Long term conditions

Question 1

Vit D def risk factors

Answer 1

Pigmented skin
• Use of sun cream/concealing clothes
• Old age
• Nursing home
• Malabsorption
• Short bowel
• Renal disease
• Cholestatic liver disease
• Drugs (anticonvulsants, rifampicin, HAART)

Question 2

Vit D présentation

Answer 2

• Proximal muscle weakness/pain (osteomalacia may be asymptomatic)
• ↓ bone density on DEXA or osteopenia on plain x-ray may indicate vitamin D deficiency
• Severe vitamin D deficiency causes hypocalcaemia, tetany, seizures
• Rickets in children presents with deformities (knock knees, bowed legs) and impaired growth

Question 3

Investigations for Vitamin D Deficiency

Answer 3

• ↓ serum 25-hydroxy-D3
• <25mmol/Linosteomalacia
• 25-50mmol/LinvitaminDinsufficiency
• ↑ ALP, PTH
• ↓/normal phosphate and calcium
• X-ray shows characteristic defective mineralisation and Looser’s pseudofractures (low density bands running perpendicular to the cortex, commonest in femur/pelvis)

Question 4

Management of Vitamin D Deficiency

Answer 4

Vitamin D supplementation
• Initial loading dose stage and subsequent maintenance
phase (oral/IM)
• Supplementary calcium (1000-1200mg/day)
• e.g. Cholecalciferol / calcichew

Question 5

RA presentation

Answer 5

• Insidious onset of pain, early morning stiffness (>30 mins)
• Symmetrical swelling of proximal joints of hands/feet
• PIPJs affected, but DIPJs not affected
• Ulnar deviation, MCP/PIPJ swelling, Z-shaped thumb, Boutonniere deformity, Swan-neck deformity
• May also involve wrists, elbows, shoulders, cervical spine, knees, ankles, feet

Question 6

joints for RA

Answer 6

• PIPJs affected

MCP/PIPJ swelling, Z-shaped thumb, Boutonniere deformity, Swan-neck deformity

Question 7

Investigation for RA

Answer 7

Investigations for Rheumatoid Arthritis
• FBC: Normochromic, normocytic anaemia; thrombocytosis
• ESR, CRP raised in proportion with inflammatory activity
• Rheumatoid Factor (RhF) not specific for RA
• Anti-CCP
• X-ray
• Synovial fluid: sterile, raised neutrophils

Question 8

Management of Rheumatoid Arthritis

Answer 8

• NSAIDs and Coxibs (± Paracetamol, codine)
• Relieve pain but do not slow disease progression
• Corticosteroids
• Suppress disease activity but require high doses (short-term use)
• Disease Modifying Anti-Rheumatic Drugs (DMARDs); start <6 weeks from first presentation
• Methotrexate (mouth ulcers, diarrhoea, liver fibrosis, pulmonary fibrosis, renal impairment,
teratogenic)
• Sulfasalazine (mouth ulcers, hepatitis, reversible male infertility)
• Leflunomide (diarrhoea, hypertension, hepatitis, alopecia)
• Biologics
• TNF-α blockers (CXR before starting; immunosuppression risks latent TB)
• Stop smoking

Question 9

Clinical Features of Psoriatic Arthritis

Answer 9

Peripheral arthritis
• Absence of RhF or Anti-CCP (“seronegative”)
• DIPJ swelling
• Dactylitis (“sausage fingers”)
• Arthritis mutilans is a severe form with destruction of small bones in hands and feet

Question 10

Investigations for Psoriatic Arthritis

Answer 10

Routine bloods, ESR normal
• RhF, anti-CCP negative
• X-ray: “pencil-in-cup” deformity in IPJs

Question 11

Management of Psoriatic Arthritis

Answer 11

• NSAIDs ± paracetamol
• Intra-articular corticosteroid injections
• If severe, methotrexate/TNF-α blockers
• Emollients for skin disease

Question 12

Parathyroid hormone (PTH)

Answer 12

Kidney→increased calcium resorption and reduced reabsorption of phosphate convert vitamin D to active form
Bone→release of calcium
Small intestine→increased absorption of dietary calcium

Question 13

Primary Hyperparathyroidism causes

Answer 13

Primary = Hypersecretion of PTH Causes:
• 85% isolated parathyroid adenoma
• 15% diffuse parathyroid hyperplasia
• <1% parathyroid carcinoma

Question 14

Primary Hyperparathyroidism presentation

Answer 14

PTH - raised
Calcium - increased
phosphate decreased

Question 15

2ndary Hyperparathyroidsim causes

Answer 15

Causes:
• Chronic kidney disease
• Vitamin D deficiency

Question 16

2ndary Hyperparathyroidsim presentation

Answer 16

PTH - raised
Calcium - low or normal
phosphate increased or decreased

Question 17

Hypercalcaemia presentation

Answer 17

Thirst
• Increased urination
• Constipation
• Bone pain
• Fatigue
• Depression
• Confusion
• Kidney stones
• Palpitations

Question 18

Hypoparathyroidism = Reduced or absent PTH

Answer 18

PTH low
Calcium decreased
Phosphate increased

Question 19

Clinical Features of Paget’s Disease of bone

Answer 19

Common sites: pelvis, femur, lumbar spine, skull, tibia
• Most cases asymptomatic
• Pain in bone/nearby joint (cartilage/adjacent bone damage)
• Deformities: enlargement of skull, bowing of tibia
• Complications: nerve compression (deafness, paraparesis), pathological fractures, high output heart failure, osteosarcoma

Question 20

Investigations for Paget’s Disease

Answer 20

• ↑ ALP (reflects level of bone formation) • Often >1000 u/L
• Normal Ca2+, PO43-
• Urine hydroxyproline excretion ↑
• X-ray shows localised bony enlargement and distortion, sclerotic changes (↑ density) and osteolytic areas (loss of bone and ↓ density)
• Radionucleotide bone scan shows ↑ uptake of bone- seeking radionucleotides

Question 21

Management of Paget’s Disease

Answer 21

• Bisphosphonates (zoledronate IV)
• Inhibitboneresorptionby↓osteoclasticactivity
• Indicated in symptomatic patients and asymptomatic patients at risk of complications
• Disease activity monitored by serum ALP or urinary hydroxyproline

Question 22

Osteoporosis vs Osteopenia

Answer 22

Osteoporosis = bone mineral density >2.5 SD below young adult mean value (T-score ≤ –2.5)
•Osteopenia = T-score –1 to –2.5

Question 23

Risk Factors for Osteoporosis

Answer 23

• ↑ age
• Previous fragility fracture • Family history of #NOF
• ↓ BMI
• Smoking
• Alcohol abuse
• Glucocorticoid therapy
• ↑ bone turnover
• ↑ risk of falls
• Rheumatoid arthritis

Question 24

Clinical Features of Osteoporosis

Answer 24

• Symptoms result from fractures, typically • Thoracicvertebrae
• Lumbarvertebrae
• Proximalfemur
• Distal radius (Colles’ fracture)
• Thoracic vertebral fractures may lead to kyphosis and loss of height (“widow’s stoop”)

Question 25

Osteoporosis tests

Answer 25

X-rays detect fractures but are insensitive for osteopenia • Dual Energy X-ray Absorptiometry (DEXA) • Gold standard measurement of bone mineral density • Indicated in radiographic osteopenia, previous fragility fracture (<75 years), glucocorticoid therapy (<65 years), BMI <19, maternal history #NOF, BMD-dependent risk factors • FRAX assessment tool • Estimates 10 year probability of osteoporotic fracture for untreated patient aged 40-90

Question 26

Management of Osteoporosis

Answer 26

• New vertebral fractures require bed rest for 1-2 weeks and strong analgesia • Muscle relaxants (e.g. diazepam), calcitonin SC, pamidronate IV • Non-spinal fractures treated by orthopaedics • Stop smoking, ↓ alcohol, adequate dietary calcium/vitamin D, regular weightbearing exercises • Elderly: physiotherapy, assessment of home safety to ↓ risk of falls, hip protectors as required medical • Bisphosphonates (e.g. alendronate, risedronate, zoledronate); inhibit osteoclasts, ↑ bone mass at hip/spine, ↓ fracture incidence • Denosumab (monoclonal Ab to RANKL) SC 6 monthly; anti- resorptive agent, ↑ bone mineral density, ↓ fracture incidence • Selective oestrogen-receptor modulators (SERMs, e.g. raloxifene, bazedoxifene); activate bone oestrogen receptors (not endometrial oestrogen receptors) • Recombinant human parathyroid peptide 1-34 (teriparatide); stimulate bone formation, indicated in severe/refractory osteoporosis • Oestrogen therapy (e.g. HRT); early post-menopausal women • Testosterone; men with evidence of hypogonadism

Question 27

Microbial keratitis causes

Answer 27

Microbial keratitis Infection of the cornea causing an epithelial breach with underlying stromal involvement Broad range of causes: • Bacterial – most common • Protozoan (acanthoemeba) – uncommon but severe • Fungus – rare in UK (common elsewhere) • Viral – HSV, VZV

Question 28

Bacterial keratitis: organisms

Answer 28

Common organisms: Pseudomonas Aeruginosa Staphylococcus Aureus Streptococci (pyogenes, pneumonia) Neisseria Gonorrhoeae

Question 29

Bacterial keratitis: risk factors

Answer 29

``` Risk factors: *Contact lens wear* • Extended wear • Poor hygiene • Swimming/shower/sleeping Trauma Ocular surface disease Immunosuppression/diabetes/vit A def ```

Question 30

microbial keratitis symtoms

Answer 30

Symptoms and signs: Painful red eye, watering and photopobia White infiltrate on the cornea with overlying epithelial defect

Question 31

Bacterial keratitis management

Answer 31

Rx: Topical antibiotics (moxifloxacin). Stop contact lens wear for now

Question 32

fungal keratitis symtoms

Answer 32

Symptoms and signs: Gradual onset of pain, blurred vision, watery, red eye and photophobia. White fluffy lesion on cornea, filamentary or satellite lesions +/- hypopyon (white blood cells)

Question 33

fungal keratitis management

Answer 33

Rx: topical amphotericin/natamycin + antibacterial drops. | Slower recovery, long treatment duration

Question 34

Acanthamoeba keratitis:

Answer 34

``` Ubiquitous protozoa in soil, water and upper respiratory tract Cystic, highly resilient Risk factors: *Contact lens wear* • Extended wear • Poor hygiene • Swimming/shower/sleeping Trauma ```

Question 35

Acanthamoeba keratitis: symtoms

Answer 35

Symptoms: Blurred vision, red eye and severe disproportionate pain Signs: Early subtle signs such as white lines and later circular ring infiltrate

Question 36

Acanthamoeba keratitis: treatment

Answer 36

Treatment: topical amoebicides (polyhexamethylene biguanide PHMB +/- chlorhexidine) Later corneal transplant if scarring

Question 37

Viral keratitis:

Answer 37

Common organisms: Herpes simplex Herpes zoster Risk factors: History of cold sores or other herpetic rashes History of trauma Atopy/ocular surface disease Poor sanitation Immunosuppression/diabetes

Question 38

Viral keratitis: symtoms

Answer 38

Symptoms: mild discomfort, red eye, watering, photophobia and blurred vision Signs: Red eye with dendritic corneal ulcer staining with fluorescein. Reduced corneal sensation.

Question 39

Viral keratitis treatment

Answer 39

Treatment: topical antiviral (acyclovir or ganciclovir) 5 x day for around 2 weeks

Question 40

keratitis tests

Answer 40

Not always enough to recognize aetiology clinically so will need lab diagnosis via corneal scrape Empirical cover with hourly topical antibiotic with 48 hour review Contact lens education important

Question 41

gout what is this - things that cause this

Answer 41

Impaired renal excretion of uric acid • Drugs (e.g. thiazide diuretics, low-dose aspirin) • Hypertension • Hypothyroidism • Primary hyperparathyroidism • Increased lactic acid production (e.g. alcohol, exercise, starvation)

Question 42

gout investigations

Answer 42

* Serum uric acid – raised * RhF, anti-CCP negative * Synovial aspiration * Negatively birefringent needle-shaped sodium urate crystals = normal gout

Question 43

gout management

Answer 43

• NSAIDs • Colchicine; high dose for 24 hours, tapered doses for 1 week • Weight loss, reduce alcohol, rationalise diuretics • Low purine diet (spinach, shellfish, offal) • Allopurinol (start 2 weeks after acute gout) or febuxostat

Question 44

gout aspiration

Answer 44

Negatively birefringent needle-shaped sodium urate crystals = normal gout

Question 45

red flags in back pain

Answer 45

``` RED FLAG SYMPTOMS: • Extremes of age <20 or >55 years • Acute onset pain • History of malignancy • History of trauma • Immunocompromised- HIV, long term steroids • Systemic symptoms: fever, night sweats, loss of weight • Thoracic pain • Pain at rest or night pain • Focal or progressive neurological deficit • Urinary or bowel disturbance • Disturbed gait, saddle anaesthesia ```

Question 46

back pain ddx

Answer 46

``` Mechanical back pain: • Spondylosis • Spondylolithesis • Intervertebral disc prolapse • Spinal stenosis (claudication pain) • Apophyseal joint disease • Musculoskeletal • Non specific back pain ``` Referred back pain: • Aortic aneurysm • Pyelonephritis, renal calculus • Pancreatitis, duodenal ulcer ``` Sinister causes: • Infection (discitis/ epidural abscess) • Malignancy (primary spinal or bony metastases) • Cauda equina or metastatic compression of the spinal cord • Multiple myeloma • Traumatic spinal fracture • Osteoporotic crush fracture • Paget’s disease ``` Inflammatory - Rheumatoid arthritis Seronegative spondyloarthritides Psoriatic Ankylosing spondylitis Reiter’s syndrome Enteropathic

Question 47

Investigations back pain

Answer 47

Pathway for investigating back pain • XR of the spine +/- CXR (for ?malignancy) • FBC and ESR (elevated in sinister causes) • Biochemical profile (calcium, ALP and phosphate) • Immunoglobulins, protein electrophoresis, Bence jones protein and urine protein electrophoresis (myeloma) • PSA (prostate)

Question 48

managment back pain

Answer 48

Management: Analgesia, rest, exercises, physiotherapy, appropriate referral to a specialist if findings from investigation or not improving after 2-3 weeks

Question 49

Clinical Features of Ankylosing Spondylitis

Answer 49

Clinical Features of Ankylosing Spondylitis • Asymmetrical peripheral arthritis • Absence of RhF or Anti-CCP (“seronegative”) • Loss of lumbar lordosis and increased kyphosis • Limitation of lumbar spine mobility in both sagittal and coronal planes • Abnormal Schober’s test

Question 50

Investigations for Ankylosing Spondylitis

Answer 50

``` Investigations for Ankylosing Spondylitis • ESR, CRP raised • RhF, anti-CCP negative • X-ray: bamboo spine (or normal) • MRI: sacroilitis ```

Question 51

Management of Ankylosing Spondylitis

Answer 51

``` Management of Ankylosing Spondylitis • Morning exercises • NSAIDs; slow release, taken at night • Methotrexate (helps peripheral arthritis, not spinal disease) • TNF-α blockers ```

Question 52

6 associated A’s of Ankylosing Spondylitis

Answer 52

6 associated A’s of Ankylosing Spondylitis 1. Apical pulmonary fibrosis 2. Anterior uveitis 3. Aortic regurgitation 4. Achilles’ tendonitis 5. AV node block 6. Amyloidosis

Question 53

Pesudogout associated conditions

Answer 53

haemochromatosis, hyperparathyroidism, Wilson’s disease, alkaptonuria

Question 54

Acute CPP crystal arthritis (“Pseudogout”) presentation

Answer 54

* Acute CPP crystal arthritis (“Pseudogout”) * Mono-/oligo-arthritis * Most commonly affects knees; also wrists, shoulders, ankles, hands, feet * Joint pain and swelling * Mayhaveassociatedfever

Question 55

Chronic CPP crystal inflammatory arthritis presentation

Answer 55

Chronic CPP crystal inflammatory arthritis • Destructive changes (similar to osteoarthritis) • Progressive destruction may lead to neuropathic joint • Usuallyaffectsknees,wrists,shoulders,hips

Question 56

pseudogout cystals

Answer 56

Positively birefringent rhomboidal calcium pyrophosphate crystals

Question 57

management of Pesudogout

Answer 57

Management of Pesudogout • NSAIDs • Colchicine; high dose for 24 hours, tapered doses for 1 week • Local corticosteroids – must exclude septic arthritis

Question 58

red flags in chronic pain

Answer 58

``` Age less than 20 greater than 55 Neurological symptoms/signs Trauma Thoracic back pain History of cancer Weight loss Systemic symptoms Pain incapacitating/worsening Deformity ```

Question 59

Yellow flags - Psychosocial risk factors for chronic pain

Answer 59

Belief that back pain is potentially severely disabling Fear avoidance behaviour Low mood and social withdrawal Expectation of passive treatment rather than the belief that active participation will help

Question 60

There is no rationale for using strong opioids in chronic pain use?

Answer 60

gabapentin | amitriptyline

Question 61

AST:ALT

Answer 61

chronic liver disease | <1 (i.e. more ALT) suggests chronic liver disease/non-alcoholic; >1 suggests cirrhosis; >2 suggests alcoholic disease

Question 62

cholestasis LFT's

Answer 62

Increased ALP raised GGT

Question 63

ALP increase more than ALT

Answer 63

extrahepatic problem – usually obstruction e.g. gall stones; can be seen also in primary biliary cirrhosis and primary sclerosing cholangitis

Question 64

Indicators of liver damage

Answer 64

ALT AST ALP GGT – useful to discern if raised ALP is due to liver or bone (or rarely another) pathology

Question 65

Indicators of liver synthetic function

Answer 65

Bilirubin Albumin INR

Question 66

LFT's | Obstructive aka Cholestatic Pattern

Answer 66

High bilirubin High ALP Normal ALT

Question 67

LFTs | Hepatitic Pattern –

Answer 67

Very high ALT – between 200- 2000 U/L Varying bilirubin – the higher the level, the greater the degree of damage Slightly raised ALP – should be no higher than 2x normal. Increased prothrombin time – usually will be slightly raised. In cases of severe liver failure it may exceed 25 seconds

Question 68

hepatocellular injury.

Answer 68

A greater than 10-fold increase in ALT and a less than 3-fold increase in ALP

Question 69

cholestasis.

Answer 69

less than 10-fold increase in ALT and a more than 3-fold increase in ALP

Question 70

cause of jaundice:

Answer 70

Normal urine + normal stools = pre-hepatic cause Dark urine + normal stools = hepatic cause Dark urine + pale stools = post-hepatic cause (obstructive)

Question 71

Common causes of acute hepatocellular injury

Answer 71

Poisoning (paracetamol overdose) Infection (Hepatitis A and B) Liver ischaemia

Question 72

Common causes of chronic hepatocellular injury

Answer 72

Alcoholic fatty liver disease Non-alcoholic fatty liver disease Chronic infection (Hepatitis B or C) Primary biliary cirrhosis

Question 73

monitoring requirements | Statins

Answer 73

LFTs at baseline, 3 months and 12 months

Question 74

monitoring requirements | Ace inhibitors

Answer 74

U&E prior to treatment U&E after increasing dose U&E at least annually

Question 75

Amiodarone | monitoring requirements

Answer 75

TFT, LFT, U&E, CXR prior to treatment | TFT, LFT every 6 months

Question 76

Azathioprine | monitoring requirements

Answer 76

FBC, LFT before treatment FBC weekly for the first 4 weeks FBC, LFT every 3 months

Question 77

Lithium | moitoring requirements

Answer 77

TFT, U&E prior to treatment Lithium levels weekly until stabilised then every 3 months TFT, U&E every 6 months

Question 78

Sodium valproate | monitoring requirements

Answer 78

LFT, FBC before treatment | LFT 'periodically' during first 6 months

Question 79

!st line depression

Answer 79

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression citalopram and fluoxetine are currently the preferred SSRIs sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated.

Question 80

Adverse effects of SSRI's

Answer 80

dverse effects gastrointestinal symptoms are the most common side-effect there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI fluoxetine and paroxetine have a higher propensity for drug interactions

Question 81

Citalopram and the QT interval

Answer 81

it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment

Question 82

SSRI's interactions

Answer 82

Interactions NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a proton pump inhibitor warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine aspirin: see above triptans - increased risk of serotonin syndrome monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

Question 83

SSRI discontinuation

Answer 83

When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms. ``` Discontinuation symptoms increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia ```

Question 84

SSRI's and pregnancy

Answer 84

SSRIs and pregnancy - 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

Question 85

Lithium use and Mode of action

Answer 85

Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys. Mechanism of action - not fully understood, two theories: interferes with inositol triphosphate formation interferes with cAMP formation

Question 86

Lithium adverse effects

Answer 86

nausea/vomiting, diarrhoea fine tremor nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus thyroid enlargement, may lead to hypothyroidism ECG: T wave flattening/inversion weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia

Question 87

lithium moitoring

Answer 87

when checking lithium levels, the sample should be taken 12 hours post-dose after starting lithium levels should be performed weekly and after each dose change until concentrations are stable once established, lithium blood level should 'normally' be checked every 3 months after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable. thyroid and renal function should be checked every 6 months patients should be issued with an information booklet, alert card and record book

Question 88

Olanzapine specific side effects

Answer 88

dyslipidemia and weight gain, and is also associated with diabetes and sedation.

Question 89

Quetiapine specific side effects

Answer 89

weight gain and dyslipidemia. | posteural hypertension

Question 90

Clozapine specific side effects

Answer 90

f agranulocytosis and full blood count monitoring is therefore essential during treatment reduced seizure threshold - can induce seizures in up to 3% of patients constipation myocarditis: a baseline ECG should be taken before starting treatment hypersalivation

Question 91

Risperidone specific side effects

Answer 91

extrapyramidal side effects, as well as cause postural hypotension and sexual dysfunction.

Question 92

Symptoms of mania in primary care:

Answer 92

Urgent referral to CMHT

Question 93

Duloxetine mechanism of action

Answer 93

serotonin and noradrenaline reuptake inhibitor

Question 94

OCD associations

Answer 94

``` Associations depression (30%) schizophrenia (3%) Sydenham's chorea Tourette's syndrome anorexia nervosa ```

Question 95

reverse dystonia which may be induced by haloperidol.

Answer 95

procyclidine

Question 96

Extrapyramidal side-effects (EPSEs) of antipsychotics

Answer 96

Parkinsonism acute dystonia: sustained muscle contraction (e.g. torticollis, oculogyric crisis) akathisia (severe restlessness) tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw) EPSEs may be managed with procyclidine

Question 97

diagnosis of depression over dementia

Answer 97

short history, rapid onset biological symptoms e.g. weight loss, sleep disturbance patient worried about poor memory reluctant to take tests, disappointed with results mini-mental test score: variable global memory loss (dementia characteristically causes recent memory loss)

Question 98

Alcohol withdrawal timeline

Answer 98

symptoms: 6-12 hours seizures: 36 hours delirium tremens: 72 hours

Question 99

Alcohol withdrawa

Answer 99

Management patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised first-line: benzodiazepines e.g. chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol carbamazepine also effective in treatment of alcohol withdrawal phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures

Question 100

Management of generalised anxiety disorder (GAD)

Answer 100

NICE suggest a step-wise approach: step 1: education about GAD + active monitoring step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups) step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information step 4: highly specialist input e.g. Multi agency teams

Question 101

Drug treatment | generalised anxiety disorder (GAD)

Answer 101

NICE suggest sertraline should be considered the first-line SSRI if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) examples of SNRIs include duloxetine and venlafaxine If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Question 102

panic disorder drug treatment

Answer 102

Treatment in primary care NICE recommend either cognitive behavioural therapy or drug treatment SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offere

Question 103

Schizoid personality disorder is characterized by at least 3 of the following:

Answer 103

Few, if any, activities, provide pleasure; Emotional coldness, detachment or flattened affectivity; Limited capacity to express either warm, tender feelings or anger towards others; Apparent indifference to either praise or criticism; Little interest in having sexual experiences with another person (taking into account age); Almost invariable preference for solitary activities; Excessive preoccupation with fantasy and introspection; Lack of close friends or confiding relationships (or having only one) and of desire for such relationships; Marked insensitivity to prevailing social norms and conventions.

Question 104

mirtazapine,

Answer 104

works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters. Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.