Primary Care Flashcards
(154 cards)
1
Q
Can you make a new diagnosis of IBS (irritable bowel syndrome) in someone over the age of 50 years?
A
You shouldn’t make this diagnosis without first excluding/ considering other causes such as bowel cancer or diverticulosis which are more common with advancing age
2
Q
What is the commonest cause of food poisoning in the UK?
A
Campylobacter - and its most common in the summer
3
Q
When taking a history for diarrhoea, what diagnoses might blood in the stool indicate?
A
Infective- campylobacter, E.coli, shigella.
Inflammatory- IBD.
Neoplastic - bowel cancer.
4
Q
A patient presents with diarrhoea alongside crampy abdominal pain which is relieved on defecation. What diagnosis may this suggest?
A
Irritable bowel syndrome (IBS)
5
Q
When can people who have had gastroenteritis return to work or school?
A
They should not return to work or school until 48 hours after the diarrhoea has stopped
6
Q
If a patient has diarrhoea, what medications should they stop taking until the diarrhoea has resolved and why?
A
ACE inhibitors, NSAIDs and diuretics. If the patient continues to take these drugs whilst they have diarrhoea, they run the risk of developing an AKI.
7
Q
Should patients with acute diarrhoea be advised to take Loperamide (Imodium)?
A
Consider loperamide if it is important to stop the diarrhoea (e.g. before a long journey), but otherwise it should be avoided.
8
Q
What type of drug is loperamide?
A
It is an opioid that does not cross the BBB, but increases colonic transit time
9
Q
Which specific circumstances should loperamide definitely not be used to treat diarrhoea?
A
In children and in anyone with bloody diarrhoea, as it may increase their risk of complications
10
Q
Which arm should you use to measure a patient’s blood pressure?
A
Unless there are good reasons for not doing so (such as patient discomfort), you should use the patient’s right arm
11
Q
What are the ALARMs symptoms (red flag symptoms) that warrant immediate endoscopy?
A
Anaemia (iron deficiency) Loss of weight Anorexia Recent onset/ progressive symptoms Melaena / haematemesis Swallowing difficulty
12
Q
What drugs/ medications can cause heartburn symptoms?
A
Antibiotics e.g. tetracyclines, NSAIDs, corticosteroids, iron compounds, nitrates, bisphosphonates, calcium preparations, calcium channel antagonists and theophylline.
13
Q
What is the typical eradication therapy for H. Pylori?
A
A PPI such as omeprazole and 2 antibiotics e.g. amoxicillin and clarithromycin.
14
Q
Patients can complete self-certificates for time off work due to illness, how does this work and for how long does it last?
A
The self certificate will cover the first 7 days off work due to sickness. They complete their own self certificate/ form which is available from their employer.
15
Q
What are some important points about medical certificates supplied by doctors for statements of fitness to work?
A
They are provided free of charge. The doctor does not personally have to see the patient. They can be backdated, but cannot be issued for longer than 3 months.
16
Q
Which patient groups are exempt from prescription charges?
A
All those aged >60 years, children, pregnant women (or those who have given birth in the last year), people with certain diseases e.g. diabetes, epilepsy, hypothyroidism, people receiving Tx for cancer and people on renal dialysis
17
Q
Which contraceptive might be prescribed for a patient to help with acne?
A
Some COCPs such as co-cyprindiol (Dianette)
18
Q
What contraceptive method may lead to a delay in fertility?
A
The injection (injectable contraceptives)
19
Q
How do COCPs work?
A
They inhibit ovulation
20
Q
What are some of the advantages of the COCP?
A
Regulates cycles and reduces pain (PMT) and amount of bleeding.
Reduces symptomatic fibroids and benign breast disease
Reduces risk of ovarian, colorectal and endometrial cancer
21
Q
In terms of the COCP, which pills in the pill packet are ‘most important’ not to miss?
A
It is very important not to miss any of the first 7 pills in the packet (these pills stop ovulation from occurring)
22
Q
What type of patients would the POP be suitable for rather than the COCP?
A
Women who are breastfeeding, patients who have migraine with aura, or those who are smokers and aged >35.
23
Q
How are POPs (progesterone only pills) taken?
A
Usually need to be taken within 3 hours of the same time everyday and are taken daily without a break. However, Desogestrel pills are a form of POP that can be taken within 12 hours of the time it is due so is useful as a first-line contraceptive.
24
Q
How does the POP work?
A
The traditional POP prevents pregnancy by thickening cervical mucus, the desogestrel pills can also stop ovulation.
25
In terms of injectable contraceptives, what types are there and how long do they last?
Most common one is Depo-Provera which is given every 13 weeks (previously 12). Noristerat which is given every 8 weeks. Sayana press (a newer one) can be given every 13 weeks and the patient can administer it themselves.
26
What are some side effects of the injectable contraceptives?
They can be effective at reducing heavy or painful menstrual bleeding but can cause amenorrhoea or regular bleeding. Side effects such as unscheduled bleeding or return of fertility can last for up to a year on stopping. There is also increased risk of osteoporosis and weight gain is another side effect.
27
How long do progesterone implants last/ how long are they licensed for?
3 years
28
How long do copper and Mirena coils last for?
Copper coil lasts 5-10 years depending on the brand. Mirena IUS lasts 5 years.
29
What investigation should you do if the threads of a coil are not palpable or visible?
A pelvic ultrasound scan to assess the position of the coil
30
If a lady becomes pregnant with a coil in situ, what does this increase the risk of?
Ectopic pregnancy
31
What does the copper coil and the Mirena IUS do to bleeding?
The copper coil makes periods heavier (warn the patient of this), but doesn’t interfere with their normal cycle. The Mirena coil is used as a treatment for heavy, painful periods.
32
Outline the options for emergency contraception
One off dose of a pill (Levonorgestrel or Ulipristal acetate) or non-hormonal e.g. copper IUD
33
What are the key points to remember about the Levonorgestrel pill for emergency contraception?
It is a progesterone medication. Single dose of 1.5mg. Taken up to 72 hours post UPSI. More effective ASAP after UPSI. Need double dose (3mg) if BMI >26 or weight >70kg.
34
Is emergency contraceptive effective after ovulation has taken place?
The evidence suggests that it is not
35
What are the key points about the Ulipristal acetate pill (ellaOne) for emergency contraception?
It is a selective progesterone receptor modulator (SPRM). Primary action is by inhibiting or delaying ovulation. More effective than Levonorgestrel and can be taken within 120 hours (5 days) of UPSI as a single dose. EllaOne is usually chosen over Levonorgestrel unless there has been recent progesterone use or the patient has severe asthma
36
What if a patient vomits after taking an emergency contraceptive pill?
If patient vomits within 2 hours (3 for ulipristal) of taking, she should repeat the dose (with an anti-emetic) or consider having an IUD inserted instead.
37
How long after taking an emergency contraceptive pill can a woman have sex again?
She should abstain from sex (or at least use barrier methods) until she has her next period (ulipristal reduces the efficacy of hormonal contraceptives) or if Levonelle given until contraceptive cover is resumed (7 days of COCP and 2 days of POP).
38
What is the most effective emergency contraceptive?
The copper IUD
39
What are the key points about the copper IUD for emergency contraception?
Effective. Can be inserted up to 120 hours (5 days) after UPSI (or up to 5 days after estimated earliest date of ovulation). Prevents fertilisation and unless removed, provides ongoing contraception. Must screen for STDs at the time of insertion
40
What are some non-modifiable risk factors for cardiovascular disease?
Increasing age, male sex, family history, ethnicity, socioeconomic deprivation, genetic factors
41
What are some modifiable risk factors for cardiovascular disease?
Smoking, hypertension, high cholesterol, diabetes, obesity, physical inactivity
42
What tool is used to calculate cardiovascular risk in the UK?
QRISK3
43
Outline current pharmacotherapies for people who want to quit smoking (note it is best if the measures are supplemented with counselling/ expert support)
Nicotine replacement therapy, bupropion, varenicline, e-cigarettes
44
How do you go about trying to get an accurate ‘clinic blood pressure’ (in terms of multiple measurements)?
If a BP measurement is >140/90 it should be repeated, if the two differ substantially (i.e. ~>20mmHg) a third should be taken. The lower of the last two measurements is taken as the clinic BP.
45
What should you do next if a patient has a ‘clinic BP’ of >140/90mmHg?
Ambulatory BP monitoring (ABPM) (at least 14 measurements over waking hours) should be offered to confirm the diagnosis of HTN. Home BP monitoring (HBPM) can be used as an alternative (ideally twice daily pairs of measurements for 7 days). Average all readings.
46
How to NICE define the stages of hypertension?
Stage 1: clinic BP is 140/90 or higher AND subsequent ABPM is 135/85 or higher
Stage 2: clinic BP is 160/100 or higher AND subsequent ABPM is 150/95 or higher
Severe: clinic systolic BP is 180 or higher OR clinic diastolic BP is 110 or higher
Malignant: >180/110 + organ damage
47
When should drug treatment be considered for HTN?
Immediately (before any ABPM/HBPM) if clinic BP >180/110
All stage 2 HTN
Stage 1 HTN if elevated risk (e.g. QRISK3 >10%, diabetes, end organ damage)
48
NICE recommend treating HTN to a clinic BP of what?
<140/90 (or <150/90 in those aged >80)
49
In the stepwise treatment of HTN, how long after starting a treatment should you wait until you reassess BP?
BP should be reassessed after 4-6 weeks before considering progressing to the next stage of treatment
50
What is the stepwise treatment regimen for HTN?
Step 1: ACE inhibitor OR calcium channel blocker (if >55 or black)
Step 2: ACE inhibitor PLUS calcium channel blocker
Step 3: ACE inhibitor PLUS calcium channel blocker PLUS thiazide-like diuretic (indapamide)
Step 4: Consider adding beta-blocker (e.g. metoprolol) OR alpha-blocker OR alternative diuretic
51
What antihypertensive should you use in a patient with T2DM?
ACE inhibitor
52
A patient is unable to tolerate their ACE inhibitor (due to cough), what antihypertensive should you consider instead?
An angiotensin II receptor blocker (ARB) e.g. Lorsartan
53
What are some of the causes of ‘secondary dyslipidaemia’?
Excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome.
54
What is the first-line recommended primary prevention drug treatment for high cholesterol? (Include the dosage in your answer)- note I am asking about DRUG treatment but always remember to give lifestyle advice
Atorvastatin 20mg
55
Under what circumstances should a patient be treated with statins?
If their estimated 10 year CVD risk (QRISK) is >10% (and lifestyle modification is ineffective or inappropriate). Note this should include people with type 2 diabetes.
People with type 1 diabetes
To people with CKD (without the need for a formal risk assessment)
56
You’ve just started a patient on a statin, what blood tests should you do next and when?
Full lipid profile (and LFTs) should be repeated after 3 months (aiming for 40% reduction in non-HDL cholesterol). If not achieved, discuss medication adherence, lifestyle factors and consider increasing statin dose.
57
When should you do LFTs after a patient has been started on a statin?
Statins can affect liver function; NICE advise checking LFTs before and at 3 and 12 months after starting Tx. Stop the statin if transaminases are >3 times normal
58
What side effects (other than liver function) are associated with statins?
GI disturbance/ upset, myopathy/myalgia and statins can increase the risk of diabetes (but this risk is offset by the benefits)
59
What should you do if a patient develops GI upset whilst on statin treatment?
Confirm that the statin is the cause by stopping it and restarting it once the symptoms have resolved to see if the problems recur. If the statin is felt to be the cause then consider a lower dose or a milder statin (e.g. simvastatin) instead.
60
Statins can cause myopathy, tell me about the guidance surrounding checking CK levels
CK should be checked before starting statins in patients with myalgia, and should also be checked if muscle pain develops once a statin has been started. If the CK is >5 times normal, stop the statin. Do not routinely measure CK levels in asymptomatic people
61
What is the advice surrounding the amount of physical exercise that people should do?
At least 150 minutes of moderate intensity aerobic activity OR >75 minutes of vigorous intensity aerobic activity every week. Muscle strengthening activities on at least 2 days a week that work all major muscle groups.
62
What medications should be considered as secondary prevention following an MI? (Note: pharmacotherapy should be indefinite)
```
ACE inhibitors
Low dose (75mg) aspirin.
A 2nd antiplatelet e.g. clopidogrel or ticagrelor can be used in combination with aspirin (DAPT) for up to 12 months post-MI.
Beta blockers
Statins
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63
What type and dose of statin is used for secondary prevention of CVD e.g. following an MI?
Atorvastatin 80mg
64
What else should you remember in patients following an MI? (Other than secondary prevention drugs)
Annual flu vaccine and one-off pneumococcal vaccine (as at higher risk of complications from flu). DVLA: no driving for at least 4 weeks post-MI (6 weeks for bus or lorry drivers) and inform DVLA. Risk of depression- prescribe an SSRI if necessary (sertraline)
65
What factors can precipitate migraines?
Stress, fatigue, certain foods (chocolate, cheese), hormones (puberty, menopause, menstruation and COCP), other factors (strong light, high altitude, head injury)
66
What 2 main types of migraine are there?
Migraine with aura (classical migraine)
| Migraine without aura (common migraine)
67
Tell me about migraine with aura (classical migraine) and its 2 stages.
Prodromal (aura): transient neurological symptoms develop over ~5 minutes and last up to 1 hour. Can be visual, transient aphasia, tingling/numbness or weakness.
Headache: either starts before the end of the aura or within 1 hour of the aura finishing. Lasts several hrs (sometimes more than a day). Often unilateral and often begins in one spot -> generalised. Ass with nausea/vomiting and photophobia.
68
Tell me about migraine without aura (common migraine)
The commonest form = recurrent headache associated with N&V. Typically unilateral pulsating headache which is aggravated by physical activity. Can be difficult to differentiate from tension headache. Prodromal symptoms often vague
69
What are the differential diagnoses for a migraine?
Tension headache, cluster headache, sinus headache, medication overuse headache, temporal arteritis (GCA), TIA, meningitis, SAH, brain tumour
70
What are some headache red flags?
Onset age >50. Worst headache patient has ever had/ very rapid onset (SAH). History of cancer (esp. lung/breast). Headache that gets progressively worse over days (tumour/abscess). Wakes patient at night (tumour). Early morning vomiting (raised ICP). Unilateral loss of power (stroke/TIA). Seizure (tumour). Weight loss (tumour/ cerebral TB). Altered consciousness (meningitis). Fever (meningitis).
71
What should you do if you find a patient has papilloedema?
Emergency admission to hospital
72
Outline the general management of migraines
Reassure patient, avoid precipitating dietary factors, try different brand of COCP or switch to POP (COCP is CI in classical migraine with aura), simple analgesia e.g. soluble aspirin 900mg or NSAIDs (caution as overuse can lead to analgesic-rebound headache), antiemetics (prochlorperazine or metoclopramide), triptans
73
What is the general mechanism of action of triptans for migraine?
They are 5-HT1 receptor agonists
74
How quickly do triptans work in the treatment of migraine attacks?
Oral triptans start working within 1 hour; nasal and s/c forms have more rapid onset
75
In which group of patients are triptans contraindicated?
Patients with angina or those with high risk of IHD
76
Can you purchase triptan medications over the counter?
Yes, sumatriptan (which was the first triptan to come onto the market) is available OTC without a prescription as a 50mg tablet
77
At what point should you consider prescribing migraine prophylaxis for a patient?
Consider prophylaxis if >2 attacks per month or if the attacks are particularly severe/prolonged
78
What is the first-line treatment for migraine prophylaxis?
Propranolol (providing there are no CIs e.g. asthma or peripheral vascular disease)
79
What drug is 2nd line in the prophylaxis of migraines? And what SEs or cautions are there with its use?
Topiramate (an anti-epilepsy drug)
SEs: paraesthesia, impaired concentration and sleep, weight loss
Affects efficacy of contraceptive pills
80
In terms of length of illness time for URTI, how long does it take for 90% of people to recover from the following illnesses? Acute sore throat/pharyngitis/tonsillitis, common cold, acute rhinosinusitis, acute cough/bronchitis.
Acute sore throat/pharyngitis/tonsillitis = 1 week
Common cold = 1.5 weeks
Acute rhinosinusitis = 2.5 weeks
Acute cough/ bronchitis = 3 weeks
81
How can you further categorise the symptom of a sore throat?
Tonsillitis
| Acute pharyngitis- inflammation of the part of the throat behind the soft palate
82
What are the infectious causes for a sore throat?
```
Common cold viruses e.g. rhinovirus- 25%
Bacteria- most commonly GABHS (group A beta-haemolytic strep)
Influenza
Herpes simplex (HSV-1)
EBV (peak incidence 15-25 year olds)
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83
What investigation(s) can you do if you suspect EBV?
Monospot blood test plus FBC and LFTs
84
What is the management of a patient presenting with an acute sore throat?
Reassure that most sore throats are self-limiting and resolve within 7 days without antibiotic treatment. Antibiotics should not be prescribed routinely (refer to Centor criteria / FeverPAIN criteria to help make decisions about Abx)
85
NICE advises using one of two criteria to aid diagnosis of GABHS as the cause of a sore throat, and hence guide when it might be appropriate to use Abx- these are Centor and FeverPAIN criteria. Outline the Centor Criteria.
```
Tonsillitis exudate
Tender anterior cervical lymph nodes
Absence of cough
History of fever
Presence of 3 or 4 of these signs suggest the chance of having GABHS is between 40-60% so the patient may benefit from Abx Tx.
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86
Outline the FeverPAIN criteria
```
Fever
Pus (exudate)
Attends rapidly (<3 days)
Inflamed tonsils
No cough/ coryza
Each factor scores 1. If score = 0 or 1- no Abx. If score = 2 or 3- delayed antibiotic prescription. If score = 4 or 5 - immediate antibiotics
```
87
What should you do if a patient who is taking a DMARD drug or carbimazole or is on chemotherapy presents with a sore throat?
Arrange an urgent FBC and seek specialist advice- this is due to the risk of neutropenia and agranulocytosis
88
At what point should you consider a non-urgent referral to ENT for tonsillectomy?
If 7 or more episodes in 1 year disrupting normal activities (or if 5 or more episodes in 2 years)
89
What is the classic triad of Glandular fever? And what age group is more commonly symptomatic?
Classic triad of: fever, acute pharyngitis and lymphadenopathy.
More commonly symptomatic in adolescence/ early adulthood
Tiredness and headache are also common and the fatigue can sometimes persist for 1-2 months
90
What is the management of glandular fever (infectious mononucleosis) and what specific advise should you give people?
It is usually self-limiting with no specific Tx required. Supportive care with adequate hydration and analgesics. Up to 50% of people develop splenomegaly and should be advised to avoid contact sports until resolved.
91
What antibiotic should you avoid prescribing if someone could have a diagnosis of glandular fever and why?
Amoxicillin because it can cause a RASH in people with glandular fever
92
Name 3 complications of influenza
Otitis media, bronchitis and pneumonia (less commonly)
93
Outline the treatment of influenza
Rest. Regular paracetamol (+/- ibuprofen if not CI). Fluids. Keep away from others as much as possible.
Anti-viral medication (neuraminidase inhibitors) only given during an epidemic when certain requirements met or during a pandemic: Oseltamivir (Tamiflu) or Zanamivir (Relenza)
94
What is the route and dose of Oseltamivir (Tamiflu) and Zanamivir (Relenza) - remember that these are neuraminidase inhibitors (anti-viral medications) for influenza that are only given under certain circumstances.
Oseltamivir (Tamiflu): tablet 75mg BD for 5 days (CI in pregnancy)
Zanamivir (Relenza): inhaled 5mg BD for 5 days
95
What groups of people is the influenza vaccine given to?
Everyone >65 years. People who live in e.g. nursing homes. Front line health professionals. Those <65 years with certain chronic conditions e.g. diabetes, chronic lung disease, heart disease, kidney disease, liver disease, neurological disease and those who are immunocompromised, pregnant women and carers
96
What is the risk of examining the throat of e.g. a young unvaccinated child with stridor (i.e. suspected epiglottitis) ?
It may provoke acute airway obstruction
97
If you offer a delayed antibiotic prescription for a patient with an acute sore throat what should you tell them? And what is the safety net advice you should tell all patients?
If delayed prescription say: antibiotic is not needed immediately, use the prescription if no improvement in 3-5 days or if symptoms worsen.
Safety net: seek medical help if symptoms worsen rapidly or significantly or the person becomes very unwell. If no Abx prescription is given then tell them to seek help if symptoms do not start to improve after 1 week
98
If you were to prescribe an antibiotic for acute otitis media (AOM) which antibiotic is given first line? (Remember however that antibiotic prescription is not routinely recommended for AOM).
Amoxicillin (for 5 days) (check not pen allergic - if allergic would give clarithromycin/ erythromycin)
99
For AOM, what patients does NICE recommend giving immediate antibiotics to?
Under 3 months of age. Systemically very unwell. If at high risk of serious complications due to other health problems. Under 2 years of age with bilateral symptoms. If perforation/ otorrhoea.
100
What organisms cause acute otitis media (AOM)? (Hint: name 3)
Strep pneumonia, Haemophilus Influenzae and Moraxella catarrhalis
101
If you see petechiae on the soft palate (although uncommon) what does this tend to indicate in terms of the cause of an acute sore throat?
It’s a highly specific finding in strep pharyngitis
102
How many URTIs does the average adult and child get each year?
The average adult has 4-6 URTIs per year and the average child has 6-8.
103
What are 3 key general things that you need to be able to differentiate between when a patient presents with back pain?
1. Non-specific lower back pain
2. Nerve root pain/ sciatica- low back and buttock pain radiating down one leg +/- pins and needles or tingling. Usually due to a disc problem.
3. Possible serious spinal pathology
104
What are the red flags for back pain?
```
Presentation under age 20 or onset over age 50
Non-mechanical pain including night pain
Thoracic pain
PMHx- cancer, steroids, HIV, immunosuppression, TB
Unwell- weight loss, night sweats, fever
Trauma
Structural deformity
Severe progressive neurological signs
Symptoms of cauda equina
```
105
What are the symptoms of cauda equina?
Urinary/bladder symptoms, saddle anaesthesia/ paraesthesia, reduced anal sphincter tone
106
What are the yellow flags for back pain (that predict poor outcomes)?
A belief that back pain is harmful or potentially severely disabling
Fear-avoidance behaviour and reduced activity levels
Tendency to low mood and social withdrawal
Expectation of passive treatment(s) rather than a belief that active participation will help
107
For what reasons should you consider both 1). Emergency referral to secondary care, and 2). Urgent referral to secondary care.
1) . Consider emergency referral to secondary care if suspecting: cauda equina syndrome, infection or fracture, spinal malignancy.
2) . Consider urgent referral to secondary care if suspecting: ankylosing spondylitis (to rheumatology) or disc prolapse
108
What are the two commonest causes of dysuria in women?
UTI and chlamydia
109
What other symptoms/ things should you ask about in a woman presenting with dysuria?
Urinary frequency, any blood in urine?, fever, abdominal pain (suprapubic consistent with simple UTI, loin/groin consistent with pyelonephritis, iliac fossa consistent with PID), nausea, sexual history, contraception, any possibility of pregnancy? Dyspareunia? IMB or PCB? Vaginal discharge?
110
What are 3 common organisms that cause UTI?
E.coli (the commonest), Staphylococcus saprophyticus, Proteus mirabilis
111
With chlamydia infection what term is used to describe the urine sample?
Sterile pyuria (this is the presence of leukocytes in the urine in the absence of demonstrable UTI (culture wise))
112
How is chlamydia tested for in both men and women?
Women: typically a low vaginal swab for NAAT
Men: typically first catch urine sample for NAAT
113
What is the treatment for an uncomplicated UTI in adults?
| And what do you need to be aware of if prescribing one of these antibiotics in the elderly
Empirical Rx with 3 day course of Trimethoprim 200mg BD or Nitrofurantoin 50mg QDS. 7 day course in men.
Avoid nitrofurantoin if eGFR <45
114
What is the Rx of UTI in pregnancy (first and third trimester)
7 days of treatment.
First trimester- give nitroFurantoin (NB avoid in the third trimester)
Third trimester- give trimeThoprim
115
In terms of haematuria, when should you refer patients?
If the patient has painless macroscopic haematuria at any age.
If the patient is over 50 with unexplained microscopic haematuria
116
What two screening questions can you use for depression?
1. During the last month, have you been bothered by feeling down, depressed or hopeless?
2. During the last month, have you often been bothered by having little interest or pleasure in doing things?
117
What are the 3 core symptoms of depression?
Low mood
Low energy
Anhedonia
118
In order to diagnose someone with depression how long must the symptoms have lasted?
Symptoms must be present everyday, or nearly everyday without significant changes throughout the day for MORE THAN 2 WEEKS.
119
Other than the 3 core symptoms of depression, what else should you ask the patient about? (Hint: these can be used to grade severity)
Disturbed sleep, change in appetite, poor concentration, low self-esteem/ confidence, suicidal thoughts/plans, feelings of guilt, change in psychomotor activity
120
What tool can be used to diagnose the severity of depression e.g. in primary care - it is a self-completed questionnaire.
PHQ-9
121
Outline management of mild depression
Low intensity psychological interventions focused on sleep hygiene, anxiety management (mindfulness) and problem solving techniques. E.g. individual guided self help, computerised CBT and structured group-based physical activity programmes. Unless symptoms persist beyond 8 weeks or previous Hx of depression, antidepressants should not routinely be used
122
Outline the management of moderate depression
Combination of an antidepressant and high intensity psychological intervention (8-12 sessions of CBT or interpersonal therapy)
123
When should you review a patient after starting them on an antidepressant?
Within 2 weeks (or within 1 week if patient <30 years old or has an increased risk of suicide).
124
How long should a patient continue an antidepressant for?
For at least 6 months after the patient is feeling better (important to tell the patient not to stop suddenly)
125
How long do antidepressants take to work?
Would usually expect to see a response by ~4 weeks, so this is when you could consider increasing the dose/ switching antidepressant if there has been little improvement
126
What side effects should you warn the patient of when you start them on an SSRI antidepressant?
Increased anxiety in the first two weeks or so, headaches, GI symptoms (nausea), sexual dysfunction, GI bleeds and hyponatraemia (in the elderly)
127
Which SSRI may cause prolonged QT?
Citalopram (and escitalopram)
128
What tool can be used to assess alcohol use in primary care? (It is a screening questionnaire designed to pick up early signs of harmful drinking)
AUDIT
129
Classically, the chest pain experienced in pericarditis is relieved by..?
Leaning/ sitting forwards
130
What is the overall most important modifiable risk factor for the development of cancers?
Smoking
131
Which 4 common cancers is obesity a risk factor for?
Breast, bowel, endometrium and oesophagus
132
Outline the guidance for GP referral to genetics clinics for breast/ovarian cancer.
Refer if woman has 2 or more first degree or second degree relatives with breast cancer.
Refer if just 1 first or second degree relative has breast cancer if the woman is Jewish, or has a family history of ovarian or male breast cancer
133
In the UK screening programmes exist for 3 cancers- which ones?
Breast, bowel and cervix
134
Outline the screening offered for breast cancer
Offered to women aged 50-70 (or 47-73 as part of a trial in some areas) every 3 years.
135
Outline the screening offered for bowel cancer
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FOB testing (or FIT) every 2 years to men and women aged 60-74
If positive result from FOB/FIT testing then offered colonoscopy.
In England, all adults offered a one off flexible sigmoidoscopy when they reach the age of 55.
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136
Why is FIT testing replacing FOB testing for bowel cancer screening?
It is more sensitive and is more patient friendly; the patient is given a brush that is attached to the lid of a pot
137
Outline the screening offered for cervical cancer
Offered to all women- every 3 years from age 25-49, then every 5 years from age 50-64.
138
How is cervical screening conducted/ carried out?
Sample is tested for HPV first- if HPV negative, cytology is not done and the patient is returned to routine recall. If HPV positive, then cytological analysis is done. If cytology is abnormal, the patient is referred for colposcopy. If cytology is normal, the patient is invited to have another smear 1 year later.
139
What is the NICE guidance about referral for suspected breast cancer?
Refer via 2 week wait:
Women >30 with unexplained breast lump +/- pain.
Women >50 with unilateral nipple symptoms (such as discharge or retraction).
Consider referral via 2 week wait:
Women with skin changes that suggest cancer
Women >30 with unexplained lump in axilla
Consider non-urgent referral in people aged <30 with an unexplained breast lump +/- pain.
140
What symptoms should prompt examination of the prostate gland and consideration for checking PSA levels?
Symptoms of an enlarged prostate: nocturia, frequency, poor stream, hesitancy, terminal dribbling
Symptoms of local spread: erectile dysfunction, visible haematuria
Symptoms of metastases: lower back pain, bone pain, weight loss
141
What is important to remember about PSA screening and considerations regarding PSA testing?
PSA SCREENING not currently recommended in the UK.
Must exclude urinary infection before PSA testing.
Postpone PSA test for at least 1 month after Tx of a proven UTI, 1 week after DRE and 3 days after ejaculation.
142
When should you refer men under a 2ww for suspected prostate cancer?
If their prostate feels malignant on DRE or if PSA levels are above the age-specific reference range
143
Which of the following symptoms is associated with the largest risk of having colorectal cancer? : Constipation, Diarrhoea, Weight loss, Abdominal pain, Rectal bleeding or Anaemia?
Anaemia- risk of up to 13%
144
When should you refer under the 2ww for suspected colorectal cancer?
Any patient with an unexplained anal mass or ulceration
Age >40 with unexplained weight loss and abdominal pain
Age >50 with unexplained rectal bleeding
Age >60 with iron deficiency anaemia / change in bowel habit
Any age if FOB/FIT positive
145
Under what circumstances is a FIT test recommended?
Age 50 or over and have abdominal pain OR weight loss
Age under 60 and have a change in bowel habit or iron deficiency anaemia
Age 60 or over and are anaemia (even if not iron deficient)
146
What symptom carries the highest risk of being lung cancer?
Haemoptysis
147
When you should refer under the 2ww for suspected lung cancer?
Refer for appt within 2 weeks if they: have CXR findings that suggest lung cancer or are aged >40 with unexplained haemoptysis.
Investigate with an urgent CXR (performed within 2 weeks) in people aged >40 if they have 2 or more of the following unexplained symptoms or if they have ever smoked and have 1 or more of the following unexplained symptoms: cough, fatigue, SOB, chest pain, weight loss, appetite loss.
148
So from a cancer point of view, under NICE guidelines, what investigation would be important to order if e.g. an ex-smoker presented with chest pain
A CXR- consider lung cancer as a diagnosis
149
If you suspect lung cancer in a patient and the CXR comes back as normal, does this rule out lung cancer as a cause of their symptoms?
No as CXRs may be negative even when the patient has cancer. If the CXR is normal and we still suspect lung cancer, we should request a CT scan or refer the patient for a bronchoscopy.
150
Does a normal CT chest rule out lung cancer?
Yes
151
What are the features of a headache and other associated symptoms that would increase the risk of it being a brain tumour?
Headache wakes them up, headache progressively worsening over days, vomiting, seizures, progressive numbness/ weakness, personality change, weight loss
152
What is pulsus paradoxus and what types of condition is it associated with?
It is the exaggerated fall in systolic BP during inspiration. If the difference in systolic BP between expiration and inspiration is >10mmHg this may be an important diagnostic finding. Causes are conditions that seriously constraint the hearts action e.g. cardiac tamponade and constrictive pericarditis
153
What is important to note about drug screening that is done by urine testing?
It does not give information about the QUANTITIES of drugs being used
154
What is alcohol dependency characterised by?
Craving, tolerance and a preoccupation with drinking and continued drinking in spite of harmful consequences.
