GP and primary healthcare Flashcards

Question

Differentials for rectal bleeding

Answer 1

- Anal fissures - Haemorroids - Diverticulosis - Inflammatory bowel disease - Colorectal cancer

Answer 2

Topical - Anusol/Anusol HC (+hydrocortisone)+ - Germoloid (contains lidocaine) - Proctosedyl ointment (cinchocine + HC)+ Non-surgical tx: - Rubber band ligation - Injection sclerotherapy (phenol oil to cause sclerosis and atropy) - Infrared coagulation - Bipolar diathermy (electrical current) | + Short-term use only

Answer 3

- Haemorrhoidal artery ligation - cutting off blood supply to haemorroid - Haemorrhoidectomy - excision Thrombosed haemorrhoids - caused by strangulation at base, resolve within a few weeks or admission + surgery if presents <72hrs with extreme pain.

Answer 4

Main one in GP Dovobet gel

Answer 5

Inflammatory skin condition characterised by dry, pruritic skin Chronic and replasing Usually dx < 5yo Acute = flare-up Chronic = chronic inflammation e.g. lichenification

Answer 6

Usually in childhood - Sore, itchy skin in flexor surfaces, face, neck - Caused by defects in skin barrier that allow irritants, microbes and allergens to trigger immune response - Part of atopy (asthma, hayfever)

Answer 7

- Maintenance and management of flares Maintenance: artifical skin barrier - Emollients to apply and in shower Avoid triggers: e.g. cold weather, washing powders, cleaning products, stress Flares: thicker emollients, topical steroids, "wet wraps"1 Very severe flare require: IV abx, oral steroids, zinc impregnanted bandages, phototherapy, systemic immunosuppressant e.g. methothrexate | 1 applying thick emollient and coering in wrap to lock moisture

Answer 8

Use as thick as tolerated Thin: E45, diprobase cream, cetraben, oilatum Thick,greasy: 50:50 ointment (50% liquid paraffin), diprobase or centraben ointment

Answer 9

Better to use stronger steroids for shortest time than weak steroids for a long time Thin skin e.g. eyelids/face = weak Thick skin e.g. palms = potent - Mild: Hydrocortisone 0.5%, 1% and 2.5% - Moderate: Eumovate (clobetasone butyrate 0.05%) - Potent: Betnovate (betamethasone 0.1%) - Very potent: Dermovate (clobetasol propionate 0.05%)

Answer 10

- Staphylococcus aureus = admission and IV abx - Eczema herpeticum1 = HSV/VZV. Viral swabs and aciclovir ## Footnote 1 Patients are very unwell with widespread, painful, vesicular rash and fever/lethargy.

Answer 11

- Dryness, atrophy and loss of elasticity of vaginal mucosa due to lack of oestrogen - More prone to inflammation - Change in vaginal pH and microbial flora = infection - Oestrogen = thicker vaginal and urinary tract epithelial lining, more secretions, elastic

Answer 12

Postmenopausal women: - Itching - Dryness - Dyspareunia - Bleeding (inflammation) - Recurrent UTIs - Stress incontinence - Pelvic organ prolapse

Answer 13

Examine the labia and vagina - Pale mucosa - Thin skin - Reduced skin folds - Erythema and inflammation - Dryness - Thinning pubic hair

Answer 14

Vaginal lubricants e.g. Sylk, YES Topical oestrogen = significant symptom improvements! - Estriol cream (applicator at night), pessaries (inserted at night), tablets, rings (3 monthly replacement) - CI in breast cancer, angina, VTE, monitor at least annually, stop tx if possible

Answer 15

Acute, sudden-onset, unilateral facial palsy, single episode, no constitutional symptoms, keratoconjunctibitis sicca (dry eye) Cause: maybe HSV-1 Clinical dx of exclusion Tx is high-dose corticosteroid e.g. prednisolone, eye protection (glasses, artifical tears) Exclude Lyme's disease-associated facial paralysis before tx as worsen outcome

Answer 16

- Inflammation of eyelid margins - Gritty, itchy and dry sensation - Associated with dysfunction of Meibomian glands (secrets meibum (oil) onto eye surface) - Can lead to styes and chalazions - Mx = warm compress and gentle cleaning

Answer 17

Hordeolum externum: infection of gland of Zeis and Moll, sebaceous and sweat glands at base of eyelashes Hordeolum internum: infection of the Meibomian glands, deeper, more painful Mx: hot compresses, analgesia, topical abx (e.g. chloramphenicol) if conjuctivitis or persistent

Answer 18

Meibomian gland becomes blocked and swells. Swelling in eyelid, can be tender and red but usually not! Mx: warm compresses, massage towards eyelashes to help drainage, surgical drainage might be needed

Answer 19

When eyelids turn inwards and lashes press against the eye Pain, coneal damage and ulceration Mx: tape eyelid to prevent inward turn, then refer to ophhalmology for surgery, same-day if risk to sight

Answer 20

Eyelid turns outwards, exposing inner membrane Usually bottom eyelids = exposure keratopathy as eyeball not lubricated and protected Mx: mild cases = lubricating eye drops, severe cases = surgery, same-day referral to opthalmology if risk to sight

Answer 21

Inward growth of eyelashes, pain, corneal damage and ulceration Mx: remove affected eyelashes, if recurrent then electrolysis, cryotherapy or laser tx to stop regrowth. Same-day ophthalmology referral if risk to sight

Answer 22

Infection of the eyelid and skin in front of the orbital septum (in front of the eye) Swollen, red, hot skin around eyelid and eye Tx with systemic (oral or IV) abx, can develop into orbital cellulitis so children etc. need admission and monitoring Key ddx is orbital cellulitis = sight and life-threatening emergency

Answer 23

Infection around eyelid of the tissue behind orbital septum Pain on eye movement, reduced eye movement, vision changes, proptosis, abnormal pupil reactions Emergency admission to opthalmology and IV abx per local policy, surgical drainage if abscess

Answer 24

- Causes recurrent episodes of vertigo triggered by head movement - Variety of head movements trigger vertigo, e.g. turning over in bed, lasts 20 to 60s - Episodes over several weeks, then resolves, then reoccurs weeks or months later - Peripheral cause of veritgo = inner ear cause, not the brain - Does not cause hearing loss or tinnitus

Answer 25

Calcium carbonate crystals called otoconia that become displaced in the semicircular canals. Causes: viral infection, head trauma, aging Distruption of the endolymph flow through canals, confusing the vestibular system. Head movement = endolymph flow = vertigo

Answer 26

Dix-Hallpike Manoeuvre Dix for Dx Triggers endolymph flow through semicicular canals Positive signs = rotational nystagmus towards affected ear and vertigo

Answer 27

Epley Manoeuvre to move crystals in semicircular canal to a position that does not disrupt endolymph flow.

Answer 28

- Common in men > 50 - Hyperplasia of stromal and epithelial cells of the prostate

Answer 29

Lower urinary tract symptoms (LUTS), typically: FUNI: frequency, urgency, nocturia, intermittency (flow starts/stops) SHID: (poor) stream, hesitancy, incomplete empyting, dribbling (terminal) ## Footnote International prostate symptom score (IPSS) - socre to assess LUTS severity

Answer 30

- Digital rectal exam (prostate exam) - Abdo exam for bladder - Urinary frequenct volume chart - Urine dipstick - PSA (unreliable)

Answer 31

Benign prostate: smooth, symmetrical and soft, central sulcus Cancerous:firm/hard, asymmetrical, craggy, irregular, loss of central sulcus

Answer 32

- Mild = conservative Medical: - Alpha-blockers1 (e.g. tamsulosin) relax smooth muscle for symptoms - 5-alpha reductase inhibtor2 (finasteride) for tx of BPH Surgery: - MC is transurethral resection of the prostate (TURP) - remove parts of prostate from inside of urethra ## Footnote 1 Key SE: postural hypotension, consider tamsulosin as cause of dizziness on standing/falls in older man 2 Key SE is erectile dysfunction

Answer 33

Narrowing of arteries supplying limbs and peripheries Most common in lower limbs > intermittent claudication (ischaemia in a limb during exertion, better on rest) Chronic limb-threatening ischaemia - end-stage of PAD, inadquate blood supply to limb even at rest.

Answer 34

Intermittent claudication - crampy achy pain in calf, thigh or buttock muscles when walking beyond a certain distance Chronic limb threatening ischaemia - burning pain at rest, worse at night, non-healing ulcers and gangrene

Answer 35

Generally, peripheral arterial disease: - Skin pallor - Cyanosis - Depedent rubor (deep red when limb is lower than body) - Muscle wasting - Hair loss - Ulcer - Poor woundhealing - Reduced skin temp - Reduced sensation - CRT > 2s - Positive Buerger's test

Answer 36

Non-modifiable risk factors: older age, FHx, male Modifiable risk factors: - Smoking - Alcohol consumption - Poor diet (high in sugar and trans-fat and low in fruit, vegetables and omega 3s) - Low exercise / sedentary lifestyle - Obesity - Poor sleep - Stress Medical co-morbidities that increase the risk: - Diabetes - HTN - CKD - Inflammatory conditions e.g. RA - Atypical antipsychotics ## Footnote Tom tip: make sure to think and ask about RFs when taking a hx from someone with atherosclerotic disease: exercise, diet, PMH, FHx, occupation, smoking, alcohol, meds

Answer 37

Occurs when a thrombus blocks the arterial supply of a distal limb. 6Ps - Pain - Pallor - Pulseless - Paralysis - Paraesthesia (abnormal sensation or “pins and needles”) - Perishing cold

Answer 38

Occlusion in distal aorta or proximal common iliac artery - Thigh/buttock claudication - Absent femoral pulses - Male impotence

Answer 39

Assesses for PAD in legs Part one: patient lies supine, straight leg lift 45 degrees for 1 - 2 mins, PAD = pallor Part two: patient sits up with legs dangling, in PAD: - Blue initially as ischaemic tissue deoxygenates blood - Dark red (rubor) after due to vasodilation from waste products from anaerobic respiration

Answer 40

- Ankle-brachial pressure index: compares ankle systolic BP to arm systolic BP. - Duplex USS - speed and volume of blood flow - Angiography (CT+MRI) -

Answer 41

- Lifestyle changes for modifiable RFs, optimise co-morbidities e.g. HTN and diabetes - Excercise training - walking to near-maxial claudication then rest and repeat - Medical: Atorvastatin 80mg, clopidogrel 75mg daily, naftidrofuryl oxalate (peripheral vasodilator) - Surgery: eg. endovascular angioplasty and stenting

Answer 42

- Urgent vascular team referral - Analgesia - Endovascular angioplasty and stenting - Endarerectomy (cut vessel open, remove atheromatous plaque) - Amputation if unable to restore blood supply

Answer 43

- Urgent vascular team referral for assessment - Endovascular thrombolysis/thrombectomy - Surgerical thrombrctomy - Then same as mx of critical limb ischaemia

Answer 44

Inflammation of a bursa, which are sacs created by synovial membrane filled with small amount of synovial fluid Found at bony prominences e.g. greater tronchanter or elbow to reduce fricton during movemtn

Answer 45

- Friction from repetitive movements or leaning on the elbow - Trauma - Inflammatory conditions (e.g., rheumatoid arthritis or gout) - Infection – referred to as septic bursitis

Answer 46

Bursitis of the bursa over the elbow, olecranon is a bony lump at elbow, part of the ulna bone Typically, a student studying and leaning on elbow for a long time Elbow is swollenm warm, tender and fluctuant (fluid-filled) Signs of infection: hot to touch, more tender, erythema, fever, sepsis (tachy, hypotension, confusion) Septic arthritis: joint swelling, pain and reduced ROM

Answer 47

Aspiration of bursa if infection suspected - Pus = infection - Straw-colour = infection less likely - Blood-stained = trauma/infection.inflammatory - Milky = gout/pseudogout Sent for microscopy and culture

Answer 48

Supportive: rest, ice, compression, analgesia (e.g., paracetamol or NSAIDs), protect elbow, - Aspiration to relieve pressure - Steroid injections Infection: - Diagnostic aspiration - Antibiotics (flucloxacillin 1st line) - If systemically unwell = hospital for bloods (including lactate), blood cultures, IV abx, IV fluids

Answer 49

Inflammation of a bursa over the greater trochanter on the outer hip Presentation: - Middle aged patient with gradual-onset lateral hip pain (over greater trochanter) = greater trochanteric pain syndrome - Buring/aching - Radiation to outer thigh - Worse with activity, standing after sitting for long time - Disrupts sleep

Answer 50

- Trendelenburg test - Resisted abduction of the hip - Resisted internal rotation of the hip - Resisted external rotation of the hip Pain on resisted movement = postiive

Answer 51

Dx by history and examination Supportive: rest, ice, analgesia (ibuprofen/naproxen), physio Steroid injection if ineffective If caused by infection (warmth, erythema, swelling and pain over bursa) then abx Can take 6 - 9m to recover, sometimes longer

Answer 52

At least 3 months of disabling fatigue affecting mental and physical function > 50% Cannot be explained by other diseases More females, PMH of psychiatric conditions not a RF Fatigue is key feature, sleep problems (too much/little), muscle/joint pain, headaches, painful lymph nodes, cognitive dysfunction e.g. brain fog, worse after physical/mental exertion, general malaise

Answer 53

NICE recommends: - Bloods to rule out other causes e.g. FBC, U+E, LFT, glucose, TFT, ESR, CPR, calcium, CK, ferritin, coeliac screen, urinalysis NICE diagnostic criteria (all symptoms at least 3m) - Debilitating fatigue worsened by activity - Post-exertional malaise - Unrefreshing sleep - Cognitive difficulties (brain fog)

Answer 54

- Refer to specialist CFS service Supervised by CFS specalist team: - Self-mx of activity to stay within energy limit - Phscial activity and exercise - CBT (supportive not curative)

Answer 55

- Inflammation of conjunctiva (thin layer of tissue covering inside of eyelids and sclera) - Bacterial, viral, allergic - Red boodshot eye - Itchy/gritty feel - Discharge DOES NOT cause pain, photophobia or reduced visual acuity

Answer 56

- Acute angle-closure glaucoma - Anterior uveitis - Scleritis - Corneal abrasions or ulceration - Keratitis - Foreign body - Traumatic or chemical injury | If pain or reduced visual acuity = same day ophthalomology referral

Answer 57

- Self-resolve in 1-2 weeks - Hygiene measure e.g. no towel sharing, handwashing - Clean eye with cooled, boiled water - Chloramphenicol/fusidic acid eye drops for bacterial conjunctivtis - Neonates < 1m = urgent ophthalmology assessment, possible gonococcal infection, permanent vision loss if untx

Answer 58

Contact with allergens, swelling of conjunctival sac and eye with itching and watery discharge Tx: antihistamines (oral or topical) or topical mast-cell stabilisers for chronic seasonal symptoms

Answer 59

Defecation that is unsatisfactory because of infrequent stools (< 3 times weekly) and difficulty passing stools with straining or discomfort Ix: exclude secondary causes and red flags, exclude faecal impaction Mx: increase dietary fibre, adequate fluids and activity levels Meds: - 1st line is bulk-forming laxative e.g. ispaghula - 2nd line: osmotic laxative e.g. macrogol

Answer 60

Skin reaction in contact with causative agent. Nearly always itchy - Irritant contact dermatitis - eczema in affected area with buring/pain, higher risk if pre-existing skin condition - Allergic contact dermatitis:1 itchy eczematous rash (vesciles, fissures, erythema), caused by nickel (jewellery), perfumes, latax, hair dye and henna | 1 Type IV hypersensitivity reaction, sensitised over time

Answer 61

- Avoidance of causative agent - Generous emollient and soap substitutes - Oral antihistamines - Topical steroids - Refer to dermatalogy if severe, chronic, persistant or tx ineffective

Answer 62

Crystal arthropathy due to chronically high blood uric acid levels Urate crystals in joints > inflammation, acute, hot, swollen, pain usually in single joint - metatarsophalangeal joint (big toe base), carpometacarpal joint (base of thumb), wrist Gouty tophi = SC uric acid desposits ## Footnote Key differential: septic arthritis

Answer 63

- Male - Family history - Obesity - High purine diet (e.g., meat and seafood) - Alcohol - Diuretics - Cardiovascular disease - Kidney disease

Answer 64

Clinical diagnosis with raised serum urate levels Joint aspirate: Gout: monosodium urate cystals, needle-shaped negatively birefringent **P**seudogout: calcium pyrophosphate cystals, rhomboid-shaped and **p**ositively birefringent ## Footnote If any signs of septic arthritis, emergency mx with joint aspiration and abx

Answer 65

1st line: NSAID (e.g. naproxen) + PPI - 2nd line Cochicine (if renal impairment) - 3rd line: prednisolone - Prophylaxis with allopurinol or febuxostat (xabthine oxidase inhibitors - lowers uric acid levels) - started weeks after acute episode, then continued through acute episodes after (COMMON EXAM Q)

Answer 66

Crystal arthropathy, calcium pyrophosphate crystals in joints Typcially >65 with rapid-onset, hot, swollen, stiff and painful knee/shoulers/hips/wrists | Key ddx = septic arthritis, much more severe sx

Answer 67

Symptoms tend to be milder than gout and septic arthritis DIagnostic = joint aspiration, calcium pyrophsphate crystals - rhomboid-shaped, +ve birefringent of polarised light X-ray finding: chrondrocalcinosis (calcium deposits as thin white line in joint space

Answer 68

Symptom mangement, if asymptomatic changes on x-ray = no tx Usually self-resolves in several weeks - NSAIDs e.g. naproxen is 1st line + PPI - Colchicine - Intra-articular steroid injections (exclude septic arthritis) - Oral steroids

Answer 69

Fungal infection of the skin - Tinea capitis - scalp - Tinea pedis - feet - Tinea cruris - groin - Tinea corporis - body - Onchomycosis - nail Itchy, erythematous, scaly, well demacrated rash Most commonly caused by trichophyton fungus

Answer 70

Clinical dx, can send scales off for microscopy and culture Anti-fungal medications: - Clotrimazole and miconazole cream - Tinea capitis: ketoconazole shampoo - Oral anti-fungals: fluconazole - Fungal nail infections = 6 - 12m amorolfine nail lacquer, oral terbinafine if ineffective, LFTs before and during tx - Mild steroid for inflammation + itching e.g. miconazole 2% and hydrocortisone 1% cream (Daktacort), steroids > tinea Incogito

GP and primary healthcare Flashcards

(96 cards)