GP High Yield - Dr. Manar AlMansoor.pdf

GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • What are the causes of menorrhagia? Fibroids, congenital uterine abnormality, pelvic infection, endometriosis, endometrial or cervical polyps, endometrial cancer, IUCD, bleeding tendency or anticoagulant use, ho...

GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • What are the causes of menorrhagia? Fibroids, congenital uterine abnormality, pelvic infection, endometriosis, endometrial or cervical polyps, endometrial cancer, IUCD, bleeding tendency or anticoagulant use, hormone-producing tumors. What are contraindications to IUCD? Copper allergy, Wilson’s disease, menorrhagia or dysmenorrhea. What is the contraceptive method of choice in a woman >40 years and has heavy periods? Progestin IUD such as Mirena. DEFINITELY NOT IUCD What are the treatment options available for osteoporosis? N.B. DMA scan will show BMD of less than -2.5. o Lifestyle modifications: smoking cessation, exercise, weight loss, maintaining adequate nutrition with a BMI above 19. OFFERED TO ALL AT RISK. o Vitamin D and calcium supplements. Post-menopausal with dietary deficiency, >80yrs, on steroids, housebound/institutionalized. o Bisphosphonates such as alendronic acid ONCE WEEKLY, ibandronate and risedronate. This is the mainstay of treatment in osteoporosis. (N.B. SE? Esophagitis and osteonecrosis of the jaw. Esophagitis can be prevented by taking the pill with water, up straight and remaining so for 30 minutes). o SERMs such as raloxifene (N.B. Caution in DVT/PE/stroke). o Denosumab, SC injection 60mg every 6 months, works by RANKL inhibition. USED IN SEVERE OSTEOPOROSIS WHERE BISPHOSPHONATES ARE CONTRAINDICATED Decreases osteoclast activation and decreases bone resorption. Which breast conditions require urgent referral? Abscesses within 24 hours for I+D, mastitis first give antibiotics and refer if symptoms do not resolve within 48 hours, suspicious breast cancer. What is the definition of menopause? 1 year of amenorrhea. It is a retrospective diagnosis. N.B. Biochemically, LH/FSH will both be high. What are possible adverse outcomes of menopause? Osteoporosis, CVD, stroke. What is the most effective treatment for hot flashes in menopause? HRT, lowest dose should be used for the shortest time (N.B. SEs include VTE, CVA, breast cancer). Grey/white, thin, fishy vaginal discharge, no soreness? Bacterial vaginosis (CAUSED BY GARDNERELLA VAGINALIS), NOT AN STI thus no need to treat partner, treated with metronidazole or clindamycin or tinidazole (N.B. Commonest cause of vaginal discharge in women of reproductive age, pH will be >4.5 due to replacement of lactobacilli by mixed anaerobes). Cottage cheese, thick, creamy discharge, pruritis, superficial dyspareunia (versus deep dyspareunia in PID)? Candidiasis, treated with clotrimazole pessaries or oral fluconazole which is contraindicated in pregnancy and breastfeeding. N.B. Candidiasis will only be treated if the patient is symptomatic, as a lot of women are carriers. THERE IS NO NEED TO TREAT PARTNER. How do we diagnose and treat STIs caused by chlamydia? Diagnosed with appropriate swabs sent for NAAT, treated with doxycycline OR azithromycin if allergic/pregnant/breastfeeding. GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • • • • • • • • • • • • What is the treatment of STIs caused by trichomonas vaginalis? Metronidazole or tinidazole as a second-line agent. What is the treatment of gonococcal STIs? IM ceftriaxone and PO azithromycin. What is the first line emergency contraception? Cu-IUD. This also works by providing ongoing contraception, unlike oral EC. Mid-diastolic murmur loudest at apex? Mitral stenosis. Pansystolic murmur loudest at left lower sternal border? VSD. Best next step in a patient with AOM and now presenting with acute mastoiditis? Refer to ED. Best next step in a patient presenting with cauda equina syndrome? Refer to ED. REQUIRES IMMEDIATE ADMISSION Type of anemia in menorrhagia? Hypochromic microcytic. Most important parameter to check before starting DOACs? Renal function tests or eGFR. Unilateral epistaxis in a child, most likely cause? FB. What is the CHA2DS2VASc score? 0 no therapy preferred, 1 either aspirin or oral anticoagulation, 2 or more oral anticoagulation is indicated. CHF, HTN, age 75+ (2 points), DM, stroke (2 points), vascular disease, age 65+, female. 60-year-old male with anemia, next best step? Colonoscopy. HTN, <55 years, what is the first line treatment? ACE inhibitor or ARB. If can’t then beta blocker. ACE INHIBITORS AND ARBS ARE TERATOGENIC HTN, >55 years OR African/Caribbean, what is the first line treatment? CCB like amlodipine. If HF or high risk for HF? Thiazide-related diuretic such as indapamide and chlortalidone. N.B. CCBs are contraindicated in heart failure. Band-like headache i.e., bilateral, worse at work? Tension headache. Usually still able to do normal activities, not exacerbated by physical activity and not associated with vomiting. What is the treatment of HFM disease? Supportive treatment. WILL PRESENT WITH VESICLES IN HANDS, FOOT, MOUTH AND IS CAUSED BY COXSACKIE VIRUS, REMEMBER THAT THIS IS CONTAGIOUS How would you manage a child with bronchiolitis? Supportive treatment. Presenting symptoms of DVT? Calf swelling, erythema, tenderness, fever, warmth, distended collateral superficial veins. Presenting features of cerebellar disease? Intentional tremor, wide-based gait, slurred speech. Mass in RUQ, child is pale between attacks, what is the diagnosis? Intussusception. Elderly, tiredness and fatigue, dyspepsia, loss of appetite, anemic, what would you do? Upper GI endoscopy. What is the medication used to treat burning foot sensation in diabetic patients? Carbamazepine. BMD values and their meaning? o Normal should be -1 and more. o Osteopenia is between -1 and -2.5. GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • • • • • o Osteoporosis is -2.5 and less. Shingles rash in the face involving the tip of the nose, what do you do? Examine cornea for ulceration with fluorescein drops then give patient oral acyclovir. LOC/sedation, pinpoint pupils, low RR? Opioid overdose. REVERSE WITH NALOXONE AKA NARCAN What are some lab features associated with alcohol use? Raised GGT and macrocytic anemia. Possibly also B1/thiamine deficiency. What is Centor criteria? Used in sore throat to predict the likelihood of a streptococcal infection. 4 features, 1 point for each: tonsillar exudate, tender anterior cervical lymph nodes, history of fever >38, absence of cough. IF ¾ OR MORE THEN GIVE ANTIBIOTICS What is the drug used to prevent symptoms of alcohol withdrawal? Chlordiazepoxide. What medication to give for diabetic patients with microalbuminuria? ACE inhibitors such as ramipril. Child with suspected meningococcal disease including high fever, lethargy and purpuric lesions, hospital is a few minutes away, what do you give? IM benzylpenicillin or IV cefotaxime. DEFINITIVE TREATMENT WITH IV CEFTRIAXONE What is the HAS-BLED score? HTN, Abnormal renal and/or liver function, stroke, bleeding, labile INRs, >65 years, drugs and/or alcohol (N.B. high risk of bleeding if 3 or more points). What are side effects of ACE inhibitors? Cough, renal impairment, hyperkalemia, hypotension, angioedema. REMEMBER THAT ACE INHIBITORS AND ARB ARE TERATOGENIC How do we manage gout? Acute attacks are managed with NSAID+PPI OR colchicine OR corticosteroid and reviewed after 4-6 weeks where urate-lowering therapy can be considered. Start with allopurinol, if it doesn’t work or can’t be tolerated switch to febuxostat. Consider sulfinpyrazone either in addition or instead if target serum levels are not reached. N.B. Do not stop urate-lowering therapy during an acute attack of gout. Special considerations to the cervical spine in RA? Atlantoaxial instability leading to a risk of cord compression, which makes X-rays important to acquire prior to general anesthesia. N.B. RA classically spares the spine (except for cervical spine) and DIPs. Example of autoantibodies which can be seen in RA? RF which is an IgM autoantibody directed against Fc portion of IgG, anti-CCP MORE SPECIFIC THAN RF, ANA. What is the definition of critical limb ischemia? ABPI <0.5. What are the commonest causes of the common cold? Rhinoviruses, coronaviruses, influenza viruses. OTHERS ALSO INCLUDE RSV, ENTEROVIRUS, ADENOVIRUS What are the commonest causes of pneumonia? Streptococcus pneumoniae, haemophilus influenzae MORE COMMON IN ELDERLY, influenza A and B, mycoplasma pneumoniae LESS COMMON IN THE ELDERLY. What are the screening tests used for TB? Tuberculin skin test i.e., Mantoux test and interferon gamma release assay. IF PATIENT IS SYMPTOMATIC, WE DON’T GET ANY OF THESE; GET A CXR! GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • • • • • • • • • What is the first line treatment for TB? 6 months of rifampicin and isoniazid, with pyrazinamide and ethambutol included for the first 2 months. THE RIPE DRUGS Presenting features of hyperthyroidism? Tremor, weight loss, palpitations, AF, hyperactivity, hyperhidrosis, eye changes, alopecia, infertility. Woman with breast soreness/nipple hyperpigmentation/urinary frequency (DUE TO EXTERNAL PRESSURE), what would you order? Beta hCG (N.B. Nipple hyperpigmentation can occur in pregnancy, breastfeeding or as a side effect of highdose estrogen therapy). Woman with post-menopausal bleeding, what would you order? Endometrial biopsy. Absent red reflex in a 6-week-old baby, what do you do? Urgent referral to ophthalmology to r/o retinoblastoma. Presenting features of cluster headaches? Unilateral headaches focused around one eye with autonomic symptoms on that side including runny or blocked nose/red watery eye/ptosis/miosis/forehead sweating. Attacks last between 15-180 minutes. What is the acute management of cluster headaches? 100% oxygen and selective serotonin receptor agonists such as sumatriptan. What is the medication used for prophylaxis in cluster headaches? Verapamil may be used if the attacks are frequent. Which anti-convulsive is associated with the greatest chances of SJS? Lamotrigine. Multiple flat café au lait spots on the back, painless, positive family history? NF-1, gene is located on chromosome 17. Neurological symptoms that are worse in hot temperatures? Multiple sclerosis; specifically, Uhtoff’s phenomenon. N.B. Other sign is called Lhermitte’s sign where the patient experiences an electric shock-like feeling on flexion of the neck. Monitoring test for statins? LFTs. What are the rotator cuff muscles and their actions? Supraspinatus (abduction) JOBE’S OR EMPTY CAN TEST, infraspinatus (lateral/external rotation), teres minor (lateral/external rotation), subscapularis (medial/internal rotation) LIFT OFF TEST. APLEY’S SCRACTH TEST IS USED FOR RAPID ASSESSMENT OF SHOULDER MOVEMENT What is the antibiotic management of UTIs? Nitrofurantoin or trimethoprim. 3-day course in females if uncomplicated, 7-10 days in males/immunocompromised/GU malformation/relapse and recurrent infections. What is guttate psoriasis? Multiple drop-like lesions that are usually preceded by a streptococcal sore throat. THIS TYPE IS NOT AS COMMON AS PLAQUE PSORIASIS. What is the treatment for impetigo? Topical mupirocin. What is the treatment for cellulitis? Flucloxacillin. What is the treatment for shingles? Oral acyclovir or valacyclovir, analgesia, antibiotics for secondary bacterial infection. What are the medications given in angioedema? Adrenaline, hydrocortisone, antihistamine. What does a vaginal pH of more than 4.5 indicate? Bacterial vaginosis or Trichomonas vaginalis. NOTE THAT VAGINAL PH IS NORMAL OR <4.5 IN CANDIDIASIS. GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • • What are predisposing factors for candidiasis? DM, immunosuppression, pregnancy, radiotherapy/chemotherapy, steroid treatment, Cushing’s or Addison’s disease, trauma, broad-spectrum antibiotics. N.B. Candida vaginal infection is only treated if symptomatic as many women are carriers and usually no need to treat partner unless overt infection. If recurrent, >4 attacks per year, rule out DM. Give oral fluconazole to treat and treat the partner in this case. What are the consequences of PID? Tubal infertility, ectopic pregnancy, tubo-ovarian abscess, chronic pelvic pain. PID PRESENTS WITH LOWER ABDOMINAL PAIN, ADNEXAL TENDERNESS AND CERVICAL EXCITATION What are the causes of PID? Mainly STIs caused by chlamydia and gonorrhea. Others also include: Gardnerella vaginalis, anaerobes, mycoplasma genitalium. What are the treatment options available for PID? o Ofloxacin/levofloxacin, metronidazole. OR o IM ceftriaxone single dose, oral doxycycline, oral metronidazole. OR o Oral moxifloxacin if M. genitalium isolated. What are the types of urethritis? o Gonococcal urethritis: treat with ceftriaxone IM and azithromycin PO. o Non-gonococcal urethritis (e.g., chlamydia, ureaplasma, mycoplasma genitalium, TV, adenoviruses, HSV): first-line agents include doxycycline (if no work? Azithromycin and metronidazole), azithromycin (Moxifloxacin and metronidazole OR doxycycline and metronidazole), ofloxacin (Doxycycline and metronidazole). How does PID present? Lower abdominal/pelvic pain, cervical excitation/cervical motion tenderness/Chandelier sign, adnexal tenderness, purulent discharge and abnormal bleeding, fever and malaise, deep dyspareunia. What are the causes of hyperuricemia? Drugs (e.g., cytotoxics, diuretics, ethambutol), increased cell turnover (e.g., lymphoma, leukemia, hemolysis, psoriasis), decreased excretion (e.g., primary gout, CKD, hyperparathyroidism), disorders of purine synthesis (e.g., Lesch-Nyhan syndrome). What are the medical conditions associated with pseudogout? OA, hyperparathyroidism, hemochromatosis. What are the x-ray findings in RA? Normal OR periarticular osteoporosis and soft tissue swelling in early disease OR loss of joint space, erosions and joint destruction in later stages. What do we need to check prior to starting DMARDs? Baseline U/E, Cr, eGFR, LFTs, FBC, urinalysis. What can be given with MTX to reduce its side effects? Folic acid or folate 5mg after weekly dose. What is Felty’s syndrome? RA, splenomegaly, leucopenia. It occurs in patients with longstanding RA. How do we diagnose PCOS? Based on Rotterdam criteria, 2/3 should be present: o Amenorrhea or oligomenorrhea: cycle >35 days or <10 periods/year. o PCO on US. 12 OR MORE FOLLICLES IN EACH OVARY, 2-9MM EACH, OR OVARIAN VOLUME >10CM GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • o Clinical or biochemical hyperandrogenism: acne/hirsutism/alopecia, raised FAI. What are the main risks associated with PCOS? Insulin resistance, increased CVD risk, OSA, increased endometrial cancer risk. How do we diagnose BV? Based on Amsells criteria, ¾ need to be present: o Homogenous discharge o pH >4.5 o Fishy odor when combined with 10% KOH o Clue cells on microscopy CLUE CELLS ARE VAGINAL EPITHELIAL CELLS COVERED BY ADHERENT GRAM-NEGATIVE RODS What are examples of estrogenic side effects? Nausea, headache, dizziness, breast tenderness, cyclical weight gain. What are examples of progestogenic side effects? Weight gain, mood swings, acne, hirsutism, seborrhea. What are the options for emergency contraception? o IUCD: most effective form of emergency contraception, it also provides ongoing contraception. Offered as first-line. o Ulipristal acetate: mixed progestin agonist/antagonist. Maintains nearly full efficacy at 4th and 5th days unlike plan B. Particularly given in women with a raised BMI. MORE EFFECTIVE THAN PLAN B. Delay for 5 or more days before starting regular contraception. Can only be given once per cycle. o Levonorgestrel Plan B: progestin. Efficacy declines after 5 days, the sooner it is taken the better it is. Can be given more than once per cycle. Half as effective as ulipristal acetate. BEST TAKEN WITHIN THE FIRST 3 DAYS AFTER UPSI o Remember that oral EC works by delaying ovulation, meaning that they are ineffective once ovulation has occurred. What are NICE guidelines for HTN drug management? o <55yrs: first-line ACEi/ARB, second-line combine with CCB, third-line combine with thiazide-like diuretic. o >55yrs or African/Caribbean origin: first-line CCB, second-line combine with ACEi/ARB (ARB is preferred if African or Caribbean origin), third-line combine with thiazide-related diuretic. o If steps 1-3 fail to control, then this is resistant HTN. Consider adding spironolactone or increasing indapamide dose depending on potassium levels/doxazosin/atenolol. What are the stages of HTN according to NICE guidelines? o Stage 1: Clinic BP 140/90 or more AND ABPM/HBPM average of 135/85 or more. OFFER DRUG TX IF <80yrs and has at least 1 of: DM, renal disease, end-organ damage, established CVD, 10yr CVD risk of 10% or more. o Stage 2: Clinic BP 160/100 or more AND ABPM/HBPM average of 150/95 or more. OFFER DRUG TREATMENT TO ALL PATIENTS o Severe HTN: Clinic SBP 180 or more OR DBP 110 or more. OFFER DRUG TREATMENT TO ALL PATIENTS GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • When to consider referral in HTN? Resistant HTN, secondary HTN, severe end-organ damage (e.g., CVA, MI, DM, HF, CRF, hypertensive retinopathy, hypertensive encephalopathy). What is malignant HTN? BP 180/120 or more, retinal hemorrhages and exudates or papilledema, could also have renal involvement. IT IS A MEDICAL EMERGENCY. What are the NICE guidelines for A-fib management? o Rate control: bisoprolol or diltiazem/verapamil. Consider digoxin if sedentary elderly. Not everyone needs rate control, but it is offered as a first-line strategy to those who need it. o Prevention of TE: use CHA2DS2VASc score to determine risk for anticoagulation. o Rhythm control: still sx despite rate control/unsuccessful. Options include electrical cardioversion and chemical cardioversion with drugs such as amiodarone. What is the NYHA classification for SOB in heart failure? o Class I: Asymptomatic with no limitations. o Class II: Slight limitation during ordinary activity. o Class III: Marked limitation during less than ordinary activity, such as walking for short distances. o Class IV: Symptoms are present at rest. AVOID BETA BLOCKERS IN THIS GROUP What is the GOLD classification of COPD? o Mild: FEV1 80% or more. o Moderate: FEV1 between 50 and 80% of predicted. Sx? Breathlessness on walking for a long time. o Severe: FEV1 between 30 and 50% of predicted. o Very severe: FEV1 less than 30%. What is the first-line management in COPD? Offer short-acting bronchodilator whether SABA (e.g., salbutamol) or SAMA (e.g., ipratropium) as needed/PRN. What is the second-line management in COPD? o FEV1 >50%: LABA (e.g., salmeterol, formoterol) OR LAMA (e.g., tiotropium). o FEV1 <50%: LABA AND ICS OR LAMA. What is the third-line management in COPD? Triple therapy LABA, LAMA, ICS. What are the common infecting organisms in UTIs? E. coli, proteus, pseudomonas, streptococci, staphylococci. What is the management of UTIs? Remember special management in children, pregnant women, and catharized patients. o Analgesia, increase fluid intake, oral antibiotics according to local guidelines (e.g., nitrofurantoin, trimethoprim). o Uncomplicated in females? 3 days, consider delayed prescription if mild symptoms. o Males, GU malformation, immunosuppression, relapse/recurrent UTI? 7-10 days. o Pyelonephritis? Ciprofloxacin for 7 days. How do we diagnose uncomplicated UTI in an otherwise healthy female? Urine dipstick for leucocyte and nitrite. Treat if positive. NO NEED FOR MSU unless GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • • • • • child/pregnant/hematuria/abnormal renal function and tract/suspecting pyelonephritis/catheterized/recurrent/no improvement. How can we prevent recurrent cystitis? o General advice: increase fluid intake, urinate frequently, double voiding, voiding after intercourse. o PPx abx: nitrofurantoin post-coitally, nitrofurantoin or trimethoprim if continuously. o Men with BPH: finasteride/dutasteride and/or doxazosin. o HRT: topical estrogen in females of all ages. ALSO HELPS WITH CERTAIN MENOPAUSAL SYMPTOMS What are the presenting features and treatment of pyelonephritis? Fever, rigors, malaise, loin or flank pain, renal angle tenderness. Treated with ciprofloxacin for 7 days. What is another name for athletes’ foot and causative organism? Tinea pedis, caused by dermatophyte fungus. N.B. this fungus thrives in warm and humid conditions and most commonly occurs in young men. How would you describe BCC? Pearly shiny nodule, smooth surface, rolled edges, has central depression or ulceration. What is the systematic approach to pigmented lesions? ABCDE! A for asymmetry, B for irregular borders, C for two or more colors within the lesion, D for diameter >6mm, E for evolving. How can we manage skin tags? No treatment, removal by excision, removal by cryotherapy. Describe a sebaceous cyst and how can we treat it? Mobile nodule with a central punctum. Treated by excision and the whole cyst wall must be excised. What are the most common non-cancerous skin growths in older adults? Seborrheic keratosis. They can be treated by surgical excision or cryotherapy. What are the treatment options available for actinic keratosis? Cryotherapy, curettage and cautery, topical 5-FU or 3% diclofenac gel. THIS IS A PRE-MALIGNANT CONDITION What is the management for malignant melanoma? Surgical excision, radiotherapy, chemotherapy for metastatic disease. MUST REFER TO DERMATOLOGY What are the types of BCC and what is the commonest one? Nodular, superficial, pigmented, morphoeic. Nodular BCC is commonest. What are the areas affected in atopic dermatitis? Face and extensor aspects of limbs in infants, flexor aspects of limbs in children and adults. PLAQUE PSORIASIS TYPICALLY AFFECTS EXTENSOR SURFACES How can we manage atopic dermatitis? Emollients, topical steroids for flare ups, topical immunomodulators such as tacrolimus, phototherapy if severe and non-responding. How can we treat venous eczema? Elevate legs, supportive stockings, weight loss, emollients, topical steroids. What is the treatment of seborrheic dermatitis? Ketoconazole shampoo, topical keratolytics e.g., salicylic acid and steroids. What is the treatment for mild acne? Benzoyl peroxide/clindamycin i.e., topical duac and topical retinoids SUCH AS DIFFERIN. GENERALLY TOPICAL TX GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • • • • • • What is the treatment for moderate acne? Oral abx such as doxycycline, oral antiandrogens in females such as dianette. What is the treatment for severe acne? Oral retinoids such as Roaccutane. What is the treatment of rosacea? Topical abx like metronidazole gel, oral abx like doxycycline, oral isotretinoin if resistant. TRIGGERS INCLUDE HEAT, SUNLIGHT, ALCOHOL Etiology and treatment of chicken pox? Caused by varicella zoster virus, managed symptomatically/supportively. How do we treat ringworm i.e., tinea corporis? Topical antifungal creams like clotrimazole and miconazole. Patient presents with hoarseness for 6 weeks, what do you do? Refer to ENT. Patient develops quinsy, what do you do? Refer for IV abx and I+D. Patients develops retropharyngeal abscess, what do you do? Refer for IV abx and I+D. Etiology of sore throat? 70% are viral in origin, rest are bacterial; mostly caused by group A beta-hemolytic streptococci. What is the management of seizures? Buccal midazolam, rectal diazepam, IV lorazepam after 5 mins. May repeat dose if still seizing after 10-15 minutes of first dose of medication. Consider checking finger prick blood glucose if prolonged fit as hypoglycemia can precipitate seizures and is a REVERSIBLE CAUSE. What are examples of anti-hypertensives safe to use in pregnancy? Methyldopa, nifedipine, labetalol. REMEMBER ACE INHIBITORS AND ARBS ARE TERATOGENIC, CAN LEAD TO FETAL RENAL DAMAGE, PROLONGED HYPOTENSION, NEONATAL DEATH. What are the guidelines for TOC in chlamydia and gonorrhea infections? o Chlamydia: if pregnant or confirmed rectal infection then 3 weeks or more after treatment. <25yrs OR 25+ and at high risk of reinfection re-test 3-6 months after treatment. o Gonorrhea: persisting sx after treatment TOC with swabs for MCS >72 hours after completion of therapy. If asx following tx? 2 weeks after completion with NAAT. If positive, then culture/MCS. What are clinical features of trichomonas vaginalis infection? Discharge, dysuria, offensive odor, low abdominal discomfort, itchiness, ulceration. On examination will have frothy yellow discharge and strawberry cervix. REMEMBER THAT VAGINAL PH WILL BE GREATER THAN 4.5. How can we diagnose trichomonas vaginalis? Send HVS from posterior fornix for NAAT and MCS. How can we diagnose Neisseria gonorrhea? If patient is asymptomatic? First-catch urine sample for NAAT in men AND self-taken vulvovaginal swab for NAAT in women. If patient is symptomatic? Urethral/endocervical, rectal, pharyngeal swabs for NAAT and MCS as appropriate. What is the risk associated with female sterilization? Increased risk of ectopic pregnancy, GA risks, difficult to reverse, post-op complication. What are the advantages of progestogen-containing IUS? Decreased menorrhagia and dysmenorrhea, decreased risk for ectopic pregnancy, endometrial protection. GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • chronic neurodegenarive disorder that damages certain areas of brain • • What are the causes of HTN? Essential HTN, endocrine causes (e.g., Cushing’s syndrome, Conn’s syndrome, pheochromocytoma, acromegaly, hyperparathyroidism, DM), renal disease, CoA, pregnancy. What are the symptoms of HTN? Asx, visual disturbances, headaches, signs of end-organ damage e.g., LVH, MI, stroke/TIA, angina, renal impairment. When do we give statins in the context of HTN? If complicated by CVD OR for primary prevention in those >40yrs with 10yr CVD risk of 10% or more. What are the treatment targets for HTN? o No DM, no CKD: <140/90 and ABPM/HBPM <135/85. IF 80 OR MORE? <150/90 and ABPM/HBPM <145/85. o Uncomplicated T2DM: <140/80 o Uncomplicated T1DM: <135/85 o Complicated T1DM/T2DM: <130/80 o CKD: <140/90 o CKD + DM/ACR of 70mg/mmol or more: <130/80 o History of stroke/TIA: SBP <130 but if carotid stenosis then 140-150. What are the drugs of choice for rate limitation in AF? o First-line: bisoprolol, diltiazem, digoxin (only if sedentary). o Second-line: bisoprolol + diltiazem, bisoprolol + digoxin, diltiazem + digoxin. What are common precipitants for acute AF? Acute infection, high alcohol intake, surgery, electrocution, hyperthyroidism, MI, pericarditis, PE. What are ECG findings in AF? Rapid and irregularly irregular rhythm, narrow QRS complexes, absent P waves. What are the presenting features in symptomatic AF? Palpitations, SOB, dizziness, postural hypotension, chest discomfort. When not to offer rate limitation as first-line therapy in AF? Reversible cause, recentonset, heart failure caused by AF, atrial flutter suitable for ablation, rhythm control would be more suitable. What are the causes of parkinsonism? PD, other neurodegenerative disorders e.g., Alzheimer’s and multisystem atrophy, post-encephalitis, drugs e.g., typical antipsychotics and anti-emetics, toxins e.g., CO poisoning, trauma, NPH. normal pressure hydrocephalus What are the motor symptoms in PD? Tremor, rigidity, difficulty initiating movement, bradykinesia, abnormal gait, micrographia. small handwriting What are the non-motor symptoms in PD? Neuropsychiatric e.g., apathy, mood disorders, psychosis, dementia, sleep e.g., excessive daytime sleepiness and restless legs, autonomic e.g., weight loss, dysphagia, constipation, SD, urinary dysfunction, postural hypotension. What is Steel-Richardson-Olszewski syndrome? Parkinsonism, absent vertical gaze, dementia. Due to progressive supranuclear palsy. What are the problems associated with L-dopa therapy? On-off effect where there is levedopa fluctuation between periods of exaggerated involuntary movements and periods of immobility, end-of-dose effect where duration of benefit reduces after each dose, increasing abnormal involuntary movements. the end of dose effect is where the benefit of the medication reducesafter each dose therefor increasing abnormal involuntary movements GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • inflammation of the mucous membrane in the nose • • • • • • • • • euthyroid is the normal thyroid state • • • What is the FeverPAIN score for sore throat? Fever in last 24 hours, pus on tonsils, attends rapidly i.e., less than 3 days after onset, severely inflamed tonsils, no cough or coryza. IF 4 OR MORE THEN NEED TO GIVE ABX IMMEDIATELY When to consider referral for tonsillectomy? Recurrent acute tonsillitis, recurrent quinsy, chronic tonsillitis i.e., >3 months with halitosis, unilateral tonsillar enlargement to r/o malignancy, airway obstruction. When do we need to consider infectious mononucleosis? In teenagers or young adults presenting with sore throat for more than a week. What are complications of infectious mononucleosis? Secondary infections, rash with ampicillin, hepatitis/jaundice, pneumonitis, splenic rupture, neurological disturbances. What are antibiotic choices in sore throat and when do we need to give antibiotics immediately? Phenoxymethylpenicillin, erythromycin, clarithromycin. Give immediately: Centor criteria 3 or more OR FeverPAIN criteria 4 or more, systemically very unwell, suggestions of a serious illness or complications, increased risk for complications due to a pre-existing co-morbid condition e.g., heart/lung/renal disease, CF, immunosuppression. When to consider prescribing antibiotics immediately in acute secretory otitis media? Bilateral OM/associated with otorrhea, systemically very unwell, increased risk for complications because of an existing co-morbidity. AMOXICILLIN TDS IS THE DRUG OF CHOICE, ALSO GIVE ABX IN THOSE PRESENTING <2 YEARS OF AGE When to consider ENT referral in acute secretory otitis media? Recurrent attacks e.g., >3 in 6 months OR >4 in 1 year and acute perforation fails to heal in <1 month. What are the causes of hyperthyroidism? Graves’ disease (MOST COMMON CAUSE), toxic nodular goiter, thyroiditis, amiodarone, kelp ingestion. What are the causes of hypothyroidism? Chronic autoimmune thyroiditis, RAI ablation, thyroidectomy. absolute neutrophil count is less than 100 What are the side effects of carbimazole? Agranulocytosis (IF PATIENTS DEVELOPS SORE THROAT ADVICE TO STOP DRUG AND SEEK URGENT MEDICAL ATTENTION), aplastic anemia, hepatitis, lupus-like syndrome. N.B. Carbimazole is used temporarily to achieve euthyroid state prior to surgery/RAI ablation or for long-term/induction of remission i.e., 12-18 months, but >50% relapse. It is not effective for thyroiditis. Protective medications against colorectal cancer? HRT, COC pill, statin, aspirin. Risk factors for colorectal cancer? Overweight/obese, alcohol drinking, low physical activity, dietary factors i.e., high processed and red meat, low vegetables/fiber/fish/milk, T2DM, gallbladder disease and/or cholecystectomy, Crohn’s disease and UC. When to refer urgently i.e., <2 weeks when suspicious for lower GI malignancy? o Any age: abdominal or rectal mass consistent with involvement of large bowel, rectal bleeding and abdominal pain/weight loss/changes in bowel habits/IDA. o 40yrs or more: unexplained weight loss and abdominal pain. o 50yrs or more: unexplained rectal bleeding. o 60yrs or more: IDA/changes in bowel habits/positive FOB test. feacal occult blood test GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • BBV = benign paroxysmal positional vertigo • • • • • • • • • • • • HA = headache • N/V = nausea and vomit • What is the management of an acute attack of migraine? Combination therapy of sumatriptan and NSAID/paracetamol with anti-emetic. When to consider prophylaxis in migraine and what are the options available? Consider if 4 or more attacks per month or severe attacks. Try drug for 2 months before deeming it ineffective. First-line is propranolol or topiramate TERTAOGENIC AND MAY DECREASE THE EFFECTIVENESS OF HORMONAL CONTRACEPTION. Second-line is gabapentin or acupuncture. Third-line consider referral, botulinum type A toxin may be helpful. What is the presentation of cyclical breast pain? Bilateral, starts pre-menstrual and relieved with menstruation. Female, abdominal pain and diarrhea, all tests normal, what is the diagnosis? IBS. Opera singer with hoarseness, what is the cause? Vocal nodules. What deficiency causes neurological issues from alcohol? Vitamin B1 or thiamine. K/c/o hypothyroidism and on levothyroxine, high T4 and TSH, what is the likely cause? Over-medication. Started on SSRI, complaining of worsened mood and increased anxiety, what would you do? Continue with same medication at the same dose. Which heart murmur may be associated with a carotid bruit? Aortic stenosis. First-line treatment for acne rosacea? Give topical metronidazole. Where can we find a hazy cornea? Acute angle closure glaucoma. ALSO PRESENTS WITH EYE PAIN, HEADACHE AND FIXED PUPIL TFTs result show subclinical hypothyroidism, what do you do? If any symptoms like depression/hypercholesterolemia/infertility, then consider a trial of treatment. If asymptomatic repeat tests after 3-6 months, then monitor annually. Dx and Tx of BPPV? Dix-Hallpike test, Epley’s maneuver. Mx of anal fissure? Stool softener. tendon rubs Shoulder pain, painful arc syndrome, cause? Acromion impingement. against acromion Blepharitis, what do you do? Warm compress. Pathology behind bitemporal hemianopia? Pituitary tumor. End-of-life COPD, how would you manage SOB symptoms? Morphine sulphate. Obese women, mild OA, didn’t want to discuss weight loss, what do you do? Come back when ready to discuss. Tension HA, what do you give? Advise on relaxation techniques. First-line treatment for nasal polyps AND allergic rhinitis? Nasal steroids. Poorly controlled DM, possible complication seen on urine dipstick? Proteins. Male, joint pain, sudden LOV unilateral, what do you do? Prednisone 60mg and refer urgently for temporal artery biopsy. loss of vision might be giant cell arteritis What is the management of constipation in pregnancy? Increase fluid and fiber intake and use a bulk-forming laxative e.g., ispaghula husk. N.B. Avoid use of bowel stimulants such as senna as they increase uterine activity. Pregnant, with a HA/severe or sudden increase onset swelling, what do you do? Check BP and urine for proteinuria to rule out pre-eclampsia. If severe N/V in pregnancy, what do we need to rule out? Multiple pregnancies, trophoblastic disease, UTI. N.B. If severe and disabling then consider treatment with GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • aplastic crisis = temporary shut down of red cell production coc = combined oral contraceptive • • • • • • • • • • • • pioglitazone used for T2DM • • • • uncontrollable vomiting leading to weight loss antiemetics such as cyclizine. Dehydrated/>2-5 kg loss? Hyperemesis gravidum, affects 1% of all pregnancies, need to admit patient for rehydration. Pregnant, epigastric/right upper abdominal pain non-responsive to antacids? Check BP and urine dipstick for proteinuria to rule out pre-eclampsia. Then refer for same-day assessment even if normal. PRE-ECLAMPSIA CAN PRESENT WITH UPPER ABDOMINAL carpal tunnel PAIN syndrome How do we manage CTS in pregnancy? Night splints and if severe consider steroid injections. If it does not resolve after pregnancy, then refer to ortho for assessment. What causes an aplastic crisis? Parvovirus infection in sickle cell patients. What causes molluscum contagiosum? Poxvirus. Drug used to prevent crises in sickle cell patients? Hydroxycarbamide or hydroxyurea. Some contraindications to COC? Women with migraine (especially if aura), history of VTE. What is the pathophysiology behind migraines? Disturbed cerebral blood flow under the influence of serotonin. What are causes of facial pain? Trigeminal neuralgia, sinusitis, TMJ disorders, dental disorders, migranious neuralgia, shingles and post-herpetic neuralgia. N.B. If no cause identified then it is termed atypical facial pain. Start with simple analgesics like paracetamol or NSAIDs, if it fails try amitriptyline. What is the treatment of choice in trigeminal neuralgia? Carbamazepine which is often poorly tolerated. Oxcarbamazepine is used as an alternative. IF BOTH DID NOT WORK THEN REFER TO NEUROLOGY What are the causes of tension-type headache? Stress, anxiety, structural or functional abnormalities of the head and neck. When to refer to neurology in trigeminal neuralgia? <50 years, neurological deficit between attacks, no response to carbamazepine and oxcarbamazepine. What is the clinical presentation of migraines? Mod-severe, unilateral or bilateral, pulsating HA, lasts for 4-72 hours, prevents usual activities, aura, N/V, photophobia, phonophobia. CAN BE EPISODIC OR CHRONIC What are secondary causes of diabetes? Drugs e.g., steroids and thiazides, pancreatic disease e.g., pancreatitis, surgery, cancer, CF, hemochromatosis, endocrine causes e.g., Cushing’s, acromegaly, thyrotoxicosis, pheochromocytoma, pregnancy, others e.g., glycogen storage disorders and insulin receptor antibodies. What are the side effects of pioglitazone? Weight gain, fluid retention, heat failure, bone fractures, bladder cancer. N.B. Remember to check LFTs before starting and then regularly during treatment. This drug works by increasing sensitivity to insulin. What are the side effects of SGLT2i? UTI, genital thrush and rarely DKA even with normal glucose levels EUGLYCEMIC DKA. N.B. Avoid in patients >75 years and if eGFR <60. What do you do if HbA1c >58 despite triple therapy? Metformin, sulphonylurea, GLP-1 mimetic e.g., liraglutide, exenatide. What are causes/RFs for varicose veins? RFs include age, parity, obesity, prolonged standing. Secondary causes include DVT, pelvic tumor, pregnancy, AV fistula. GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • What are the presenting features of varicose veins? Heaviness, tension, aching that is worse in the evening/when standing and better when elevating the leg/with support stockings. What are the types of varicose veins? Trunk (varicosities of the long or short saphenous veins or their branches), reticular (dilated tortuous subcutaneous veins not belonging to the main branches of the long or short saphenous veins), telangiectasia (intradermal venules <1mm, also called spider veins). What is the management of varicose veins? If symptoms are troublesome? Weight loss if obese, support stockings (MAKE SURE THAT ABPI IS >0.8), avoid standing still for ABPI =ankle pressure prolonged periods of time. If severe symptoms or complications? Refer for vascular brachial index surgery assessment. What is saphena varix? Dilatation of the saphenous vein at its confluence with the femoral vein which transmits a cough impulse. Groin and it looks like hernia Which disease is often associated with thrombophlebitis migrans? Pancreatic carcinoma. What is a common cause of upper limb DVT? Central venous catheters. - you can feel the What are causes of raised D-dimers? DVT, pregnancy, malignancy, recent trauma, tenderness wound healing, inflammation, anticoagulant use, sepsis, liver impairment. along the venous What are complications of DVT? PE, post-thrombotic syndrome/chronic venous system insufficiency, recurrent VTE. distribution - the calf What can we use to predict DVT clinically? Wells’ score. diameter on o Add 1 point if: active cancer, immobilization of legs, bedridden for 3 days or more or the affected side is more major surgery in last 12 weeks, localized tenderness along the distribution of the than 3cm deep venous system, entire leg swelling, calf diameter of affected >3cm than - pitting edema on the unaffected leg, pitting edema of affected but not the unaffected leg, collateral affected side superficial veins (non-varicose), previous DVT. only o Take away 2 points if: an alternative cause is as/more likely than DVT. o Interpretation: less than 2 unlikely, 2 or more unlikely. What are the guidelines to refer for suspected laryngeal cancer? Refer urgently i.e., seen by ENT in <2 weeks if 45yrs and older with persistent unexplained hoarseness or MND = motor neuron disease unexplained neck lump. MG = myasenthia gravis What are the causes of hoarseness? Local causes (E.g., URTI WHICH IS THE COMMONEST, laryngitis, trauma, carcinoma, hypothyroidism, acromegaly), neurological problems (e.g., laryngeal nerve palsy, MND, MG, MS), muscular problems (e.g., muscular dystrophy), functional problems. N.B. Check TFTs if a patient presents with hoarseness and weight gain. What are the primary care treatments available for menorrhagia? excessive bleeding o Iron supplements if anemic. o First line? Levonorgestrel-releasing IUS. Only given if no identified pathology, adenomyosis, fibroids <3cm that are not distorting the uterine cavity. Reassess response to treatment after 6 months. o Non-hormonal: tranexamic acid or NSAIDs like mefenamic acid. Start on day 1 and continue for days of heavy flow. Reassess response in 2-3 months. levonorgestrel releasing IUS is a device that contains the hormone levon and is placed in the uterus GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) combined hormonal contraceptive • • • • • naftidrofuryl inc. walking distance but can only be considered if any previous work out has shown no improvement and the patient is NOT suited for angioplasty/ bypass • • • • • • • • IHD = Ischemic heart disease SOBOE = shortness of breath on exertion • • • • o Hormonal: CHC or cyclical progestogen e.g., norethisterone acetate and medroxyprogesterone (MPA). Reassess response in 2-3 months. When to consider gynae referral in the context of menorrhagia? If primary treatment has failed, if fibroids >3cm or distorting the uterine cavity, out-patient hysteroscopy is indicated, submucus fibroid (to consider hysteroscopic removal), other abnormality detected on USS that needs referral. What are treatment options available for menorrhagia in secondary care? Endometrial ablation, embolization of fibroids, hysteroscopic resection of polyps/fibroids, myomectomy, hysterectomy and oophorectomy. GnRH analogues may be used prior to when progesterone surgery. levels do not What are examples of risk factors for endometrial cancer? Tamoxifen, unopposed balance estrogen levels estrogen, PCOS, obesity, previous treatment has been unsuccessful. How do we manage critical limb ischemia? Give analgesia, often require opioids and refer for urgent vascular surgery assessment. What are the features of atherosclerotic disease in the superficial femoral artery? Will have calf claudication. Popliteal and foot pulses will be absent. Femoral pulses will be normal. so you wont be able to feel the pulse in the foot and back of knee but youll feel the femoral (groin) What are the features of atherosclerotic disease in the aorta or iliac artery? Will have calf, thigh and buttock claudication. Weak or absent femoral pulses and may also have a femoral bruit. What is the drug that may be used for IC and when do we offer it? Naftidrofuryl increases walking distance. To be considered only if supervised exercise has not led to improvement and patient is not fit for angioplasty/bypass surgery. Reassess after 3-6 months and discontinue if no improvement. What is the first step in management of asthma according to GINA guidelines? Low-dose ICS/LABA e.g., budesonide and formoterol combined inhaler AS NEEDED. Suspected cholecystitis, what would you start with? FBC. Poorly localized arm pain in 3yo baby, swung around while behind held at the wrist, unable to move elbow, what is the diagnosis? Dislocation/subluxation of the radial head or pulled elbow. Typical pose will be of the elbow in extension and forearm in pronation. How do we prescribe pain medications? According to WHO pain ladder: paracetamol, ibuprofen, weak opioids like codeine and tramadol, strong opioids like morphine and fentanyl. Male, painful punched-out ulceration in foot, what is your next step? Measure ABPI. What are the forms of contraception contraindicated in PID? Hormonal intrauterine devices such as Mirena. Best contraceptive options for a woman with HTN, DM, PID? Implantable progestogen. Woman, fatigue, lethargy, hair loss, weight gain, what blood test do you prioritize? TSH. Man, history of IHD, fatigue and increasing SOBOE, which investigation do you prioritize? FBC, anemia might worsen his angina. Middle-aged man, LIF pain/fever/malaise, what pre-existing pathology would have led to this presentations? Diverticulosis. GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • less than 40 y/o glenohumeral instability from connective tissue laxity or labral injury • • • • • GLUE EAR is when fluid builds up inside middle ear and becomes thick and sticky Which condition increases the risk for compression fractures? Osteoporosis. Swollen painful knee, red eye, what is the cause of his arthritis? Rheumatoid arthritis. Old man presents with glue ear/OME, what should you rule out? Nasopharyngeal carcinoma. What are the conditions that fall under atopy? Asthma, allergic rhinitis, eczema, hay so basically anything allergic fever. Baby with fever, vomiting, abdominal pain, what do you prioritize? FBC. Pros and cons of combined contraceptive pill/patch/ring? Pros include regular cycle and lighter periods, cycle control, reduced dysmenorrhea. Cons include poor compliance, side effects, increased risk of thromboembolism and breast cancer. Pros and cons of injectable progestogen? Pros include reduced menorrhagia and helps PMS, decreased risk of ectopic pregnancy, decreased risk of endometrial cancer. Cons include menstrual irregularities, weight gain, increased risk of osteoporosis, inflammatory arthritis unpredictable return of fertility. General rules in approaching shoulder problems? IA disease presents with painful limitation of movement in all directions. Tendonitis presents with painful limitation of movement in one plane only. Tendon rupture/neurological lesion presents with painless weakness. What are the causes of stiff, painful shoulder joint? Adhesive capsulitis, inflammatory arthritis, infectious arthritis, OA, prolonged immobilization, polymyalgia rheumatica. What is the usual presentation for frozen shoulder or adhesive capsulitis? Painful, stiff shoulder with global limitation of movement notably ER. Pain is often worse at night. Presents in 40–60-year-olds. Incidence is high in diabetic patients and those with intrathoracic pathology like lung disease or MI and neck disease. What are features/diagnosis of rotator cuff tears? May accompany subacromial impingement. Suspect if recurrent impingement or if drop arm test is positive. Refer to orthopedics. What are the clinical features of subacromial impingement? Pain in a limited arc of older than 40 y/o - chronic rotator abduction 60-120 or on internal rotation. <40 yrs? Associated with glenohumeral cuff tendonitis or instability from connective tissue laxity or labral injury. Older? Chronic rotator cuff functional cuff weakness/tear tendonitis or functional cuff weakness/tear. What are the investigations and management in rotator cuff injury? o Ix: x-ray may show calcification of supraspinatus tendon in acute tendonitis and irregularities/cysts in greater tuberosity in chronic cuff tendonitis, Dynamic US may demonstrate impingement, tendonitis and/or rotator cuff tears. o Mx: rest, NSAIDs, physiotherapy, subacromial steroid injection. Refer to orthopedics if conservative measures fail. Fall on arm/shoulder, flattening of deltoid/lost shoulder contour/absent sensation in regimental patch, what do you do? Refer to ED for x-ray and shoulder reduction. Presentation and management of rupture of long head of biceps? Discomfort in the arm on lifting, lump appears of biceps muscle on elbow flexion. Mx by excluding distal rupture of the tendon at the elbow and reassurance as no treatment is necessary. What are the two types of epicondylitis and their features? GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) Pancoast syndrome refers to superior sulcus tumors along with ipsilateral shoulder and arm pain, paresthesias, paresis and atrophy • of the thenar muscles of the hand and Horners syndrome (ptosis, • miosis, and anhidrosis). SIADH = Syndrome of inappropriat e antidiuretic hormone ADH release • • • • • • • • • • o Medial epicondylitis: Golfer’s elbow: tenderness over medial epicondyle, medial elbow pain on resisted wrist pronation. o Lateral epicondylitis: Tennis elbow: tenderness over lateral epicondyle, lateral elbow pain on resisted wrist extension. What are the x-ray findings in OA? LOSS: loss of joint space, osteophyte formation, subchondral cysts, subchondral sclerosis. What is Pancoast syndrome? Apical lung cancer and ipsilateral Horner’s syndrome. Caused by invasion of the cervical sympathetic plexus. Other features include shoulder and arm pain due to brachial plexus invasion C8-T2, hoarseness/bovine cough due to unilateral RLN palsy and vocal cord paralysis. recurrent laryngeal nerve palsy What are examples of paraneoplastic syndromes seen in lung cancer? Ectopic ACTH production, SIADH, hypercalcemia, hypercoagulability. Particularly more common with small cell lung cancer. Refer to specialist management if suspected. NNT = # needed to treat How do we calculate the NNT? 1/ARR where ARR= control – treatment. ARR = absolute risk reduction Subclinical hypothyroidism with subfertility? Start treatment with Eltroxin 25mg OD PO. What is the contraceptive method contraindicated in patients on warfarin? Depot medroxyprogesterone acetate, as it reduces warfarin clearance and may increase its effects. Pharmacological management of pain in palliative care? o Non-opioid, adjuvant: paracetamol or NSAID. o Weak opioid, non-opioid, adjuvant: solpadol (paracetamol & codeine), tramadol. o Strong opioid, non-opioid, adjuvant: morphine, oxycodone, hydromorphone, fentanyl, buprenorphine. o Example of adjuvant analgesics: gabapentin, pregabalin, TCAs, SNRIs, lignocaine patches. Pharmacological management of SOB in palliative care? Morphine, and may also give benzodiazepines as anxiety can exacerbate SOB. Pharmacological management of anorexia in palliative care? Domperidone, steroids, megestrol. increases movements of stomach Pharmacological management of nausea in palliative care? o Prokinetics e.g., domperidone, metoclopramide: nausea caused by early satiety, belching and delayed gastric emptying. o Centrally acting e.g., cyclizine, haloperidol, levomepromazine: nausea caused by metabolic factors or drugs. o Ondansetron: nausea caused by toxic causes such as chemotherapy and radiotherapy. o Dexamethasone: nausea caused by chemotherapy/radiotherapy, increased ICP, intestinal obstruction, unknown cause. Pharmacological management of constipation in palliative care? o Review meds possibly causing constipation: opioids, anticholinergics, 5-HT3 antagonists. o Stool softener like lactulose/macrogol AND a stimulant like senna or picosulfate. Starting treatment in adults and adolescents with a diagnosis of asthma? GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) okay so what youre doing is basically just increasing the dose step 1-2: Low dose ICS/ formoterol step 3: low dose AGAIN step 4: hes suffering give him medium dose step 5: add a LAMA and think about a high dose ICS and at this stage just refer for phenotypic assess for ige, anti il4 & il5 • • • • • • • • • • • o Step 1-2 i.e., symptoms <4-5 days a week: low-dose ICS/formoterol PRN. o Step 3 i.e., symptoms most days/ waking with asthma once a week or more: so if his Low-dose maintenance ICS-formoterol. alzheimers are mild o Step 4 i.e., daily symptoms/waking with asthma once a week or more/low lung symtoms to moderate - give function: medium-dose maintenance ICS-formoterol. anticholinesterase o Step 5: Add-on LAMA, consider high-dose ICS-formoterol, refer for phenotypic inhibitors like donepezil, assessment including IgE/anti-IL4/anti-IL5. galantamine, rivastigmine o Reliever? Low-dose ICS-formoterol PRN. if moderate/ What are features of Alzheimer’s disease? Most common form of dementia, presents severe - give with a steady decrease in memory and cognition. Defective genes in chr 14, 19, 21. Risk memantine factors include family history, Down’s syndrome, late-onset depression, hypothyroidism, history of head injury. What is the drug management of cognitive symptoms in Alzheimer’s disease? If mild or moderate? Anticholinesterase inhibitors like donepezil, galantamine, rivastigmine. If moderate/severe? Memantine. What are features of vascular/multi-infarct dementia? It presents in a stepwise progression. Final picture: dementia, pseudobulbar palsy, shuffling gait with small steps. Treatment? Secondary prevention of TIA/stroke. lewy body dimentia What are features of LBD? Fluctuating but persistent cognitive impairment, parkinsonism, hallucinations. Avoid AP as they can be fatal. If tranquilization is necessary? Use benzodiazepines. Son calls to ask about their father, what do you tell them? That you can’t share anything, and they must ask for the father’s permission first. What are early symptoms of dementia? Loss of short-term memory and inability to perform normally simple tasks. What are examples of drugs that can cause or exacerbate urinary incontinence? Diuretics, antihistamines, anxiolytics, alpha-blockers, sedative and hypnotics, anticholinergics, TCAs. What are the features of stress incontinence? Small losses, without warning, often related to coughing or exercise. Caused by prostatectomy, childbirth, deterioration of pelvic floor muscles/nerves. What is the treatment for stress incontinence? o Pelvic floor exercises OR PHYSIOTHERAPY?, if continued >3 months can help 60% of patients. o This may be assisted by vaginal cones and/or electrical stimulation. o Mechanical devices may also help. What are the features of urge incontinence/overactive bladder syndrome? The bladder contracts unintentionally due to detrusor instability or hyperreflexia. Overwhelming desire to void, often precipitated by stressful event, large losses and nocturia. What are the treatments for urge incontinence/overactive bladder syndrome? Bladder training (continue for >6 weeks). If ineffective? Try oxybutynin first-line. Other drug options also include solifenacin, tolterodine, trospium, duloxetine. Spontaneously remission/relapse. Reassess every 3-4 months. GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • • • • • What are causes/treatment of overflow incontinence? BPH, prostate cancer, urethral strictures, fecal impaction, LMN lesions, side effects of medication. Treatment is aimed at relieving the obstruction. fertile women who What are causes/management of urinary fistulas? Causes include congenital, have not given birth to a live baby malignancy or a complication of surgery. Refer to gynecology/urology. What are the uses of copper IUD? Old parous women, second line in young nulliparous women, emergency contraception. What are the uses of progestogen IUS? Contraception NOT emergency, menorrhagia, prevention of endometrial hyperplasia with estrogen therapy. What are contraindications to copper IUD and progestogen IUS? Pregnancy or <4 weeks postpartum, current or high risk of STI/PID including severe immunosuppression and if pelvic infection has only been treated for <3 months, undiagnosed uterine bleeding or distorted uterine cavity, endometrial/uterine/cervical cancer or trophoblastic disease, anticoagulation. What drugs can cause DKA with normal blood glucose? Gliflozins. Who to refer in the context of seizures? Refer for urgent assessment in any adult with the first seizure and in any child with a first seizure that is not related to a fever i.e., inflammation non-febrile seizures. of the lining of What are the causes of tenesmus? IBS, IBD, proctitis, tumor. the rectum What is abdominal migraine or periodic syndrome? Seen in children, some of which go on to develop classical migraine later in life. Presents as stereotyped attacks with abdominal pain, N/V, headache. Tx? Same as migraine. Steroid use and osteoporosis? If taking oral/high-dose inhaled steroids >3 months or frequent courses of steroids: >65yrs or history of fragility fracture then give bisphosphonates, if <65 yrs without history of fragility fracture? Refer for DXA scan and give bisphosphonates if T-score is -1.5 or less. If DXA scan reports back osteopenia, how do you manage the patient? Provide lifestyle advice and repeat DXA scan in 2 years. When should we avoid bisphosphonates? Avoid if severe CKD or in women of childbearing age as it can be teratogenic. What are instructions for bisphosphonates use? Take on an empty stomach first thing in the morning, at least 30 mins before food or other medication. Take it in an upright position, wash it down with plenty of water then sit up straight for 30 minutes after. When should we avoid raloxifene in treating osteoporosis? If history of DVT/PE, cholestasis, endometrial cancer, undiagnosed vaginal bleeding. What are the options for treating osteoporosis in men? First-line? Bisphosphonates. Second-line? Teriparatide (given as a daily injection, maximum duration of use is 18 months). What is the main issue with prolonged use of bisphosphonates? Atypical femoral fractures, acute subtrochanteric and mid-shaft femoral fractures are most common. Drug holiday of 1-5 years for low-risk patients after use for 5 yrs has been proposed to prevent this from happening. GP High Yield Sheet – Dr. Manar AlMansoor (RCSI Class of 2023) • • • • • • • • • • • • • • • • Monitoring/duration of treatment in osteoporosis? No specifics but consider repeat DXA scan if: fragility fracture while patient is on treatment, if considering a change in treatment, if considering restarting therapy after a drug holiday. What information do FRAX and Qfracture provide? 10-year probability of hip or other osteoporotic fracture. What are the exceptions to getting x-ray in back pain? Young <25? Get x-ray of sacroiliac joints to exclude ankylosing spondylitis, history of trauma, elderly is suspecting vertebral collapse i.e., compression fractures or malignancy. What are the risk factors for pre-eclampsia? Moderate: first pregnancy, multiple so if the pregnancy, pregnancy interval >10 years, 40 yrs and above, BMI 35 and above at first firs visit had a BMI visit, family history. High: chronic HTN, high BP in previous pregnancies, DM, CKD, of 35< or autoimmune disease including SLE and APS. anti phospholipid sydrome more Management of pre-eclampsia based on risk factors? If one or more high risk OR if two more moderate risk? Give aspirin 75mg from week 12 up to birth. Refer <20 weeks for specialist obstetric care. What is the criteria for dia