Miscellaneous Flashcards
(171 cards)
1
Q
What is primary focal hyperhidrosis and what are the diagnostic criteria?
A
It is excessive sweating of a benign cause, sometimes running in families.
Diagnostic criteria:
Typically symmetrical, bilateral sweating
Sweating eases off at night and there is no focal nocturnal sweating
Age of onset < 25 years
Affecting ADLs
Frequency of at least 1x episode per week
Positive family history
Features that suggest alternative cause are onset > 25, night sweats and uniliateral.
2
Q
In which circumstances should urine MCS be sent from GP if suspecting a UTI?
A
Treat on clinical suspicion / positive dip generally
Ensure send MCS if
> 65
Visible OR non-visible haematuria
Pregnant women symptomatic of UTI (always treat for 7/7, even if asymptomatic bacteruria in pregnancy due to risk of ascending infection, send repeat urine MCS after completing abx for test of cure)
Men with suspected UTI (also treated for 7/7)
3
Q
What is the Widowed Partner’s Allowance?
A
This is a payout from the government to someone who’s spouse or civil partner has died and they have dependent children.
They are eligible until their oldest child leaves full time education or they reach retirement age or they REMARRY whichever is sooner
The payout is dependent on the deceased having made sufficient national insurance contributions while alive
4
Q
What is the funeral payment?
A
This is a ONE-OFF payment to the partner or parents of the deceased if they are ON BENEFITS to help pay for a funeral
5
Q
What is the bereavement support payment?
A
This is a lumpsum and then 18 monthly payments that you are eligible for if you are under the state pension age when your partner dies.
This is dependent on sufficient national insurance contributions
The amount given changes depending on whether you are also on benefits
6
Q
True or false - beta blockers can reduce hypoglycaemic awareness in diabetics / those on insulin?
A
TRUE
Beta blockers can block the adrenergic mediated response to hypoglycaemia and so diabetics should be cautioned re this
7
Q
According to the GMC, what is the most common monitoring error in prescribing?
A
Failing to order the appropriate monitoring test
8
Q
What is the FRAMEs model of communication and for what can it be used for?
A
FRAMES is a brief intervention / motivational interview approach that can be used e.g for those with drug abuse.
Feedback, Recommendations, Advice, Menu of Options, Empathy and Self-efficacy
9
Q
How do you calculate the number of units in an alcoholic drink?
A
The volume (ml) x the ABV (alcohol by volume e.g 9%) divided by a 1,000
10
Q
What associated medical conditions have an increased prevalence in Down’s syndrome?
A
Hypothyroidism
Type I DM (no ^ risk of Type 2 DM in Down’s!)
Congenital heart disease
Congenital GIT abnormalities
Atlanto-axial instability
Alzheimer’s
Leukaemia
Cataracts
Deafness
11
Q
What is the standard recommended dose of vitamin D recommended for adults in the UK?
A
400 IU / 10 mcg per day for everyone aged over 1 years including during pregnancy and breast feeding
12
Q
What age range is faecal calprotectin recommended for use as a screening tool in primary care for IBD?
A
18 - 60
Not recommended > 60. If fit negative, then refer if concerns
13
Q
True or false - paternity testing can be offered on the NHS?
A
FALSE
GPs should direct patients requesting paternity testing to private providers. NOT provided on the NHS
14
Q
What is the most common cause of vitamin B12 deficiency in adult, especially elderly adults?
A
Food-cobalamin malabsorption
Food-cobalamin malabsorption is the inability to absorb vit B12 from food despite adequate oral intake. It is very common in the elderly. It is mainly caused by atrophic gastritis which can be caused by multiple factors including long-term PPI use, metformin, H.pylori infection or age-related gastric atrophy.
It does respond to high dose oral Cobalamin so can save them needing IM B12 like in pernicious anaemia
15
Q
What are the criteria for an URGENT referral for obstructive sleep apnoea?
A
Drive for a living or a job for which vigilance is essential
Pregnant
Undergoing preoperative major surgery
Unstable cardiovascular disease (uncontrolled HTN, uncontrolled arrhythmia or nocturnal angina)
Non-arteritic anterior ischaemic optic neuropathy
16
Q
What is the definition of obesity class I, II and III
A
Class I = BMI 30-35
Class II = BMI 35-40
Class III = BMI > 40
(Overweight = BMI 25 and over)
17
Q
What is the minimum amount of moderate and vigorous activity that an adult should do each week?
A
Should do at least 150 minutes of moderate intensity activity (brisk walking or cycling) OR 75 minutes of vigorous intensity activity
18
Q
What does the MUST screening tool screen for?
A
Malnutrition Universal Screening Tool
Screens for those that are malnourished, at risk of malnourishment or obese
19
Q
What IQ levels define mild, moderate, severe and profound learning disability respectively?
A
Mild = 50-70
Moderate - 35 - 50
Severe - 20 - 35
Profound - < 20
20
Q
Which cancers does Epstein Barr infection confer a greater risk of ?
A
Nasopharyngeal cancer
Lymphoma
21
Q
What are the age-related doses for IM BenPen in suspected meningococcal meningitis?
A
< 1 = 300mg
1 - 9 = 600mg
10+ and adults = 1200 mg
22
Q
What antibody test is used to screen for pernicious anaemia?
A
Intrinsic factor
23
Q
How much moderate physical activity is needed per day to protect from obesity and how much should people that have previously been obese aim to do to prevent relapse?
A
45-60 mins moderate activity per day to prevent obesity
If prev obese, recommended to do 60-90 minutes mod activity per day to prevent relapse
24
Q
What is the daily recommended calcium intake for adults?
A
700 - 1200mg per day
25
For adults with osteopenia/osteoporosis, what dose of calcium and vitamin D should they be having daily?
1200mg calcium & 400-800 IU of Vitamin D
(If dietary calcium is inadequate ie less than 700mg then prescribe at least 1,000 mg calcium and 400IU Vit D if not exposed to much sunlight, 800IU if elderly or in a care home)
26
What is the minimum visual acuity required to be allowed to drive group 1 vehicles (cars and motorbikes)?
Must have at least 6/12 vision with both eyes open and must have adequate visual fields
27
What is the inheritance pattern for duchenne muscular dystrophy?
X Linked Recessive (only boys can get it)
2/3rds of cases inherited from the maternal line
1/3 occurs from spontaneous mutation (so mother NOT always a carrier)
A mother that is a carrier has a 50% chance of passing it on. So 50% chance her daughter will be a CARRIER and 50% chance her son will be affected.
28
What is the presentation of obesity hypoventilation syndrome?
Obesity + raised pCO2 when awake + breathing abnormalities when asleep e.g OSA
29
Melatonin is licensed for short term use in insomnia for patients over which age?
Over 55
30
How do you calculate ABPI?
ABPI = the highest recorded systolic blood pressure in the affected leg / the highest blood pressure recorded in either arm
31
What are the NICE guidelines on initiating medication in type II diabetes?
Assess if current heart failure or atherosclerotic disease (angina, CVD, TIA, stroke, peripheral arterial disease) - if so then metformin & SGLT2 (Dapagliflozin, empagliflozin) from the off-set
If not the above but QRIsk > 10% then CONSIDER metformin & SGLT2 dual therapy from the off-set
(If metformin contraindicated for either of the above groups, start with SGLT2 inhibitor monotherapy)
If neither of the above, then start with metformin monotherapy
If HBA1C not meeting targets on metformin & SGLT2 then add in 3rd oral agent (DPP4 inhibitor (the gliptins e.g Sitagliptin), sulphonylureas (gliclazide) or Pioglitazone)
NICE recommend addition of GLP-agonists if not got good control on triple therapy AND BMI 35+ (
or < 35 but insulin would have significant occupational risks OR weightloss would benefit other obesity related complications)
If need initial rescue therapy (e.g symptomatic with very high glucose level) then give either insulin or a sulphonylurea (Gliclazide) initially to bring down blood sugars quickly and then re-review once better controlled
If Type II DM & CKD then should be on max tolerated ACEi AND an SGLT2 inhibitor if ACR > 30 (consider SGLT2 if ACR >3)
32
What are the 2 types of psychological therapies recommended by NICE for use in chronic pain syndromes?
CBT & Acceptance and Committment therapy
33
What pain management options are recommended by NICE for chronic primary pain?
CBT & Acceptance and Commitment therapy
Simple analgesia (paracetamol & ibuprofen) -> if not effective offer anti-depressant (Duloxetine, Amitriptyline, Paroxetine, Sertraline, Citalopram etc)
34
What is the most common type of domestic abuse?
Coercive control
(an act or pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish or frighten their victim’.)
35
If you suspect vitamin b12 deficiency in pregnancy, what test should you order to confirm it?
Serum total B12 not reliable in pregnancy as goes down in normal pregnancies without a true deficiency being present
Test serum holotranscobalamin (active B12) in pregnancy
36
What is the risk of ovarian and breast cancer respectively in patients that carry BRCA 1 or 2 mutations?
40-60% risk of ovarian cancer
65-85% risk of breast cancer
37
What is the inheritance pattern of BRCA1 / 2 mutations? A
Autosomal dominant
38
Which cancers are male carriers of BRCA 1 or 2 mutations at higher risk of?
Male breast cancer
Prostate cancer
Pancreatic cancer
39
What intervention can reduce the risk of colorectal cancer for patients with Lynch syndrome?
Aspirin 150mg per day
Colonoscopy surveillance every 2 years from aged 20-25
Screen for H.Pylori as increases risk of bleeding if on long-term aspirin and also increases the risk of gastric cancer in those with Lynch syndrome
40
What is the inheritance pattern of Lynch syndrome?
Autosomal dominant
41
The NICE guidelines recommend testing Vit B12 levels in patients that have 1x sign / symptom and 1x risk factor for B12 deficiency - what are the common signs/symptoms?
Anaemia or macrocytosis on FBC
Unexplained fatigue
Glossitis
Cognitive dysfunction / brain fog
Optic nerve dysfunction (blurred vision, visual field loss (scotoma), optic nerve atrophy)
Symptoms of subacute combined degeneration of the spinal cord (affects dorsal column, get peripheral pins and needles in the legs, then spastic weakness (UMN signs)
Signs or symptoms that anaemia is not resolving despite iron in pregnancy
42
The NICE guidelines recommend testing Vit B12 levels in patients that have 1x sign / symptom and 1x risk factor for B12 deficiency - what are the common risk factors?
A personal or family history of other autoimmune condition
A family history of B12 deficiency
Vegan / veggie diet or restricted diet due to egg/fish allergies, ED or poor income
Medicines that impair B12 absorption (metformin, colchicine, ranitidine / PPIs, pregabalin, topiramate)
Gastrectomy or terminal ileal resection
43
What common factors can falsely affect B12 levels?
COCP - can lower total B12 levels without actually causing a deficiency
OTC multivitamins containing B12 can show the level to be normal when there could be a deficiency that's under-treated
44
If you suspect Vit B12 deficiency in pregnancy, which test should you order to confirm?
Active B12 levels (holotranscobalamin)
45
Which total B12 levels (cobalamin) would suggest a confirmed deficiency, an intermediate result and a confirmed normal result?
Cobalamin < 180 nannograms - confirmed deficiency
180 - 350 = intermediate result - consider testing methylmalonic acid
Cobalamin > 350 nannograms - B12 deficiency unlikely
46
For patients with an initial indeterminate total B12 result, NICE recommend testing for methylmalonic acid. For which patients with an interdeterminate result does NICE recommend starting treatment while waiting?
If suspect autoimmune gastritis / pernicious anaemia
If pregnant or breast-feeding
If prev gastric / illeal surgery or resection
47
If you suspect autoimmune gastritis / pernicious anaemia, which antibody should you check to confirm it?
Anti Intrinsic Factor Antibody
48
Anti intrinsic factor is not always positive in everycase of autoimmune gastritis. If it's negative but you strongly suspect it, what further test should you do?
Anti gastric parietal cell antibody
or
Cobasorb test to see if B12 is getting absorbed
49
For which patients with B12 deficiency do NICE recommend lifelong IM replacement for?
Autoimmune gastritis / pernicious anaemia
Total gastrectomy or ileal resection
definitiely need IM
IM is also probably preferable in coeliac disease or other conditions leading to malabsorption
50
For which patients might a high dose (1mg OD) oral replacement B12 be suitable?
Those with medication-induced deficiency
Dietary deficiencies
Unexplained deficiency that is thought not to be secondary to malabsorption
51
How should you manage a patient with known autoimmune gastritis / pernicious anaemia who presents with new / worsening upper GI symptoms (dyspepsia, N&V)?
2WW endoscopy referral!!
Those with autoimmune gastritis are at ^ risk of gastric cancers
52
what are the correct doses of IM Benzylpenicillin for different age groups
Adults and children > 10 year old = 1,200mg
Children 1 - 9 years = 600mg
Children < 1 year = 300mg
53
For how long after patient's are sober from alcohol dependence do they need to wait before resuming driving according to the DVLA?
1 year for group 1 drivers
3 years for group 3 drivers
54
What health surveillance monitoring is needed for HIV positive patients?
Annual cervical cytology 25 -64
Annual lipids and HBA1C for 40+
3 yearly FRAX score for 50+
55
What is the typical presentation of herpangina and what is the causative orgnaism?
Herpangina presents with high fever and vesicles on the soft palate, uvula and tonsillar fauces with pain ++ on swallowing
Cause = Coxsackie A virus
56
What is the first line medication for excessive salivation in those with cognitive impairment?
Glycopyrolate
(for everyone else without cognitive impairment, Hyoscine should be used first line for excessive salivation)
57
Most ACE inhibitors are pro-drugs, meaning they rely on first pass metabolism in order to become active. In the elderly, who's first pass metabolism reduces, which 2x ACE inhibitors are NOT prodrugs and therefore won't be affected by reduced first pass metabolism?
Lisinopril and Captopril
58
What BMI is required for a patient to be eligible for bariatric surgery, provided they have tried lifestyle and pharmacological interventions with no success?
BMI > 40
OR
BMI > 35 with weight-related complication e.g Type II DM or HTN that would improve with weightloss
59
Which 2 outcomes do antibiotics for acute otitis media in children improve?
Improves the rates of tympanic membrane perforation and spread to the contralateral ear
60
Patient's with stress incontinence should be referred to physio for guided pelvic floor exercises first line true or false ?
TRUE
No evidence to support giving patients pelvic floor exercises to try themselves, better to be guided by physio
61
What factor is the most significant factor in determining how likely a vasectomy reversal will be ?
The time since the initial vasectomy
Pregnancy rates post-reversal can be upto 75% if reversed within 3 years, whereas drop to 10% if it's been 20+ years
62
Which antibody is typically elevated in primary biliary cholangitis (Autoimmune attack of biliary ducts)?
Anti mitochondrial antibodies
63
How does primary biliary cholangitis typically present?
Fatigue++
Itch
Right UQ pain
May have slightly enlarged liver
Palmar erythema
Tx: lifelong Urseodeoxycholic acid
64
What is the minimum amount of moderate and vigorous activity that an adult should aim for per week?
Should aim for either 150 mins moderate activity OR 75 mins vigorous activity
(or a blend of the 2)
65
What is the first line treatment for thrush in pregnancy?
Intravaginal clotrimazole WITHOUT the applicator (the applicator itself not licensed in pregnancy)
66
What are the Vitamin B12 replacement schedules for those with and without neurological symptoms respectively?
WITH neurological symptoms - alternate daily until no further improvement in symptoms then every 2 months lifelong
WITHOUT neurological symptoms - three times per week for 2 weeks then every 3 months
67
What diameter of abdominal aorta is considered an aneurysm?
3cm+
(AAAs 3 - 5.4 cm should be referred to vascular to be seen within 12 weeks
AAAs > 5,5 should be referred to be seen within 2 weeks)
68
When is elective surgery of AAA considered
With diameter > 5.5 and surgically fit
69
At what age are men offered AAA screening?
65 - one-off USS the abdomen
70
For which asymptomatic women should you consider an aortic USS to exclude AAA?
Consider aortic USS in women > 70 with COPD, coronary/cardiovascular disease, HTN, smoker or ex-smoker, family history of AAA
Although AAAs are more common in men, they actually at higher risk of rupture in women!!
71
When is follow-up USS arranged if a AAA is found on screening?
If 3cm - 4.4 = F/U USS in 1 year
If 4.4 - 5.4 = F/U USS in 3 months
5.5+ = urgent referral
72
When should fracture risk assessment be performed in men and women with no additional risk factors?
Age 65 in women
Age 75 in men
73
When assessing patients with community acquired pneumonia, what CURB-65 score would indicate they should go in for hospital treatmnt
A score of 2 or more
74
Above what concentration of morphine solution is a controlled drug prescription required?
A controlled drug prescription is only needed when morphine oral solution strength exceeds 13mg/5ml
75
Patients with chronic disease of which organ have the highest mortality from influenza?
Chronic liver disease
76
What are the indications to refer patients with varicose veins to vascular surgery ?
If symptomatic (e.g discomfort, swelling)
If superficial venous thrombosis
If skin changes suggestive of venous eczema / insufficiency
Venous leg ulcer
Interventions for varicose veins are not suitable during pregnancy
Don't recommend compression hosiery for varicose veins unless unsuitable for interventional treatment (endthermal ablation is 1st line followed by USS-guided sclerotherapy)
77
What percentage men are found NOT to have prostate cancer after biopsy for an elevated PSA?
75%
(ie 3/4s won't have prostate Ca, 1/4 will)
78
For how long after a mild head injury should patients avoid contact sports?
3 weeks
79
What are the first and second line treatment for primary focal and generalised hyperhidrosis (excessive sweating)?
Primary focal hyperhidrosis (normally axillae and plantars of the feet) 1st line - topical aluminium chloride applied at night and washed off in the morning. 2nd line if topical aluminium doesn't work - oral anticholinergic Propantheline TDS.
Primary generalised hyperhidrosis = 1st line oral anticholinergic Propantheline TDS for 1 month, stop if no improvement
If no improvement with above, refer to secondary care for botox injection
80
What is the target INR for patients with atrial fibrillation started on warfarin?
2.5 (range 2-3)
81
At what ages is the pneumococcal vaccine offered?
Babies - at 12 weeks and booster at12 months
Older adults - stat dose offered at age 65
At risk adults - offered as a stat dose (other than in CKD, asplenia and splenic dysfunction where need pneumococcal vaccine every 5 years):
- CKD
- Asplenia / splenic dysfunction
- Chronic lung disease inc COPD, CF, bronchiectasis, fibrosis (NOT ASTHMA UNLESS SO SEVERE THAT NEED FREQUENT COURSES OF ORAL STEROIDS)
- Chronic heart failure
- Chronic liver failure
- Diabetes that is controlled with insulin or diabetic medication (NOT diet controlled diabetes!)
- Immunosuppressed (e.g post transplant, HIV, haematological cancers)
- Welders !!! (increased risk of pneumococcal pneumonia with exposure to metal fumes!)
82
what is the typical presentation of scombroid food poisoning and what foods cause it?
Caused by fish like mackeral or tuna
Presents with a quick reaction 1-3 hours after eating the food, with dizziness, facial flushing and GI symptoms. Normally resolves quickly after a few hours.
83
After how long of being seizure-free, should anti-epileptics be considered to be withdrawn in children?
After 2 years seizure free
84
Which PPIs should NOT be given to patients on Clopidogrel due to them reducing the efficicacy of Clopidogrel?
Omeprazole & Esomeprazole
85
Which SSRIs should NOT be used alongside Tamoxifen due to them decreasing the efficacy and increasing the risk of breast cancer death?
Fluoxetine and Paroxetine
86
what are the age ranges within which you can give blood?
Age 17 - 65
(can give blood upto age 70 if you have given blood before and above 70 if you have given blood in the past 2 years)
87
How long after childbirth can you donate blood?
6 months
88
Do patients with obstructive sleep apnoea with daytime sleepiness need to inform the DVLA?
If daytime sleepiness should stop driving immediately. Only need to inform DVLA if symptoms not under control at 3 months
HOWEVER if moderate-severe OSA should inform the DVLA and their license should be re-reviewed every 3 YEARS
89
Which eye drops must you be cautious of use in asthma / COPD because they can cause bronchospasm?
Beta blocker eyedrops (e.g Timolol, Cartelol)
90
Which eye drops must you be cautious of use in angina / ischaemic heart disease ?
Brimonidine - can aggravate coronary insufficiency
91
What category of diuretics carries a risk of sensorineural deafness and what factors increase the risk of this happening?
Loop diuretics
More likely with high IV doses, rapid starting and in renal impairment
92
What factors make up the ORBIT bleeding risk score?
O - older (age > 74)
R - Reduced haemoglobin ie anaemia
B - Bleed in the past
I - Insufficient kidney function (eGFR < 60)
T - Treatment with antiplatelet drug
93
What is defined as recurrent UTI?
2 or more episodes in 6 months or 3 in a year
94
What is the gold standard investigation to diagnose bronchiectasis?
High resolution CT chest
95
For which conditions should a QRisk3 NOT be performed but lipid lowering therapy started regardless?
Type I diabetes
Familial hypercholesterolaemia
CKD stage 3 or higher and/or albuminuria
Established cardiovascular disease
All these patients should routinely be on a lipid-lowering therapy
96
What is the minimum amount of time you should wait after an acute out attack before measuring serum urate levels>
2 weeks
97
What is the first line test for HIV in a patient that has been exposed?
Lab HIV 1 and 2 antibodies plus p24 antigen at presentation (if exposure was at least 4 weeks ago) and repeated at 3 months
Negative test at 4 weeks unlikely to have HIV but follow-up test at 3 months recommended
98
What proportion of the UK population are carers?
1 in 10!
99
What is the typical LFT derangement seen in NAFLD?
ALT is disproportionally increased compared to AST
100
Which body governs the promotion / advertisement of prescription medications in the UK?
Association of the British Pharmaceutical Industry
101
How should you manage influenza-like illness or close contact with someone with flu-like illness in a pregnant patient?
Should offer Oseltamivir OD for 10 days if presents within 48 hours of most recent exposure or with flu-like symptoms
102
What blood pressure range is associated with the lowest risk of cardiovascular events?
Between 120 / 70 to 140/80 has the lowest risk of cardiovascular events
Systolics under 120 or over 140 and diastolics under 70 or over 80 are associated with increased risk of cardiovascular events
103
What is the typical presentation of Reye's syndrome?
Reye's syndrome presents with personality changes, effortless, persistent vomiting, drowsiness, raised LFTs, fatty infiltration of the liver
Can progress to cerebral oedema and death
An association between childhood aspirin use and Reye's syndrome so ASPIRIN NOT RECOMMENDED FOR USE IN UNDER 16s (unless for a specific reason like Kawasaki)
104
What is the single greatest risk factors for any type of gastric cancer?
H. pylori infection
(doubles the risk of gastric cancer)
105
What proportion of patients with cystic fibrosis develop diabetes?
50% of adults with cystic fibrosis develop type 3c diabetes (due to pancreatic deficiency of insulin production)
106
How should you manage a positive sputum or nasal aspirate culture in a patient with CF?
Always check respiratory cultures regularly and treat any positive cultures with antibiotics even if clinically well / asymptomatic!!
107
What is the name of the formula used to adjust the global sum paid per patient to the practice dependent on the demographics?
The Carr-Hill Formula
108
what is the presentation of plummer-vinson syndrome?
Plummer-Vinson syndrome is the development of an oesophageal web leading to dysphagia symptoms in those with chronic iron-deficiency
Treating with oral iron replacement normally improves dysphagia symptoms but occasionally balloon dilation is needed
109
Which LFTs are associated with intrahepatic derangement versus cholestatic derangement?
Intrahepatic = ALT & AST
Cholestatic = GGT + ALP (+bilirubin)
110
When should varenicline be started in the context of smoking cessation?
Patients should still be smoking when they start Varenicline (Champix) and should stop smoking 7-14 days after starting it.
Does is gradually titrated up with 500mg OD for the first 3 days then 500mg BD until day 7 then 1g BD for 12 weeks
111
Between what age ranges can QRisk 3 be used?
25 - 84
112
What lifestyle advice should be given to patients at high cardiovascular risk (high QRisk score)?
To reduce their dietary saturated fat (max 7% of energy intake) and total fat (max 30% of energy intake)
To replace saturated fats for monounsaturated and polyunsaturated fats
Should NOT routinely advice the intake of plant stenols to reduce cardiovascular risk
113
Which cholesterol results should merit referral to a specialist?
A total cholesterol over 9
A non-HDL over 7.5
Triglycerides over 10 mmol (after confirmed with a fasting result)
114
Which food should be avoided in patients on statins?
Grapefruits
115
Transaminases (ALT and AST) should be checked before starting statin therapy. Above what level of ALT / AST derangement should statins NOT be started?
If either ALT or AST is greater than 3x the normal range
116
If a patient reports previous unexplained generalised muscle symptoms then CK should be checked before starting statins. What level of CK would be a contraindication to starting to statins?
If CK is 5x the normal range then statins should NOT be started
If CK < 5x the normal range then safe to start but start at a lower dose than normal
117
How longer before pregnancy should statins ideally be stopped?
Statins should be stopped 3 months before trying to conceive and should not resume until finished breast-feeding
118
For patients taking statins for primary prevention of cardiovascular disease, what is the target you are looking for in their cholesterol levels?
You are aiming for a reduction in non-HDL cholesterol of 40% of more.
119
What is the standard dose of statin for primary prevention and secondary prevention respectively?
Atorvastatin 20mg - primary prevention
Atorvastatin 80mg - secondary prevention (unless for secondary prevention in someone with CKD in which case start with Atorvastatin 20mg and titrate up if target not met so long as eGFR > 30)
120
For patients taking statins for secondary prevention of cardiovascular disease, what is the target you are looking for in their cholesterol levels?
LDL < 2 and non-HDL < 2.6
121
Patients with Type I DM are automatically at high risk of cardiovascular disease and so QRisk should not be performed on them. When should statins be started in patients with Type I DM?
Age over 40
Had Type 1 DM for > 10 years
Established diabetic nephropathy
Additional cardiovascular risk factors
122
What blood monitoring is required after starting statins?
LFTs and lipid profile at 2-3 months after starting
Repeat LFTs at 12 months after starting
Thereafter just need annual lipid profile
123
First line treatment for overactive bladder is weightloss, caffeine reduction and 6-weeks of bladder re-training. If these don't work, what are the first line medications?
IR Oxybutynin OR IR Tolterodine OR IR Darifenacin
If anticholinergic medicine NOT appropriate or anticholinergic SEs not tolerable, can trial Mirabegron. (Mirabegron is first line in the frail / elderly)
124
What is a contraindication to the use of Mirabegron for overactive bladder?
Severe uncontrolled hypertension (>180 / 110)
125
What treatment options are recommended for stress incontinence?
1st line = at least 3 months of physio-guided pelvic floor exercises (involving at least 8 contractions 3 times per day)
If no improvement, then offer surgical managmeent - Duloxetine should only be offered if surgery is not appropriate or the woman prefers medical management
126
If you have a positive FIT test on screening, what is the risk of you having bowel cancer?
7%
127
What is the 1st line anti-emetic for N&V related to opioids?
Dopamine receptor antagonists such as Haloperidol or Metoclopramide
128
What is the first line treatment for suspected anal fissure (very painful on opening bowels, rectal bleeding)
Topical GTN ointment BD for 8 weeks or until fully healed
129
What are the diagnostic criteria for chronic fatigue syndrome / myalgic encephalitis?
Symptoms must be present for 3 months to be diagnostic, but can suspect after 4 weeks in children and after 6 weeks in adults.
Must have all of the below:
1) Post-exertional fatigue / malaise that is disproportionate to the activity (may be delayed in onset)
AND
2) Unrefreshing sleep (may include waking up feeling flu-like or stiff)
AND
3) Cognitive difficulties ie brain fog
AND
4) Debilitating fatigue that is not satisfactorily relieved by rest
Patients meeting these criteria should be referred to ME/CFS specialist / paediatrician
130
What management options are recommended by NICE in the management of chronic fatigue syndrome / myalgic encephalitis?
Energy management strategy
Physio-guided physical activity programme (NOT graded exercise therapy) - warn patients that personalised exercise programmes sometimes make ME better sometimes worse and sometimes no difference
Rest periods - relaxation techniques at the beginning of each rest period can be helpful
CBT
131
How frequently should a patient with ME / CFS be reviewed in primary care?
Every 6 months for a child
every 12 months for an adult
132
From what age is RSV vaccine given to elderly patients?
From 75 years
133
What age is the shingles vaccine given?
If you turn 65 after Sep 2023, you should be offered shingles vaccine at 65
(2x doses 6-12 months apart)
Prior to 2023, vaccine was offered between aged of 70-80
134
Which nutrient deficiency is most likely in restless legs syndrome?
Iron deficiency
135
What is the typical presentation of otosclerosis?
Otosclerosis is when the stapes bone fuses with the other bones in the middle
Presents with usually BILATERAL progressive CONDUCTIVE hearing loss (Rinne's negative, Weber's positive ie bone conduction louder than air conduction) with patients hearing better in NOISY ENVIRONMENTS
More common in women between 20-40 and can get worse during pregnancies!!
136
Which medications INCREASE urate levels hence increasing the risk of gout?
Beta blockers
ACEis
Aspirin
Diuretics
137
Which medications DECREASE urate levels?
Fenofibrate
SGLT inhibitors
Calcium channel blockers
ARBs (e.g losartan)
138
Which populations should get the hPV vaccine and how many doses do they all need respectively
Boys & Girls aged 12-13 - single dose (can have catch up vaccine if missed at school upto aged 26)
MSM upto and including age 45 - need 2 doses if get after 25 years of age
Sex workers - 2 doses if get after aged 25
Immunosupressed e.g HIV - 3 doses needed
139
In which patients is eGFR less reliable?
Pregnancy
Oedematous states
Body builders / those on protein supplements (underestimates eGFR)
Those with amputations
Muscle wasting disorders / malnourishment (overestimates eGFR)
Minority ethnic groups
140
For how long should patients not eat meat before a blood test for eGFR / creatinine?
Should avoid eating meat 12 hours before the blood test
141
For patients with a suprise finding of reduced eGFR on bloods, how soon after should it be repeated to exclude AKI?
After 2 weeks
142
What is defined as accelerated progression in CKD?
A decline in eGFR of 25% or more within 12 months
OR
persistent decline in eGFR of 15% every year
143
Which adults with CKD should be referred for specialist renal input?
Decrease in eGFR of 25% or more within 12 months
Sustained decrease of eGFR of 15% annually
A:Cr > 70 (unless caused by diabetes and under control)
A:Cr > 30 with co-existent haematuria
Risk of needing renal repalcement in the next 5 years of 5% or more
Suspected renal artery stenosis
144
when should children or young people with CKD be referred for specialist renal input?
A:Cr > 3 (confirm on a repeat early morning sample if > 3 and < 70)
Haematuria
Any decrease in eGFR
HTN
Suspected renal artery stenosis or renal outflow obstruction
145
What are the BP targets for patient's with CKD?
Target 140 / 90
UNLESS A:Cr > 7o in which case target 130 / 80
146
What antihypertensive medications are recommended for patients with CKD and HTN?
If A:Cr > 30 then first line is ACEi/ARB
(don't start ACEi / ARB if K+ is 5+ pre-treatment and stop if rises above 6)
If not, then follow standard HTN guidelines
147
The renal function can decline after starting an ACEi/ARB - a decline above which level should prompt you to stop the ACEi/ARB?
A decline in eGFR of more than 25% or a rise in creatinine of more than 30%
If there is a slight decrease in renal function but less than 25% decline in eGFR / 30% rise in creatinine then repeat renal function in 1-2 weeks
148
How long after a Hep B exposure (e.g a needlestick injury) can the HepB vaccine be given?
Upto 7 days after (but ideally within 24 hrs)
149
Which ethnic group is benign ethnic neutropenia most common in?
Black African / Afro-Carribean
= an absolute reduction in neutrophils in the absence of other causes
150
What is a second line option for chronic urticaria if not controlled with non-sedating antihistamines alone?
Can trial add in of Montelukast
151
What tool can be used to predict progression of NAFLD to fibrosis in primary care?
FIB-4
(takes into account ALT, AST, Plts and age)
152
Children and adults with low body weight e.g secondary to anorexia are at increased risk of osteoporosis / osteopenia. After how long of being underweight does NICE recommend DEXA scan?
After 1 year of being underweight in children (or sooner if bone pain or recurrent fractures)
After 2 years of being underweight in adults (or sooner if bone pain or recurrent fracture)
153
What conditions can artificiially raise Ca125?
Diabetes
CCF
Liver disease
other tumours
154
How long does the yellow fever vaccine protect you for and how long after the injection does it take for you to be protected?
Yellow fever vaccine is a 1-off dose which gives LIFELONG PROTECTION!!!
80% are protected by day 10 post vaccine, 99% protected by day 30
155
What are risk factors for developing long Covid syndrome?
Older age
High BMI
Femle gender
Asthma
156
What is the target haemoglobin for a patient with CKD on erythropoeitin?
Target Hb 100 - 120
(check for and correct iron deficiency before treating anaemia with EPO in CKD - oral iron replacement 1st line if not on haemodialysis, IV iron 1st line if on dialysis)
157
What are the first line management options for managing / preventing hyperphophataemia in advanced CKD?
1st line - dietary modifications
2nd line - phosphate binders (1st choice = calcium acetate, 2nd choice if calcium high is sevelemar carbonate
158
For those with Benzodiazepine addiction, NICE recommends switching to Diazepam and then reducing the dose by 1/10th to 1/4 every 2 weeks. How do you calculate the equivalent dose of Diazepam from other benzos (chlordiazepoxide, temazapeman, lorazepam)
Lorazepam = 5-10 times stronger than diazepam (So Lorazepam 0.5-1mg = Diazepam 5mg)
Temazepam = half as strong so Temazepam 10mg = Diazepam 5mg
Chlordiazepoxide = three times weaker than diazepam so Chlordiazepoxide 15mg = Diazepam 5mg
159
Which medications should be avoided in heart failure as they may worsen existing HF?
NSAIDs
Alpha blockers like Doxazosin
Pioglitozone
DPP4 inhibitors - the gliptins !! e.g sitagliptin
Rate-limiting calcium channel blockers
160
Which screening tools can be used to screen for substance misuse in adolescents?
CRAFFT
and
DAST-A tools
161
How should you manage bleeding / raised INR on warfarin?
Major bleeding at any INR - stop the warfarin, give IV Vit K, give dried prothrombin complex
INR > 8:
-> If minor bleeding - stop the warfarin, give IV vitamin K (can rpt after 24 hrs) don't restart warfarin until INR <5
-> If not bleeding - stop the warfarin, give ORAL vit K
INR 5-8:
-> If minor bleeding - stop warfarin, give IV vitamin K, don't restart until INR < 5
-> If no bleeding - withold the next 1-2 doses and then reduce the subsequent maintenance dose
162
How many days before elective surgery should Warfarin be stopped and what to do if INR remains > 1.5 on the day before surgery?
Should stop warfarin 5 days before elective surgery
Oral vit K can be given the day before surgery if INR remains > 1.5
163
Target INR is typically 2.5 for most indications for warfarin, in which circumstance is a target INR of 3.5 aimed for
Recurrent DVT or PE
164
Which smoking cessation medication is the most effective at helping people to stop smoking and stay abstinent?
Varenicline (increases odds of smoking cessation 3-fold)
Varenicline = partial nicotine agonist - reduces withdrawal symptoms and cravings
165
For how long are Buproprion and Vareniciline recommended to be given for?
Varenicline - should be given a 12 week course (need to start 1-2 weeks before quit date) - if successfully abstinent at 12 weeks can then offer a further 12 week course to help maintain abstinence
Buproprion - discontinue at 7 weeks if not abstinent (Also need to start 1-2 weeks before quit date)
166
What is the difference between episodic and chronic migraine / tension-headaches?
Chronic = > 15 episodes per month
Episodic =. < 15 per month
167
Between what ages is colorectal cancer screening using FIT testing offered?
Between age 54 - 74 (but being expanded to 50 - 74)
FIT test every 2 years
If over 74 can request ongoing FIT tests
168
When is an extended nuclear antigen panel used?
Often used after a positive antimitochondrial antibody result or in patients that you suspect autoimmune condition such as Sjogrens or Lupus - includes multiple antibodies including anti-Ro and anti-La
169
How should you manage a woman presenting with a groin hernia?
URGENT REFERRAL TO SURGEONS (<2 WEEKS)
due to the higher rates of femoral hernia in this population and the difficulty differentiating inguinal from femoral
Femoral = lateral and below pubic tubercle
Inguinal = medial and above pubic tubercle
170
An ejection fraction below what per centage signifies heart failure with reduced ejection fraction?
< 40% of HFrEF
171
For how long before and after taking desmopressin for nocturnal enuresis do fluids need to be restricted?
1 hour before and 8 hours after
