Placement

Question 1

What is a beclometasone inhaler and what colour is it?

Answer 1

• a steroid inhaler used to prevent asthma symptoms
• brown inhaler

Question 2

What colour is a salbutamol inhaler and when is it used?

Answer 2

• blue inhaler
• used when needed, works by relaxing the muscles of airways leading to the lungs

Question 3

What chart do we record physical examination findings on?

Answer 3

• National Early Warning Score chart

Question 4

What are 4 viral infections which are transmitted by mosquitoes as the vector?

Answer 4

• Dengue
• Zika
• Yellow fever
• Chikungunya
• Japanese encephalitis

Question 5

What sort of symptoms would indicate hospital admission for a 16 year old boy presenting with a 3 day history of a fever (38 C), and influenza like symptoms, he also has asthma?

Answer 5

• meningism (photophobia and neck stiffness) or petechial rash (rash that does not go away when pressure applied - glass test)
• suspicion of sepsis (overwhelming, whole body response to infection)
• symptoms such as rigors (high fever with associated shaking - body internal thermal set point is too high)
• change in cognitive level or confusion (think of encephalitis, meningitis, or sepsis)
• acute exacerbation of his asthma

Question 6

What is an important side effect of paracetamol?

Answer 6

• liver toxicity in overdose

Question 7

What are Non-Steroidal Anti-Inflammatory Drugs useful for?

Answer 7

• especially good for inflammation or MSK pain
• can also be used to lower temperature

Question 8

What are some side effects of NSAIDs?

Answer 8

• stomach ulceration
• kidney failure
• heart failure
• worsening of asthma

Question 9

What are the 4 main NSAIDs used in practice?

Answer 9

• ibuprofen
• naproxen
• diclofenac
• aspirin (low-dose aspirin is a blood thinner not an NSAID)

Question 10

What are some side effects of codeine?

Answer 10

• addiction
• constipation
• drowsiness
• nausea
• dizziness
• confusion
• low blood pressure
• respiratory suppression

Question 11

At what time of the day would you recommend people take ibuprofen? And what might you prescribe alongside it?

Answer 11

• with / after food
• Proton Pump Inhibitor (PPI)

Question 12

Why should you avoid prescribing NSAIDs for a patient who has a condition where they have to take blood thinners?

Answer 12

• NSAIDs could cause stomach bleeding which could be very serious

Question 13

What is a notifiable disease?

Answer 13

• A condition which if suspected/diagnosed/confirmed, health professionals must notify/report the condition to the local health protection team (proper officer of the local authority)

Question 14

Name 3 reasons why it might be useful to have a system for notifying diseases?

Answer 14

• guide contact tracing and treat/isolate contacts to reduce morbidity and spread
• help to trace the source of infectious outbreaks (eg. food poisoning)
• contribute to epidemiological statistics
• guide targeting of immunisations

Question 15

List of notifiable diseases…

Answer 15

Question 16

What does VITAMIN CDEF stand for?

Answer 16

V - Vascular(caused by arterial or venous problems)
I - Inflammatory or Infective
T - Trauma (caused by injury)
A - Autoimmune (caused by the immune system)
M - Metabolic (eg. caused by deficiencies or overload of substances)
I - Idiopathic (cause is unknown) or Iatrogenic (drug side effects)
N - Neoplastic (cancer)

C - Congenital (present from birth, genetic)
D - Degenerative (gradual wearing over time)
E - Environmental or Endocrine (caused by external environment or caused by hormones)
F - Functional (disease/symptoms without an obvious underlying pathological process)

Question 17

What are some benefits of antibiotic prescribing for respiratory tract infections?

Answer 17

• May help to shorten the duration and severity of illness if bacterial infection is present
• May help to prevent serious complications – e.g. sepsis, brain abscess, pneumonia, respiratory failure – and death
• May help to prevent hospital admission – better for the patient and the NHS
• May help to catch the illness in it’s mild stages, allowing a quicker recovery – better for the patient’s quality of life, better for the economy if people get back to work more quickly etc.
• May help to prevent the need for further GP appointments if infections are managed sooner

Question 18

What are the risks of antibiotic prescribing for respiratory tract infections?

Answer 18

• Will have no benefit if given for viral infections, although these may get better of their own accord anyway, making the patient think that antibiotics have helped, reinforcing the idea that they are needed for mild, self-limiting infections
• May cause side effects – rash, thrush infection, upset stomach, antibiotic-associated gut infections (e.g. Clostridium difficile)
• May cause an allergic reaction
• Costs the NHS money from providing prescription
• Unnecessary antibiotic usage may contribute towards antibiotic resistance, which can be a major public health issue e.g. MRSA, multi-drug resistant TB

Question 19

What are the clinical features of deep vein thrombosis?

Answer 19

• dilated superficial veins
• sometimes erythema
• unilateral pitting oedema
• localised tenderness along the deep venous system (ie. along the posterior calf muscles)

Question 20

What are the clinical features of arterial insufficiency?

Answer 20

• pale, hairless leg
• cool to touch
• absent pulses
• arterial ulcers (shown in image)

Question 21

What is superficial thrombophlebitis and what are the clinical features?

Answer 21

• Superficial thrombophlebitis = thrombosis and inflammation of superficial veins
• Clinical features: red, inflamed areas following the path of a superficial vein, warm and tender

Question 22

What are the clinical features of venous insufficiency?

Answer 22

• brown (haemosiderin) discolouration
• oedema
• varicose veins
• varicose ulcers (usually above the ankle, medial side)

Question 23

What are the clinical features of pre-patellar bursitis?

Answer 23

• anterior knee swellin
• soft, fluctuant to touch
• may or may not be red, warm and tender
• knee flexion may be painful

Question 24

What are the clinical features of an ankle sprain?

Answer 24

• swelling and bruising to medial or lateral areas
• tender on palpation
• reduced range of ankle movement
• antalgia
• Ottawa rules negative

Question 25

What are the clinical features of cellulitis?

Answer 25

- well demarcated (well-defined), red, inflamed - warm and tender

Question 26

What are the clinical features of Achilles tendonitis and/or Achilles tendon rupture?

Answer 26

- swelling and muscle atrophy may be evident (compare both sides) - tenderness over the Achilles tendon - palpable nodules may be present over the Achilles tendon - in tendon rupture there is acute pain and complete loss of plantarflexion of the ankle - patient unable to stand on tiptoes on the affected side and Simmonds test is positive

Question 27

What are the clinical features of peripheral neuropathy?

Answer 27

- may or may not be painful - reduced sensation when touched, usually worst at the toes and spreading upwards - muscles may be weak, reflexes reduced and muscle wasting/atrophy may be seen - ulcers can occur (shown in image)

Question 28

Pitting oedema...

Answer 28

Question 29

VITAMIN CDEF for bone...

Answer 29

Question 30

VITAMIN CDEF for soft tissue...

Answer 30

Question 31

Dermatomes and spinal nerves...

Answer 31

Question 32

Spinal anatomy (vertebral bodies)...

Answer 32

Question 33

What are some psychosocial factors that can influence pain?

Answer 33

- tiredness (insomnia) - obesity/sedentary lifestyle - stress/anxiety/depression - money problems - relationship issues/social issues

Question 34

Spondylolysis, spondylolisthesis, spondylosis...

Answer 34

Question 35

Shoulder anatomy (anterior view)...

Answer 35

Question 36

Shoulder anatomy (posterior view)...

Answer 36

Question 37

Rotator cuff muscles (SITS)...

Answer 37

Question 38

Describe the normal gait cycle.

Answer 38

Each limb alternates between stance phase and swing phase

Question 39

Describe the 'stance phase' of the normal gait cycle.

Answer 39

Stance phase: - limb with foot on the ground - starts with "heel strike", ends with toe-off - hip abductors of the limb in stance phase contract to stabilise the pelvic girdle and prevent the pelvis dropping on the contralateral side

Question 40

Describe the 'swing phase' of the normal gait cycle.

Answer 40

Swing phase: - limb with foot not touching the ground - starts with toe-off, when foot plantar flexes to push foot off the ground - knee and hip flex to draw the limb forward - foot dorsiflexes immediately after toe-off so the foot clears the floor and does not drag

Question 41

What causes a myopathic gait and what does this gait look like?

Answer 41

- Cause: weakness in hip girdle muscles - Appearance: pelvis drops on contralateral side during stance phase (like a positive Trendelenburg test), may be unilateral or bilateral (‘waddling gait’) (link: https://stanfordmedicine25.stanford.edu/the25/gait.html)

Question 42

What causes a neuropathic gait and what does this gait look like?

Answer 42

- Cause: foot drop (weakness of foot dorsiflexion), unilateral causes include peroneal nerve palsy and L5 nerve root impingement, bilateral causes include motor neurone disease, Charcot-Marie-Tooth disease and other peripheral neuropathies (e.g. uncontrolled diabetes) - Appearance: ‘high stepping’ gait to prevent toe catching on the floor (link: https://www.youtube.com/watch?v=EJhvgFvoXvI)

Question 43

What causes an antalgic gait and what does this gait look like?

Answer 43

- Cause: painful limb during stance phase - Appearance: ‘limping’ gait – the affected limb spends less time in stance phase and more in swing phase (the unaffected limb is the reverse of this). (link: https://www.youtube.com/watch?v=W-S8Pk63YRE)

Question 44

What causes a hemiplegic gait and what does this gait look like?

Answer 44

- Cause: unilateral weakness (eg. stroke) - Appearance: limbs are stiff, elbow and wrist are held flexed, hip and knee are extended, foot is plantar flexed, leg is dragged in semicircles (circumduction) (link:https://www.youtube.com/watch?v=jOHhGS-XQPg)

Question 45

What causes a diplegic gait and what does this gait look like?

Answer 45

- Cause: bilaterally weakness e.g. spinal injury or Cerebral palsy - Appearance: ‘scissoring gait’ - Narrow base, drags legs and scraping toes (link:https://www.youtube.com/watch?v=aAnY7n0ZND8)

Question 46

What causes a Parkinsonian gait and what does this gait look like?

Answer 46

- Cause: parkinson’s disease, antipsychotic drugs, stroke - Appearance: rigid and slow movements (bradykinesia), stooped posture, tremor in hands, small steps, freezing, difficulty initiating steps, turning and stopping (link:https://www.youtube.com/watch?v=j86omOwx0Hk)

Question 47

What causes an ataxic gait and what does this gait look like?

Answer 47

- Cause: cerebellar disorders (e.g. stroke, tumour, drugs), alcohol intoxication - Appearance: clumsy, staggering movements with a wide-base, standing still body may sway back, forth and side to side, cannot heel-toe walk (link:https://www.youtube.com/watch?v=yhgUOY2ohUE)

Question 48

Give four red flag symptoms that a GP should inquire about in a patient whose pain has changed

Answer 48

- Night pain - Persistent pain - Weight loss - Night sweats - Persistent excessive tiredness - Progressive neurological symptoms - Fever