GP Conditions Flashcards
(211 cards)
1
Q
Type 2 Diabetes complications (3)
A
Infections e.g. candida
Macrovascular arterial e.g. coronary artery disease, stroke
Microvascular e.g. neuropathy, nephropathy, retinopathy
2
Q
1st line medication to manage T2DM patients of any age with hypertension
A
ACE inhibitors
3
Q
Medication started in T2DM when the patient has CKD with ACR above 30mg/mmol
A
SGLT-2 inhibitors
4
Q
Type of medication used for erectile dysfunction
A
Phosphodiesterase-5 inhibitors e.g. sildenafil
5
Q
4 options for neuropathic pain in diabetic neuropathy
A
Amitriptyline (TCA)
Duloxetine (SNRI)
Gabapentin (anticonvulsant)
Pregabalin (anticonvulsant)
6
Q
Step-wise medical management of T2DM
A
1st line: Metformin, once settled ADD SGLT-2 inhibitor if the patient has CVD or HF or QRISK above 10%
2nd line: ADD sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor
3rd line: Triple therapy (metformin plus 2) or insulin therapy
7
Q
Two side effects of SGLT-2 inhibitors
A
Increased frequency of UTIs and genital thrush more glucose in the wee due to inhibiting reabsorption
Diabetic ketoacidosis
8
Q
T2DM diagnostic results (3)
A
HbA1c > 48
Fasting plasma glucose > 7
Random plasma glucose: > 11.1
9
Q
Pre-diabetes HbA1c
A
42-47 mmol/mol
10
Q
Pathophysiology of T1DM
A
Autoimmune disorder where the insulin producing beta cells of the islets of Langerhans in the pancreas are destroyed by the immune system
11
Q
Main side effects of insulin treatment
A
Hypoglycaemia
Weight gain
Lipodystrophy
12
Q
MOA metformin (3)
A
- Increase insulin sensitivity
- Decreases hepatic gluconeogenesis
- Decreases intestinal absorption of glucose
13
Q
Metformin side effects
A
GI upset
Lactic acidosis
14
Q
Secondary hyperthyroidism definition
A
Pathology in the hypothalamus or pituitary producing too much TSH
15
Q
Graves’ disease definition
A
Autoimmune condition where TSH receptor antibodies cause primary hyperthyroidism
16
Q
Most common cause of hyperthyroidism / thyrotoxicosis
A
Graves’ disease
17
Q
Which condition causing hyperthyroidism is most common in patients over 50
A
Toxic multinodular goitre
nodules develop on the thyroid gland, which are unregulated by the thyroid axis and continuously produce excessive thyroid hormones
18
Q
Pathophysiology of exophthalmos (proptosis)
A
Bulging of the eyes caused by Graves’ disease
inflammation, swelling and hypertrophy of the tissue behind the eyeballs force them forward, causing them to bulge out of the sockets
19
Q
Pretibial myxoedema definition
A
Skin condition caused by glycosaminoglycans under the skin on the anterior aspect of the leg (the pre-tibial area)
Gives the skin a discoloured, waxy, oedematous appearance over this area
Specific to Graves’ disease and is a reaction to TSH receptor antibodies
20
Q
Causes of hyperthyroidism (4)
A
GIST:
Graves’ disease
Inflammation (thyroiditis)
Solitary toxic thyroid nodule
Toxic multinodular goitre
21
Q
Thyroiditis (thyroid gland inflammation) disease pattern
A
Initial period of hyperthyroidism followed by hypothyroidism
22
Q
4 causes of thyroiditis
A
De Quervain’s thyroiditis
Hashimoto’s thyroiditis
Postpartum thyroiditis
Drug-induced thyroiditis
23
Q
Graves’ disease specific features
A
Diffuse goitre (w/o nodules)
Graves’ eye disease with exophthalmos
Pretibial myxoedema
Thyroid acropachy (hand swelling and finger clubbing)
24
Q
Presentation of hyperthyroidism
A
Anxiety and irritability
Sweating and heat intolerance
Tachycardia
Weight loss
Fatigue
Insomnia
Frequent loose stools
Sexual dysfunction
Brisk reflexes on examination
25
1st line anti-thyroid drug
**Carbimazole**, usually taken for 12 to 18 months
Methods of dosing:
- Titrate to maintain normal levels
- Block all production and replace with levothyroxine
26
2 complications of carbimazole use
**Acute pancreatitis** (look for severe epigastric pain radiating to back)
**Agranulocytosis** (look for susceptible to infections/sore throat)
27
Blood results of thyrotoxicosis (e.g. Graves’)
TSH: low
Free T4: high
28
Antibodies found in Graves’ disease
TSH receptor antibodies
29
Antibodies found in Hashimoto’s thyroiditis
anti-TPO antibodies
30
1st line symptomatic management of hyperthyroidism
Propranolol
31
Most common cause of hypothyroidism in the developed world
Hashimoto’s thyroiditis
32
Most common cause of hypothyroidism in the developing world
Iodine deficiency
33
Presentation of hypothyroidism
Weight gain
Fatigue
Dry skin
Coarse hair and hair loss
Fluid retention (oedema, pleural effusions and ascites)
Heavy or irregular periods
Constipation
34
Treatment of hypothyroidism
Oral levothyroxine (synthetic T4 which metabolises to T3)
35
Investigations following a hypertension diagnosis
**Fundoscopy**: to check for hypertensive retinopathy
**U+Es, Urine dipstick**: to check for renal disease (as a cause or consequence of)
**ECG**: left ventricular hypertrophy or IHD
**HbA1c**: check for co-existing DM (CVD RF)
**Lipids**: check for hyperlipidaemia (CVD RF)
36
Hypertension stage 1 definition
ABPM/HBPM monitoring = > 135 / 85 mmHg
Or
Clinic reading persistently = > 140 / 90 mmHg
37
Step 1 management for hypertension in patient who is <55 or T2DM
1st line: ACE inhibitor
2nd line (e.g. because of ACEi cough side effect): Angiotensin 2 Receptor blocker
38
Step 1 management for hypertension in patient who is >55 or Afro-Caribbean with NO T2DM
1st line: Calcium channel blocker
39
Step 2 management for hypertension
ACEi/A2RB + CCB
OR
ACEi/A2RB + thiazide-like Diuretic
40
Step 3 management for hypertension
ACEi/A2RB + CCB + thiazide-like D
41
Step 4 management of hypertension based on K+ results
K+ < 4.5 add low dose spironolactone
K+ > 4.5 add alpha or beta blocker
42
Stage 2 hypertension definition
Clinic BP > 160/100
ABPM/HBPM > 150/95
43
Severe hypertension definition
Clinic systolic > 180 mmHg
Clinic diastolic > 120 mmHg
44
What would indicate a same-day specialist review in BP 180/120 mmHg
Retinal haemorrhage or papilloedema
Life threatening symptoms (new onset confusion, chest pain, HF Sx, AKI)
Suspected phaeochromocytoma (labile or postural hypotension, headache)
45
Single most common cause of secondary hypertension
Primary hyperaldosteronism (Conn’s)
46
Renal conditions which would increase BP
Glomerulonephritis
Pyelonephritis
APKD
Renal artery stenosis
47
Drug causes of secondary hypertension
Steroids
MAOIs
COC
NSAIDs (by blocking prostaglandins)
48
Top differentials for a non blanching rash (bleeding under the skin)
Leukaemia
Meningococcal septicaemia
Henoch-schonlein purpura
ITP
TTP
Traumatic
49
Analgesia management in osteoarthritis
1st line: topical NSAIDs (particularly beneficial for OA of knee or hand)
2nd line: oral NSAIDs - a PPI should be co-prescribed e.g. omeprazole
50
Characteristic features of OA of the hand
Unsymmetrical
Carpometacarpal (CMC) and distal interphalangeal (DIP) joints
Heberden’s nodes at the DIP pints
Bouchard’s nodes at the PIP joints
Squaring of the thumbs (fixed adduction)
51
X-ray investigation results of OA
LOSS:
Loss of joint space
Osteophytes forming at joint margins
Subchondral sclerosis
Subchondral cysts
52
Diagnosis of OA w/o investigations
Over 45, typical pain associated with activity and has no morning stiffness (or stiffness lasting under 30 minutes)
53
Which patients is OA most commonly seen in
Post-menopausal women (due to loss of protective oestrogen)
54
Gout definition
A type of crystal athropathy associated with chronic hyperuricaemia
Urate crystals are deposited in the joint, causing it to become inflamed
Episodes last several days with symptom-free periods in between
55
Gout typical presentation
Single acute hot, swollen painful joint (key DDx: septic arthritis)
Gouty tophi (subcutaneous uric acid in the hands, elbows and ears)
56
Risk factors for gout
Male
FHx
Obesity
High purine diet (meat and seafood)
Alcohol
Diuretics
CVD
Renal disease
57
Most commonly affected joints in gout
Base of the big toe: metatarsophalangeal joint (MTP joint) - 70% of first presentations affect 1st MTP
Base of the thumb: carpometacarpal joint (CMC joint)
Wrist
Gout can also affect larger joints e.g. knee and ankle
58
Diagnosis of gout
Clinical diagnosis
- supported by a raised serum urate level on blood test (typically checked 2 weeks later as may be high, normal or low during acute attack)
59
Aspirated joint fluid 2 findings in gout that differentiate it from septic arthritis and pseudogout
1. No bacterial growth (important to exclude septic arthritis)
2. Monosodium urate crystals: needle shaped and negatively birefringent of polarised light (PseudOgOut = rhOmbOid shaped and Positively birefringent)
60
X-ray findings in gout
No loss of joint space
Lytic lesion in the bone
Punched out erosions
Erosions can have sclerotic borders with overhanging edges
61
Management of acute flares of gout
1st line: **NSAIDs** e.g. naproxen - co-prescribed with PPI
2nd line: **colchicine** (if renal impairment or significant heart disease)
3rd line: oral steroids e.g. prednisolone
62
Gout prophylaxis
Xanthine oxidase inhibitors which lower uric acid level e.g. Allopurinol (1st) or Febuxostat (2nd)
- offered to all patients after their first attack of gout
- Prophylaxis is not started until inflammation has settled after the acute attack (NSAIDs/colchicine can be continued)
- Once established on allopurinol, continue during future acute attacks
63
Main side effect of colchicine
Diarrhoea
64
4 causes of acute liver failure
Paracetamol overdose
Alcohol
Viral hepatitis (usually A or B)
Acute fatty liver of pregnancy
65
Features of acute liver failure
Jaundice
Coagulopathy: raised PT time
Hypoalbuminaemia
Hepatic encephalopathy
Renal failure is common (hepatorenal syndrome)
66
Differentiating features of Crohn’s disease
‘Crows’ NESTS:
N - No blood or mucus (PR bleeding is less common)
E - Entire GI tract (mouth to anus)
S - ‘Skip’ lesions on endoscopy
T - Terminal ileum most affects and Transmural inflammation
S - Smoking is a risk factor
+ strictures and fissures
67
Differentiating features of Ulcerative Colitis
You See (UC) CLOSE UP:
C - Continuous inflammation
L - Limited to the colon and rectum
O - Only superficial mucosa affected
S - Smoking may be protective (UC less common in smokers)
E - Excrete blood and mucus
U - Use Aminosalicylates
P - Primary sclerosing cholangitis
68
Blood tests for IBD investigations
FBC: Hb (anaemia), platelet count (raised w inflammation)
CRP
U&Es: electrolyte imbalance, kidney function
LFTs: low albumin in severe disease (protein lost in bowel)
TFTs: hyperthyroidism as DDx for diarrhoea
Anti-TTG: coeliac
69
IBD screening and diagnostic investigations
Screening: faecal calprotectin (90% sensitive and specific)
Diagnostic: colonoscopy with multiple intestinal biopsies
70
UC management
Mild to moderate:
**1st line = Aminosalicylate e.g. mesalazine**
2nd line = Corticosteroids e.g. oral/PR prednisolone
Acute severe:
**1st line = IV steroids e.g. IV hydrocortisone**
Maintaining remission: aminosalicylate, Azathioprine, mercaptopurine
Panproctocolectomy will remove the disase = patient will have ileostomy or J pouch
71
Crohn’s management
1st line in inducing remission: glucocorticoids e.g. oral pred or IV hydrocortisone
1st line in maintaining remission: Azathioprine, mercaptopurine
72
Most common cause of hyperthyroidism in pregnancy
Graves disease
73
Cushing's disease
Cushing's syndrome caused specifically by a pituitary gland tumour
74
Causes of Cushing's syndrome
High/chronic doses of exogenous steroids (most common cause)
Pituitary gland tumour (Cushing's disease) - *most common endogenous/ACTH dependent cause*
Adrenal tumour (excessive cortisol)
Paraneoplastic ectopic ACTH i.e. small cell carcinoma in the lungs
75
5 mechanisms of cortisol
Inhibits the immune system
Inhibits bone formation
Raises blood glucose
Increases metabolism
Increases alertness
76
electrolyte imbalance associated with ectopic ACTH secretion
Hypokalaemia
77
1st line / Gold standard test to diagnose Cushing's syndrome
**Overnight (low-dose) dexamethasone suppression test**
*high-dose test can be used to localise pathology e.g. cortisol + ACTH suppressed = pituitary adenoma)*
78
Most common cause of primary hyperaldosteronism (Conn's)
bilateral idiopathic adrenal hyperplasia
79
Features of primary hyperaldosteronism (Conn's)
Hypertension
Hypokalaemia e.g. muscle weakness
Hypernatraemia
Metabolic alkalosis
*aldosterone causes sodium retention and resulting potassium excretion in the kidneys*
80
1st line investigation in Conn's
**Plasma aldosterone:renin ratio**
*= high aldosterone/low renin: aldosterone causes sodium retention which has a negative feedback on renin*
81
Management of Conn's (bilateral adrenocortical hyperplasia)
Aldosterone antagonist e.g. spironolactone
82
Renal colic definition
Unilateral loin to groin pain
Colicky (flucuating in severity)
83
Investigation renal colic
**CT KUB (CT of the kidneys, ureters and bladder)** *within 24 hours of presentation*
*Ultrasound should be used for pregnant women and children*
84
Presentation of hypercalcaemia/hyperparathyroidism
Renal stones
Painful bones
Abdominal groans
Psychiatric moans
85
3 causes of hypercalcaemia
Calcium supplementation
Hyperparathyroidism
Cancer (e.g. myeloma, breast, lung)
86
Most common type of renal stone
Calcium oxalate
87
Complications of renal stones (2)
Obstruction (leading to acute kidney injury)
Infection (obstructive pyelonephritis)
88
Presentation of renal stones
Renal colic
Haematuria
89
Most effective type of analgesia for renal stones
NSAIDs e.g. IM diclofenac
2nd line: IV paracetamol
90
Renal stones <5mm management
**Watchful waiting** (50-80% will pass)
**Tamsulosin** (alpha blocker) can be used to help aid passing
*Surgical intervention: stones >10mm, won't pass, signs of infection*
91
Thiazide diuretic MOA in prevention of renal stones
Prevention of **hypercalciuria** by increasing distal tubular **calcium resorption**
92
2 prerenal causes of AKI
Hypovolaemia (secondary to D+V)
Renal artery stenosis
*both cause lack of blood flowing to the kidneys/ischaemia*
93
2 renal causes of AKI
glomerulonephritis
rhabdomyolysis
94
2 postrenal causes of AKI
renal stones
benign prostatic hyperplasia
95
Nephrotoxic drugs (5)
NSAIDs *e.g. ibuprofen, aspirin can be continued at a cardioprotective 75mg dose*
amingolycoside antibiotics *e.g. gentamicin*
ACE inhibitors *e.g. ramipril*
Angiotensin II receptor antagonists (ARBs) *e.g. candesartan*
Diuretics *e.g. furosemide*
96
Stage 1 AKI
urine output of less than 0.5 ml/kg/hour for ≥ 6 hours
OR
Increase in creatinine to 1.5-1.9 times baseline
97
Stage 2 AKI
urine output of less than 0.5 mL/kg/hour for ≥ 12 hours
OR
Increase in creatinine to 2.0 to 2.9 times baseline
98
Stage 3 AKI
urine output of less than 0.3 mL/kg/hour for ≥24 hours
OR
Increase in creatinine to ≥ 3.0 times baseline
99
Bladder cancer features (5)
frequency
urgency
nocturia
weight loss
**painless haematuria**
100
1st line investigation bladder cancer
cystoscopy and biopsy
101
2 major risk factors for transitional cell carcinoma of the bladder
Smoking
Exposure to aniline dyes
102
H. pylori treatment
1 PPI + 2 antibiotics + lifestyle modifications
e.g. **lansoprazole** + **clarithromycin** + **metronidazole** + stop smoking/caffeine
103
gastric ulcer vs duodenal ulcer pain
gastric ulcer = pain IMMEDIATELY **after eating**
104
CKD stages
Stage 1: > 90 mL + abnormal kidney tests
Stage 2: 60-89 mL + abnormal kidney tests *(-30)*
Stage 3A: 45-59 mL *(-15)*
Stage 3B: 30-44 mL *(-15)*
Stage 4: 15-29 mL *(-15)*
Stage 5/ESRF: <15mL
105
Ratio investigating proteinuria in CKD
albumin:creatinine ratio (ACR)
106
Management of CKD patients where ACR >30
1st line: ACE inhibitors
other: SGLT-2 inhibitors
107
How does CKD impact bone health
high phosphate (not being excreted in kidneys) drags calcium from the bones resulting in osteomalacia
secondary hyperparathyroidism (**low calcium**, low vitamin D, high phosphate)
108
renal ultrasound differentiation of CKD and AKI
bilateral small kidneys in CKD
109
how does CKD lead to anaemia
reduced erythropoietin levels
110
COPD stepwise treatment pathway (steroid responsive)
*i.e. asthmatic features/atopic illness/FEV1 variation*
Step 1: SABA e.g. salbutamol or SAMA e.g. ipratropium bromide
Step 2: SABA + LABA + ICS e.g. beclomethasone (if they were originally on SAMA, discontinue and start SABA)
Step 3: SABA + triple therapy i.e. LABA + ICS + LAMA e.g. tiotropium
111
COPD stepwise treatment pathway (***non***-steroid responsive)
*i.e. no asthmatic features/no atopic illness/no FEV1 variation*
Step 1: SABA or SAMA
Step 2: SABA + LABA + LAMA (if they were originally on SAMA, discontinue and start SABA)
112
Drug classes in asthma/COPD treatment and examples
SABA = short acting beta 2 agonist e.g salbutamol
LABA = long-acting beta 2 agonist e.g salmeterol
SAMA = short-acting muscarinic antagonist e.g ipratropium
LAMA= long-acting muscarinic antagonist e.g tiotropium
ICS = inhaled corticosteroid e.g. beclometasone, fluticasone
113
Moderate asthma definition
PEFR 50-75% best or predicted
**Speech normal**
114
Severe asthma definition
PEFR 33 - 50% best or predicted
Can't complete sentences
115
Life threatening asthma definition + signs
PEFR < 33% best or predicted
Oxygen sats < 92%
'Normal' pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
116
Feature of 'near-fatal asthma'
Raised pCO2 > 6 kPa
117
Management for life threatening asthma
1st line Nebulised SABA (salbutamol) delivered in O2
Nebulised ipratropium bromide
Oral prednisolone for 5 days
118
positive asthma reversibility test
Improvement in FEV1 of 12% or more after inhalation of SABA
119
QRISK score
Risk of developing a heart attack or stroke in the next 10 years
*>10% = benefit from a prescribed statin*
120
3 key investigations in MI
ECG
CXR
Cardiac enzymes (troponin, myoglobin and creatinine kinase)
121
Primary hyperparathyroidism
Excess secretion of PTH resulting in hypercalcaemia
**most common cause of hypercalcaemia in outpatients**
122
Cause of 85% of primary hyperparathyroidism
Solitary adenoma
123
Primary hyperparathyroidism investigations
Bloods: **high calcium**, low phosphate
X-ray: pepperpot skull
124
What has occurred when PTH still not corrected after correcting underlying cause of secondary hyperparathyroidism
Secondary has caused hyperplasia of parathyroid glands = **tertiary**
125
2 main causes of secondary hyperparathyroidism
1. Low vitamin D
2. CKD
= cause **low calcium** which *causes* **high PTH**
126
Acute bacterial endocarditis contraindicated medication
Heparin
127
Rheumatoid arthritis hand signs (4)
Z-shaped deformity
Swan neck deformity
Boutonniere deformity
Ulnar deviation
128
Causes of clubbing
Cardiac = atrial myxoma, cyanotic heart disease, endocarditis, pericarditis
Gastrointestinal = malabsorption, inflammatory bowel disease, liver cirrhosis
Respiratory = Cystic fibrosis, Tuberculosis, Pulmonary fibrosis, bronchiectasis, bronchial carcinoma
129
Immediate management MI
MONA
Morphine
Oxygen therapy (if sats are less than 94%)
Nitrates
Aspirin + Antiplatelet
130
Mechanism of action of beta agonists in asthma
e.g. salbutamol or salmeterol
Stimulation of **G-protein coupled receptor** causes **smooth muscle relaxation** and hence bronchodilation
131
Mechanism of action of **antimuscarinics** in asthma
e.g **ipratropium bromide**
competitive inhibitor of acetylcholine
muscarinic receptors = **parasympathetic effects e.g. bronchoconstriction**
blocking these receptors causes the opposite effect and result in **bronchodilation (sympathetic response)**
132
1st line test coeliac disease
Tissue transglutaminase (TTG) antibodies (IgA)
**Remember you also need to look for selective IgA deficiency (endomyseal antibody)**
133
Gold standard investigation for coeliac disease
Endoscopic intestinal biopsy
134
Biopsy findings coeliac disease
Villous Atrophy
Crypt Hyperplasia
Increase in intraepithelial lymphocytes
135
Key signs of gastric cancer (3)
Dysphagia + palpable mass in abdomen + ascites
136
Chronic heart failure: NYHA classification
1: no symptoms + no limitations
2: mild symptoms + comfortable at rest but ordinary activity = symptomatic
3: moderate symptoms + comfortable at rest but less than ordinary activity = symptomatic
4: severe symptoms + symptoms even at rest
137
Management if BNP is 'high' when investigating HF
**Transthoracic doppler echo within 2 weeks**
*’raised’ = transthoracic doppler echo within 6 weeks*
138
1st line investigation heart failure
NT-proBNP
139
Radiological findings in HF
ABCDE
Alveolar oedema
Kerley B lines
Cardiomegaly
Dilated upper lobe veins
Pleural effusion
140
Key treatment for **acute pulmonary oedema** (acute heart failure)
IV loop diuretics e.g. furosemide
141
1st line therapy chronic heart failure
ACE inhibitor and beta blocker e.g. ramipril and bisoprolol
142
2nd line therapy chronic heart failure
Aldosterone antagonist e.g. spironolactone
SGLT-2 inhibitors e.g. dapagliflozin
143
AUDIT-C score
3 Qs:
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6 or more units (female) / 8 or more units (male), on a single occasion in the last year?
144
When should you double your dose of hydrocortisone in adrenal insufficiency
temperature of > 38.0 degrees
cold, flu, diarrhoea or other infection
break a bone
145
IBS presentation
Abdominal pain **relieved by defecation**
Bloating
Change in bowel habit
+ Made worse by **stress, menstruation**
146
IBS pain relief
Buscopan (antispasmodic)
147
C diff management
Metronidazole
148
Charcot’s triad
Cholangitis: RUQ pain, jaundice, and fever
*Cholecystitis = jaundice is absent*
149
Most common cause of cholecystitis
Gallstones
150
Biliary colic vs other gallstone related conditions
**No fever** and LFTs/inflammatory markers are **normal**
151
Gallstones risk factors
4 F's
Fat
Female
Fertile
Fourty
+ Crohn's, DM, rapid weight loss, drugs (COC)
152
Management biliary colic
Elective laparoscopic cholecystectomy
153
common bacteria which are causative of COPD exacerbations
Moraxella catarrhalis
Haemophilus influenzae
Strep pneumoniae
154
Differentiating acute bronchitis from pneumonia
Hx: ***absent in acute bronchitis***: sputum, wheeze, breathlessness
O/E: ***absent in acute bronchitis***: no other focal chest signs (dullness to percussion, crepitations, bronchial breathing), systemic features (malaise, myalgia, fever)
155
Management acute bronchitis
Supportive (analgesia, good fluid intake)
**Antibiotic therapy**: if the patient is systemically very unwell, pre-existing co-morbidities, high CRP
* 1st line = doxycycline (unless pregnant or a child)
* 2nd line = amoxicillin
156
3 key points children’s influenza vaccine
It’s given intranasally
First dose is given at 2-3 years then annually after that
It is a **live vaccine**
157
Contraindications to intranasal flu vaccine in children
Immunosuppressed
Aged < 2 years
Current febrile illness or blocked nose
Current wheeze or history of severe asthma
Egg allergy
Aspirin (e.g. Kawasaki)
**inactivated, injectable vaccine given**
158
Who receives the annual influenza vaccine
All people over 65
Chronic disease
Diabetes Mellitus
Immunosuppression
Pregnant women
**inactivated vaccine so cannot cause influenza**
159
Majority of hiatus hernia types
Sliding (GI junction moves above the diaphragm)
160
Risk factors hiatus hernia
Obesity
Increased abdominal pressure e.g. ascites, multiparity
161
Features of a hiatus hernia (4)
Heartburn
Dysphagia
Regurgitation
Chest pain
162
Hiatus hernia investigation
1st line: **endoscopy**
Most sensitive: Barium swallow
163
Management of hiatus hernia
All patients benefit from **conservative management e.g. weight loss**
Medical management: **PPI therapy**
164
External haemorrhoids
Originate below the dentate line
Prone to thrombosis, may be painful
165
Internal haemorrhoids
Originate above the dentate line
**Do not generally cause pain**
166
Grading of internal haemorrhoids
I: do not prolapse
II: prolapse on defecation
III: manually reduced
IV: cannot be reduced
167
Management of haemorrhoids
GP:
**Soften stools** (increase dietary fibre and fluid intake)
Topical local anaesthetics and steroids
Outpatient:
Rubber band ligation (1st) or injection sclerotherapy
168
GORD management
PPI (-prazole) for 1 month *(full dose)*
- If response, low dose treatment of PPI as required
- If no response:
Endoscopically proven oesophagitis: **double dose** PPI for 1 month
Endoscopically negative reflux disease: H2RA or prokinetic for one month
169
Complications of GORD
Oesophagitis
Ulcers
Anaemia
Barrett’s oesophagus
Oesophageal carcinoma
170
Risk factors for developing GORD
Stress and anxiety
Smoking and alcohol
Coffee and chocolate (reduce LOS tone)
Obesity
171
Features of fibromyalgia
Chronic pain (multiple site, sometimes all over)
Lethargy
Cognitive impairment (fibro fog)
Sleep disturbance, headaches, dizziness
172
4 points on fibromyalgia management
Explanation
Aerobic exercise
CBT
Medication (pregabalin, duloxetine, amitriptyline)
173
Early features of Lyme disease (within 30 days)
Erythema migrans (‘**Bulls-eye**’ rash at site of tick bite), usually painless - **pathognomic**
Systemic features
174
Management of asymptomatic tick bites
Remove tick, no antibiotic treatment routinely recommended
175
Management of suspected/confirmed Lyme disease
**Doxycycline**
176
Polymyalgia rheumatica key features
Typical patient **> 60 years old**
Usually **rapid onset** (e.g. < 1 month)
Aching, **morning stiffness** in proximal limb muscles *(weakness is not considered a symptom in polymyalgia)*
*Other: Mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats*
177
Investigations polymyalgia rheumatica
**Raised inflammatory markers**
**Creatinine kinase** and electromyography = **normal**
178
Treatment polymyalgia rheumatica
Prednisolone
*patients typically respond rapidly to steroids, failure to do so should prompt DDx*
179
Most important causative **viral pathogen** of COPD exacerbation
Human rhinovirus
180
Features of COPD exacerbation
Increased dyspnoea, cough, wheeze
Increase in sputum (yellow-green)
Hypoxia / acute confusion
Fever
Cyanosis
Peripheral oedema
181
Differentials COPD exacerbation
Pneumonia
Pneumothorax
Pleural effusion
Pulmonary embolism
182
Management of COPD exacerbation (3)
1. Increase frequency of **bronchodilator** (consider nebuliser)
2. **Prednisolone 30mg daily for 5 days**
3. Antibiotics: amoxicillin, clarithromycin, doxycycline (**give Abx if sputum is purulent or clinical signs of pneumonia**)
183
Admission criteria for COPD exacerbation
Severe breathlessness
Acute confusion or impaired consciousness
Cyanosis
Oxygen saturation <90%
Social reasons (inability to cope at home)
Significant comorbidity (cardiac disease, insulin diabetes)
184
thiazide-like diuretic examples
metolazone, indapamide, chlorthalidone
185
Units of alcohol calculation
Vol (L) x % ABV
186
Management of male with UTI
Nitrofurantoin for 7 days
187
Atrial fibrillation 1st line rate control medication
**beta-blocker** or a rate-limiting calcium channel blocker (e.g. **diltiazem**)
188
Bacterial conjunctivitis presentation
**Purulent** discharge (eyes make be ‘stuck together’ in the morning)
189
Viral conjunctivitis presentation
Serous discharge + recent URTI
190
Management of infective conjunctivitis
**Self limiting condition - settles without treatment within 1-2 weeks**
1st line = **Topical antibiotic therapy** e.g. chloramphenicol drops (topical fusidic acid is used for pregnant women)
**Contact lens should not be worn during an episode of conjunctivitis**
*School exclusion is not necessary*
191
Acute vs chronic anal fissure
Acute = less than 6 weeks
Chronic = more than 6 weeks
192
3 risk factors for anal fissures
Constipation
IBS
STIs e.g. HIV, syphilis, herpes
193
Presentation of anal fissures
**Painful, bright red, rectal bleeding**
194
Management of an acute anal fissure
Soften stool: dietary advice (high fibre, high fluid), bulk-forming laxatives
Lubricants
Topical anaesthetics
Analgesia
195
Chronic anal fissure management
*Add to acute management*: **topical glyceryl trinitrate (GTN)**
196
Most common form of prostate cancer
Adenocarcinoma
197
Other causes of raised PSA
Benign prostatic hyperplasia (BPH)
Prostatitis and UTI
Ejaculation
Vigorous exercise
198
Management of low-grade prostate cancer
Active monitoring and watchful waiting
199
Common complication of radical prostatectomy
Erectile dysfunction
200
Complications of radiotherapy for prostate cancer (2)
Proctitis
Increased risk of bladder, colon and rectal cancer
201
Classic triad reactive arthritis
Urethritis, conjunctivitis and arthritis
‘Can’t see, pee or climb a tree’
202
Time course of reactive arthritis
Typically develops within **4 weeks** of initial infection (symptoms generally last around **4-6 months**)
203
Most common STI associated with reactive arthritis
Chlamydia trachomatis
204
Management of reactive arthritis
Symptomatic: **analgesia, NSAIDs, intra-articular steroids**
**Methotrexate** for persistent disease
205
Common trigger for otitis externa
Recent swimming
206
1st line treatment otitis externa
Topical antibiotics with or without steroid
*if the patient fails to respond then refer to ENT*
207
End stage heart failure disease prognosis
High risk of dying within 6-12 months
208
Raised urea and creatinine
Renal failure
209
Blood tests to screen for alcohol dependence
Raised:
GGT
MCV
CDT
210
Hypertension 4 further investigations
Creatinine
Electrolytes
ECG
Urinary protein
211
4 causes of constipation
Advanced age
Inactivity
Low calorie intake
Low fibre diet
Medications
Female sex
Hypothyroidism
