GP clinic Flashcards by Emily Southall

what exams and Ix

Urine dip
Abdo exam
Pregnancy test
Basic set of obs

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ddx?

HR borderline high
BO normal
Apyrexic, rr and sats normal
High HR because struggling to lie still

Renal colic – loin to groin pain, in waves – as move into ureter = colicky type pain. N and V because so painful (can also be caused by infection) Blood in urine

UTI/pyelonephritis – no evidence of infection in urine or fever = less likely. Pain more constant

Ectopic pregnancy – want negative test

Biliary colic – would be more on R

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Mx of renal colic

are there complications – complete urinary tract obstruction, infection, unable to keep fluids in – vomit = shock/dehydrate = a and e, eg fever or infection in urine

Risk of AKI because one kidney obstructed – normally other can compensate. If CKD, bilateral stones or one kidney – risk of AKI = A and E

no sign of infection, obs normal, no PMH – still need urgent ix - CT KUB in 24hr – ambulatory care

Analgesia – paracetamol and an anti-inflammatory

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safety netting for renal colic

Complications = a and e

fever
If not passing urine/intermittent urine flow
If persistently vomit, or cant tolerate oral fluids

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qns in Hx

Other urinary sx – dysuria, anything suggest UTI but leukocytes and nitrites -ve

Freq dribbling, LUTs

Systemic – FLAWS

Is it renal colic – loin to groin pain

Urethral discharge

Any medications

Social hx – RF for urological malignancy – smoke, and have they been in contact with aromatic amines – dyes, rubbers and textiles

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ddx

Bladder cancer
Cancer in urinary tract – renal/prostate
BPH
Prostatitis
Urinary tract infection
Pyelonephritis but no sign of infection
Transient – if exercised/sexual intercourse cause haematuria
If female and on period might be transient cause of blood in sample

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next steps

Repeat dipstick – see if persistent or transient cause –

need to be 2 out of 3 samples taken a couple of weeks apart

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causes of macroscopic haematuria

malignancy - prostate, bladder or kidney

stones

infection

trauma

renal disease

BPGH

transient - vigorous exercise, menstrual blood

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Ix for haematuria

depend on pt demographic, Hx and Ex

repeat dip

check BP

urine MCS

urine ACR

blood - eGFR

specialist - cystoscopy, imaging, biopsy

bp, ACR and eGFR are for glomerulonephritis

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when would you consider 2ww for haematuria

age >/=45 with unexplained visible haematuria

age >/=60 with unexplained non-visible haematuria and raised WCC or dysuria

If had really high index of suspicion of malignancy – could still make a 2ww based on suspicion

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what would you do now

Examine throat
Obs
Check for cervical LN
Listen to chest – because URTI
Wouldn’t go straight to swab – might do further down line if struggling with mx

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ddx

Tonsilitis – more common
- Bacterial or viral
- Majority are viral
Glandular fever

just tachy because of temp

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Centor criteria or FeverPain score

Centor:

age 3-14 = +1, 15-44 = 0, >=45 = -1
exudate or swelling in tonsils = 1
tender/swollen anterior cervical LN = 1
temp >38 = 1
no cough = 1

3 or 4 = AB - penicillin V or erythromycin for 7-10days

0-2 = likely viral - watch and wait/delayed prescription

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after amoxicillin for sore throat:

what has happened

Glandular fever – caused by EBV – if give amoxicillin to pt with EBV – cross reactivity between Ab on EBV and AB = rash

Only happens with amoxicillin not other penicillins

Could be drug allergy but had amoxicillin before

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signs of glandular fever

enlarged spleen

axillary lymphadenopathy

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ix for glandular fever

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Monospot test same as heterophile Ab test
In some cases might do serology
Wouldn’t do swab unless monospot -ve and think you need other AB
FBC – haemolytic anaemia, thrombocytopenia, reactive lymphocytosis

advice for glandular fever

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Avoid close contact with people

Avoid contact sport for 8weeks because risk of splenic ruture

Make sure well hydrated analgesia

Sx can linger for weeks to months

ddx

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Gallstone – biliary colic, cholecystitis
Pancreatitis
Gord
Peptic ulcer
Lower lobe pneumonia
Liver – hepatitis

Most likely is biliary colic – worse after eating, last 1hr, sick and vomiting

what Ix would you do

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Not tender and no mass in RUQ*
If think gallstone is it biliary colic or is it cholecystitis – when stuck in tree = inflammation: constant pain, tachy, tender, temp*
LFT
US
Lipid profile – if cholesterol stones
Not XR – cant see biliary stones
Amylase and lipase

mx of biliary colic

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Diet advice – avoid fatty foods
Safety net
Analgesia
Refer to upper GI surgeons

Risk could get stuck somewhere = refer for laparoscopic cholecystectomy

asymptomatic and tree normal – don’t need referral

asymptomatic but stones in tree – need referral because high risk of complication

Acute cholecystitis/cholangitis need urgent referral

ddx

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PVD
- Intermittent claudication – vasculopathy, and relived by rest
- Chronic limb ischemia
Diabetic neuropathy
SE of statin – myopathy – typically wouldn’t just be in leg when walked – ask how long ago started statin
Spinal stenosis – narrow of spinal canal mimic claudication sx – typically other neuro sx – better when bend over, sit, in foetal position – stretch the spinal canal and release pressure
MSK

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Peripheral vascular exam
Pulse
Temp
Beurgeur’s test
Loss of hair
Check skin for ulcers – arterial and venous
Temp
Muscle atrophy
Skin change
Cap refill in both legs
Look for signs of acute limb ischemia
CVS exam because of CV risk

signs of peripheral arterial disease

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Weak pulse, legs can look normal
Think skin, tissue loss near heal and around toes, hair loss
Beugeur’s test – arterial insufficiency – when elevate leg goes pale, when hang over bed it is more red

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ABPI – ankle brachial pressure index – make dx and determine mx based on this
Overall cardio risk
- Smoking cessation
- Exercise
Supervised exercise program
Safety net for acute ischemic sx
Make sure on med needs to be on for PVD – statin (maybe higher dose), antiplt

what is peripheral arterial disease

umbrella term for intermittent claudication, critical limb ischemia and acute limb ischemia chronic limb ischemia encompasses intermittent claudication and critical limb ischemia

intermittent claudication

critical limb ischemia

blood flow is more impaired - more risk of losing limb so need surgery

acute limb ischemia

sx come on more quickly – thrombosis from atherosclerotic plaque rupture – complete blockage of peripheral arteries. This is a vascular emergency – need to go straight to A and E

what else would you like to ask

* Cough * Dysphagia – red flag * Is it worse when lie down * RF - Smoking, large meals, alcohol, stress * Tried anything to help already * Any med – any OTC, what on regularly

ddx

* GORD * Peptic ulcer Sx high up in throat with acid taste and no stomach pain – GORD is top dx Worse after eating so peptic ulcer back in mind Oesophageal cancer – rule out with hx and ex

* Don’t need endoscopy unless initial treatments don’t work * Given young age and no systemic sx mx in primary care * Either 4wk trial of omeprazole and lifestyle and sx might respond * Test and treat – test for H pylori and if +ve give rx * If either don’t work try the other * Each time you see assess for red flags and think if need referral * Need to be off PPI for 2wk and AB for 4wks before test for H pylori – so do it before start PPI

Mx for H pylori

* Triple therapy – amoxicillin, PPI twice a day (normally once a day if not H p) clarithromycin or metronidazole

ddx and ex

* Stoke * Bell’s palsy - idiopathic acute facial nerve palsu * Facial nerve palsy – need to know if UMN or LMN * CN exam * Upper and lower limb * Look in ear, at scalp, mastoid region, oral cavity * Parotid gland exam * Need to see if forehead affected – if effected suggest LMN * If forehead spared – UMN – because forehead is bilaterally innervated

Mx of Bell's palsy

* Reassurance – recover in 3-4mo * Eye care – particularly when sleeping – eye might not shut = corneal scratch, and get dry – need eye lubricant and tape eye shut * If eye get painful, itch, red – refer * if present within 72hr Steroids – pred 50mg for 10days? * If no improvement refer to neurology in a few weeks

causes of facial nerve palsy

can give acyclovir for Ramsay hunt

GP clinic Flashcards

(35 cards)