tender lymphadenopathy Often not seen in women (the lesion may be on the cervix)

Answer 774

Occurs 6-10 weeks after primary infection

Answer 775

Systemic symptoms: fevers, lymphadenopathy Rash on trunk, palms and soles Buccal 'snail track' ulcers (30%) Condylomata lata (painless, warty lesions on the genitalia )

Answer 776

Gummas (granulomatous lesions of the skin and bones) Ascending aortic aneurysms General paralysis of the insane Tabes dorsalis Argyll-Robertson pupil

Answer 777

Blunted upper incisor teeth (Hutchinson's teeth), 'mulberry' molars Rhagades (linear scars at the angle of the mouth) Keratitis Saber shins Saddle nose Deafness

Answer 778

Consistent with active syphilis infection

Answer 779

Consistent with a false-positive syphilis result e.g. due to pregnancy or SLE

Answer 780

Consistent with successfully treated syphilis

Answer 781

Intramuscular benzathine penicillin is the first-line management

Answer 782

Doxycycline

Answer 783

Jarisch-Herxheimer reaction No treatment is needed other than antipyretics if required

Answer 784

Painful genital ulceration Tender inguinal lymphadenopathy Urinary retention may occur

Answer 785

The primary infection is often more severe than recurrent episodes - systemic features such as headache, fever and malaise are more common in primary episodes

Answer 786

Nucleic acid amplification test

Answer 787

Oral aciclovir

Answer 788

Saline bathing Analgesia Topical anaesthetic agents e.g. lidocaine

Answer 789

Elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation Women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low

Answer 790

HSV-1 in 90%

Answer 791

Analgesia - Paracetamol and Ibuprofen Topical Acyclovir - can be purchased over counter Oral acyclovir

Answer 792

Irritant contact dermatitis: common - non-allergic reaction due to weak acids or alkalis Allergic contact dermatitis: type IV hypersensitivity reaction

Answer 793

'Cottage cheese', non-offensive discharge Vulvitis: superficial dyspareunia, dysuria Itch Vulval erythema, fissuring, satellite lesions may be seen

Answer 794

Diabetes mellitus Drugs; antibiotics and steroids Pregnancy Immunosuppression: HIV

Answer 795

A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis

Answer 796

Oral fluconazole 150 mg as a single dose first-line

Answer 797

Clotrimazole 500 mg intravaginal pessary as a single dose Oral treatments are contraindicated

Answer 798

BASHH define recurrent vaginal candidiasis as 4 or more episodes per year

Answer 799

Compliance with previous treatment should be checked High vaginal swab for microscopy and culture Consider a blood glucose test to exclude diabetes

Answer 800

Induction: oral fluconazole every 3 days for 3 doses Maintenance: oral fluconazole weekly for 6 months

Answer 801

Spirochaete Borrelia burgdorferi and is spread by ticks

Answer 802

Erythema migrans - 80% of patients Headache Lethargy Fever Arthralgia

Answer 803

Bulls-eye' rash is typically at the site of the tick bite typically develops 1-4 weeks after the initial bite Usually painless, more than 5 cm in diameter and slowly increases in size

Answer 804

Cardiovascular: Heart block Peri/myocarditis Neurological: Facial nerve palsy Radicular pain Meningitis

Answer 805

Lyme disease can be diagnosed clinically if erythema migrans is present (ELISA) antibodies to Borrelia burgdorferi are the first-line test If negative then another 4-6 weeks after is still suspicion If still negative after 12 weeks then immunoblot

Answer 806

If tick still present - fine-tipped tweezers near to the skin then wash the skin

Answer 807

Doxycycline if early disease Amoxicillin if pregnant or other contraindication

Answer 808

Ceftriaxone

Answer 809

Jarisch-Herxheimer

Answer 810

Longitudinal or elliptical tears of the squamous lining of the distal anal canal Acute <6 weeks, Chronic >6 weeks

Answer 811

Constipation Inflammatory bowel disease STIs

Answer 812

Painful, bright red, rectal bleeding Up to 90% occur in the posterior midline - if not then underlying causes should be considered e.g. Crohn's disease

Answer 813

Bulk-forming laxatives - first line Dietary advice - high-fibre, high-fluid Lubricants before defecation Topical anaethetics

Answer 814

Topical glyceryl trinitrate (GTN) is first-line treatment as well as those in acute Shincterotomy if after 8 weeks

Answer 815

Vaginal atrophy

Answer 816

Protrusion of intra-abdominal contents into the thoracic cavity though an enlarged oesophageal hiatus of the diaphragm

Answer 817

GORD in 50% of large hernias

Answer 818

Upper GI endoscopy Barium swallow to confirm diagnosis

Answer 819

Conservative management - weight loss Medical management - PPI Surgical management - only if symptomatic

Answer 820

Painful inflammatory condition of the breast

Answer 821

Continue breastfeeding

Answer 822

Oral flucloxacillin 10-14 days Breastfeeding or expressing should continue through Abx treatment

Answer 823

Staphylococcus aureus

Answer 824

A localised collection of pus within the breast. Can be either lactational or non-lactational