learning Flashcards

Question

Alcohol screening tools

Answer 1

AUDIT CAGE FAST

Answer 2

Epworth Sleepiness Scale

Answer 3

Gleason score

Answer 4

Bishop score

Answer 5

Waterlow score

Answer 6

Ranson criteria

Answer 7

The Glasgow-Blatchford Bleeding Score (GBS) stratifies upper GI bleeding patients who are 'low-risk' and candidates for outpatient management.

Answer 8

## Footnote prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery prelabour premature rupture of the membranes, where labour does not start diabetic mother \> 38 weeks pre-eclampsia rhesus incompatibility

Answer 9

cord prolapse is an obstetric emergency the presenting part of the fetus may be pushed back into the uterus to avoid compression if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm the patient is asked to go on 'all fours' until preparations for an immediate caesarian section have been carried out the left lateral position is an alternative tocolytics may be used to reduce uterine contractions retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.

Answer 10

A - appearance and behaviour S - speech (how they are speaking, rather than what they are saying, which comes under thought content) E - emotion (mood and affect; how the patient says they feel compared with how they appear to you) P - perceptions (any unusual experiences/ hallucinations etc) T - thought (form and content) Thought form - this is where you describe if the patient shows any evidence of formal thought disorder Thought content - this is where you describe if the patient is very fixated on one particular idea, or if there is a general tone or theme to their thoughts I - insight C - cognition

Answer 11

tachypnoea tachycardia sunken eyes reduced skin turgor

Answer 12

Ask about respiratory symptoms (breathlessness, cough, chest tightness) Ask about cardiovascular symptoms (chest pain, palpitations, leg swelling) Ask about gastrointestinal symptoms (nausea, vomiting, diarrhoea, constipation, anorexia) Ask about urogenital symptoms (urinary frequency, dysuria, genital itch, genital pain, dyspareunia) Ask about dermatological symptoms (rash, pruritus) Ask about neurological symptoms (headache, visual disturbance, weakness, paraesthesia, dizziness, syncope) Ask about systemic symptoms (fever, weight loss)

Answer 13

**Ascertain gravidity and parity** 1. Gravidity is the number of times a person has been pregnant, regardless of outcome, so in this case she is gravida 3 2. Parity is the number of times a person has delivered a foetus/baby of at least 24 weeks gestation, regardless of mode of delivery or live/stillborn, in this case she is para 0 **Ask gestation** * A question such as "Do you know how far along you are in the pregnancy?" may prompt the patient to tell you **Ask specifically about the last menstrual cycle (LMP)** **Calculate approximate gestation** **Ask about any problems in pregnancy** * May be useful to ask if she has attended any extra appointments or clinics, and if she's attended the GP for anything else **Ask about ultrasound scans** * Remember a normal schedule for ultrasound scans is a "dating" scan at 10-14 weeks and a foetal anomaly scan at 20 weeks. Additional scans are dictated by clinical picture **Ask if any other investigations during pregnancy** **Ask about foetal movements** * Foetal movements are usually not felt until 16-20 weeks gestation, so if she's feeling movements, this suggests she is a later gestation than we think! It's important to tell the patient it's NORMAL not to feel movements at this gestation! Ask about uterine activity E.g. hardening of stomach or cramping Ask about vaginal losses E.g. discharge, fluid, mucous plug, tissue, ??foetus Ask about symptoms of pre-eclampsia if you haven't already (headache, visual disturbance, epigastric pain, oedema) Ask about history of sexually transmitted/pelvic infections

Answer 14

**Cause** * overactive bladder (OAB)/urge incontinence * due to detrusor overactivity **Investigations** * 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 **Management** * 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), tolterodine (immediate release) or darifenacin (once daily preparation) * Immediate release oxybutynin should, however, be avoided in 'frail older women' * mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

Answer 15

**Desmopressin-sublingual/tablet form** * 1-2hrs before Bed time * Warn about excessive drinking and illness * Not used when there is only day time symptoms **Anticholinergic(oxybutynin)** * overactive bladder(detrusor instability) * used with desmopressin used in bedwetting + day time symptom **Tricyclics(imipramine)** * second line * Used in enuresis clinics * More side effects Toxicity in overdose a concern

Answer 16

**Cause (1)** * leaking small amounts when coughing or laughing **Investigations (4)** * 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 **Management (4)** * pelvic floor muscle training - NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months * surgical procedures: e.g. retropubic mid-urethral tape procedures * duloxetine may be offered to women if they decline surgical procedures * a combined noradrenaline and serotonin reuptake inhibitor * mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced

Answer 17

**Management** * look for possible underlying causes/triggers * constipation * diabetes mellitus * UTI if recent onset * emotional trauma **general advice** * fluid intake * toileting patterns: encourage to empty bladder regularly during the day and before sleep * lifting and waking **reward systems (e.g. Star charts)** * NICE recommend these 'should be given for agreed behaviour rather than dry nights' e.g. Using the toilet to pass urine before sleep **enuresis alarm** * generally first-line for children * have sensor pads that sense wetness * high success rate **desmopressin** * particularly if short-term control is needed (e.g. for sleepovers) or an enuresis alarm has been ineffective/is not acceptable to the family

Answer 18

Briefly explains about hypercholesterolaemia Explains the potential complications Explains how statins work Explains that statins are a daily medication Advises the patient to take the medication in the evening Explains that the treatment is lifelong Explains that statins decrease a patient's risk profile over many years Statin prescriptions require regular monitoring. Lipids and LFTs should be performed prior to starting treatment. LFTs should be repeated after three months. Further monitoring is then done yearly. Talks about common side effects Important side effects include rhabdomyolysis, hepatic disorders, and pancreatitisAdvises the patient to let their clinician know about any side effects that they experience Asks the patient to consult with their clinician if they are about to start any new medications Explains to the patient that some types of statin can interact with grapefruit juice Checks for any allergies Asks about current drug history

Answer 19

**Explains the mechanism of action of lithium** * Mood stabiliser - balances the patient's mood in between depression and mania, exact mechanism is unknown. Thought to interfere with neurotransmitter release in the brain. **Explains how the patient should take the medication** * Tablet, to be taken once daily **Explains the duration of treatment** * Usually lifelong, with regular reviews by a psychiatrist **Explains how long it takes for the medication to work** * Takes 1-2 weeks to work **Explains appropriate monitoring tests before initiation:** * FBC * U&Es * TFTs * b-HCG (pregnancy test) * ECG **During treatment:** * Li levels after 5 days, then every week until stable for 4 weeks, them 3-monthly * TFTs, U&Es, Ca should be monitored 6-monthly **Explains some of the important side effects** * Water symptoms: thirst, polyuria, impaired urinary concentration, weight gain, oedema **GI side effects:** * abdominal pain, nausea * Metallic taste * Fine tremor **Explains some of the symptoms of lithium toxicity** * anorexia * diarrhoea * vomiting * dysarthria * dizziness * muscle twitching * tremor * Drowsiness * Apathy * Restlessness **Provides supplementary advice to the patient for further help (e.g. Bipolar UK charity)** **Checks the patient understanding, using "chunk and check" method** **Asks if the patient has any remaining questions**

Answer 20

Explains what Addison's disease is to the patient Explains that without treatment he could become seriously ill Explains the need for him to wear a medical emergency identification bracelet Explains that he will also need a steroid card Explains that these are different steroids to anabolic steroids, and he will not gain muscle mass Explains that he will not experience testicular shrinking Reassures the patient that although steroids do have many potential side effects fertility issues are not considered to be likely Talks briefly through how steroids work with the patient Explains how often he needs to take the steroids Explains that steroids are taken orally as a tablet Discusses the length of treatment Discusses ongoing monitoring requirements Tells the candidate the potential common side effects of steroids Tells the candidate the potential serious side effects of steroids Emphasises the importance of not missing steroid doses Explains to the patient that he should not stop taking the steroids abruptly Talks to the patient about sick day rules for steroids (Patient should take double the dose of steroids if they feel unwell) Explains to the patient that they will need to double their dose of medication if they feel unwell Emphasises that the patient should seek medical help if they are so unwell they cannot take medication orally Gives the patient advice for travelling, for example, they should carry extra medication and an emergency intramuscular injection Advises the patient to let their clinician know about any side effects they experience Ask the patient to consult with their clinician if they are about to start any new medication whilst taking steroids Explains the need for concurrent prescription of alendronate to prevent steroid-induced osteoporosis Checks for any allergies Asks about current drug history

Answer 21

magnesium sulfate 4g

Answer 22

**fluid replacement** * most patients with DKA are deplete around 5-8 litres * isotonic saline is used initially, even if the patient is severely acidotic * please see an example fluid regime below. **insulin** * an intravenous infusion should be started at 0.1 unit/kg/hour * once blood glucose is \< 15 mmol/l an infusion of 5% dextrose should be started **correction of electrolyte disturbance** * serum potassium is often high on admission despite total body potassium being low * this often falls quickly following treatment with insulin resulting in hypokalaemia * potassium may therefore need to be added to the replacement fluids * if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required **long-acting insulin should be continued, short-acting insulin should be stopped**

Answer 23

Establishes patient's current understanding Offers detailed explanation of osteoporosis as a condition Explains possible causes of osteoporosis Discusses lifestyle modifications that can be of benefit Discusses weight bearing exercise Discusses quitting smoking Discusses limiting alcohol Discusses reducing the risk of future falls by addressing high risk activities/ modifying high risk areas of the home e.g. by installing shower rails Recommends calcium and vitamin D supplements for healthy bones

Answer 24

Asks specifically about any previous gastric/ duodenal ulcers Asks about alcohol intake Establishes current medication regime Asks about patient functioning to establish ability to comply with administration requirements Confirms suitability for bisphosphonate therapy Explains action of drug Explains how to take bisphosphonates Explains that it is taken weekly, on the same day each week Explains that it should be taken with a glass of water a minimum of 30 minutes before food Explains that they will need to sit upright for a minimum of 30 minutes following administration Explains that bisphosphonates are a long term medication but do not need to be taken lifelong Explains they would be taken for a minimum 3 years to get the most benefit Explains potential side effects and complications Explains minor side effects of indigestion/ general gastro-intestinal irritation (oesophagitis, diarrhoea, abdominal pain) Explains major potential side effect of osteonecrosis of jaw (rare but serious) Explains need for dental check before starting therapy and to continue with regular dental checks throughout treatment Explains that GI side effects are significantly reduced if administration instructions are followed carefully Explains that if patient is experiencing side effects they should come back to see their GP Explains that in cases where patient's do not tolerate the drug orally there are alternative therapies that can be considered

Answer 25

Checks patient understanding at this stage Explains the risks associated with atrial fibrillation - clot formaiton Explains the indication for rivaroxaban - stroke prevention Clarifies drug as rivaroxaban 20mg once daily Explains that treatment will be life long, or until a decision is made to stop Explains it should be taken at the same time each day Explains that if a dose is missed this can be taken up to 12 hours late Explains not to double dose or take a dose more than 12 hours late (wait until next dose due) Explains if takes a double dose by mistake to speak to a pharmacist, contact his GP or call 111 Reiterates importance of good compliance Explains risks of poor compliance in terms of thrombosis risk Explains side effects and possible complications of therapy Unexplained bruising Bleeding - minor (nosebleeds, increased bruising, small cuts taking longer to stop bleeding) versus major bleeding (intracranial bleeds , intra-abdominal bleeds) Explains appropriate management of self-terminating bleeding episode - advises patient to speak to pharmacist or GP Explains appropriate management of ongoing bleeding, severe bleeding, recurrent episodes of bleeding, rectal bleeding, haematuria or head injury / other major injury - advises patient to go to the Emergency Department for assessment Explains that rivaroxaban can be reversed in the event of significant bleeding or trauma Explains the need to tell dentists/ doctors in the future that he is on this medication due to blood thinning effects Explains that some medications can interact with rivaroxaban Patient should avoid NSAIDs such as ibuprofen Patient should always check with a doctor before starting a new medication Chunks information and regularly checks patient understanding throughout

Answer 26

**mechanical heart valves** * target INR depends on the valve type and location * mitral valves generally require a higher INR than aortic valves. **second-line after DOACs:** * venous thromboembolism: target INR = 2.5, if recurrent 3.5 * atrial fibrillation, target INR = 2.5

Answer 27

Counselling DOACs specifically: Rrivaroxaban is a "blood thinner" and helps reduce the risk of blood clot formation and by extension, the risk of stroke. It is taken once daily as a tablet, the duration of which is lifelong. It doesn't require regular monitoring with blood tests, unlike older medications including warfarin. It will require a one off test of kidney function before starting the medication. It does carry a small risk of serious bleeding events. There are no specific dietary or lifestyle alterations needed. Seeking medical advice is recommended if any unexpected bleeding occurs. Seeking medical advice is recommended if any injuries to the head are sustained, or following any significant falls, as scans will be required to evaluate for internal bleeds.

Answer 28

The regular heartbeat we all have is regulated by a certain parts of your heart called the pacemakers. They also ensure that the heart beats in a co-ordinated manner and hence pumps out blood effectively. In atrial fibrillation, one of the pacemakers has lost its ability to provide control and this results in an irregular heart beat which can affect the heart's effectiveness in pumping blood. This can leave you with palpitations, feeling lightheaded, and dangerously low blood pressure if left unchecked. Often the underlying trigger for this condition cannot be pinpointed. The diagnosis is made by looking at your heart rhythm trace and the unsuccessful attempts at reverting your heart back to normal rhythm. If left untreated, it carries a risk of blood clot formation which itself can lead to stroke. It can also be worsened by alcohol, infections, caffeine. A long term (lifetime) treatment will be required as attempts to reverse the heart rhythm to its normal state have failed. Early initiation of treatment is highly recommended to minimise the long term risk of stroke.

Answer 29

regular emollients may help to reduce scale loss and reduce pruritus **first-line: NICE recommend:** * a potent corticosteroid applied once daily plus vitamin D analogue applied once daily * should be applied separately, one in the morning and the other in the evening) * for up to 4 weeks as initial treatment **second-line: if no improvement after 8 weeks then offer:** * a vitamin D analogue twice daily **third-line: if no improvement after 8-12 weeks then offer either:** * a potent corticosteroid applied twice daily for up to 4 weeks, or * a coal tar preparation applied once or twice daily * short-acting dithranol can also be used

Answer 30

Management ## Footnote topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques) topical brimonidine gel may be considered for patients with predominant flushing but limited telangiectasia more severe disease is treated with systemic antibiotics e.g. Oxytetracycline recommend daily application of a high-factor sunscreen camouflage creams may help conceal redness laser therapy may be appropriate for patients with prominent telangiectasia patients with a rhinophyma should be referred to dermatology

Answer 31

* avoid irritants * simple emollients * large quantities should be prescribed (e.g. 250g / week), roughly in a ratio of with topical steroids of 10:1 * if a topical steroid is also being used the emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid * creams soak into the skin faster than ointments * emollients can become contaminated with bacteria - fingers should not be inserted into pots (many brands have pump dispensers) * topical steroids * wet wrapping * large amounts of emollient (and sometimes topical steroids) applied under wet bandages * in severe cases, oral ciclosporin may be used