GP Flashcards

Question

what is age related macular degeneration?

Answer 1

central part of retina that's used for detailed work is called the macular - macular disease is the collective term for conditions causing damage no cure but can sometimes be slowed or halted in some cases with medical treatment, drug therapy or laser treatment. most common eye condition in the UK.

Answer 2

inherited diseases of retina - leads to gradual reduction in vision, initially night and peripheral vision then difficulties in reading and colour vision

Answer 3

condition affecting optic nerve. once affected, can't be reverse. often the nerve is damaged before vision loss is noticed

Answer 4

blood supply to retina is impaired. | if caught early can be treated by laser - stops progression but doesn't restore loss.

Answer 5

very common - lens changes with ageing, becoming less transparent - turns misty or cloudy.

Answer 6

% ABV * ml / 1000

Answer 7

- drinking within the family - childhood problem behaviour relating to impulse control - early use of alcohol, nicotine and drugs - poor coping responses to life events - depression as a cause (not a result!) of problem drinking

Answer 8

- accidents and violence - malignancies - cerebrovascular disease - coronary heart disease

Answer 9

occurs if persistent drinking throughout pregnancy small underweight babies, slack muscle tone mental retardation, behavioural and speech problems. characteristic facial appearance. cardiac, renal and ocular abnormalities.

Answer 10

AUDIT CAGE also - PAT, FAST, abbreviated AUDIT DON'T use blood tests

Answer 11

well-researched technique - use 5-15 mins to cover potential harm caused, reasons for changing incl health and well-being benefits, cover obstacles to change, strategies to combat and goals.

Answer 12

Stage I - No limitation on ordinary physical activity Stage II - Normal at rest. Ordinary physical activity causes breathlessness. Stage III - Normal at rest. Less-than-ordinary activity causes breathlessness. Stage IV - Symptoms at rest.

Answer 13

when output of the heart is inadequate to meet the needs of the body - end stage of all cardiac diseases

Answer 14

high output heart failure occurs when heart is working at normal/increased rate, but needs of the body are increased. causes - hyperthyroidism, anaemia, Paget's disease, AV malformation

Answer 15

low output = due to reduced heart function, due to either increased preload, pump failure or chronically excessive afterload. causes - mitral regurg, fluid overload, ischaemic heart disease, cardiomyopathy, MI, AF, aortic stenosis, restrictive cardiomyopathy, constrictive pericarditis, tamponade, chronic HTN drug causes - beta blockers (if making them really bradycardic), verapamil, diltiazem

Answer 16

BNP (serum B type natriuretic peptides) and NTproBNP (N-terminal-pro-BNP) - if raised, refer to cardiology for review. ECG (if ECG and BNP normal, NICE says it's probs not heart failure) might do an echo - can identify cause. also - CXR, lung function tests if trying to exclude respiratory cause, bloods (FBC, U&E, creatinine, eGFR, TFTs, BM/HbA1c) - these are to test for exacerbating factors and things you can treat!

Answer 17

diagnosis of CCF needs 2 major or 1 major + 2 minor criteria: MAJOR - paroxysmal nocturnal dyspnoea, neck vein distension, crepitations, acute pulmonary oedema, S3 gallop, hepatojugular reflux, cardiomegaly, increased central venous pressure, weight loss >4.5kg in 5 days in response to treatment MINOR - bilateral ankle oedema, nocturnal cough, dyspnoea on ordinary exertion, tachycardia >120, pleural effusion, hepatomegaly, reduced vital capacity

Answer 18

6 monthly review - check functional capacity, fluid status, screen for depression, medication review etc educate - about disease and prognosis lifestyle measures - stop smoking, low salt diet, weight loss, healthy diet, regular exercise. discuss needs for benefits, disabled badge etc. give annual flu and pneumococcal vaccines.

Answer 19

diuretics - used to relieve congestion/fluid retention - use a loop diuretic (e.g. furosemide 20-40mg or bumetanide 1-2mg). add thiazide if problems with oedema/HTN continue. monitor for hypokalaemia - treat with amiloride or K+ supplements if needed.

Answer 20

diuretics - usually loop (furosemide), might add thiazide ACE inhibitors - ramipril, start low and titrate up beta-blockers - bisoprolol - 'start low, go slow' might substitute an ARB in if the ACEi gives a cough (e.g. candesartan)

Answer 21

this is less common - basically can't do anything beyond give diuretics and treat co-morbidities

Answer 22

- making initial diagnosis (should have a routine referral) - unable to manage at home - severe - not controlled by first line medication - angina, AF, other symptomatic arrhythmia - heart failure due to valve disease - comorbidity that might impact heart failure e.g. COPD, renal failure, anaemia, thyroid disease, PVD, urinary frequency, gout - woman with heart failure planning pregnancy

Answer 23

aldosterone antagonists e.g. spironolactone hydralazine + nitrate in combo ARB - in combo with ACEi and beta blocker digoxin - anti-arrhythmic and positive inotrope amiodarone - used for arrhytmias

Answer 24

progressive deterioration to death, high BNP is poor prognostic factor 50% dead at 5 years - this is improving though

Answer 25

dyspnoea, poor exercise tolerance, fatigue, orthopnoea, PND, nocturnal cough, wheeze, nocturia, cold peripheries, weight loss

Answer 26

peripheral oedema, ascites, nausea, anorexia, facial engorgement. causes - left ventricular failure, pulmonary stenosis, lung disease

Answer 27

``` ABCDE! Alveolar oedema Kerley B lines Cardiomegaly Dilated upper lobe vessels pleaural Effusion ```

Answer 28

laymans terms = works on kidneys to help you get rid of excess fluid, which can make symptoms better acts on ascending limb of loop of Henle to inhibit the Na/K/2Cl co transporter SEs - hypokalaemia, renal impairment. monitor U&Es!

Answer 29

angiotensin-converting enzyme inhibitors - ramipril, lisinopril. first line for chronic heart failure - improves symptoms and prognosis laymans - reduces the strain on your heart by lowering your blood pressure, makes it easier for heart to work. block action of ACE, preventing conversion of angiotensin I to angiotensin II - reduces peripheral vascular resistance, so lowers BP (and afterload!) SEs - hypotension (esp first dose), dry cough (due to excess bradykinin), hyperkalaemia, renal impairment be aware of first-dose hypotension, especially if starting on loop diuretic at the same time!

Answer 30

angiotensin-converting enzyme inhibitors - ramipril, lisinopril. first line if <55yrs and not afro-carribbean laymans - improves blood pressure by encouraging veins and arteries around your body to relax a bit, reduces strain on your heart. block action of ACE, preventing conversion of angiotensin I to angiotensin II - reduces peripheral vascular resistance, so lowers BP. SEs - hypotension (esp first dose), dry cough (due to excess bradykinin), hyperkalaemia, renal impairment be aware of first-dose hypotension, especially if starting on loop diuretic at the same time!

Answer 31

e.g. bisoprolol, atenolol first line option - improves prognosis via beta1-adrenoreceptors (in heart, beta2 ones are in vessels and airways) these drugs reduce force of contraction and speed of conduction in heart - 'protects' heart from effects of chronic sympathetic stimulation. start low, go slow - might initially impair cardiac function, so don't just whack the dose straight up - titrate up every 2+ weeks. SEs - fatigue, cold extremities, headache, GI upset, erectile dysfunction. CONTRA-INDICATED IN ASTHMA

Answer 32

used if at least moderate severity, or heart failure arising within 1 month of an MI, generally as addition to beta blocker and ACEi/ARB. it's an aldosterone antagonist. inhibits action of aldosterone by competitively binding to the aldosterone receptor - increases sodium and water excretion, and potassium retention (risk of hyperkalaemia when combined with ACEi). SEs - hyperkalaemia, gynaecomastia, erectile dysfunction

Answer 33

5+ medications. inappropriate as soon as 1 drug prescribed that shouldn't be there: - no evidence based indication, expired indication, dose too high - medicines that aren't working - combination of, or any one, drug(s) causing adverse reaction **patient doesn't want/isn't able to take as intended**

Answer 34

``` increasing costs of healthcare increasing adverse drug events drug interactions medicines non-adhesive cognitive impairment, functional impairment, falls, urinary incontinence, nutrition ```

Answer 35

cardiac rehab (psuchological support, education, structured exercise programme, RF modification) regular reviews - heart failure nurses support groups

Answer 36

``` unknown/'essential' (95%) renal disease endocrine - Cushing's, Conns, phaeochromocytoma, acromegaly, hyperparathyroidism Pregnancy Coarctation of the aorta ```

Answer 37

>160/100 if otherwise healthy. | If >140/90 might treat if other risk factors/co-morbidities.

Answer 38

stage 1 = clinic BP >140/90 and subsequent daytime average ABPM/HBPM >135/85 stage 2 = clinic BP >160/100, average ABPM/HBPM >150/95 severe = clinica systolic >180 or diastolic >110

Answer 39

``` ABPM = ambulatory BP monitoring - continuous BP monitoring usually for 24 hours. HBPM = home BP monitoring - BP taken at home, not a continuous machine. ```

Answer 40

if <80y age and 1+ of: - target organ damage - established CVD - diabetes - renal disease - 10y CVD risk 20+% (Q risk)

Answer 41

all stage 2 hypertension needs drug treatment! | sneaky trick qu

Answer 42

education - to make sure pts understand why it's important they take drugs etc lifestyle - smoking cessation, regular exercise, reduce alcohol intake, reduce dietary salt, increase fruit and veg intake, reduce caffeine, encourage relaxation/stree management

Answer 43

if existing CVD - give statin regardless of baseline cholesterole/LDL levels OR - for primary prevention in patients >40y with HTN and 10y CVD risk 20+%

Answer 44

first line = ACEi (or ARB) if <55yrs. if >55 or african/caribbean = CCB (e.g. amlodipine) Step 2 = ACEi + CCB Step 3 = ACEi + CCB + thiazide-like diuretic Step 4 = add spironolactone or higher dose thiazide-like diuretic. consider alpha/beta blocker.

Answer 45

``` non-diabetic, no CKD = <140/80 diabetic, T2DM = <140/90 T1DM = <135/85 if any renal, foot, eye or cardiovascular complications in a diabetic patient - need tighter control, aim for <130/80 CKD = <130/80 ```

Answer 46

- check BP (obvs) and look for signs of end-organ failure (incl urine dip for proteinuria) - discuss symptoms and medication - assess and treat other modifiable RFs - reinforce lifestyle advice

Answer 47

- accelerated hypertension - renal impairment - suspected secondary hypertension - patients <40yr - BP difficult to treat (got to step 4) - pregnancy

Answer 48

ACE inhibitor - ramipril or lisinopril

Answer 49

reduce risk of stroke, MI and death from CVD. block action of ACE to prevent conversion of angiotensin I to angiotensin II. angiotensin II would normally be causing vasoconstriction, so blocking it means peripheral vascular resistance drops. SEs - dry cough!! due to increased levels of bradykinin, which is usually inactivated by ACE. also first dose hypotension, hyperkalaemia, renal failure.

Answer 50

calcium channel blockers e.g. amlodipine, nifedipine

Answer 51

reduce calcium entry into vascular and cardiac cells - causing relaxation and vasodilation in arterial smooth muscle - lowers BP amlodipine/nifedipine (dihydropyridines) are selective-ish for vessels, while diltiazem/verapamil (non-dihydropyradines) are more cardio-selective. SEs (of dihydropyridines) = ankle swelling, flushing, headache and palpitations.

Answer 52

ACEi / ARB + CCB

Answer 53

ACEi + CCB + thiazide-like diuretic

Answer 54

add spironolactone or higher dose thiazide-like diuretic. consider alpha/beta blocker. probs refer to cardiology - this is resistant hypertension

Answer 55

e.g. bendroflumethiazide (no longer NICE recommended though), indapamide inhibit Na/Cl co-transporter in distal convoluted tubule of nephron - prevents reabsorption of sodium and so more water excreted. tell patient - offering you a 'water tablet' for your high BP, will also help with leg swelling if they have it - ask about difficulty getting to toilet on time! SEs - erectile dysfunction, hyponatraemia, hypokalaemia

Answer 56

doxazosin, tamsulosin, alfuzosin used in resistant hypertension (also first line option for BPH) act on alpha1 adrenoceptors, which are mostly found in smooth muscle and urinary tract. so block those to induce relaxation, can drop BP. SE - hypotension! esp. postural. dizziness and syncope.

Answer 57

if risk of first dose hypotension - take at bed time!

Answer 58

all patients should be offered the following drugs: dual antiplatelet therapy (aspirin plus a second antiplatelet agent, typically clopidogrel) ACE inhibitor beta-blocker statin

Answer 59

diet: advise a Mediterranean style diet, don't recommend omega-3 supplements or eating oily fish exercise: advise 20-30 mins a day until patients are 'slightly breathless' (cardiac rehab programmes helpful) sexual activity may resume 4 weeks after an uncomplicated MI. Reassure patients that sex does not increase their likelihood of a further MI. advise weight loss, reduce alcohol.

Answer 60

first line always an ACE inhibitor in diabetes, as they're renoprotective

Answer 61

cardiac rehabilitation! | including an exercise programme of some kind

Answer 62

- pale/mottled/ashen/blue skin, lips or tongue - no response to social cues - appearing ill to a healthcare professional - doesn't wake/stay awake if roused - weak, high pitched or continuous cry - grunting - RR >60 - moderate/severe chest indrawing - reduced skin turgor - bulging fontanelle

Answer 63

- pale skin/lips/tongue reported by carer - not responding normally to social cues - no smile - wakes only with prolonged stimulation - reduced activity - nasal flaring - dry mucous membranes - poor feeding in infants - reduced urine output - rigors

Answer 64

green if they have all of the below, and no amber/red signs: - normal colour of skin/lips/tongue - responds normally to social cues - content/smiles - stays awake/wakens quickly - strong, normal cry/not crying - normal skin and eyes - moist mucous membranes

Answer 65

1) check your ABCDEs 2) assess against red/amber/green criteria 3) measure and record - HR (tachycardia = at least amber), RR, CRT (3+ is amber sign), temp (if < 3 months, 38+ C = red risk, if 3-9 months and 39+ C = at least amber) 4) assess for dehydration (prolonged CRT, abnormal skin turgor, abnormal resp pattern, weak pulse, cool extremities)

Answer 66

a competent child is one who can understand the nature, purpose and possible competence of a proposed procedure + the consequences of not undergoing the procedure. competent child (<16) can consent to treatment, but if they refuse they can be overruled by parents/court. if not competent - only someone with parental responsibility can authorise/refuse UNLESS it's an emergency - can provide any medical treatment, limited to what is necessary for saving life

Answer 67

Patient needs to be able to: 1) understand the information 2) retain the information 3) weight it up 4) communicate decision back You have a duty to take all reasonable steps to attempt to make them capacitous e.g. Braille/sign language, giving lots of time to explain and weigh it up etc.

Answer 68

- take all factors affecting the decision into consideration - involve the patient with decision making as far as possible - take the patient's previously known wishes into consideration - consult everyone else involved in patient's care/welfare (but remember, up to you to make best interests decision, not giving relative power to decide)

Answer 69

refer for immediate/same day review by a paediatrician

Answer 70

treat cause if found if no cause located, decide based on concerns of you and family: - advise parent's to ring up if any deterioration/failure to improve - arrange to review within a few hours - refer for paediatric review SAFETY NET - advise on warning symptoms (amber/red) and how to access further healthcare e.g. walk in/OOOH

Answer 71

infection most common cause - consider UTI if no localizing symptoms/signs. non-infective causes - malignancy (leukaemia, lymphoma), immunological (Still's, Kawasaki's disease), drugs, liver or renal disease

Answer 72

non-blanching rash - particularly with 1+ of: - ill-looking child - lesions >2mm in diameter (purpura) - CRT 3+ - neck stiffness

Answer 73

``` tachypnoea (>60 if 0-5m, >50 if 6-12m, >40 if >12m) crackles in chest nasal flaring chest indrawing cyanosis O2 sats <95% ```

Answer 74

neck stiffness bulging fontanelle decreased level of consciousness convulsive status epilepticus.

Answer 75

focal neurological signs focal seizures decreased level of consciousness

Answer 76

``` vomiting poor feeding lethargy irritability abdominal pain or tenderness urinary frequency or dysuria ```

Answer 77

swelling of a limb or joint not using an extremity non-weight bearing

Answer 78

bilateral conjunctival injection change in mucous membranes in the upper respiratory tract (for example, injected pharynx, dry cracked lips or strawberry tongue) change in the extremities (for example, oedema, erythema or desquamation) polymorphous rash cervical lymphadenopathy

Answer 79

- to look out for red/amber signs, how to access healthcare if deteriorate e.g. OOOH - temperature management - DON'T use tepid sponging/underdressing/over-wrapping - can use alternating paracetamol and ibuprofen if child distressed - regular fluids (breastmilk if breast fed) - any fluid fine, watch for signs of dehydration - if present, encourage fluids, seek advice if worried (111, walk i centre) - how to identify non-blanching rash - check child during night - keep off school - notify them of febrile illness

Answer 80

- if child has a fit - develops non-blanching rash - if parent/carer feels child is getting worse - if parent/carer becomes more worried - fever lasts >5 days - carer is distressed or worried they can't look after their child

Answer 81

``` sunken fontanelle (if young enough) dry mouth sunken eyes absence of tears poor overall appearance ```

Answer 82

- immunisations have caused massive improvements in health since they were introduced - their quick, safe and effective - child's body will then be able to fight off diseases better - there's a greater risk of them being exposed to harm if they aren't vaccinated (due to risk of catching, a being very ill from, the illness) herd immunity = when a large portion of population have been vaccinated, everyone benefits from herd immmunity - important that all healthy children are vaccinated, as there's a proportion who can't due to immune problems - herd immunity helps to protect them. it also prevents large outbreaks, and can lead to virus eradication.

Answer 83

- redness or swelling around the injection site - might be irritable/unwell/slight fever for a couple of days (esp common with MenB - advised to give 3 doses paracetamol after to prevent/treat fever) - after MMR - can get a rash about a week later, may also get fever/swollen glands

Answer 84

WHO targets >95%, PHE targets >94% (we don't normally meet that in England!) higher unemployment and lower household income significantly associated with low uptake.

Answer 85

- acute encephalitis - acute infectious hepatitis - acute meningitis - acute poliomyelitis - anthrax - botulism - brucellosis - cholera - diphtheria - enteric fever (typhoid/parathyroid) - food poisoning - haemolytic uraemic syndrome - infectious bloody diarrhoea - invasive group A strep disease and scarlet fever - Leggionnarie's - leprosy - malaria - measles - meningococcal septicaemia - mumps - plague - rabies - rubella - SARS - smallpox - tetanus - TB - typhus - viral haemorrhagic fever - whooping cough - yellow fever

Answer 86

public health england / local health protection team

Answer 87

diphtheria, tetanus, pertussis, polio, Hib, hep B - (DTaP/IPV/Hib/HepB) pneumococcal conjugate vaccine (PCV) MenB Rotavirus

Answer 88

diphtheria, tetanus, pertussis, polio, Hib, hepB | rotavirus

Answer 89

Diphtheria, tetanus, pertussis, polio, Hib and HepB pneumococcal (PCV) MenB

Answer 90

Hib and MenC pneumococcal (PCV) MMR MenB

Answer 91

``` children aged 2 and 3 on August 31st of that year children in reception class and school years 1, 2, 3, 4 and 5 piloting all primary school-aged children in some parts of country children aged 2 to 17 with long-term health conditions ``` delivered via nasal spray

Answer 92

diphtheria, tetanus, pertussis and polio | MMR (confirm first dose given)

Answer 93

HPV types 6, 11, 16, 18 - protects against genital warts and cervical cancer. two doses given 6-24 months apart.

Answer 94

tetanus, diphtheria and polio (confirm MMR status) | MenACWY

Answer 95

orally - drops

Answer 96

NO - prematurity means the babies are at greater risk of infection, so important to give them as normal from 2 months after birth.

Answer 97

8 weeks 12 weeks 16 weeks protects against diphtheria, tetanus, pertussis, polio, Hib, hepB further DTap/IPV at 3y 4m. also tetanus/diphtheria and polio given at 14yrs

Answer 98

8 weeks 16 weeks 1 year old

Answer 99

8 weeks 16 weeks 1 year

Answer 100

8 weeks | 12 weeks

Answer 101

combined with Hib at one year. as part of MenACWY for 14 year olds.

Answer 102

one year | 3y 4m

Answer 103

8/12/16 weeks as part of DTap/IPV/Hib/HepB | one year as part of Hib/MenC

Answer 104

bacterial vaginosis candidiasis also - normal changes! consider STIs and other non-infective causes

Answer 105

white/clear, non-offensive, varies with menstrual cycle

Answer 106

- heavier than usual - thicker than usual - pus-like discharge - white and clumpy discharge - greyish/greenish/yellowish/blood-tinged - foul-smelling discharge - discharge accompanied by bloodiness, itching, burning, rash, soreness

Answer 107

thin, profuse, fishy-smelling - no itch or soreness

Answer 108

thick, curd-like/cottage cheese, white, non-offensive - associated with vulval itch and soreness can cause mild dyspareunia and dysuria

Answer 109

asymptomatic in 80% | but - can see copious purulent discharge

Answer 110

can cause offensive yellow discharge, often profuse and frothy associated w/ vulval itch, soreness, dysuria, abdo pain, superficial dyspareunia

Answer 111

often asymptomatic | may present with purulent vaginal discharge

Answer 112

patients need to be offered a chaperone for all intimate examinations. should ideally be another medical professional - NOT a relative/friend (impartial observer). record that chaperone present and who it was.

Answer 113

U - understands advice and risks involved P - parents - can you persuade/encourage them to speak to parents S - suffer - without the contraception, their physical/mental health is likely to suffer S - sex - still gonna have sex either way! I - interests - it's in the best interests of the patient to have the contraception without parental consent if under 25 - offer chlamydia screening

Answer 114

CONDOMS - high failure rate but advise essential for preventing STIs!!!! remember, <25yrs = chlamydia screening LARC - suggest use in combination with condom (for STI cover) - implant/IUCD/IUS - injection if needed, but raises osteoporosis risk (defs don't use for >2 yrs) COCP/POP - suitable method, but compliance issues - relatively high failure rate. POP only really used if LARCs not wanted and COCP CI'ed due to menstrual irregularity.

Answer 115

bloods - FBC, U&Es, LFTs, renal function, TFTs, glucose, B12, folate, syphilis serology ECG BP urine dip will probs also get a CT head, can be organised by GP or memory clinic

Answer 116

alzheimer's vascular dementia with Lewy bodies Frontotemporal dementia mixed Parkinson's

Answer 117

progressive degeneration of cerebral cortex - cortical atrophy neurones affected develop amyloid plaques, neurofibrillary tangles, and produce less ACh "irreversible global, progressive impairment of brain function leading to reduce intellectual ability"

Answer 118

``` increasing age (obviously) Caucasian family hx female apoplipoprotein E4 variant (genetic) head injury the usual vascular RFs ```

Answer 119

insidious! initially - memory lapses, forgetting names, word-finding-difficulty, forgetting appts then - language difficulties, apraxia, problems with planning and decision making, confusion later - wandering, disorientation, apathy, psychiatric symptoms, behaviour problems, altered eating habits, incontinence

Answer 120

acetylcholinesterase inhibitors - donepezil, galatamine, rivastigmine these slow progression, but don't stop it. only work for some people. can have GI side effects. memantine - NMDA antagonist

Answer 121

memory aids - notes, lists, diaries etc CBT aromatherpay etc also - think about advanced planning. memory clinic referral.

Answer 122

- cognitive impairment caused by ischaemia or haemorrhage, secondary to cerebrovascular disease. main subtypes = stroke-related, subcortical, mixed dementia (e.g. vascular dementia and alzheimers)

Answer 123

- hx of stroke/TIA - AF - hypertension - DM - hyperlipidaemia - smoking - obesity - CHD - FHx stroke/CVD

Answer 124

progression may be sudden or gradual but is classically **stepwise** imaging shows cerebrovascular disease features indicating possible vascular cause: - focal neurology - difficulty w/ attention and concentration - seizures - depression ± anxiety - early present of disturbance in gait/falls - bladder symptoms

Answer 125

- no pharmacological options - AChE inhibitors and NMDA antagonists should NOT be used for anything other than Alzheimer's dementia. occasionally donepezil used prognosis - bad - life expectancy 3-5yrs

Answer 126

'eosinophillic intracytoplasmic neuronal inclusion bodies' (Lewy bodies) in the brainstem and neocortex

Answer 127

- dementia symptoms - memory loss, decline in problem solving etc - characteristic fluctuation in levels of awareness and attention - signs of mild Parkinsonism - visual hallucinations - sleep disorders - fainting spells - "drop attacks"

Answer 128

- avoid anti-Parkinsonian treatment - cholinesterase inhibitors e.g. rivastigmine at >6mg/day can treat cognitive decline according to NICE when I did GP - disputed in Cochrane review - maybe check this?? prognosis = 5-8y survival from onset

Answer 129

atrophy of fontal and temporal lobes - compared to diffuse atrophy in Alzheimer's

Answer 130

1) behavioural variant - loss of inhibition, inappropriate social behaviour, loss of empathy etc - most common 2) semantic dementia - loss of vocab with fluency of speech maintained, word finding difficulty, loss of facial recognition, memory comparatively well-preserved 3) progressive non-fluent aphasia - slow, hesitant speech, loss of literacy, difficulty with complex sentences

Answer 131

care and support plan / support plan for carers - gets put in place after health and social needs assessment Admiral nurses - dementia experts Alzheimer's society/other charity sector things - memory cafes, befriending, singing for the brain etc Community care - home care / personal assistants, day hospitals/services Memory clinic - does CT head, extensive questionnaire's/assessments, treatment, take detailed collateral history

Answer 132

independent mental capacity advocate service that provides advocacy for people deemed lacking in capacity - they know lows about the Mental Capacity Act, human rights, ethics/law stuff etc, spend time with patient trying to understand their wishes. used when making decisions about: - long-term care move; • serious medical treatment; • adult protection procedures; or • a care review. appointed when someone has no nominated friend/family to help make these decisions, or anyone with power of Attorney (personal and welfare) or a personal welfare Deputy

Answer 133

- everything that's done on behalf of someone who lacks capacity must be in that persons best interests - the person is able to put wishes in a written statement, and these must be taken into account (even if lacks capacity) - carers/family have right to be consulted

Answer 134

1) every adult has the right to make decisions and must be assumed to have capacity until proved otherwise 2) every adult must be given all possible help and support to make and communicate decisions before being consider to have lost capacity 3) making an unwise decision doesn't mean they lack capacity 4) anything done or decision made on behalf of them must be in their best interests 5) it must also be the least restrictive of their basic rights and freedoms

Answer 135

legal document an individual might have drawn up to appoint someone else to make decisions for them - can be written any time whilst the person has capacity - no legal standing till registered with Office of the Public Guardian. two types - property and affairs vs personal welfare. personal welfare is the healthcare one, only works when registered and the individual lacks capacity. Attorney can only make decisions about life-sustaining treatment if the LPA specifies that.

Answer 136

- these are statements about wishes regarding medical treatment in case individual become incapable later - legally binding, don't have to be written except for refusal of life-sustaining treatment - if refusing life-sustaining treatment, must be: written, specific (e.g. CRP), signed by individual and a witness - respect any refusal of treatment as long as clearly applicable to given circumstances! - cannot include decisions about what patient would like, only refusals - can't include directions to prematurely end life - if a Dr is unwilling to carry through an advance directive, should pass over care to another doctor who is - BMA recommends don't withhold 'basic care' (e.g. symptom control) even in face of directive specifying no treatment - if no formal advance decision - take patients wishes into consideration where known

Answer 137

used in care homes and hospitals, written document, aims to make sure people can be given the care they need in the least restrictive regimes possible. 'deprivation of liberty' is where someone is under continuous supervision and control, is not free to leave, and they lack capacity to consent to these arrangements. DoLS helps prevent arbitrary DoL, allows patients the right to challenge unlawful detention

Answer 138

``` Medications Vascular */+ Alzheimer's + Alcohol */+ Arrhythmias Normal pressure hydrocephalus ICP (raised) Insomnia */+ Subdural haematoma HIV Hypothyroid + Hypoglycaemia * Hypertension Head trauma * Emotional (severe depression) + Dementia + Delirium * Drug abuse */+ Deficiency (B12) * ``` * = acute, + = chronic others - Parkinson's, Syphilis, Stress, Wilson's disease, CJD, renal failure

Answer 139

deciding on the person’s routine, stopping them from walking about at night, or preventing them from leaving. anything that restricts someone/makes decisions for them

Answer 140

'The person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements.'

Answer 141

- to provide the person with a representative – a person who is given certain rights and who should look out for and monitor the person receiving care - to give the person (or their representative) the right to challenge a deprivation of liberty through the Court of Protection - to provide a mechanism for a deprivation of liberty to be reviewed and monitored regularly

Answer 142

care home/hospital requests assessment/authorisation from local authority if think person is/will be deprived of liberties Two people do assessment - best interests assessor, mental health assessor - appointed by local authority, need experience/trained best interests assessor = qualified social worker, nurse, occupational therapist or chartered psychologist - must not know patient. mental health assessor = doctor capable of determining if has 'mental illness' and impact of DoL on that

Answer 143

Age – Is the person aged 18 years or over? Mental health – Does the person have a ‘mental disorder’? Mental capacity – Does the person lack ‘capacity’ (the ability) to make their own decisions about treatment or care in the place that is applying for the authorisation? Best interests – Is a deprivation of liberty taking place? If so, is it: – in the person’s best interests? – needed to keep the person safe from harm? – a reasonable response to the likelihood of the person suffering harm (including whether there are any less restrictive options and if they are more appropriate)? Eligibility – Is the person already liable to detention under the Mental Health Act 1983, or would they meet the requirements for detention under this Act? No refusals – Does the authorisation contradict or conflict with any advance decision the person has made refusing treatment, or with any decisions made by, for example, a court-appointed deputy or someone with Lasting power of attorney? Has to meet all 6 to be approved

Answer 144

A DoLS authorisation should last for as little time as possible, and only up to a maximum of 12 months. Each individual DoLS authorisation will state the date it lasts until. However, during this time both the care provider and local authority should: make regular checks to see if the authorisation is still needed remove the authorisation when it is no longer needed provide the person’s representative with information about their care and treatment.

Answer 145

'any disease of an infectious or toxic nature caused by, or thought to be caused by, the consumption of food/water' includes illness caused by toxic chemicals if transported in food. actions: - identify affected cohort - identify source - ?close restaurant - people sampling, food sampling, questionnaires (to detect cause)

Answer 146

depression schizophrenia other psych conditions - anxiety, eating disorders dementia SAD bereavement organic cause - hypothyroid/hyperthyroid, endocrine (Addison's, Cushing syndrome, prolactinomas) some medications - methyldopa, propanolol, benzodiazepines, progesterone contraceptives

Answer 147

- female sex - pregnancy and postnatal period - past history of depression (alters how you treat) - physical illnesses - other mental health problems e.g. dementia - bereavement - divorce, illness, redundancy, financial worries - family history - isolation - learning disabilities - asylum seekers/refugees - African and Asian communities - elderly people

Answer 148

- previous suicide attempt/self harm - male - age (40-44yrs = highest group) - concurrent mental disorders or prev psych treatment - unemployment - homelessness - alcohol and drug abuse - physically disabling or painful illness - low SE status, loss of a job - isolation - significant life events - institutionalised e.g. prisons, army

Answer 149

During the last month, have you often been bothered by: feeling down, depressed or hopeless? having little interest or pleasure in doing things?

Answer 150

sleep hygiene advice active monitoring (if you think they'll recover without other intervention, arrange to see in 2 weeks and re-assess) low-intensity psychosocial interventions e.g. online/guided self-help CBT, group exercise programme group-based CBT (if decline self-help style CBT) typically - DON'T use antidepressants, but consider if past history of depression or no response to the above

Answer 151

anti-depressant (usually SSRI) high-intensity psychological intervention e.g. CBT, IPT if moderate/severe depression - provide combination of the above

Answer 152

- assess severity, comprehensive assessment - consider degree of functional impairment, duration of episode - assess past history - always ask directly about suicidal ideation!

Answer 153

NOT used typically, only use if: past history of moderate/severe depression symptoms persist after other interventions

Answer 154

start with SSRI normally - citalopram, sertraline (not in older people), fluoxetine, paroxetine warn patients of SEs and importance of continuation, discuss gradual development of full antidepressant effect and the need to continue beyond remission monitoring - see at 2 weeks, then every 2-4 weeks for first 3 months, then longer intervals. initial lack of response at 3-4 - check compliance, increase dose if no SEs, switch drug - different SSRI, or try TCA/MAOI/venfalaxine - may be less well tolerated. REFER if need to start combining/augmenting

Answer 155

encourage them to keep taking it for at least 6 months - this reduces risk of relapse. taper doses down before stopping - including taking lowest dose every other day etc.

Answer 156

PHQ-9 is the classic - should also do GAD-7 (anxiety version) at the same time. edinburgh PND questionnaire - done by health visitors for all postnatal women. HADS = hospital anxiety and depression scale, can be used in primary care setting. Also alcohol ones to be aware of - CAGE, AUDIT, SADQ

Answer 157

Consider for: Patients with moderate/ severe depression ± psychological therapy Dysthymia (subthreshold depressive symptoms lasting > 2y) Mild depression if other treatment strategies have failed

Answer 158

* The reasons for prescribing * Timescale of action— unlikely to have any effect for 2wk; effects build up to maximum effect at 4– 6wk, and * Likely side effects including possible exacerbation of anxiety in the first 2wk of treatment

Answer 159

GI upset is the most common appetite and weight disturbance (loss or gain) hypersensitivity reactions e.g. rash initial increase in anxiety and suicidal ideation can lower seizure threshold prolong QT interval can increase risk of bleeding

Answer 160

SSRIs given at high doses or in overdose can cause this - triad of autonomic hyperactivity, altered mental state and neuromuscular excitation

Answer 161

``` GI upset neurological symptoms flu-like symptoms sleep disturbance avoid sudden withdrawal!! ```

Answer 162

``` URTI (would have coryzal symptoms, normal chest) acute bronchitis common cold LRTI - viral or bacterial pneumonia asthma acute exacerbation of COPD inhaled foreign body pertussis PE pneumothorax/tension pneumothorax lung cancer GORD ACE inhibitors ```

Answer 163

``` foreign body aspiration lung cancer pulmonary TB post-infectious cough bronchitis pneumonia asthma pertussis ```

Answer 164

``` foreign body lung cancer pulmonary TB smoking-related cough ACE inhibitor induced cough asthma GORD eosinophilic bronchitis COPD pertussis heart failure bronchiectasis interstitial lung disease ```

Answer 165

- born in high prevalence areas - close contacts - prev (especially incomplete) treatment for TB - comorbidities e.g. HIV, diabetes, CKD - drugs - steroids, chemo - social risk factors - homeless, institutionalised, overcrowding - alcohol/drug misuse - low body weight - old/young - malnourished

Answer 166

- if diagnosed in GP clinic - leave via back door, consider home visits/telephone consultations to avoid spread in waiting room, or have TB clinics (this is all if GP practice is high risk area) - BCG vaccine for at risk groups - main thing is just identifying and treating adequately - within households - adequate ventilation, educate on cough etiquette, hand washing, avoid public transport/crowded places, sleep separately

Answer 167

CXR Sputum samples for culture (state on the form that you are looking for acid-fast bacilli) Tuberculin test + ve (may be − ve if immunocompromised) If diagnosis is confirmed, refer for treatment and contact tracing.

Answer 168

RIPE! 2 months on Rifampicin, Isoniazid, Pyrazinamide, Ethambutol then further 4 months of just isoniazid and rifampicin

Answer 169

Rifampicin - raised LFTs, low platelets, ORANGE WEE, inactivation of Pill, flu symptoms Isoniazid - can get neuropathy - switch to pyridoxine if so Pyrazinamide - hepatitis, arthralgia (don't give if they have gout) Ethambutol - optic neuritis (first symp. is loss of colour vision)

Answer 170

PaO2 - want this >10 if healthy and room air. if on O2, should be well above 10. <10 = hypoxaemic, <8 =severely hypoxaemic. Type 1 resp failure = hypoxaemic but normal CO2 Type 2 resp failure = hypoxaemic but high CO2 pH <7.35 = acidotic, >7.45 = alkalotic if pH change is respiratory driven - abnormal CO2 if metabolically driven - abnormal HCO3 HCO3 should be 22-26 Base excess > +2 indicates metabolic alkalosis or compensated respiratory acidosis < -2 indicates metabolic acidosis or compensated respiratory alkalosis

Answer 171

(pH low, CO2 high) Respiratory depression (e.g. opiates) Guillain-Barre – paralysis leads to an inability to adequately ventilate Asthma Chronic obstructive pulmonary disease (COPD) Iatrogenic (incorrect mechanical ventilation settings)

Answer 172

(pH high, CO2 low) Anxiety – often referred to as a panic attack Pain – causing an increased respiratory rate Hypoxia – resulting in increased alveolar ventilation in an attempt to compensate Pulmonary embolism Pneumothorax Iatrogenic (excessive mechanical ventilation)

Answer 173

usually - coronary artery disease | Rarer - HOCM, valve disease, hypoperfusion during arrhythmia, arteritis, anaemia, or thyrotoxicosis.

Answer 174

episodic central-crushing or band-like chest pain that may radiate to jaw/neck and/or one or both arms precipitated by exertion, cold, emotion, and/or heavy meals - stops with rest or GTN spray associated with palpitations, sweating, nausea, and/ or breathlessness during attacks has risk factors - smoking, FHx, hx of other vascular disease, peripheral vascular disease

Answer 175

Bloods - FBC, fasting lipid profile, fasting blood glucose. Consider checking ESR (to exclude arteritis) and TFTs if clinical suspicion of thyrotoxicosis ECG - for arrhythmias, presence of heart block, previous MI, myocardial hypertrophy, and/or ischaemia ECG doesn't rule out coronary artery disease, but identifies those at bigger risk of future MI etc

Answer 176

general advice - avoid heavy manual labour, might need to inform DVLA, stop smoking/modify other RFs where poss cardiac rehab PRN drugs - GTN spray (1-2 puffs in response to pain or before exertion) regular meds - beta blockers or CCB first line, then long acting nitrates (e.g. ivabradine, nicorandil) secondary prevention - aspirin, statins, ACEi - give to all with angina

Answer 177

Admit: unstable angina/rapidly progressive symptoms Urgent referral: aortic stenosis with angina, angina following MI, abnormal ECG at diagnosis Routine referral: angina not controlled by medication with two drugs, if diagnosis is in doubt, strong family history, other factors, e.g. occupation affected

Answer 178

angina pain occurring at rest, in the night, or which is rapidly worsening in frequency/severity etc do urgent referrral to cardiology

Answer 179

PCI/CABG - consider if not responding after trialling 2 drugs

Answer 180

occurs with coronary artery spasm, rather than on exertion ECG will show ST elevation - cardiology referral to exclude MI and atherosclerotic angina. GTN spray will offer immediate release always, CCBs used to prevent attacks.

Answer 181

rapid irregularly irregular narrow QRS complex tachycardia with absence of P-waves. risk of embolic stroke.

Answer 182

``` No cause (isolated AF) (12%) Coronary heart disease hypertension (especially if LVH) Cardiomyopathy Valvular heart disease (especially mitral valve disease) ```

Answer 183

``` acute infection high alcohol intake surgery MI electrocution PE hyperthyroidism ```

Answer 184

typically detected as part of testing for other reasons, being asymptomatic can cause - palpitations, chest pain, syncope, stroke/TIA, fatigue, dyspnoea

Answer 185

Routine investigations - resting ECG, CXR, Bloods - TFTs, FBC, U&E further investigations - ambulatory ECG or cardiac memo (measures ECG trace when triggered by patient e.g. to see if symptoms are due to arrhythmia) if paroxysmal AF. echo if < 50y or murmur/ heart failure detected consider exercise tolerance test if exercise-related

Answer 186

to relieve symptoms (e.g. palpitations, fatigue), maintain cardiac function and prevention thromboembolism and stroke risk if infrequent paroxysmal AF can consider no drugs/'pill-in-pocket' approach but if chronic or frequent paroxysms need to think about continuous treatment/anticoagulation

Answer 187

regular, sawtooth baseline at rate of 300bpm, with a narrow QRS complex tachycardia superimposed at a rate of 150bpm or 100bpm. managed similar to AF

Answer 188

self-medication with PRN beta blocker (e.g .atenolol 50-100mg)

Answer 189

either rate or rhythm control rhythm control = electrical/chemical cardioversion to sinus rhythm - used if - associated heart failure, new onset AF, atrial flutter suitable for ablation, AF secondary to a treated/corrected precipitant, rate control not successful rate control - with beta blocked (e.g. atenolol, bisoprolol) or rate-limiting calcium channel locker (e.g. diltiazem). can also use digoxin (but getting into specialist areas here)

Answer 190

drug that slows how fast your heart goes - prolongs refractory period of the AV node. SEs - fatigue, cold extremities, headache, GI upset, sleep disturbance, erectile dysfunction CI in asthma!!!!!!!! can cause bronchospasm as they block the beta 2 adenoreceptors in the airways

Answer 191

diltiazem and verapamil are the ones used for this (cardioselective) they suppress cardiac conduction across the AV node, slowing ventricular rate. SEs - ankle swelling, flushing, headache, palpitations, constipation (verapamil), bradycardia, heart block. DON'T prescribe with beta blockers - can cause heart failure/block

Answer 192

score used to assess risk of stroke in AF patients to decide whether oral anticoagulants are needed. Get points for the following: ``` Congestive heart failure Hypertension Age: ≥ 75 (2 pts) or 65-74 (1pt) Diabetes mellitus Stroke/TIA/thrombo-embolism (2 pts) Vascular disease Sex - Female ``` score of 1 = consider anticoagulating if male score 2+ for female to consider anticoagulating target INR = 2-3

Answer 193

used to weigh benefits of anticoagulating against risk of bleeding. one point for each of: Hypertension - uncontrolled, > 160 mmHg systolic Abnormal liver function Abnormal renal function Stroke Bleeding Labile INRs Elderly (Age >65) Drugs/alcohol score 3+ means consider carefully whether need to anticoagulate

Answer 194

lots of people on warfarin for this (target INR 2-3) - NICE now says to use NOACs only: apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist.

Answer 195

Offer rate control as first-line to people with AF, except in people: whose AF has a reversible cause who have heart failure thought to be primarily caused by AF with new-onset AF with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm for whom a rhythm control strategy would be more suitable based on clinical judgement.

Answer 196

Use the QRISK2 scoring system. decide between statins and lifestyle adjustments only - depends on overall risk, willingness to change etc. offer atorvastatin 20mg OD to anyone with 10yr CVD risk >10% as determined by Q Risk if dealing with secondary prevention (e.g. after MI) - always give statin - usually 80mg atorvastatin

Answer 197

stick to alcohol recommendations reduce intake of (saturated) fatty foods - eat more mono-unsaturated fats e.g. olive oil reduce sugar intake, get 5 a day, 2 portions fish per week, 4-5 portions unsalted nuts/seeds/legumes per week 150 mins of moderate intensity aerobic exercise per week, + 2 days of muscle strengthening exercises STOP smoking maintain normal BMI

Answer 198

reduce serum cholesterol levels - given to everyone with a 10 yr CVD risk of >10% (some places say 20% but think it's been lowered to 10) inhibit 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG CoA reductase) - enzyme that makes cholesterol. this decreases cholesterol production in liver, and increases clearance of LDL-cholesterol from blood. also reduce triglycerides and slightly increase HDL levels - slows atherosclerotic process and poss even reverses SEs - headache and GI upset most common. but can affect muscles - aches, myopathy or rhabdomyolysis

Answer 199

Physical inactivity Smoking cessation— mean weight ↑ 3– 4kg Cultural factors Low education Polygenic genetic predisposition - around 1 in 3 obese people - more prone to obesity again after successful dieting Childbirth— especially if not breastfeeding Drugs— steroids, antipsychotics (e.g. olanzapine), contraceptives (especially depo-injections), sulfonylureas, insulin Endocrine causes (rare) - hypothyroidism, Cushing’s syndrome, PCOS Ongoing binge eating disorder

Answer 200

DIET AND EXERCISE - target weight loss of 1-2lbs per week, equivalent to calorie deficit of 600kcal/day (decrease consumption and increase expenditure) drugs - orlistat, decreases fat consumption, trial if >3m consistent weight loss effort has failed surgery - adjustable gastric band most common. use if BMI >40 and all non-surgical options have failed. Complications: band slippage/ damage; gastric erosion, pouch dilatation; infection; malabsorption.

Answer 201

NRT e.g. patches, gum, sprays - swap out for cigarettes, use for 8 weeks then stop completely bupropion - an atypical antidepressant shown to aid smoking cessation. don't give if seizure prone. varenicline - alpha-4 beta-2 (α4β2) nicotinic acetylcholine receptor partial agonist - both blocks and stimulates the receptor - both reduces nicotine cravings, and reduces pleasure effect of smoking.

Answer 202

reduced bone mass and deterioration of bone architecture - usually described as low bone density. means bones are more fragile and prone to fracture. fracture risk assessed using FRAX (can calculate with or without BMD) or QFracture (based on UK pop, doesn't use BMD)

Answer 203

Endocrine - hypogonadism (e.g. premature menopause, anorexia, androgen blockade, taking aromatase inhibitors), hyperthyroidism, hyperparathyroidism, hyperprolactinaemia, Cushing’s disease, type 1 DM GI - coeliac disease or other causes of malabsorption, inflammatory bowel disease, chronic liver disease, chronic pancreatitis Rheumatological - RA, other inflammatory arthropathies Other - immobility, multiple myeloma, haemoglobinopathy, systemic mastocytosis, CF, COPD, CKD, homocystinuria STEROIDS

Answer 204

Fracture sustained falling from ≤ standing height— includes vertebral collapse (may not be as a result of a fall). commonly - hip, wrist (Colle's #), osteoporotic vertebral collapse (get pain, reduced height, kyphosis)

Answer 205

Female sex. Low body mass (<19 kg/m2) and anorexia nervosa. Parental history of hip fracture. Past history of fragility fracture (especially hip, wrist and spine fracture). Corticosteroid therapy (current treatment at any dose orally for three months or more). Cushing's syndrome. Alcohol intake of three or more units per day. Smoking. Falls and conditions increasing the risk of falls, such as: Visual impairment. Lack of neuromuscular co-ordination or strength. Cognitive impairment. Sedative medication and alcohol.

Answer 206

scoring system for osteoporosis that compares bone mineral density (BMD) of patient to the young adult mean. osteoporosis then defined as anything below -2.5 SDs away from that mean. osteopenia = between -1 and -2.5 (reduced density but not osteoporosis yet)

Answer 207

dual energy X ray absorpimetry - only use after assessing fracture risk with FRAX or Qfracture. often wouldn't bother if >75yo as likely will treat anyway, so doesn't change the management much.

Answer 208

``` add it from the start if think they'll be on it for >3 months - don't wait till 3 months have passed! use alendronate (bisphosphonate) - common side effect of GI upset, switch to risedronate ```

Answer 209

advise adequate calcium/vit D intake - consider supplementation. regular weight bearing exercise, stop smoking, reduce alcohol consumption. bisphosphonates = alendronic acid/alendronate 70mg once weekly - take on empty stomach, 30 mins before any other food/meds, sitting upright for 30 mins after, drink loads of water. common GI upset - switch to risedronate if so. other meds - strontium (not recommended any more) raloxifene (works on oestrogen) - used if bisphosphonates CI'd denosumab - monoclonal ab, used further down line of treatment

Answer 210

'wear and tear' arthritis - now thought to be metabolically active. usually localised to knee or hip or base of thumb initially - pain on movement, crepitus, worse at end of day, background pain at rest, gelling (stiffness after rest), joint instability

Answer 211

``` LOSS Loss of joint space Osteophytes Subarticular sclerosis Subchondral cysts ```

Answer 212

``` ↑ age (uncommon < 45y) F > M black and Asian populations genetic predisposition obesity abnormal mechanical loading of joint, e.g. instability poor muscle function post-meniscectomy certain occupations, e.g. farming ```

Answer 213

reduce load on joint - physio, walking aids exercise improves local muscle strength and reduces pain and disability avoid pharmacological treatment where poss - local heat, TENS etc then 1g paracetamol QDS first line ± topical NSAIDs (if knee or hand) second line - codeine, NSAIDs (+ omeprazole), topical capsaicin

Answer 214

intra-articular steroids - short-term can really relieve intra-articular hyaluronic acid - not NICE recommended cos expensive if severe - joint replacement (hips or knees)

Answer 215

chronic systemic inflammatory disease - symmetrical, deforming peripheral polyarthritis typical presentation = symmetrical swollen, painful and stiff small joints of hands and feet, worse in morning.

Answer 216

ulnar deviation of fingers dorsal wrist subluxation Boutonniere and swan-neck deformities of fingers Z deformity of thumbs

Answer 217

``` rheumatoid factor (positive in 70%) anticyclic citrullinated peptide antibodies (ACPA/anti-CCP) - very specific for RA inflammation means - raised platelets, ESR and CRP XR - may be normal, show periarticular osteoporosis or soft tissue swelling - late on shows loss of joint space, erosions and joint destruction ```

Answer 218

all patients with persistent synovitis should be reviewed. refer urgently if: - the small joints of the hands or feet are affected - more than one joint is affected - there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice. new NICE guidelines say they should be seen by rheumatology within 3 weeks

Answer 219

use the MDT!! physio OT hand exercise programmes podiatry psychological therapies - consider IAPT referral, ensure regularly screening for depression encourage mediterranean diet - but no link between any particular foods and RA generally complementary therapy - welcome to try, but shouldn't replace conventional treatments

Answer 220

if any of the following do not respond to optimal non-surgical management: persistent pain due to joint damage or other identifiable soft tissue cause worsening joint function progressive deformity persistent localised synovitis. ALSO - if they have any of the following complications for a specialist surgical opinion before damage or deformity becomes irreversible: imminent or actual tendon rupture nerve compression (for example, carpal tunnel syndrome) stress fracture.

Answer 221

treat-to-target - patients should have regular disease monitoring/reviews e.g. monthly rheumatology appts until they're in remission/meet disease control target (generally should be remission!) first line - monotherapy with conventional DMARD - methotrexate, sulfasalazine, hydroxychloroquine - ideally start < 3 months after symptom onset. titrate dose up to have effect - if that doesn't work, try the above in combination (step-up strategy)

Answer 222

biologics - sarilumab, dalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept - all used in combination with methotrexate rituximab used if the above don't work/are intolerated tocilizumab also used later on in treatment steps.

Answer 223

oral NSAIDs + PPI | short term course of steroids - oral, or intra-articular injections if disease quite localised

Answer 224

respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy osteoporosis ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus increased risk of infections depression

Answer 225

PEFR 33– 50% predicted or best (if recorded) Sats ≥ 92% Unable to talk in sentences Intercostal recession Tachypnoea (respiratory rate ≥ 25 breaths/ min) Tachycardia (heart rate ≥ 110bpm)

Answer 226

``` PEFR < 33% predicted or best (if known) Sats < 92% Arrhythmia Hypotension Cyanosis Exhaustion Poor respiratory effort Silent chest (inaudible wheeze) Altered consciousness ```

Answer 227

give oxygen salbutamol nebs (or via spacer if no nebuliser available) steroids - po pred or iv hydrocortisone if no response - ADMIT if any life-threatening signs/symps - ADMIT

Answer 228

paroxysmal, reversible airways obstruction 3 characteristic features: - Airflow limitation— usually reversible spontaneously or with treatment - Airway hyper-responsiveness to a wide range of stimuli - Inflammation of the bronchi

Answer 229

``` > 1 of: Wheeze Breathlessness Chest tightness Cough ``` ``` Particularly if: Symptoms are worse - at night/ early morning, with exercise, allergen and/ or cold air exposure, after aspirin/ beta-blockers PMH of atopy FH asthma and/or atopy Widespread wheeze Unexplained low FEV1 or PEFR Unexplained eosinophilia ```

Answer 230

Prominent dizziness, light-headedness, peripheral tingling Chronic productive cough without wheeze/breathlessness Normal examination of chest when symptomatic Voice disturbance Symptoms with colds only Smoking history (> 20 pack y) Cardiac disease Normal PEFR/ spirometry when symptomatic

Answer 231

spirometry preferred - FEV1/FVC ratio <70% = airway obstruction - but this can be normal if asymptomatic at the time of assessment! peak flow diaries more useful in monitoring controlled asthma, but are sometimes used fractional exhaled nitric oxide testing can be used if "intermediate" probability - more nitric oxide meant to indicate more inflammation in lungs might use reversibility testing - if airflow obstruction at time, test FEV1 before and after give salbumatol inhaler. if no airflow obstruction, test before and after trial of treatment with beclometasone

Answer 232

1) SABA - reliever inhaler, salbutamol (blue) step up if using blue inhaler 3 times a week 2) add low dose ICS 3) add leukotriene receptor agonist, review in 4-8 weeks 4) add LABA, continue LTRA if helpful 5) SABA ± LTRA, plus switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS 5) increase ICS to moderate dose - either as MART, or switch to LABA + ICS maintenance with SABA reliever 6) SABA +/- LTRA + one of the following options: - increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART) - a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline) - seeking advice from a healthcare professional with expertise in asthma

Answer 233

slowly progressive disorder characterized by airflow obstruction with little or no reversibility SMOKING Genetic— bronchial hyperresponsiveness; alpha1-antitrypsin deficiency Race— Chinese and Afro-Caribbeans have reduced susceptibility Diet— poor diet and low birthweight

Answer 234

Consider in any patient > 35y with a risk factor for COPD (generally smoking) and ≥ 1 of: SOBOE - use an objective measure, e.g. MRC dyspnoea scale to grade breathlessness Chronic cough Wheeze Regular sputum production Frequent winter ‘bronchitis’

Answer 235

``` might be none! or any of: Hyperinflated chest ± poor chest expansion on inspiration ↓ cricosternal distance Hyperresonant chest with ↓ cardiac dullness on percussion Wheeze or quiet breath sounds Paradoxical movement of lower ribs Use of accessory muscles Tachypnoea Pursing of lips on expiration (purse lip breathing) Peripheral oedema Cyanosis ↑ JVP Cachexia ```

Answer 236

FEV1/FVC <70%, FEV1 <80% (some places say 70%) predicted

Answer 237

spirometry CXR to exclude other pathologies FBC calculate BMI if early onset/family linked - consider testing for alpha1 antitrypsin deficiency

Answer 238

general - smoking cessation, pneumococcal vaccine, annual flu jab SABA or SAMA (ipatropium) is first line - if remain symptomatic then treat according to FEV1 FEV1 > 50% predicted - add LABA (salmeterol) or LAMA (tiotropium) next: if on LABA, switch to LABA + ICS combi if on LAMA, keep that and add LABA + ICS combi then maybe try theophylline mucolytics can be 'considered'

Answer 239

One or more of: ↑ dyspnoea— marked dyspnoea, tachypnoea (> 25 breaths/min), use of accessory muscles at rest and purse lip breathing are signs of severe exacerbation ↓ exercise tolerance— marked ↓ in activities of daily living is a sign of severe exacerbation ↑ fatigue ↑ fluid retention— new-onset oedema is a sign of severe exacerbation ↑ wheeze Chest tightness ↑ cough ↑ sputum purulence ↑ sputum volume Upper airways symptoms, e.g. colds, sore throats New-onset cyanosis— severe exacerbation Acute confusion— severe exacerbation

Answer 240

infections or pollutants organisms: Haemophilus influenzae (most common cause) Streptococcus pneumoniae Moraxella catarrhalis

Answer 241

increase frequency of bronchodilator use and consider giving via a nebuliser give prednisolone 30 mg daily for 7-14 days (useful qu if assessing severity of COPD - how many times were you on steroids last winter?) it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE only recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' if giving abx - Use broad-spectrum antibiotic, e.g. clarithromycin 500mg bd or doxycycline 100mg od/ bd

Answer 242

Assess patients for suitability if any of the following: very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be 'considered' for patients with severe airflow obstruction (FEV1 30-49% predicted) cyanosis polycythaemia peripheral oedema raised jugular venous pressure oxygen saturations less than or equal to 92% on room air Assessment is done by measuring ABGs on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management. ``` Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following: secondary polycythaemia nocturnal hypoxaemia peripheral oedema pulmonary hypertension ``` LTOT involves 15h a day of supplementary O2 via oxygen concentrator.

Answer 243

``` Smoking Alcohol Coffee Fatty food Big meals Obesity Hiatus hernia Tight clothes Pregnancy Systemic sclerosis Drugs (NSAIDs, TCAs, SSRIs, iron supplements, anticholinergics, nitrates, alendronic acid) Surgery for achalasia ```

Answer 244

retrograde flow of gastric contents through incompetent gastro-oesophageal junction - gives heart burn type symptoms. conditions causing GORD: Oesophagitis (defined by mucosal breaks) ± oesophageal ulcer Benign oesophageal stricture Intestinal metaplasia: Barrett’s oesophagus Oesophageal haemorrhage Anaemia

Answer 245

Heartburn: most common symptom. Burning retrosternal or epigastric pain which worsens on bending, stooping or lying, and with hot drinks. Relieved by antacids. Other symptoms: Waterbrash— mouth fills with saliva Reflux of acid into the mouth (bad/funny taste) - especially on lying flat Nausea and vomiting Nocturnal cough/ wheeze due to aspiration of refluxed stomach contents

Answer 246

``` symptoms for >4 weeks persistent vomiting GI bleeding/iron-deficient anaemia palpable mass age >55 dysphagia symptoms despite treatment weight loss ```

Answer 247

endoscopy barium swallow - identifies hiatus hernia oesophageal pH monitoring / manometry - useful if endoscopy normal

Answer 248

lifestyle - raise bed head, weight loss, smoking cessation, avoid spicy food/alcohol/citrus/hot drinks/choc, small regular meals drugs - antacids or alginates, PPI if oesophagitis or unresponsive to initial treatment. surgery - aims to increase resting LOS pressure, consider in severe GORD - Nissen fundoplication

Answer 249

compound inhalers - contain ICS and LABA Seretide = fluticasone and salmeterol Symbicort = budesonide and formoterol SEs - ICS's cause oral thrush (rinse mouth out), hoarse voice. LABAs can cause tremor, tachycardia, arrhythmias, muscle cramps. advise patient - must use every morning to work, might take a few days to feel benefit. rinse mouth and gargle immediately after - prevents oral thrush/hoarse voice.

Answer 250

used in GORD/dyspepsia - act to increase viscosity of stomach contents, reducing reflux of stomach acid into oesophagus - forms floating 'raft' on top of acid as well. usually used with antacids as Gaviscon/Peptac. antacids work by buffering stomach acids. SEs - rare, but diarrhoea or contraception. can reduce absorption of other drugs.

Answer 251

e.g. alendronate used first line for pts at risk of osteoporotic fragility fractures they reduce bone turnover, by inhibiting action of osteoclasts (cells responsible for bone resorption) patients take it once a week, before any food/drink, with lots of water, sitting upright for 30 mins after. SEs - oesophagitis, hypophosphataemia. avoid in severe kidney failure, CI if hypocalcaemia or upper GI disorders.

Answer 252

SABA (salbutamol, terbutaline) or LABA (salmeterol, formoterol) beta2 receptors are found in smooth muscle of bronchi, GI tract, uterus and blood vessels - stimulation by SABA/LABA causes smooth muscle relaxation, improving airflow, reducing breathlessness. SEs - tachycardia, palpitations, anxiety, tremor. LABAs can cause muscle cramps.

Answer 253

SAMA (ipratropium) vs LAMA (tiotropium) bind to muscarinic receptor, competitively inhibiting acetylcholine - reduce smooth muscle tone and secretions by blocking action of muscarinic receptor. SEs - none really, might get a dry mouth.

Answer 254

e.g. beclometasone, budesonide, fluticasone used in asthma and COPD 'dampen down' inflammation in lung - hardly any absorbed into the body. basically pass into cytoplasma, activate receptors then modify transcription of loads of genes - results in downregulation of pro-inflammatory interleukins, cytokines etc, and upregulation of anti-inflammatory ones - reduces mucosal inflammation, widens airways, reduces mucus secretion. both improves symptoms and reduces exacerbations. SEs - very local - oral thrush and hoarse voice.

Answer 255

e.g. omeprazole, lansoprazole reduce gastric acid secretion - irreversibly inhibit H+/K+-ATPase in gastric parietal cells (proton pump) which normally secretes H+ - can suppress gastric acid production almost completely cos they act on this last step. SEs - GI disturbance, headache

Answer 256

e.g. ranitidine used in GORD/peptic ulcer disease reduce gastric acid secretion - not completely though, so PPIs better really - ranitidine only blocks one pathway from stimulating proton pump SEs - usually well tolerated, might get diarrhoea, headache, dizziness

Answer 257

villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia

Answer 258

gluten sensitivity resulting in inflammation of bowel and malabsorption - T cell mediated autoimmune disease of small bowel. associated with HLA-DQ2 and HLA-DQ8, and other autoimmune diseases usually presents with kinda vague history of diarrhoea and weight loss/anaemia. also steattorrhoea, abdo pain, bloating, N&V, aphthous ulcers, angular stomatitis, fatigue, weight loss, osteomalacia

Answer 259

tissue transglutaminase anti-endomyseal antibodies alpha-gliadin (pt must have eaten 1+ meal with gluten per day for >6 weeks for tests to work) also do - FBC, ESR/ CRP, B12, folate, ferritin, LFTs, Ca2 +, TFTs, and stool sample for M, C& S (if diarrhoea)

Answer 260

gluten free diet - can prescribe gluten free breads, biscuits etc. refer to dietician. give pneumococcal vaccine - at risk due to secondary hyposplenism

Answer 261

anaemia, secondary lactose-intolerance, GI T cell lymphoma (rare), general raised risk of malignancy (gastric, oesophageal, bladder, breast, brain), myopathies, hyposplenism, osteoporosis

Answer 262

ulcerative colitis and crohns: chronic, relapsing-remitting diseases characterized by acute, non-infectious inflammation of the gut. UC - inflammation limited to mucosa. varies from disease limited to the rectum (proctitis) to affecting the whole colon (pancolitis). Crohn’s, any part of the gut from mouth to anus can be affected with normal bowel between affected areas (skip lesions).

Answer 263

protective factor!

Answer 264

relapsing and remitting inflammatory disorder - hyperaemic/haemmorrhagic granular colonic mucosa ± pseudopolyps formed by inflammation - might see punctate ulcers extedning into lamina propria, but inflammation not normally transmural

Answer 265

symps - episodic or chronic diarrhoea (± blood/mucus), crampy abdo discomfort, urgency/tenesmus (rectal UC) - frequency of bowel movements relates to severity. signs - might be none, or clubbing, aphthous oral ulcers, erythema nodosum, pyoderma grangrenosum, conjunctivity, episcleritis, iritis, sacroiliitis etc etc

Answer 266

bloods - FBC, ESR, CRP, U&E, blood culture stool MC&S to exclude infection colonoscopy - shows disease extent, allows biopsy

Answer 267

perforation bleeding toxic megacolon venous thrombosis - higher risk

Answer 268

induce remission with a 5-aminosalicylic acid (sulfasalazine or mesalazine), steroids (prednisolone) can also help. maintenance - often stay on 5-ASA also - suppositories (e.g of pred or mesalazine) helpful in proctitis, foams PR can help procto-sigmoiditis. immunomodulation (e.g. azathioprine, methotrexate, infliximab) used if steroids not inducing remission surgery - eventually - resulting in stoma usually.

Answer 269

characterized by transmural granulomatous inflammation - affects any part of gut from mouth to anus, can have skip lesions.

Answer 270

symps - diarrhoea with urgency, abdo pain, wt loss, fever/malaise/anorexia, steattorrhoea signs - aphthous ulcers, abdo tenderness, perianal abscess/fistulae, skin tags, anal strictures.

Answer 271

``` small bowel obstruction toxic megacolon abscess formation fistulae e.g. colovesical malnutrition osteomalacia ```

Answer 272

blood - FBC, ESR, CRP, U&E, LFT, INR, ferritin, B12, folate stool - MC&S to exclude infection colonoscopy and rectal biopsy

Answer 273

mild attack - mesalazine or prednisolone severe - admit, IV hydrocortisone, consider surgery there's loads of weird and wonderful drugs can try in specialist care e.g. azathioprine, methotrexate, TNF alpha inhibitors etc surgery usually last resort if other management failed - never curative

Answer 274

chronic (> 6mo) relapsing and remitting condition of unknown cause, with symptoms including ABCs: Abdominal pain or discomfort; Bloating; and Change in bowel habit.

Answer 275

Abdominal pain or discomfort that is: Relieved by defecation, or Associated with altered bowel frequency or stool form and ≥ 2 of the following: Altered stool passage (straining, urgency, incomplete evacuation) Abdominal bloating (F > M), distension, tension, or hardness Symptoms made worse by eating Passage of mucus other common symptoms - lethargy, nausea, backache and bladder problems

Answer 276

reassurance, dietary advice e.g. limit/increase fruit and veg intake, trial various diet changes try bisacodyl/sodium picosulfate for constipation for diarrhoea can try bulking agent and loperamide for cramping/colic/bloating - antispasmodis (mebeverine) psychological therapies try not to over medicalise

Answer 277

``` DIABETES hypertension SLE hypercalcaemia Urinary tract obstruction Chronic pyelonephritis Polycystic kidneys (familial) Glomerulonephritis e.g. IgA nephropathy Renovascular disease Interstitial nephritis Amyloid Myeloma PAN ```

Answer 278

History features - FH (polycystic kidneys); UTI; drugs (especially analgesics) - often none really Symptoms - often no symptoms, or - nausea, anorexia, lethargy, itch, nocturia, impotence. Later symptoms - oedema, dyspnoea, chest pain (from pericarditis), vomiting, confusion, fits, hiccups, neuropathy, coma Signs - pallor, ‘lemon tinge’ to skin, pulmonary/ peripheral oedema, pericarditis, pleural effusions, metabolic flap, ↑ BP, retinopathy

Answer 279

impaired renal function for >3 months with abnormal structure/function - OR - GFR <60 for >3 months ± evidence of kidney damage

Answer 280

normally no symptoms till stage 4+: stage / GFR / notes stage 1 = >90 = normal or high GFR with evidence of renal damage stage 2 = 60-89 = slightly low GFR with evidence of renal damage stage 3A/B = 45-59 / 30-44 = moderately low GFR with or without evidence of renal damage stage 4 = 15-29 = severely low GFR, ± evidence of renal damage stage 5 = <15 = established renal failure evidence of renal damage = proteinuria, haematuria, evidence of abnormal anatomy/systemic disease

Answer 281

patients with: diabetes hypertension cardiovascular/cerebrovascular disease structural renal disease, known stones or BPH recurrent UTIs or childhood hx of vesicoureteric reflux multisystem disorders which could involve the kidney eg. SLE FHx of end-stage renal failure or known hereditary disease e.g polycystic kidneys

Answer 282

Urine - MC& S, microalbuminuria, albumin:creatinine ratio protein:creatinine ratio, RBCs, glucose Bloods - U& E, creatinine, eGFR, glucose, Ca2 +, PO4 – urate, protein, FBC, ESR, serum electrophoresis Renal tract USS If progressive or advanced (stage 4/ 5) disease, refractory ↑ BP, haematuria, or palpable bladder/ lower urinary tract signs consider renal biopsy if rapidly progressive/unclear cause and normal size kidneys

Answer 283

- stage 4 or 5 - moderate proteinuria unless due to DM and already appropriately treated - proteinuria with haematuria - rapidly falling eGFR - poorly controlled hypertesion despite 4+ antihypertensives - known/suspected rare/genetic cause - suspected renal artery stenosis

Answer 284

- find and treat reversible causes - limit progression/complications - tight BP control, treat raised PTH to prevent renal bone disease, reduce CVD risk factors, dietician advice - symptom control - monitor for anaemia, acidosis, oedema, restless legs - prepare for renal replacement therapy

Answer 285

dialysis normally started at GFR of about 8-10 haemodialysis - need AV fistula normally to get good enough access, blood passed over membrane and waste removed, can do ultrafiltration to remove excess fluid as well haemofiltration - used in critically ill but inappropriate for long term as takes too long peritoneal dialysis - uses the peritoneum as membrane - catheter inserted into cavity, infusion of fluid, then solutes can move across - can be done at home, quite simple. dialysis has a massive impact on QoL!! the ultimate in renal replacement therapy is renal transplant - but major surgery, long term immunosuppression, risk of complications etc

Answer 286

insulin deficiency due to autoimmune destruction of insulin-secreting pancreatic beta cells. associated with HLA DR3 ± DR4 - and other autoimmune diseases. they will be insulin dependent, can present in DKA

Answer 287

reduced insulin secretion and raised insulin resistance - associated with obesity, sedentary lifestyle, calorie and alcohol excess. progresses from preliminary phase of impaired glucose tolerance or impaired fasting glucose.

Answer 288

symptoms of hyperglycaemia (e.g. polyuria, polydipsia, weight loss, vision blurring, genital thrush, lethargy) AND raised blood glucose once - fasting = 7+, random = 11.1+ mmol/L OR 2 separate occasions of raised blood glucose using above cut offs OR oral glucose tolerance test 2h value 11.1+ mmol/L HbA1c noraml at 48+ mmol/L (or 6.5%) - doesn't exclude DM, don't bother using in kids, pregnancy or T1DM

Answer 289

LIFESTYLE - education programme, smoking cessation, weight loss, good nutrition start statin, control BP, foot care inform DVLA - don't drive if hypo spells - loss of hypo awareness = loss of license (permanent if HGV driver) influenza and pneumococcal jabs

Answer 290

1) metformin (biguanide) - only effective if some insulin production still, no hypo risk, can aid weight loss second-line / if metformin CI'ed - DPP4 inhibitors, pioglitazones or sulfonyureas sulfonyurea - e.g. glicazide - increase insulin secretion, can cause hypos and weight gain pioglitazone - increases insulin sensitivity, can cause hypos, fractures, fluid retention DPP4 inhibitors - aka gliptins e.g. sitagliptin 3rd line is basically combinations of the above then you go to insulin

Answer 291

``` heart failure or history of heart failure hepatic impairment diabetic ketoacidosis current, or a history of, bladder cancer uninvestigated macroscopic haematuria. ```

Answer 292

``` reduce eGFR (<36) also if very elderly, severe heart disease, liver disease, alcohol problems ```

Answer 293

Rapid-acting analogues (e.g. insulin lispro— fastest acting; peak 0– 3h after injection; last 2– 5h; give just prior to meals) Soluble (clear) human, porcine, or bovine (e.g. Actrapid — short-acting; peak 2– 6h after injection; last 8h; give 15– 30min before meals) Intermediate- or longer-acting (cloudy) human, porcine, or bovine (e.g. Humulin I)— peak 4– 12h after injection; last up to 30h. Taken alone, od/ bd to provide background insulin, or with short/ rapid-acting insulin Long-acting insulin analogues (e.g. insulin glargine)— last 24h; provide background insulin; as no peak, associated with ↓ risk of hypoglycaemia Pre-mixed— combination of short- + long-acting insulin, e.g. 30%: 70%

Answer 294

- infection/lipohypertrophy and injection sites (advise rotation) - vascular disease - CVD, stroke - MASSIVE issue - nephropathy - diabetic retinopathy - cataracts - peripheral neuropathy / foot ulcers

Answer 295

Acute - ketoacidosis or hyperosmolar non-ketotic coma Subacute - weight ↓, polydipsia, polyuria, lethargy, irritability, infections (candidiasis, skin infection, recurrent infections slow to clear), genital itching, blurred vision, tingling in hands/ feet With complications - skin changes, neuropathy, nephropathy, arterial or eye disease Asymptomatic - incidental finding or through risk stratification

Answer 296

Graves’ disease Toxic nodular goitre— older women with past history of goitre Thyroiditis - inflammation of thyroid - e.g. postpartum Amiodarone Exogenous e.g. thyroid replacement post hypothyroidism Kelp ingestion

Answer 297

``` Weight loss Tremor Palpitations Hyperactivity AF Hyperhidrosis Eye changes Infertility Alopecia ```

Answer 298

beta blockers - rapid symptom control carbimazole - anti-thyroid meds - often given as 'block-replace' in combo with thyroxine radioiodine - absorbed into thyroid then destroys it - usually become hypothyroid after so then need replacement thyroidectomy - risk of damage to recurrent laryngeal nerve (hoarse voice) and hypoparathyroidism, might need thyroxine

Answer 299

``` symps - tired, lethargic, low mood, cold disliking, weight gain, constipation, menorrhagia, myalgia, cramps, weakness signs - BRADYCARDIC Bradycardic Reflexes relax slowly Ataxia Dry, thin hair and skin Yawning - drowsy Cold hands ± cold intolerance Ascites ± non-pitting oedema (lids/hands/feet) Round puffy face/double chin/obese Defeated demeanour Immobile ± ileus CCF ```

Answer 300

``` hyper = TSH low (suppressed), T4 and T3 high hypo = TSH high, T3/T4 low ```

Answer 301

primary atrophic hypothyroidism Hashimoto's thyroiditis iodine deficiency post-thyroidectomy or radioiodine treatment

Answer 302

replacement with levothyroxine (T4)

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