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Year 5 random facts > GP Capsule cases > Flashcards

GP Capsule cases Flashcards

1
Q

Management of Gastroenteritis

A
  • Drinking fluids regularly is encouraged to avoid dehydration.
  • In most otherwise healthy adults, encouraging fluid intake (especially if supplemented with fruit juice and soups) will be sufficient.
  • Consider supplementing fluid intake with oral rehydration salt solution in adults at increased risk of a poor outcome. This includes people who are 60 years of age or older, frail, or with comorbidities with which dehydration, hypovolaemia, or haemoconcentration would be a problem (for example cardiovascular disease or thrombotic tendencies).
  • After rehydration, advise that the consumption of solid food should be guided by appetite. Small, light, non-fatty, and non-spicy meals may be better tolerated.
  • It is important to assess fluid status and for dehydration in patients with diarrhoea and vomiting. Below are a few symptoms/signs to look out for when doing this:
    • Mild dehydration – lassitude, anorexia, nausea, postural hypotension
    • Moderate dehydration – tiredness, nausea, dizziness, headache, dry tongue, sunken eyes, tachycardia, postural hypotension
    • Severe dehydration – weakness, confusion, tachycardia, systolic hypotension, reduced urine output/no urine output, peripheral vasoconstriction
  • Simple analgesia is useful in symptomatic management. All patients with gastroenteritis should be informed of ways to prevent spread of infection through adopting hygienic measures such as regular hand washing, using separate towels and flannels to others and not attending work until they have no symptoms for at least 48 hours.
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2
Q

People with a sore throat caused by streptococcal bacteria are more likely to benefit from antibiotics. FeverPAIN or Centor criteria are clinical scoring tools that can help to identify the people in whom this is more likely. What is the criteria?

A

FeverPAIN criteria

  • Fever (during previous 24 hours)
  • Purulence (pus on tonsils)
  • Attend rapidly (within 3 days after onset of symptoms)
  • Severely Inflamed tonsils
  • No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause. A score of 0 or 1 is thought to be associated with a 13 to 18% likelihood of isolating streptococcus. A score of 2 or 3 is thought to be associated with a 34 to 40% likelihood of isolating streptococcus. A score of 4 or 5 is thought to be associated with a 62 to 65% likelihood of isolating streptococcus.

Centor criteria

  • Tonsillar exudate
  • Tender anterior cervical lymphadenopathy or lymphadenitis
  • History of fever (over 38°C)
  • Absence of cough

Each of the Centor criteria score 1 point (maximum score of 4). A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus. A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.

NICE (2018) guidance on the antimicrobial treatment in sore throat recommends antibiotics for sore throat if there is a _FeverPAIN score of 4 or 5 or a Centor Score of 3 or 4._

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3
Q

If Sarah’s presentation had been a sore throat for 5 days with fever, malaise, difficulty swallowing and examination findings of a white exudate over enlarged tonsils and marked cervical lymphadenopathy, you may decide she needs antibiotics. She has no known allergies. Which one would be the antibiotic of choice?

A

Penicillin V (500mg QDS for 10 days) is the treatment of choice with erythromycin or clarithromycin being the choices for those allergic to penicillin.

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4
Q

Why should amoxillin and ampicillin not be used in glandular fever?

A

Causes a rash

Might be mistaken for an allergy to penicillin

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5
Q

Features of scarlet fever

A
  • tongue may show a strawberry tongue caused by red papillae protruding through a white coating
  • florid punctate rash over her torso and limbs
  • penicillin V is the treatment of choice
  • Scarlet fever is a notifiable disease
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6
Q

What is Quinsy?

A
  • peri-tonsillar abscess
  • same day urgent referral to ENT as antibiotics alone may not be enough and aspiration and drainage are usually requried
  • recurrent quinsy is usually an indication for tonsillectomy
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7
Q

What is the Duke staging system for colorectal cancer?

A

Dukes A – tumour confined to bowel wall

Dukes B – tumour has gone through wall but not into nodes

Dukes C – tumour involving regional nodes

Dukes D – distant metastases are present

Dukes stage histologically affects prognosis – i.e. 90% alive at 5 years Dukes A, reducing to 10% for Dukes D.

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8
Q

What hand deformities are found in Rheumatoid arthritis?

A
  • swelling of MTP joints
  • Swan neck deformity – hyperextension of PIP joints and flexion of DIP joints
  • Boutonniere’s deformity – flexion at the PIP joint and hyperextension at the DIP joint
  • synovial swelling at the wrist
  • Ulnar deviation of fingers
  • Vasculitis and small nail infarcts may be associated with Rheumatoid Arthritis
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9
Q

Radiological findings of Rheumatoid Arthritis

A
  • peri-articular erosions
  • osteopenia
  • soft tissue swelling
  • subluxation
  • Later stages: joint fusion and deformities
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10
Q

Radiological findings of Osteoarthritis

A
  • Joint narrowing
  • subchondral cysts
  • sclerosis
  • osteophytes
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11
Q

Serological investigations for Rheumatoid Arthritis

A
  • ANA – The anti nuclear antibody test is a non specific test for autoimmune conditions. It can be positive in patients with rheumatoid arthritis and systemic lupus and other connective tissue disorders.
  • Rheumatoid factor can be present in 60-70% of people with rheumatoid arthritis.
  • Anti-CCP (anti-cyclic citrullinated peptide) antibodies are found in 80% of people with rheumatoid arthritis, and should be considered in people who are negative for rheumatoid factor.
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12
Q

DMARDs for Rheumatoid Arthritis

A
  • include methotrxate, sulfasalazine, hydroxychloroquine, leflunomide, azathiprine, and cyclosporine
  • usually initiated in secondary care under specialist supervision
  • stable on treatment, his or her primary care clinician may be asked to continue the ongoing drug monitoring
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13
Q

Extra-articular features of Rheumatoid Arthritis

A
  • vasculitis
  • skin rashes
  • skin nodules
  • eyes (scleritis, episcleritis, keratoconjunctivitis sicca)
  • heart (pericarditis)
  • lungs (pulmonary fibrosis, interstitial lung disease)
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14
Q

Steroids for Rheumatoid Arthritis

A
  • naproxen to treat inflammatory symptoms of Rheumatoid Arthritis
  • Glucocorticoids (such as Prednisolone) can be used in the short-term when patients are being started on DMARDs. The aim of this is to give symptomatic relief until DMARDs take effect.
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15
Q

What is in an annual review for Rheumatoid Arthritis in primary care?

A
  • Assessment of any flares – treatment, need for referral etc.
  • Ensuring patient is aware of how and when to access specialist help – e.g. rheumatology specialist nurse, physiotherapist, OT etc.
  • Drug monitoring – especially blood tests for DMARDs, ensure safe prescribing etc.
  • Assessing disease activity and damage, and screen for extra-articular complications – clinician may want to use health assessment questionnaires here.
  • Screen for co-morbidities – hypertension, osteoporosis, depression, ischaemic heart disease – using tools such as QRISK2 and FRAX score etc.
  • Health promotion – smoking cessation, encouraging exercise where possible, advice on healthy diet etc.
  • Offer vaccinations – pneumococcal and yearly influenza vaccination
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16
Q

What is Irritable Bowel Syndrome?

A

Irritable bowel syndrome (IBS) should be considered as a possibility in patients who have either abdominal pain or bloating or change in bowel habit for a minimum of six months.

A diagnosis can be made if abdominal pain is associated with:

  • defecation and/or increase or decrease in stool frequency and/or change in stool form and there is at least two of the following:
    • altered stool passage
    • abdominal bloating/distention or hardness
    • rectal mucus
    • symptoms worse when ingesting food
  • Patients with IBS can also suffer with:
    • lethargy
    • back pain
    • headaches
    • nausea
    • bladder complaints
    • sexual complaints such as dyspareunia (painful sex)
    • faecal soiling
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17
Q

Investigations if you suspect patients have IBS

A
  • Tests are not used to confirm a diagnosis of IBS, however are used more to exclude other differentials.
  • The following should be considered as part of initial investigations:
    • Full blood count – to exclude anaemia, markers such as white cell counts and platelet count can give ideas about whether there is any active inflammation.
    • Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) – if these are raised, you should consider infection or active inflammation as other diagnoses.
    • Coeliac serology – to exclude coeliac disease
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18
Q

What particular food components should patients with IBS avoid?

A
  • Reducing fructose will help reduce diarrhoea predominant symptoms.
  • If not well absorbed by the bowel, fructose can contribute to osmotic diarrhoea and increased flatulence.
  • In these patients, limiting fruit intake would be something worth trying.
  • They should be advised to have no more than three portions a day (a portion being 80g or the amount that would fit in the patient’s palm) and to limit fruit juice intake to one small glass a day.
  • Honey and processed foods containing high fructose corn syrup or its equivalent may need to be avoided as well.
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19
Q

What drugs are associated with dyspepsia as a GI side effect?

A
  • calcium antagonists
  • nitrates
  • theophyllines
  • bisphosphonates
  • corticosteroids
  • NSAIDs
  • alpha-blockers
  • anticholinergics
  • aspirin
  • benzodiazepines
  • beta-blocker
  • tricyclic antidepressants.
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20
Q

What is Tennis Elbow?

A

affects the Extensor muscle attachment into the lateral epicondyle of the humerus

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21
Q

What is golfer’s elbow?

A

common flexor tendon insertion is involved (MEDIAL epicondylitis)

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22
Q

What are the features of Tennis Elbow?

A

– localised point tenderness on palpation over and/or distal to the lateral epicondyle

– Painful Resisted Middle Finger Extension Muscle Test

– Weakened Grip Strength

– Full Active and Passive Elbow ROM

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23
Q

What is the management of Tennis Elbow?

A

– Modification of Activities in the short term

– Simple Exercises (eg Arthritis Research UK)

– Elbow Brace/Strap

– Physiotherapy

– Corticosteroid Injection

– Occupational Health Review

– Analgesia

Persisting pain beyond 6-12 months –> Surgical treatments such as open or arthroscopic debridement of tendinosis and/or release or repair of the damaged extensor tendon insertion may be considered.

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24
Q

Most suitable test to investigate a potential food allergy

A

Skin prick test

  • . Drops of diluted allergen are placed on the skin after which the skin is pierced using a needle.
  • A large number of allergens can be tested in one session.
  • Normally includes a histamine (positive) and sterile water (negative) control.
  • A wheal will typically develop if a patient has an allergy. Can be interpreted after 15 minutes

Useful for food allergies and also pollen

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25
Q

PAD management

A
  • Statin
  • Clopidogrel
  • Exercise training

Severe PAD or critical limb ischaemia may be treated by:

  • angioplasty
  • stenting
  • bypass surgery

Amputation reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty or bypass surgery.

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26
Q

How should you stop a SSRI like citalopram when a patient is feeling better from their depression?

A

Withdraw gradually over 4 weeks unless it is fluoxetine

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27
Q

When should SSRIs be stopped?

A
  • increased mood change
  • restlessness
  • difficulty sleeping
  • unsteadiness
  • sweating
  • gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
  • paraesthesia
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28
Q

SSRIs and pregnancy

A
  • BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
  • Use during the first trimester gives a small increased risk of congenital heart defects
  • Use during the third trimester can result in persistent pulmonary hypertension of the newborn
  • Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
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29
Q

What is Herpes Zoster Opthalmicus?

A
  • reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve
  • accounts for around 10% of cases of shingles
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30
Q

What are some characteristic features of Herpes Zoster Opthalmicus?

A
  • vesicular rash around the eye, which may or may not involve the actual eye itself
  • Hutchinson’s sign: rash on the tip or side of the nose. Indicates nasociliary involvement and is a strong risk factor for ocular involvement
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31
Q

Management of Herpes Zoster Opthalmicus

A
  • oral antiviral treatment for 7-10 days
    • ideally started within 72 hours
    • intravenous antivirals may be given for very severe infection or if the patient is immunocompromised
    • topical antiviral treatment is not given in HZO
  • topical corticosteroids may be used to treat any secondary inflammation of the eye
  • ocular involvement requires urgent ophthalmology review
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32
Q

What are some complications of Herpes Zoster Opthalmicus?

A
  • ocular: conjunctivitis, keratitis, episcleritis, anterior uveitis
  • ptosis
  • post-herpetic neuralgia
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33
Q
  • Lump in scalp
  • Slightly fluctuant
  • Smooth
  • Centrally located epithelial defect- punctum
A
  • Sebaceous cyst
    • Epidermoid cyst
      • proliferation of epidermal cells within the dermis.
    • Pilar cysts (also known as trichilemmal cysts or wen)
      • derive from the outer root sheath of the hair follicle.
  • Location: anywhere but most common scalp, ears, back, face, and upper arm (not palms of the hands and soles of the feet)
  • typically contain a punctum
  • Excision of the cyst wall needs to be complete to prevent recurrence.
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34
Q

What is malignant hyperthermia?

A
  • Malignant hyperthermia (MH) is an autosomal dominant disorder presenting as a hypermetabolic crisis characterised by:
    • an increased end-tidal carbon dioxide [ETCO2] (hypercapnia)
    • tachycardia
    • muscle rigidity
    • rhabdomyolysis
    • hyperthermia
    • arrhythmia
  • associated with volatile inhalational anaesthetic agents and the muscle relaxant succinylcholine (suxamethonium).
  • Dantrolene is the only available specific and effective treatment for MH and should be administered intravenously.
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35
Q

Neuromuscular blocking drugs

A
  • 2 types: Depolarising and Non-depolarising

Depolarising

  • Binds to nicotinic acetylcholine receptors resulting in persistent depolarization of the motor end plate e.g. suxamethonium
  • The muscle relaxant of choice for rapid sequence induction for intubation
  • May cause fasciculations
  • Adverse effects:
    • Malignant hyperthermia
    • Hyperkalaemia (normally transient)
  • contraindicated for patients with penetrating eye injuries or acute narrow-angle glaucoma, as suxamethonium increases intra-ocular pressure

Non-Depolarising

  • Competitive antagonist of nicotinic acetylcholine receptors e.g. Tubcurarine, atracurium, vecuronium, pancuronium
  • Adverse effect: hypotension
  • Reversal: Acetylcholinesterase inhibitors (e.g. neostigmine)
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36
Q

If a patient has attempted suicide, what factors are linked to an increased risk of suicide at a later date?

A
  • efforts to avoid discovery
  • planning
  • leaving a written note
  • final acts such as sorting out finances
  • violent method
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37
Q

What is oligohydramnios and what are potential causes of oligohydramnios?

A
  • less than 500ml at 32-36 weeks
  • amniotic fluid index (AFI) < 5th percentile
  • Causes
    • premature rupture of membranes
    • fetal renal problems e.g. renal agenesis
    • intrauterine growth restriction
    • post-term gestation
    • pre-eclampsia
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38
Q

Blood pressure classification

A
  • Stage 1 hypertension
    • Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
  • Stage 2 hypertension
    • Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
  • Severe hypertension
    • Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg
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39
Q

When to offer treatment in hypertension?

A
  • in 2019, NICE made a further recommendation, suggesting that we should ‘consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. ‘. This seems to be due to evidence that QRISK may underestimate the lifetime probability of developing cardiovascular disease
  • For patients < 40 years consider specialist referral to exclude secondary causes
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40
Q

What drugs to prescribe for what patients with hypertension?

A

Step 1 treatment

  • patients < 55-years-old or a background of type 2 diabetes mellitus: ACE inhibitor or a Angiotension receptor blocker (ACE-i or ARB): (A)
    • angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough)
  • patients >= 55-years-old or of Afro-Caribbean origin: Calcium channel blocker (C)
    • ACE inhibitors have reduced efficacy in patients of Afro-Caribbean origin are therefore not used first-line

Step 2 treatment

  • if already taking an ACE-i or ARB add a Calcium channel blocker or a thiazide-like Diuretic
  • if already taking a Calcium channel blocker add an ACE-i or ARB
    • for patients of Afro-Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor
  • (A + C) or (A + D)

Step 3 treatment

  • add a third drug to make, i.e.:
    • if already taking an (A + C) then add a D
    • if already (A + D) then add a C
  • (A + C + D)

Step 4 treatment

  • NICE define step 4 as resistant hypertension and suggest either adding a 4th drug or seeking specialist advice
  • first, check for:
    • confirm elevated clinic BP with ABPM or HBPM
    • assess for postural hypotension.
    • discuss adherence
  • if potassium < 4.5 mmol/l add low-dose spironolactone
  • if potassium > 4.5 mmol/l add an alpha- or beta-blocker

Patients who fail to respond to step 4 measures should be referred to a specialist.

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41
Q

What are blood pressure targets for those younger than 80 and those over the age of 80?

A

Age < 80 years

  • Clinic BP: 140/90 mmHg
  • ABPM/HBPM: 135/85 mmHg

Age > 80 years

  • Clinic BP: 150/90 mmHg
  • ABPM/HBPM: 145/85 mmHg
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42
Q

Patau syndrome (trisomy 13) clinical features

A

Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions

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43
Q

Edward’s syndrome (trisomy 18) clinical features

A

Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers

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44
Q

Fragile X Clinical Features

A
  • Learning difficulties- associated with ADHD
  • Macrocephaly
  • Long thin face
  • Large low set ears
  • Recurrent otitis media
  • High arched palate
  • Macro-orchidism
  • Hypotonia
  • Autism is more common
  • Mitral valve prolapse

Most commonly presents at puberty

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45
Q

Diagnosis of Fragile X

A
  • can be made antenatally by chorionic villus sampling or amniocentesis
  • analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot analysis
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46
Q

Noonan syndrome clinical features

A

Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis

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47
Q

Pierre-Robin syndrome clinical features

A

Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate

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48
Q

Prader-Willi syndrome Clinical Features

A

Hypotonia
Hypogonadism
Obesity

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49
Q

William’s syndrome

A

Short stature
Learning difficulties
Friendly, extrovert personality
Transient neonatal hypercalcaemia
Supravalvular aortic stenosis

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50
Q

Cri du chat syndrome (chromosome 5p deletion syndrome)

A

Characteristic cry (hence the name) due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism

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51
Q

Most common cause of nephrotic syndrome in children

A

Minimal Change Disease

Responds well to steroids

Nephrotic syndrome is classically defined as a triad of

  1. proteinuria (> 1 g/m^2 per 24 hours)
  2. hypoalbuminaemia (< 25 g/l)
  3. oedema

Other features include hyperlipidaemia, a hypercoagulable state (due to loss of antithrombin III) and a predisposition to infection (due to loss of immunoglobulins)

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52
Q

What electrolyte disturbances can Anorexia Nervosa cause?

A
  • low sodium (hyponatraemia) from excess water intake
  • low potassium (hypokalaemia) from vomiting and laxative abuse
  • low blood glucose
  • low serum cholesterol
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53
Q

3 main diagnostic features of Anorexia Nervosa

A
  • A Body Mass Index less than 17.5Kgm/m²
  • Amenorrhoea (defined as having missed at least 3 consecutive periods)
  • A distorted perception of body image
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54
Q

Ddx of a maculopapular rash in a child

A
  • Parvovirus B19 infection
  • Drug hypersensitivity
  • Measles
  • EBV virus
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55
Q

Maculopapular rash, beginning behind the ears and spreading to involve the trunk with associated symptoms

A

Pathognomonic of measles especially in non-immunised children

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56
Q

Characteristic features of measles

A
  • High fever- 39 degrees
  • Koplik spots
    • ​ tiny white/grey spots that can appear in the mucous membrane of the mouth just around the molar teeth.
  • Coryza
  • Maculopapular rash
  • Cough
  • Irritability
  • Red eyes
  • Poor appetite
  • incubation period of 10 to 12 days
  • infection occurs by droplets from the mouth or nose
  • infectious from four days before the onset of the rash until five days after it appears.
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57
Q

Complications of measles

A
  • Acute encephalitis
  • Subacute sclerosing panencephalitis (SSPE)
    • from persistent measles infection
    • behavioural and intellectual deterioration and seizures years after an acute infection
  • Transient hepatitis may occur during an acute infection
  • otitis media
  • bronchopneumonia
  • laryngotracheobronchitis (croup)
  • diarrhoea
  • infection during pregnancy –> miscarriage/ stillbirth
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58
Q

Investigation and Management of a case of suspected/ confirmed measles

A
  • The local Health Protection Team should be immediately notified
  • The HPT should give you a testing kit and a testing schedule to confirm the case – this will require an oral sample from the patient to test for IgM/IgG/RNA testing.
  • If the patient is younger than one, pregnant or immunocompromised – you must seek advice from the HPT about any additional measures/treatment to be given.
  • Advice to give to patients:
    • self-limiting condition which can cause unpleasant symptoms such as rash, fever and cough. These will usually resolve over in about a week
    • rest, drink adequate fluids, and take paracetamol or ibuprofen for symptomatic relief
    • keep away from school or work for at least 4 days after the initial development of the rash (ideally until full recovery)
    • patients should be advised to stay away from other susceptible individuals – i.e. pregnant women, children etc
    • seek urgent medical attention if there are any complications or they are not feeling any better/getting worse
    • face to face appointment not necessary –> telephone appointments may be offered instead
    • Encourage recovered patients to complete any vaccinations that they may have missed
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59
Q

Guidelines for drinking alcohol by CMO

A

The Chief Medical Officers (CMO) guidelines (2016) for both men and women recommend:

  • To drink no more than 14 units a week on a regular basis.
  • To spread your drinking evenly over three or more days if you do drink 14 units of alcohol a week. One or two heavy drinking episodes a week can increase your risk of death from long-term illness and injuries.
  • The risk of developing a range of health problems (including cancers of the mouth, throat and breast) increases the more you drink on a regular basis.
  • A good way to reduce your alcohol intake is to have several drink-free days a week.
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60
Q

What are some signs of potential alcohol dependence?

A
  • Often have a strong desire to drink alcohol and need a drink every day
  • Often drink alone
  • Need a drink to stop trembling (the shakes – sign of withdrawal)
  • Drink early, or first thing in the morning (to avoid withdrawal symptoms)
  • Spend a lot of time in activities where alcohol is available. For example, spending a lot of time at the social club or pub
  • Neglect other interests or pleasures because of alcohol drinking
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61
Q

CAGE questionnaire to screen for alcoholism

A
  • have you ever felt you should CUT down your drinking?
  • have people ANNOYED you by criticising your drinking?
  • have you ever felt bad or GUILTY about your drinking?
  • have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE- opener)?
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62
Q

What are some medical complications of alcohol abuse?

A
  • Liver cirrhosis
  • Portal hypertension
  • Oesophageal varices
  • Liver failure
  • Depression
  • Suicide
  • Pancreatitis
  • Cardiomyopathy
  • Brain damage/atrophy
  • Delirium tremens
  • Erectile dysfunction
  • Fetal alcohol syndrome in the offspring of alcoholic women
  • Increased incidence of cancer
  • Insomnia
  • Nutritional deficiencies (eg thiamine)
  • Wernicke-Korsakoff syndrome (due to thiamine deficiency)
  • Peripheral neuropathy (due to thiamine deficiency)
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63
Q

What is failure to thrive?

A

Failure to thrive is generally considered to be present when height or weight measurements have fallen by at least 2 centile lines on standard growth charts over a period of time.

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64
Q

What features of the history are pertinent to babies that are ‘failing to thrive’?

A
  • Maternal smoking
  • Maternal illness during pregnancy
  • Use of medications during pregnancy
  • Relationship of symptoms to mealtimes
    • Many cases of failure to thrive are secondary to food intolerances, e.g. cow’s milk, wheat, nuts, soya. A careful history is invaluable in establishing the associated symptoms such as colic, diarrhoea, vomiting etc when certain foods are given.
  • Breastfeeding Hx
    • A sudden drop in weight after weaning from breast milk should alert the doctor to consider a food intolerance as the cause.
  • Inadequate Diet
    • ​improper preparation of formula milk - patient education needed
  • Ethnic origin
    • standard UK growth charts are based on UK children, whereas Asian children are genetically smaller on average.
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65
Q

As part of your assessment of the infant, you perform a physical examination. What are the essential components of a physical examination in a malnourished infant?

A
  • Take serial measurements of height, weight and head circumference in all children and record this in the child’s red book
  • Important physical signs to elicit in malnutrition are:
    • Oedema
    • Muscle wasting
    • Hepatomegaly
    • Rash or skin changes
    • Hair colour and texture changes
    • Mental state changes
    • Signs of vitamin deficiency
  • As the important differential is weight loss from dehydration, the relevant physical signs should also be distinguished:
    • Decreased skin turgor
    • Depressed sensory awareness
    • Sunken anterior fontanelle
    • Dry mucous membranes
    • Absence of tears
    • Acutely ill appearance
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66
Q

What type of vaccine is MMR

A

live, attenuated viruses

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67
Q

What type of vaccine are flu and hepatitis A?

A

killed vaccines

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68
Q

What type of vaccines are diphtheria and tetanus?

A

toxoids

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69
Q

What type of vaccine is Hepatitis B?

A

subunit vaccine

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70
Q

What type of vaccine is HiB vaccine?

A

conjugate

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71
Q

Complications of MMR vaccine

A
  • Some 10% of children develop fever, malaise or a rash classically 5-21 days after the vaccination.
  • Up to 5% may develop non-specific joint pains.
  • Anaphylaxis is extremely rare and may occur with any live vaccine.
  • There is no validated evidence on a confirmed link between autism and the MMR vaccine.
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72
Q

UKMEC guidelines for prescribing contraception

A
  • UKMEC guidelines are used to determine the risks and benefit in prescribing or giving hormonal and intrauterine contraception in women.
  • Category 1
    • ​A condition for which there is no restriction for the use of the method
    • Having varicose veins is given category 1 for both the COCP and progesterone only pill (POP).
    • Also having mild cirrhosis without complications is also given category 1 for both the COCP and the POP
  • Category 2
    • A condition where the advantages of using the method generally outweigh the theoretical or proven risks
  • Category 3
    • A condition where the theoretical or proven risks usually outweigh the advantages of using the method.
    • The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable
  • Category 4
    • A condition which represents an unacceptable health risk if the method is used
    • Women who are 35 years of age or older and who smoke 15 or more cigarettes a day have category 4 for combined oral contraceptive pill (COCP).
    • Women who are breastfeeding for 0 to 6 weeks postpartum have category 4 for COCP.
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73
Q

UKMEC guidelines for prescribing COCP- categories 1 and 2

A
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74
Q

UKMEC guidelines for prescribing COCP- categories 3 and 4

A
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75
Q

Contraindications of COCP

A
  • Pregnancy
  • migraines with aura
  • decompensated liver disease
  • positive anti-phospholipid antibodies
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76
Q

Side effects of COCP

A

Side effects associated with oestrogen may include:

  • Fluid retention
  • Headache
  • Nausea and vomiting
  • Venous thrombosis
  • Increased cervical secretion / cervical erosion

Those associated with progestogen may include:

  • Breast fullness
  • Decreased libido
  • Dry vagina
  • Reduced menstrual flow
  • Disturbance in menstrual cycle
  • Acne
  • Premenstrual depression
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77
Q

Smoking withdrawal symptoms

A
  • irritability/aggression
  • depression
  • restlessness
  • poor concentration
  • increased appetite
  • light-headedness
  • disturbed sleep
  • nicotine cravings.
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78
Q

As his GP, what conservative measures would be appropriate to advise this patient to do whilst trying to quit smoking?

A
  • Write a list of reasons why you want to stop
  • Set a date for stopping and stop completely
    • ​this is usually the best way as patients who cut down their smoking usually smoke more per cigarette.
  • Tell everyone that you are giving up smoking so that they are aware
  • Get rid of ashtrays, lighters and cigarettes
  • Be prepared for smoke withdrawal symptoms
  • Anticipate a cough
  • Be positive and take each day as it comes
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79
Q

What can be prescribed to assist patients in giving up smoking?

A
  • Bupropion should be started while the person is still smoking, and they should be advised to stop smoking 7–14 days after initiating the medication.
  • The dose of bupropion is 150 mg once a day for 6 days, increasing to 150 mg twice a day for a total of 7–9 weeks. A lower dose should be used in the elderly, patients who have mild to moderate liver impairment and renal impairment where GFR is less than 50 mL/min.
  • Contraindications to prescribing bupropion include:
    • current seizures
    • a history of seizure
    • a central nervous system tumour
    • severe hepatic cirrhosis
    • if there is a history of bipolar disorder, anorexia nervosa or bulimia.
80
Q

What is Reiter’s Syndrome or Reactive Arthritis characterised by?

A

Reiter’s syndrome, also known as reactive arthritis, is the classic triad of conjunctivitis, urethritis, and arthritis occurring after an infection

81
Q

Immediate course of action after a diagnosis of Reactive arthritis

A
  • The underlying organism must be identified if possible. The GUM clinic screen is vital for Chlamydia and gonococcus.
    • Gonococcus may cause a reactive arthritis but may also cause a septic arthritis and therefore, fluid should be aspirated from the affected joint and sent for culture.
  • ​Antibiotics should NOT be prescribed until the trigger organism has been identified unless there is evidence of septicaemia or septic arthritis.
  • High dose oral steroids are contra-indicated as they might obscure the underlying infection and reduce the innate immune response.
  • Check HLA B27- Being HLA B27 positive is a poor prognostic marker in acute reactive arthritis.
82
Q

How to treat reactive arthritis caused by Chlamydia?

A
  • Doxycycline PO
  • Oral NSAIDs for acute pain
  • Once there is clear evidence that the joint is not infected, intra-articular steroids may be the treatment of choice to reduce the acute pain and inflammation in the joint.
83
Q

Characteristic symptoms of depression

A
  • patient has felt down, depressed or hopeless
  • have little interest in activities
  • low energy
  • poor concentration
  • feelings of guilt
  • suicidal ideas
  • recurrent thoughts of death
  • low libido
  • poor motivation
  • poor sleep or excessive sleep
  • physical symptoms (such as headache, palpitations and aching limbs).
84
Q

Do you prescribe antidepressants in moderate depression?

A
  • In moderate depression, offer antidepressant medication to all patients routinely.
  • Make sure to explain that craving and tolerance do not occur with antidepressant medication
  • See all patients younger than 30 years old 1 week after starting treatment
  • Continue antidepressants for at least 6 months after remission
  • If second episode of depression, continue antidepressants for at least 2 years following remission
85
Q

When assessing suicidal risk, what elements are important to ask and know about?

A
  • Do you ever feel that life is not worth living?
  • Do you think about ending your life?
  • Have you made any plans?
  • Have you got means to go through with your plan?
  • Have there been any previous suicidal attempts?
  • Have they made preparations by buying and stock piling medication?
  • Have they written a final note?
  • Is there anything that is stopping them from going through with any attempts?

Risk factors for suicide

  • being male
  • young age <30
  • elderly
  • previous attempts
  • family history of suicide
  • lives alone
  • absent or inadequate support network
  • alcohol/drug abuse
  • recent initiation of antidepressants.
86
Q

What is haematospermia?

A

Haematospermia refers to the presence of blood in the ejaculate. It is typically a benign, self-limiting symptom and the cause of the symptom is often not identified.

87
Q

Causes of haematospermia

A
  • If painful –> inflammation: prostatitis or urethritis
  • prostate malignancy esp in older men
  • prostate biopsy
  • perineal trauma
  • urinary tract calculi
  • chlamydia
  • infection with schistosomiasis
  • severe hypertension
88
Q

Investigations for haematospermia

A
  • Urinalysis
    • ​differentiate between haematospermia and haematuria.
  • Serum PSA
    • ​a non-specific marker of prostatic inflammation and is often elevated alongside prostatitis and prostate malignancy.
    • PSA is a sensitive test for prostate malignancy however it is not very specific as PSA level can be elevated by many other factors including recent intercourse or PR examination.
      • It is therefore good practice to measure serum PSA level prior to performing a PR examination to minimise the risk of finding a falsely elevated PSA level.
  • PR examination is important to feel the prostate for signs of cancer, particularly in older males and those with risk factors for prostatic malignancy.
    • The prostate may be enlarged and tender in chronic prostatitis.
  • NICE guidelines recommend recording blood pressure as severe hypertension is a recognised cause of haematospermia.
  • Chlamydia testing is available in primary care, and should be undertaken particular if any suspicions of sexually transmitted diseases.
89
Q

When would you refer a patient with haematospermia to urology?

A
  • All men aged over 40 years with no identifiable cause for haematospermia found in primary care.
  • Men of any age with signs and symptoms suggestive of prostate cancer (such as elevated PSA levels, suspicious findings on digital rectal examination), and men or boys with signs or symptoms suggestive of testicular or urological malignancies.
    • Urgent referral is required in these cases.
  • Men and boys of any age who have experienced more than ten episodes of haematospermia, with no identifiable cause found in primary care.
  • Men and boys where initial investigations have suggested that the underlying cause of haematospermia may be cysts or calculi of the prostate or seminal vesicles.
  • Men and boys who continue to experience haematospermia despite treatment of a suspected underlying cause identified in primary care.
90
Q

Chicken pox rash

A
  • classic pustular rash of chickenpox, which develops following a few days of mild flu-like symptoms.
  • Other symptoms include nausea, muscle aches, loss of appetite and headaches.
91
Q

How long is the patient infectious for in chickenpox?

A
  • The infection may spread from about 2 days before the appearance of the rash
  • The patient is infectious for roughly 5-7 days after the appearance of the rash
  • There is a danger of infection spread until the last lesions have burst and crusted over
92
Q

Why aspirin should not be given to children below the age of 16?

A
  • can cause Reye’s syndrome
  • liver damage, brain damage and death

Initial symptoms can include:

  • repeatedly being sick
  • tiredness and lack of interest or enthusiasm
  • rapid breathing
  • seizures (fits)

As the condition progresses, the symptoms may get more severe and more wide-ranging, and can include:

  • irritability, or irrational or aggressive behaviour
  • severe anxiety and confusion that’s sometimes associated with hallucinations
  • coma (loss of consciousness)
93
Q

Complications of chicken pox

A
  1. Secondary infection of lesions
  2. Secondary infection from group A streptococcal – this can cause serious complications such as necrotising fasciitis
  3. Encephalitis is a rare but serious complication – presentation includes irritability, confusion, drowsiness, neck stiffness etc.
  4. Cerebellar ataxia can occur in the recovery phase or later.
  5. Pneumonia – this can be severe and presents with chest pain, breathing difficulties and wheezing.
  6. Myocarditis
  7. Transient Arthritis
94
Q

Different forms of psoriasis

A
  • Plaque psoriasis
    • most common, affecting 75 to 90% of people with psoriasis.
    • Plaques are patches of various sizes of red skin with white scales and can be very thick, particularly in the scalp area.
  • Pustular psoriasis
    • when psoriasis presents with small fluid filled pustules.
    • It can be localised (commonly affecting hands and feet), or generalised.
    • Generalised pustular psoriasis is a medical emergency as it can be fatal.
      • Here, you have widespread erythema and non-follicular pustules which can coalesce. The patient often has fever, malaise, a raised heart rate and is systemically unwell. They should be immediately referred and managed in secondary care.
  • Guttate psoriasis
    • most of the body is usually covered with multiple tiny teardrop-like psoriatic patches.
    • It often follows a bacterial throat infection.
  • Flexural psoriasis
    • red and shiny, due to the moist nature of the skin in the flexural areas.
    • It affects areas such as the groin, axillae, inframammary folds etc.
  • Erythrodermic psoriasis
    • presents with widespread painful red skin – severe psoriasis with more than 90% of the body affected.
    • It is a serious condition and is potentially life threatening – It requires immediate referral and treatment in secondary care.
95
Q

Factors that exacerbate psoriasis

A
  • Bacterial (streptococcal) and fungal infection may precipitate psoriasis.
  • Lithium, beta-blockers, anti-malarials, ACE inhibitors and withdrawal of steroids may also cause a flare-up.
  • Psoriasis may appear in the site of a recent skin injury.
  • Stress
  • Smoking and alcohol
  • Ultraviolet light is usually beneficial except in cases of photosensitive psoriasis.
  • Additionally, hormonal changes can affect psoriasis as well – female patients may find it is worse during puberty and menopause, and improves during pregnancy.
96
Q

Treatment of psoriasis in primary care

A
  • Moisturisers soften the plaques.
  • Salicylic acid helps to lift off the scales and is often used in combination with other preparations such as coal tar and topical steroids.
  • Vitamin D based creams such as calcipotriol work well on plaque psoriasis – they are easy to use and are often the treatment of choice.
  • Topical steroids have to be used with caution and for a short period of time. When stopped, they may cause a rebound flare-up. They are useful in combination with other preparations (calcipotriol)

PUVA-oral psoralen and ultraviolet light is used by dermatologists for severe psoriasis. Drugs which affect immune response are used for severe cases. They include methotrexate and anti-TNF drugs such as Etanercept.

97
Q

Treatment of warts in children

A
  • Salicylic acid
    • not be used for facial warts as it can cause skin irritation and scarring
    • before applying the salicylic acid, you should rub off any dead tissue from the top of the wart and soak it in water for 5-10 minutes.
    • Salicylic acid needs to be applied every day and some cases may need to be continued for up to three months.
  • Duct tape occlusion therapy
    • ​warts are repeatedly covered by the tape for six days, soaked and filed
  • Cryotherapy
    • ​but can be painful- contraindicated in young children

Refer facial warts and treatment-resistant warts to the dermatologist

98
Q

What is the difference between septicaemia and bacteraemia

A

Bacteraemia- presence of bacteria in the blood

Septicaemia- multiplication of bacteria in the blood

99
Q

When you suspect that a patient has Meningitis septicaemia in GP what would you do?

A
  • Advising the patient to take himself to the ED immediately i.e. immediately dialing 999 from the surgery for an ambulance.
  • While waiting for the ambulance lying him down and give him high flow oxygen via a face mask
100
Q

Features of Infectious Mononucleosis

A
  • young age
  • symptoms of sore throat
  • reduced appetite and tiredness
  • palpable cervical lymph nodes (normally posterior in glandular fever compared to anterior cervical and submandibular in streptococcal sore throat)
  • palpable spleen
  • blood film showing atypical lymphocytosis
101
Q

Investigations in suspected infectious mononucleosis

A
  • Paul Bunnell test
  • Epstein-Barr viral serology
    • when rapid diagnosis is needed
  • Throat swab
    • Glandular fever can often cause a tonsillar exudate which can mimic a streptococcal sore throat.
    • Throat swab is indicated if there is a need to be certain that this is not a strepococcal throat infection.
102
Q

Treatment of infectious mononucleosis

A
  • Avoid amoxicillin/ ampicillin - causes maculopapular rash
  • Avoid close physical contact
  • Avoid contact sport until splenomegaly resolves due to risk of splenic rupture
  • Analgesia as needed
  • Alcohol worsens symptoms- avoid it
  • Follow-up to ensure resolution of acute symptoms
103
Q

Complications of infectious mononucleosis

A
  • Depression and lethargy are common and can last for months
  • Thrombocytopenia
  • Meningitis
  • Splenic rupture
104
Q

What is Pityriasis Rosea?

A
  • Pityriasis rosea describes an acute, self-limiting rash which tends to affect young adults.
  • The aetiology is not fully understood but is thought that herpes hominis virus 7 (HHV-7) may play a role.
  • Features
    • in the majority of patients there is no prodrome, but a minority may give a history of a recent viral infection
    • herald patch (usually on trunk)
    • followed by erythematous, oval, scaly patches which follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a ‘fir-tree’ appearance
  • Management
    • self-limiting - usually disappears after 6-12 weeks
105
Q

What causes PID?

A

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. It is usually the result of ascending infection from the endocervix.

Causative organisms

  • Chlamydia trachomatis- the most common cause
  • Neisseria gonorrhoeae
  • Mycoplasma genitalium
  • Mycoplasma hominis
106
Q

Features of PID

A
  • lower abdominal pain
  • fever
  • deep dyspareunia
  • dysuria and menstrual irregularities may occur
  • vaginal or cervical discharge
  • cervical excitation
    • unpleasant sensation or response elicited onpelvic examination with movement of the cervix by the clinician’s gloved hand, usually indicative of inflammatory processes in the pelvic organs
107
Q

Investigations needed for PID

A
  • a pregnancy test should be done to exclude an ectopic pregnancy
  • high vaginal swab
    • these are often negative so a low threshold for treatment is needed
  • screen for Chlamydia and Gonorrhoea
108
Q

Management of PID

A
  • due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
  • oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
  • RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ‘ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
109
Q

Complications of PID

A
  • perihepatitis (Fitz-Hugh Curtis Syndrome)
    • occurs in around 10% of cases
  • it is characterised by right upper quadrant pain and may be confused with cholecystitis
  • infertility - the risk may be as high as 10-20% after a single episode
  • chronic pelvic pain
  • ectopic pregnancy
110
Q

Risks of HRT

A
  • Increased incidence of endometrial cancer
  • Increased incidence of breast cancer
  • Increased incidence of VTE
111
Q

Absolute contraindications of starting HRT

A
  • undiagnosed vaginal bleeding
  • severe liver disease
  • pregnancy
  • venous thrombosis
  • personal history of breast cancer
112
Q

What is stress incontinence?

A

Leakage of small drops of urine on coughing, sneezing, exertion, moving and laughing

113
Q

What is Urgency incontinence?

A

Leakage of, usually large volume, of urine whilst trying to get to the toilet to pass urine with an urgent need to do so

114
Q

What is true incontinence of urine?

A

Often reserved for urinary fistula, when there is constant involuntary loss of urine that is not particularly related to specific activity.

115
Q

If pelvic floor muscle training fails in a patient with stress incontinence, what surgical options are available to her?

A
  • Urethral bulking agent
    • injecting a bulking agent into the wall of your urethra (waterpipe) using a small telescope
    • The bulking agent helps the urethra to make a watertight seal and to hold urine inside your bladder.
  • Mid-urethral slings
    • placing a tape underneath the urethra
    • sling supports your urethra when you laugh, sneeze, cough or are physically active and so prevents urine leaking from your bladder
  • Burch colposuspension
    • The goal of the Burch colposuspension procedure is to suspend and stabilize the urethra so that the urethrovesical junction (UVJ) and proximal urethra are replaced intra-abdominally.
    • This anatomic placement allows normal pressure transmission during periods of increased intra-abdominal pressure restoring continence in a previously incontinent, hypermobile UVJ.​
116
Q

What is the first most appropriate investigation for urgency incontinence?

A
  • Frequency volume chart
    • frequency of micturition
    • volume of micturition
    • nature, volume and timing of fluid intake
  • After this -> urodynamic assessment
117
Q

Patient with urgency incontinence:

A frequency volume chart showed the patient to be passing urine 12 times by day, drinking mainly tea and coffee with an average total fluid intake of 1050ml/day. How should the patient be managed?

A
  • Smoking cessation reduces bladder irritation that can cause overactive bladder symptoms.
  • The patient needs to increase her fluid intake to an average of 24ml/kg/day. Patients reduce their fluid intake to avoid having to go to the toilet and therefore reduce urinary urgency and urinary urgency incontinence episodes. However, reducing fluid intake leads to concentrated urine; which irritates the bladder and causes more overactive bladder symptoms. Excessive drinking on the other hand leads to the production of more urine, which in turn causes more urinary urgency and urgency incontinence episodes.
  • Excessive tea and coffee intake irritates the bladder leading to more urinary urgency and urgency incontinence episodes.
  • Bladder drill entails gradual delay of passing urine to enable the patient to regain control over her bladder and reduce both the frequency and urgency of micturition.
  • Local oestrogen can help in postmenopausal patients by improving atrophy in the bladder mucosa.

Nice guidelines recommend bladder training before considering medication.

118
Q

If conservative treatment for urgency incontinence like bladder does not work, what is the next best step?

A
  • FIRST LINE TREATMENT = anticholinergic/ antimuscaranics (oxybutinin)
    • have parasympatholytic properties
  • If this fails consider beta-3 adrenergic receptor agonist (mirabegron)
119
Q
A
120
Q

What is the commonest cause of vaginal discharge in a women of child-bearing age?

A

Bacterial vaginosis

  • caused by disruption to vaginal pH which is normally <4.5
  • pH elevated to >4.5 = lactobacilli deplete and anaerobes predominate:
    • Gardnerella vaginalis
    • Prevotella species
    • Mycoplasma hominis
    • Mobiluncus species
    • Atopobium vaginalis
  • Presentation
    • malodorous discharge “fishy”
    • not associated with itching or soring
    • 50% affected are asymptomatic
121
Q

What are the risk factors for BV?

A
  • Afro-Caribbean race
  • presence of another STI
  • “Douching”
  • using detergents to wash the genitals as these can disrupt the vaginal pH
  • new sexual partner
  • receptive cunnilingus
  • smoking
  • IUD use
122
Q

Investigations in suspected BV

A
  • Examination:
    • Visual inspection of the vulva, vagina and cervix (via speculum examination)
  • At the same time, a series of laboratory investigations will be performed.
    • BV is diagnosed via a Gram-stained vaginal smear.
      • The Hay/Ison criteria used to diagnose, which is a grading system looking at organism predominance in the vagina (lactobacillus vs anaerobic dominance).
  • BV can co-exist with other infections. She is sexually active and so is potentially at risk. If available to you, endocervical microscopy can be used to look for intra-cellular diplococci that would be consistent with Neisseria gonorrhoeae infection.
  • NAAT swabs should also be taken to rule out chlamydia and gonorrhoea.
  • A swab should be taken from the posterior fornix to rule out Trichomonas vaginalis.
123
Q

Treatment of BV

A
  • FIRST LINE TREATMENT = oral metronidazole 400mg BD orally for 5 days
    • advise against drinking alcohol during treatment AND 48 hours after completion of treatment
  • If allergic to metronidazole: Intravaginal Clindamycin cream (2%) OD for 7 days
124
Q

Risks for BV in pregnancy

A
  • Late miscarriage
  • Post-partum endometritis
  • Premature rupture of membranes
  • Pre-term birth
125
Q

Why should pregnant women/ lactating women be offered metronidazole 2g STAT/ oral clindamycin?

A

Metronidazole/ Clindamycin can enter breast milk and affect the taste so intravaginal preparations are preferred in lactating women

126
Q

Features of peri-tonsillar abscess/ quinsy

A

Features of Hx

  • preceded by sore throat and odynophagia
  • Trismus
    • inability to open mouth (lockjaw)
    • represent inflammation of the pterygoid muscles
    • consequence of abscess formation in the peritonsillar space

Features of examination

  • Abscesses typically collect supero-laterally to affected tonsil
    • As the abscess increases in size, the uvula is displaced to the contralateral side of the oropharynx - away from the site of. infection
  • A unilaterally enlarged tonsil, with or without exudate
  • A unilateral peritonsillar swelling with mucosal cellulitis​
  • Look out for signs of septic shock- high HR and hypotension
127
Q

Bilateral, exudative tonsillitis

A

Suggestive of Infectious mononucleosis caused by EBV

128
Q

Treatment of peri-tonsillar abscess

A
  • most likely caused by streptococcus
  • Benzylpenicillin
  • Anaerobe cover may be provided by Metronidazole
  • But abscesses are characterised by pseudomembranes, which prevent antibiotics from penetrating them effectively.
    • Mainstay Tx = Intra-oral incision and drainage of the peritonsillar space
    • Alternatively needle aspiration of the peritonsillar space
129
Q

Infectious Mononucleosis clinical presentation

A
  • bilateral
  • exudative tonsillitis
  • bilateral cervical adenopathy
  • fever and malaise
  • odynophagia/ dysphagia
130
Q

Treatment of Infectious Mononucleosis

A
  • Treatment is largely supportive with intravenous fluids and analgesia until the patient is able to manage oral intake.
  • Antibiotics are habitually prescribed, as secondary bacterial infections are common. (Penicillin)
  • Stat doses of corticosteroids reduce inpatient duration and improve symptoms, however, rebound deterioration following discontinuation is possible.
  • avoid contact sports for six weeks, as hepatitis and splenomegaly are associated with the condition and may predispose to hepatic/splenic haemorrhage if trauma were sustained
    • Request liver function tests while an inpatient and if abnormal, arrange for repeat testing via primary care in a number of weeks to ensure resolution.
131
Q

Clinical features of the 2 classifications of cow’s milk protein allergy

A

IgE-mediated

  • Rapid onset
  • Skin symptoms
    • Pruritis
    • Erythema
    • Acute urticaria- localised or generalised
    • Acute angioedema- lips, face, around eyes, tongue, palate
    • Atopic eczema
  • GI symptoms:
    • Nausea, vomiting
    • Colicky abdominal pain or discomfort
    • Blood in stools
    • Diarrhoea
  • Respiratory
    • LRT- cough, chest tightness, wheeze, SOB
    • URT- nasal itching, sneezing, rhinorrhoea, congestion

Non-IgE-mediated

  • Delayed onset
  • Skin symptoms
    • Pruritis
    • Erythema or flushing
    • Atopic eczema
  • GI symptoms:
    • GORD, vomiting
    • Loose and/or frequent stools
    • Blood and/or mucus in stools
    • Infantile colic, irritability
    • Food refusal or aversion
    • Constipation (especially soft stools with excessive straining)
    • Perianal redness
    • Pallor and tiredness
    • Faltering growth
  • Respiratory
    • LRT- cough, chest tightness, wheeze, SOB

Babies:

  • Wheezing
  • Irritability
  • Facial swelling
  • Poor growth
132
Q

How do you manage a cow’s milk protein allergy?

A
  • Consider referral to secondary care for a skin prick and/or specific IgE antibody blood test
  • Implement strict cow’s milk elimination diet for at least 6 months or until the child is 9-12 months
  • Breastfed babies- advise the mother to exclude cow’s milk protein from her diet. Consider prescribing daily supplement of 1000mg of calcium and 10μg of vitamin D
  • Formula-fed babies- advise replacement of cow’s milk-based formula with hypoallergenic infant formula (e.g. extensively hydrolysed formula or amino acid formula)
  • Weaned infants/ older children- exclude cow’s milk protein from their diet
  • Offer nutritional counselling with a paediatric dietician
  • Regularly monitor growth
  • Re-evaluate the child to assess for tolerance to cow’s milk protein (every 6-12 months)- this involves re-introducing cow’s milk protein into the diet
  • If tolerance is established, greater exposure of less processed milk is advised following a ‘Milk Ladder’
  • SUPPORT: British Dietic Association (BDA) has produced a useful factsheet
133
Q

When treating DKA with intravenous insulin in children what is the correct rate of soluble insulin infusion?

A

0.05 - 0.1 units/kg/hour

134
Q

Treatment of DKA in children

A
135
Q

What class of medicines used to treat hypertension are most likely to cause depression?

A

Beta-blockers

136
Q

First line medication treatment for depression

A

SSRIs

e.g. citalopram, fluoxetine, sertraline

137
Q

MOA of:

  • Venlafaxine
  • Moclobemide
  • Paroxetine
  • Dosulepin
A

Venlafaxine =SNRI

Moclobemide = RIMA (Reversible inhibitors of monoamine oxidase-A)

Paroxetine = SSRI

Dosulepin = TCA

138
Q

Why are TCAs not first-line treatment in depression?

A

Tricyclics should be used with caution where there is a risk of overdose because they are dangerous in overdose.

However, sertraline has a wider margin of safety in overdose than antidepressants from other classes

139
Q

Why is phenelzine not usually prescribed for depression?

A
  • dietary restrictions
    • risk of hypertensive crises if foods such as cheese and marmite are consumed
140
Q

What can sudden cessation of SSRIs cause?

A

Discontinuation syndrome

  • flu-like symptoms
  • dizziness
  • insomnia
  • nausea and vomiting
  • sweating
  • agitation
  • electric shock sensations
  • tinnitus
  • headaches
  • irritability
141
Q

Side-effects of SSRIs

A
  • dyspepsia
  • nausea
  • vomiting
  • diarrhoea
  • constipation
  • insomnia
  • increase suicidal behaviours and should be used with caution in children and young adults or those at risk of these behaviours already
  • SSRIs can cause hyponatraemia
142
Q

What is neuroleptic malignant syndrome?

A

Rare reaction to antipsychotics drugs that are used to conditions like Schizophrenia and Bipolar Disorder

  • Hyperthermia (> 38oC)
  • Generalised muscle rigidity
  • Altered level of consciousness
  • Autonomic instability

​Investigations:

↑CK (due to rhabdomyolysis), ↑WCC, ↑U&Es, ↑ ALT/AST

Treatment:

  • ABCDE
  • call ambulance (if on psych ward)
  • STOP antipsychotics
  • urgent medical help
  • supportive treatment
    • cool patient
    • IV fluids
    • dialysis
    • provide CV and respiratory support (ITU)
  • administer dantrolene or bromocriptine
  • symptoms resolve within 1-2 weeks
  • Death can occur- AKI secondary to rhabdomyolysis
143
Q

MOA of:

  • Mirtazapine
  • Reboxetine
  • Lofepramine
  • Trazadone
  • Duloxetine
A
  • Mirtazapine = Noradrenaline and specific serotonin antidepressant (NaSSA)
  • Reboxetine = Selective Noradrenaline reuptake inhibitor
  • Lofepramine= Tricyclic antidepressant
  • Trazadone = Tricyclic related antidepressant
  • Duloxetine = Serotonin and Noradrenaline reuptake inhibitor (SNRI)
144
Q

How should severe life-threatening depression, catatonia or prolonged maniac states be treated?

A

ECT- Electroconvulsive therapy

A typical course of ECT is between 6 and 12 treatments. ECT is usually administered twice a week. Patients are put under general anaesthesia and given muscle relaxant. Two ECT electrodes are placed on the head and current is used to induce a seizure.

145
Q

Side effects of ECT

A
  • amnesia - this can be retrograde or anterograde
  • headache
  • muscle aches and pains
146
Q

How can delirium be assessed?

A

CAM, 4AT or SQiD (Single Question in Delirium).

147
Q

Causes of delirium

A

PINCH ME (Pain, INfection, Constipation, deHydration, Medication, Environment)

148
Q

What strategies could be attempted to help manage the distress of this patient with Delirium?

A
  • Distraction- useful approach can be to find out what they are interested in and target the activities to their interests
  • Assessing for pain with Abbey pain scale
  • Speaking to relatives over the phone
149
Q

Drugs that can cause hyponatraemia

A
  • Carbamazepine
    • stimulates ADH secretion which can result in water retention in excess of sodium
  • SSRIs like citalopram
  • Thiazide and potassium-sparing diuretics like Indapamide and Spironolactone
    • cause renal tubular sodium loss
  • Excessive use of laxatives like Bisacodyl
    • excess sodium loss from the gut
  • Omeprazole
150
Q

What might precipitate delirium?

A
  • Alcohol excess
  • Codeine
  • Constipation
  • Malnutrition
  • Sepsis
151
Q

Features that support a diagnosis of Alzheimer’s Disease?

A
  • A gradually progressive course
  • Day-night reversal
  • Disorientation in time
  • Increasingly rigid daily routines
  • Problems with dressing
152
Q

Drugs that predispose to urinary retention

A
  • Amitriptyline
  • Autonomic neuropathy
  • Codeine
  • Constipation
  • Oxybutinin
153
Q

Treatment of Alzheimer’s Disease

A
  • Regular follow up with a specialist, such as a old age psychiatrist
  • 1st line for severe alzheimer’s = memantine
    • can be used in conjunction with a cholinesterase inhibitor
  • Treatment with a cholinesterase inhibitor
  • Time to talk through the diagnosis, prognosis and implications with a professional
  • Support in the community, such as carers, community psychiatric nurse involvement and day centre services should be considered based on the patient’s individual needs
154
Q

What needs to be done before cholinesterase inhibitors can be prescribed?

A

Cholinesterase inhibitors have been associated with peptic ulcer disease, can worsen asthma/COPD and worsen conduction abnormalities (sick sinus syndrome and supraventricular conduction abnormalities).

  • An ECG
  • Enquire about any history of peptic ulcer disease and dyspepsia
  • Enquire about any history of asthma
  • Enquire about any cardiac history, including arrhythmias
  • Discuss the risks and benefits with the patient and relative or carer
  • The likelihood of compliance with medication should be considered
155
Q

Preterm prelabour rupture of membranes PPROM

A
  • Rupture of membranes ≥ 24 weeks and < 37 weeks gestation
  • Presentation:
    • painless leakage of fluid from the vagina
    • initial gush
    • steady drip/ trickle
    • fluid = amniotic fluid
  • Complications of PPROM:
    • fetal: prematurity, infection, pulmonary hypoplasia
    • maternal: chorioamnionitis
  • Investigations:
    • sterile speculum examination
      • look for pooling of amniotic fluid in the posterior vaginal vault
    • ultrasound
      • ​oligohydramnios
  • Management
    • admission
    • regular observations to ensure chorioamnionitis is not developing
    • oral erythromycin should be given for 10 days
    • antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
    • delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
156
Q

Causes of snoring in children

A
  • obesity
  • nasal problems: polyps, deviated septum, hypertrophic nasal turbinates
  • recurrent tonsillitis
  • Down’s syndrome
  • hypothyroidism
157
Q

Ovarian cancer

A
  • Risk factors
    • family history: mutations of the BRCA1 or the BRCA2 gene
    • many ovulations: early menarche, late menopause, nulliparity
  • Clinical features
    • abdominal distension and bloating
    • abdominal and pelvic pain
    • urinary symptoms e.g. Urgency
    • early satiety
    • diarrhoea
  • Investigations
    • ​CA125
      • Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
      • if the CA125 > 35 IU/mL- urgent ultrasound scan of the abdomen and pelvis should be ordered
    • Ultrasound
    • diagnostic laparotomy
  • Management
    • usually a combination of surgery and platinum-based chemotherapy
  • Prognosis
    • 80% of women have advanced disease at presentation
    • the all stage 5-year survival is 46%
158
Q

Presentation of ovarian torsion

A
  • Presentation
    • iliac fossa pain that can radiate to the loin, groin or back
    • Onset may coincide with exercise.
    • N+V
    • low-grade fever esp if torsion has been happening for a long time - ovarian necrosis
    • Unilateral, tender adnexal mass on examination
159
Q

Presentation of ectopic pregnancy

A
  • A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
  • Shoulder tip pain and cervical excitation may be seen
160
Q

Presentation of miscarriage

A

Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea

161
Q

Presentation of Endometriosis

A
  • Chronic pelvic pain
  • Dysmenorrhoea - pain often starts days before bleeding
  • Deep dyspareunia
  • Subfertility
162
Q

Presentation of ovarian cyst

A
  • Unilateral dull ache which may be intermittent or only occur during intercourse.
  • Torsion or rupture may lead to severe abdominal pain
  • Large cysts may cause abdominal swelling or pressure effects on the bladder
163
Q

Presentation of urogenital prolapse

A
  • Seen in older women
  • Sensation of pressure, heaviness, ‘bearing-down’
  • Urinary symptoms: incontinence, frequency, urgency
164
Q

Causes of menorrhagia

A
  • dysfunctional uterine bleeding: this describes menorrhagia in the absence of underlying pathology. This accounts for approximately half of patients
  • anovulatory cycles: these are more common at the extremes of a women’s reproductive life
  • uterine fibroids
  • hypothyroidism
  • intrauterine devices
    • common with copper coils
    • menorrhagia is treated with intrauterine system (Mirena)
  • pelvic inflammatory disease
  • bleeding disorders e.g. von Willebrand disease
165
Q

Treatment of Eczema herpeticum

A
  • oral acyclovir
  • oral flucloxacillin- treat the secondary bacterial infection
  • stop topical steroids- prevents the spread of HSV infection
166
Q

Treatment of infected atopic eczema

A
  • Blood cultures
  • Skin swab
  • Oral flucloxacillin
  • Topical emollients
  • Topical moderate potency steroid ointment
  • Dermol 500
167
Q

Treatment of atopic eczema

A
  • Topical moderate steroid ointment (Eumovate)
  • Topical emollient ointment (Diprobase)
  • Dermol 500 for washing
168
Q

Ddx for hand dermatitis

A
  • Atopic eczema
  • Psoriasis
  • Irritant dermatitis
  • Pompholyx
  • Contact dermatitis
169
Q

Important questions in hand dermatitis

A
  1. Does the rash clear when you are on holiday?
  2. Is there a family history of eczema or psoriasis?
  3. Did you have eczema as a child?
  4. Do you wear gloves at work?
170
Q

What other areas of the body would you need to examine in hand dermatitis?

A
  • Psoriasis and eczema can affect the scalp and nails.
  • If the soles of the feet are also involved this suggests an endogenous cause rather than a contact or irritant dermatitis.
  • Mild psoriasis may present as scaling on the elbows and knees.
171
Q

Treatment of vitiligo

A
  • Cosmetic camouflage
  • Trial of potent topical steroid
  • Phototherapy
  • Topical Tacrolimus
  • Sunscreen
172
Q

Clinical features of acne

A
  • comedones
    • small ‘bumps’
    • open comedones are known as ‘blackheads’
  • pustules
    • ​comedones containing pus or fluid
  • papules
    • a raised skin of less than 1cm
  • nodules
    • a raised skin of more than 1cm
  • cysts
    • ​a fluid-filled sack.
173
Q

Treatment of acne

A
  • Topical Benzoyl peroxide and oral Lymecycline
  • Topical Adapalene and Dianette oral contraceptive
174
Q
A
175
Q

What are the recommended investigations for urinary incontinence?

A
  • bladder diaries should be completed for a minimum of 3 days
  • vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
  • urine dipstick and culture
  • urodynamic studies
176
Q

What is the recommended management for urge incontinence?

A
  • bladder retraining
    • lasts for a minimum of 6 weeks
    • the idea is to gradually increase the intervals between voiding
  • bladder stabilising drugs
    • antimuscarinics are first-line.
    • NICE recommend:
      • oxybutynin (immediate release)
        • Immediate release oxybutynin should, however, be avoided in ‘frail older women’
      • tolterodine (immediate release)
      • darifenacin (once daily preparation)
  • mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
177
Q

Mechanism of Action of Mirtazapine

A
  • alpha-2 receptor antagonist
    *
178
Q

Side effects of Mirtazapine

A
  • Sedation
  • Increased appetite
    • Beneficial in older people that are suffering from insomnia and poor appetite.

Headaches are a common withdrawal symptom of mirtazapine

179
Q

Main side effect of MAOI (monoamine oxidase inhibitor) antidepressants, such as phenelzine

A

Consumption of foods high in tyramine (such as cheese) can result in a hypertensive crisis.

180
Q

Features of Intrahepatic Cholestasis of Pregnancy

A
  • pruritus - may be intense - typical worse palms, soles and abdomen
  • worsening of rash at night
  • clinically detectable jaundice occurs in around 20% of patients
  • raised bilirubin is seen in > 90% of cases
181
Q

Management of Intrahepatic Cholestasis of Pregnancy

A
  • Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is recommended at 37-38 weeks gestation
  • ursodeoxycholic acid
  • vitamin K supplementation
182
Q

Features of ALL

A
  • anaemia: lethargy and pallor
  • neutropaenia: frequent or severe infections
  • thrombocytopenia: easy bruising, petechiae, epistaxis
  • And other features
    • bone pain (secondary to bone marrow infiltration)
    • splenomegaly
    • hepatomegaly
    • fever is present in up to 50% of new cases (representing infection or constitutional symptom)
    • testicular swelling
183
Q

Poor prognostic factors in ALL

A
  • age < 2 years or > 10 years
  • WBC > 20 * 109/l at diagnosis
  • T or B cell surface markers
  • non-Caucasian
  • male sex
184
Q

A primigravid 43 year-old woman, who is at 27 weeks gestation, presents to the maternity unit with regular weak contractions. Examination reveals her cervix is 3 cm dilated and membranes are intact. What would be the most appropriate management?

A
  • Tocolytics- stop premature labour
  • Steroids- pre-emptively given to help foetal lungs mature
185
Q

Risks of prematurity

A
  • increased mortality depends on gestation
  • respiratory distress syndrome
  • intraventricular haemorrhage
  • necrotizing enterocolitis
  • chronic lung disease
  • hypothermia
  • feeding problems
  • infection
  • jaundice
  • retinopathy of newborn
  • hearing problems
186
Q

What is a sensitising event in pregnancy?

A
  • a process whereby fetal red blood cells (RhD-positive) enter the maternal circulation, where the mother is RhD-negative.
  • The fetomaternal haemorrhage (FMH) can cause antibodies to form in the maternal circulation that can haemolyse fetal red blood cells.
  • usually affects subsequent pregnancies, if the fetus is RhD-positive
187
Q

What are potentially sensitising events in pregnancy?

A

Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:

  • Ectopic pregnancy
    • if managed surgically, if managed medically with methotrexate anti-D is not required
  • Evacuation of retained products of conception and molar pregnancy
  • Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
  • Vaginal bleeding > 12 weeks
  • Chorionic villus sampling and amniocentesis
  • Antepartum haemorrhage
  • Abdominal trauma
  • External cephalic version
  • Intra-uterine death
  • Post-delivery (if baby is RhD-positive)
188
Q

How to prevent HDN?

A
  • test for D antibodies in all Rh -ve mothers at booking
  • NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks
  • anti-D is prophylaxis - once sensitization has occurred it is irreversible
  • if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
189
Q

Features of HDN

A
  • oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
  • jaundice, anaemia, hepatosplenomegaly
  • heart failure
  • kernicterus

Treatment: transfusions, UV phototherapy

190
Q

What are the risk factors of 2nd trimester miscarriage?

A
  • Age
    • ​35- 20% risk
    • 40- 40% risk
    • 45- 80% risk
  • Previous miscarriages
    • ​2 or more
  • Chronic conditions
    • ​e.g. uncontrolled diabetes
  • Uterine or cervical problems
    • ​Mullerian duct anomalies
    • large cervical cone biopsies
  • Smoking, alcohol and illicit drugs
  • Weight
    • ​Underweight
    • Overweight
  • Invasive prenatal tests
    • ​CVS/ amniocentesis = small risk
191
Q

Features of Cystic Fibrosis

A
  • neonatal period (around 20%)
    • meconium ileus
    • less commonly prolonged jaundice
  • recurrent chest infections (40%)
  • malabsorption (30%)
    • steatorrhoea
    • failure to thrive
  • other features (10%)
    • liver disease
    • short stature
    • diabetes mellitus
    • delayed puberty
    • rectal prolapse (due to bulky stools)
    • nasal polyps
    • male infertility, female subfertility
192
Q

Management of umbilical hernias in babies

A
  • Watch and Wait
  • should resolve by 12 months of age
  • parents should be reassured that no Tx is needed
  • Safety-netting = advice should be given on signs of obstruction or strangulation:
    • vomiting
    • pain
    • being unable to push the hernia in

If hernia is still present at 2 y/o -> refer to surgeon

Associations

  • Afro-Caribbean infants
  • Down’s syndrome
  • mucopolysaccharide storage diseases
193
Q

Risk factors of DDH

A
  • female sex: 6 times greater risk
  • breech presentation
  • positive family history
  • firstborn children
  • oligohydramnios
  • birth weight > 5 kg
  • congenital calcaneovalgus foot deformity

More common in left hip

20% = bilateral

194
Q

Screening for DDH

A
  • the following infants require a routine ultrasound examination
    • first-degree family history of hip problems in early life
    • breech presentation at or after 36 weeks gestation, irrespective of presentation at birth or mode of delivery
    • multiple pregnancies
  • all infants are screened at both the newborn check and also the six-week baby check using the Barlow and Ortolani tests
    • ​Barlow test: attempts to dislocate an articulated femoral head
    • Ortolani test: attempts to relocate a dislocated femoral head
  • other important factors include:
    • symmetry of leg length
    • level of knees when hips and knees are bilaterally flexed
    • restricted abduction of the hip in flexion
195
Q

Imaging in DDH

A
  • ultrasound is generally used to confirm the diagnosis if clinically suspected
  • however, if the infant is > 4.5 months then x-ray is the first line investigation
196
Q

Management in DDH

A
  • most unstable hips will spontaneously stabilise by 3-6 weeks of age
  • Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
  • older children may require surgery
197
Q

A mother is concerned about a swelling she has noted on her newborn’s head. The girl was born four hours ago, using forceps delivery due to a prolonged second stage of labour. On examination, there is a swelling in the parietal region which does not cross the suture lines. The consultant tells her that it may take several months to resolve. Which type of head injury is this likely to be?

A

Cephalohaematoma- between periosteal membrane and cranial bone

  • forceps delivery predisposes to extracranial injuries
  • typically develops several hours after delivery and is due to bleeding between the periosteum and skull.
  • The most common site affected is the parietal region
  • Jaundice may develop as a complication.
  • A cephalohaematoma up to 3 months to resolve.

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