Www.pennine-gp-training.co.uk



BMJ summaries 2016Nov 26th – Vitamin D. We need about 10mcg (400IU) of vitamin a day to maintain health. Do not use calcium and vitamin D in healthy post menopausal women for fracture prevention. Possible small benefit for frail elderly who are housebound. ?Osteomalacia usually occurs when vitamin D level is < 15nmol/l with bone pain, fragility, proximal myopathy and a raised PTH (alk phos may be raised and calcium may be borderline low). Deficiency is defined as < 25nmol/l. No evidence that use of calcium with vitamin D or vitamin D alone changes MSK outcomes for patients without deficiency. Calcium with vit D is associated with SE e.g. GI upset and the uncommon SE of ?kidney stones and increased cardiovascular events.Nov 19th – Chronic insomnia is defined as insomnia for 3 or more nights a week for longer than three months which impacts on a patient’s quality of life. Often patients have pre-sleep arousal, feeling sleepy before retiring but becoming more alert in bed and faced with the task of sleeping. ?Common secondary causes; shift working, chronic pain, cardiac or respiratory failure, depression, anxiety, SSRIs, salbutamol, terbutaline, corticosteroids and opiods. Treat secondary causes. Try sleep hygiene +/_ antihistamines or TCAs. If that fails then CBT to change thinking around sleep. The CBT package includes sleep restriction, stimulus control, relaxation strategies, cognitive therapy and sleep hygiene.Nov12th – Haematospermia. Usually benign and self-limiting. Causes include; UTI, STI, Trauma, iatrogenic injury which includes radiotherapy, benign prostatic disease and urogenital malignant disease. Check BP, look for bruising, abdo exam re liver and spleen, genital exam and prostate exam. Send semen and urine for mcs, FBC and Coagulation studies and PSA if over 40 years. If under 40 and no underlying cause found, reassure on first occasion. But if recurs or if patient is over 40 at presentation refer.Nov 5th – Dual Anti- Platelet Therapy – Evidence is emerging that 6 months DAPT after drug eluting coronary stenting may be as effective as 12 months in reducing Major Adverse Cardiac Events BUT is associated with lower rates of minor/major bleeds. So watch this space!October 29th – Giardiasis.? A protozoal infection, faecal-oral transmission of the cysts. The trophozoites hatch from the cyst, attach to the small intestine wall, causing epithelial inflammation and villous atrophy with consequent diarrhoea and malabsorption. 75% of UK patients acquire Giardia in the UK and not from abroad! Dog ownership is a known risk. Cysts shed in the faeces can remain viable for 28 to 84 days. Most common in the under 5s and 25 - 45 ages groups. If a patient has it then there is a 30% chance a household member also has it (often asymptomatic)!5-15% are asymptomatic, typical symptoms are flatulence, abdo pain, bloating, diarrhoea and eggy burps, weight loss but blood pr is unusual. 40% have lactose intolerance which may persists for weeks after parasite eradication. Diagnosis = 3 x mcs/ocp sent 3 days apart, if that negative the 3x mcs/ocp weekly for three weeks. Newer faecal antigen PCR tests in the near future will be available for single sample testing. Rx = Single dose of Tindidazole or 5 days Metronidazole but remember due to persisting transient lactose intolerance symptoms may takes weeks to abate.October 22nd – Aortic stenosis – 1 to 3% of patients over 70? have clinically significant aortic stenosis. Usually due to calcific degeneration of the aortic leaflets.? Can occur in a younger age group if they have a ?congenital bicuspid aortic valve. As the stenosis worsens there is compensatory ventricular hypertrophy with decreasing wall compliance causing impaired ventricular filling and eventually myocardial ischaemia. Presentation may be angina, pre-syncope or syncope on exertion or LVF with pulmonary oedema. If symptomatic patients are untreated their mean survival is 2 to 5 years! Patients with severe AS if symptomatic or asymptomatic with impaired left ventricular function should be referred for possible surgery. Invx = ECG and Echo. Refer if AS is confirmed. Surgery is either prosthetic metal valve (younger patients), tissue valve (older patients) or if not fit for this then TAVI (per cutaneous Transcatheter Aortic Valve Implantation i.e. stretch up valve and put an expanding artificial within it, via the femoral artery).15th of October – Anabolic steroid use. These are testosterone derivatives commonly used by bodybuilders. Called ‘roids’ or ‘juice’ and are used in a variety of ways.: ‘cycling’ – cycling different drugs over 6 to 12 weeks, ‘stacking’ – using more than one steroid at a time and ‘pyramiding’ which involves changing doses to improve effectiveness and reduce side effects. Side effects often include mood swings, anxiety, aggression (Roid rage), acne, libido change, impotence and menstrual irregularities, cardiac complications and liver damage. Also in women – hirsutism, voice change, male pattern baldness and clitoral hypertrophy. In men – Testiscular atrophy, gynaecomastia and infertility (can take 5 months to 5 years for normal sperm production to recover. Patients may use additional drugs, such as Tamoxifen to treat their gynaecomastia or HCG to for testicular atrophy. Regards stopping the anabolic steroids there is no need for tapering, they can just be stopped and if done with continued resistance and endurance exercise this will inhibit their muscle loss.8th of OctoberTight foreskin- at 3 years of age 90% of boys have a fully retractile foreskin. Patient with a symptomatic phimosis? may complain of a tight foreskin, difficultly with cleaning the glans, splitting of the fore skin and painful erections. In adults, use a moderately potent steroid e.g. betamethasone 0.1% applied twice a day for 4 weeks, also they can use a condom as that often helps. If that fails refer urology ? for circumcision. ?Oct 1st NOACs – Concern now expressed around some of the key trials, were the risks of warfarin amplified by possible faulty INR measuring equipment– watch this space. On a side note (not in BMJ) – most guidelines require blood tests (FBC, LFTs and Cr &Es) after 6 weeks post NOAC start and annually thereafter. Cr&Es should be performed 6 monthly if the eGFR is < 60. Patients should have annual counselling regards importance of compliance and symptoms/signs of bleeding with advice re appropriate action.September 24thGynaecomastia – Typically occurs as part of normal physiological changes in new-borns, adolescents and older men. Effects 1 in 3 men between age of 50 to 69. Typically, due to imbalance in the level or action of oestrogen and androgen. Strongly linked to obesity due to increased peripheral aromatisation of oestrogen precursors. Size of gynaecomastia define by the Simon classification. Gynaecomastia may be painful.Drugs associated with gynaecomastia – antiandrogens e.g. Biclutamide, Finasteride etc. PPIs, Spironolactone, Calcium antagonists, Antipsychotics and Antivirals.Pathological causes: Gonadal failure, thyroid dysfunction, liver cirrhosis, renal failure, obesity and hormone secreting tumoursTypical blood tests: 9am morning testosterone, TFTs, LFTs and Cr &Es. If testosterone low then add SHBG, FSH, Prolactin and Oestrogen.Rx options (Neonatal no Rx, Adolescent ‘wait and see’ as 90% resolve within two years) Surgery if gynaecomastia is fibrotic otherwise consider unlicensed use of Tamoxifen (Response rate 95%).September 17thHow to apply ear drops – Lie down with the affect ear facing upwards. Pull the top of your ear upwards. Drop the required number of drops into the ear. Maintain this position for at least 3 minutes. Gentle pressure on the outer ear (the tragus) can help dispel air bubbles and aid distribution of the drops.September 10th NICE guidance on Non Alcoholic Fatty Liver Disease (NAFLD) – Found in 20 to 30% of the population. Lifestyle modification is the only treatment with BMI reduction and alcohol consumption under 10 units per week . Usually an incidental finding on USS (LFTs can be normal in NAFLD) or after investigation of abnormal LFTs. 5% of these patients will progress to Non Alcoholic Steato-Hepatitis (NASH) leading to fibrosis and cirrhosis. Offer adults with NAFLD screening for advance liver fibrosis using the Enhanced Liver fibrosis (ELF) blood test every three years. If ELF test positive (>10.51) refer to hepatology.Patient with NAFLD currently on statins should keep taking them.September 3rd Relapsing – remitting ?MS – commonest type of MS. 60 to 75% in time, usually two decades, ?will develop secondary progressive MS. Disease Modifying Therapies decrease the annual relapse rate and reduce the number of new lesions occurring on MRI and possible delay the onset of secondary progressive MS, They have no impact on established secondary progressive MS. Some debate as to use DMTs after the first episode of demyelination rather than waiting for the second which has been conventional practice (confirming the diagnosis of relapsing MS). DMTs are not used for incidental MRI discovery of demyelinated lesions in the absence of prior. clinical symptoms.Frozen shoulder – Three phases – pain, stiffness and resolution but 40% of patient would be symptomatic at 4 years if untreated. Recurrence is rare. 6 to 16% of people will suffer it in the other shoulder within 5 years. Pain in deltoid area, active and passive limitation (cf rotator cuff tears) of external rotation, no crepitus and pain on shoulder elevation. Overall physiotherapy and/or steroid injection have been shown to be beneficial with absence of evidence for other interventions.August 20thNormal pressure hydrocephalus – often missed. Usually occurs in > 60s. Presents as a triad of progressive gait/balance disturbance, cognitive impairment and urinary incontinence developing over 3 months. May be mistaken for dementia. Diagnosis CT and Rx is CSF shunting. One of the few reversible causes of dementia.August 13thNICE on Sepsis -?Red Flags warranting immediate admission< 5years of ageBehaviour – Weak, high pitched continuous crying or?looks ill to a healthcare professional or difficult to rouse.Breathing – Grunting, moderate or severe in-drawing, oxygen sats < 90% on air or breathing rate >60 in under 1s, > 50 in 1-2 years and > 40 in 3 to 4 yearsHR – Less than 60bpm OR rate > 160 in under 1s, > 150 in 1-2 years and > 140 in 3 to 4 yearsSkin – Mottled or ashen or non-blanching rash or reduced skin tugorTemp – Under 36cJuly 30thCongenital heart disease in adults -?1 in 100 babies are born with congenial heart disease.? Most will grow into adults with residual structural abnormality. They often need prophylactic antibiotics prior to general anaesthesia. Woman should be offered pre-conceptual counselling. Avoid COCP as POP is safe for all women with congenital heart disease.Adults are more at risk of AF, HF and infective endocarditis (ASD = AF, stroke and heart failure. VSD infective endocarditis).July 23rdPelvic organ prolapse – Prolapse of the anterior vaginal wall (cystocele) is twice more common than posterior wall prolapse (rectocele) and three times more common than apical prolapse. Many women may have multiple prolapses. Risk factors – vaginal child birth, rising BMI, and prior hysterectomy. ?Commonest symptoms is the sensation of vaginal bulging. 70% will have concurrent urinary symptoms (frequency and urgency more common than GSI) and 30% faecal incontinence. Offer pelvic exam and examination with a Sims speculum.? Arrange urine dip test and offer pelvic floor training advice, wt loss support and advice re avoiding constipation. Refer to continence service if symptoms remain intrusive. ??Pessary or? re-suspension ?operations are the next step. (Note recent concerns re complications from vaginal mesh procedures).? 1 in 8 women with prolapse will eventually go on to have surgery.July 16thColorectal carcinoma – adenocarcinoma accounts for >95%, usually adenomatous polyps undergoing dysplastic change to become cancer. 55% occur in the rectum & sigmoid colon. Commonest presenting features: Left sided lesions usually present with loose stools, increased frequency, rectal bleeding, or mucus or tenesmus. Rt sided lesions with weight loss, abdo pain, or mass or anaemia. Colonoscopy is the first line invx with CT colonoscopy only for patients unfit or unable to tolerate colonoscopy. You can reduce the risk of cancer with increased dietary fibre, increased consumption of dairy products, physical activity, aspirin and NSIADs (US Preventative Services recommend low dose aspirin for primary prevention of colorectal cancer? and CVD in adults aged 50 to 59 years with 10 year CVD risk > 10%.? ?UK screening consists of one off FOB testing for patients aged 60 to 74 years or single flexi sigmoidoscopy between the gages of 55 and 64yearsJuly 9thDetecting cirrhosis - Liver disease is the third commonest cause of premature death. Early diagnosis may alter outcome. Routine liver function blood tests or simple USS are not sensitive enough to detect cirrhosis. Offer Transient elastography USS ?to men drinking > 50 units per week, women > 35 units per week (over months), patients with hepatitis C and patients with NASH who have an elevated ELF score (Enhanced Liver Fibrosis score).OA hip – 2x more common in women. Increased risk with high BMI or heavy manual work. Symptom onset usually insidious, dull ache in the groin worse at the end of the day or after exercise. There is usually loss of internal rotation of the hip. Classical cases do not need X-ray to confirm the diagnosis.? Rx – weight loss helps, home exercises & physio helps, TENS and cold/hot pad application can also help. NSAIDS are more effective than paracetamol which is better than placebo. Weak opiods should be used for a short period during flares of pain. More potent opiods are better for analgesia but cause more side effects. Refer for surgery if the patient’s symptoms are impacting significantly on their quality of life.July 2ndContact dermatitis? - Commonly effects florists, hairdressers, beauticians, metalworkers and mechanics. Usually hands, feet, face, scalp and sometimes axillae are affected depending on sites of contact. Consider in adult patients with dermatitis who are resistant to treatment or promptly relapse. They also improve on holidays and time away from work. If suspected refer to dermatology? for patch testing so that the causal agent may be identified and if possible avoided. Rx = avoidance, barrier creams, soap substitutes, emollients, very potent topical steroids or calcineurin inhibitors. Potent steroids and/or calcineurin inhibitors usually have to be used for 4 to 6 weeks.? Calcineurin inhibitors should be considered for sites prone to steroid atrophy. Systemic treatment with methptrexate or PUVA is also an option.Haemochromatosis – usually autosomal recessive and occurs in patients of northern European ancestry. The C282Y mutation is the commonest form. ?Carriers are usually asymptomatic. It presents in the 4th and 5th decade of life (in women usually post menopause) with fatigue, arthralgia and or reduced libido. Ferritin is raised, transferrin saturation is raised and alt may be raised. It may eventually lead to cirrhosis, cardiomyopathy, diabetes and skin pigmentation if untreated. Genetic testing ?for haemochromatosis is indicated if ferritin > 300 in men and 200 in women, transferrin saturation > 45% or a first degree relative with haemochromatosis. Rx is intensive and then maintenance phlebotomy titrated against ferritin levels.June 25thProlonged QT interval - (QTC >450ms men and >460ms in women) – associated with torsades de pointes and sudden death. Rarely may be genetic? e.g. Romano Ward syndrome but is usually acquired due to a combination of drugs and/or metabolic disturbance. No point screening patients with ECG as 16000 screening ECGs would be needed to pick up one congenital case. ?Drugs common in GP associated with prolonged QT include Amiodarone, Macrolid & Quinolone antibiotics, Fluconazole, Domperidone, Quinnine, Hydroxyzine, antipsychotics such as Chlorpromazine, Risperidone and Quetiapine & Haloperidol, antidepressants such as Amiitriptyline, Fluoxetine, Citalopram, Escitalopram, Impramine and Dosulepin. Also Methadone can cause QT prolongation. Avoid using two drugs together which can cause QT prolongation, if at all possible.June 18th Mastitis in non lactating women – Smoking is the main risk factor. Also associated with local damage e.g. nipple piercing. Caused by a variety of bacteria, not just Staph Aureus (Bacteroides and Enterococci). Acute onset unilateral breast pain with induration and wedge shaped erythema. Rx using hot compresses and analgesia with 10 to 14 days Co-amoxiclav or clarithromycin & metronidazole.June 11thCOCP risks – review of 5 million women years of ?cocp use. For the same dose of oestrogen desogestrel, gestodene compared with levonorgestrel had 2.2 and 1.6 higher risk of PE. Oestrogen at 20mcgs with levonogestrel? has the lowest risk of all. There were no differences between the progestogens regards MI or? stroke rate.Delirium at the end of life – common reversible causes: Metabolic – Hypercalcaemia, Hypo or hypernatraemia, hypo or hyperglycaemia. Drugs – opiods, anticholinergics, corticosteroids and benzodiazepines. Sepsis. Drug withdrawal states and Brain mets. If non reversible then – explain, reassure, ensure a calm and consistent environment and consider haloperidol and if sedation is needed to add levomepromazine and or midazolam.June 4thEpilepsy in pregnancy – 96% of epileptic mothers will deliver a healthy child. Women who a seizure free in the nine months prior to pregnancy are very unlikely to have a seizure during pregnancy. It is only the generalised tonic-clonic forms of epilepsy in which seizures increase risks for the mother and foetus. Pre-conceptual counselling; refer for neurologist advice before conception, folic acid 5mg a day before and throughout pregnancy and general pre-conceptual advice. If found to be already pregnant, manage as above and leave on current rx until seen by the neurologist.Valproate has the highest risk of teratogenicity and Topirimate medium risk. Lamotrigine and Levetiracetam are considered to have the lowest risk.May 21stMetastatic cord compression – 1 in 30 patients with cancer suffer spinal mets (usually from prostate, breast and lung cancer). Back pain presents, often months before Metastatic Spinal Cord Compression (MSCC) – half have LBP & Radicular pain, 1/3 isolated back pain, 1/3 isolated radicular pain. Back pain is the most common symptom and is classically worse with straining, coughing and lying down and gets progressively worse over time. Limb weakness is the next commonest symptom with patients complaining of progressively worse unsteady gait or getting out of bed/chairs. Sensory symptoms are less common. Saddle parathaesia and urinary retention/incontinence are late symptoms. Constipation is an important symptom or MSSC and more common than faecal incontinence.If neurological symptoms are present, suggestive of MSCC, the patient needs MRI within 24 hours so as a GP admit (the patient will need? high dose steroids (dexamethasone), analgesia and possibly DXR and/or surgery).May 7thRe-implanting knocked out teeth – Usually it’s the front incisors which are knocked out, don’t re-implant baby teeth. Re-implanting adult teeth within one hour improves the survival of the tooth. Cold milk is an excellent transport media pending re-implantation. Wash tooth in running saline for 10 secs. Push tooth (convex side to lips) into socket and get the patient to bite gently onto gauze to help reposition it. < 12 years give 7 days of Amoxycillin but > 12 years use 7 days Oxytetracyline. Soft diet, Corsodyl mouthwash twice daily, gentle brushing of teeth twice daily pending visit to the dentist.Dry eye syndrome – Dry eye syndrome is common, especially in older women. The tear film has three layers: mucin that sits on the epithelial surface, an aqueous layer, and an outer lipid layer that prevent tear evaporation. Evaporative dry eye due to a deficiency in the outer lipid layer, produced by the Meibomian glands, is the most common form. Aqueous insufficiency e.g. Sjogrens is much rarer. Betablockers, SSRIs, TCAs, Oestrogen and antihistamines makes dry eye syndrome worse. Prolonged computer screen use, contact lens wears and a diet deficient in Omega-3 also makes it worse. Diagnosis – ‘Tear film break up time’ using fluorescein or Schirmer’s test can be useful. Rx - screen breaks from computer, avoid contact lens wear, medication review, use topical eye drops (if > 4x a day consider preservative free drops) +/- lubricating eye ointments at night. If mucus strands visible consider acetylcysteine drops. Increasing Omega 3 & 6 content of their diet may help.April 23rdBisphosphonate holidays? - In patients who have been on a bisphosphonates for 5 years who are; < 75, have an up to date femoral T score better than -2.5, no hx of fracture on treatment, not on long term corticosteroids or aromatase inhibitors AND are not deemed high risk on the FRAX calculator consider a bisphosphonate holiday for two years, repeat the DEXA after two years re ? re-start Rx.Travellers’ diarrhoea – Usually occurs in 1st week of travel, last for 3 days, 90% resolved within 7 days. Usually due to E.coli, Noro or Rota virus. Use of clear fluids or dilute fruit juice will suffice (or ORHS - 6 level teaspoons of sugar, half a tea spoon of salt in 1L of water). Prophylactic antibiotic is only recommended for patients with immune suppression, inflammatory bowel disease or ileostomies. Rx with antbx if in remote areas or limited access to sanitation - ?3 days of a quinolone or Azithromycin halve the duration of symptoms and allow use of loperamide. Quinolone resistance is high in S and E Asia. Areas deemed high risk are: South and East Asia, South America, East and North Africa.Consider providing a short course of antibiotics for people going to high risk countries, especially in remote areas with poor sanitation or access to health care – Rx to be started with the onset of diarrhoea.April 9thType 2 DM ?- NICE - Metformin remains first choice, switch to MR if not tolerated, then DPP-4s,?Pioglitazone and SUs are the next step according to which is the most appropriate to the patient. ?Once at maximum dose if the new medication has not produced a drop in Hba1c then withdraw it.?Target Hba1c on one agent < 48 and two agents < 53mmol/l. If BP not at target 140/80 (or 130/80 if end organ damage) review every 2 months uptitrating Rx until target BP achieved.March 26thDepression in pregnancy. Offer psychological therapies to all women with depression.? Offer antidepressants in moderate to severe depression if psychological therapies are not effective or are unavailable. SSRIs are the first line choice e.g. Sertraline with the possible exception of Paroxetine. Switching antidepressants during pregnancy or lactation is not recommended. There appears to be no increased risk in miscarriage or still birth. There does not appear to be an increased risk of major congenital defects. After delivery the infant may suffer NAS (neonatal Adaption Syndrome) for a few days after deliver (insomnia, agitated, poor feeding etc).March 19thRenal stones - In 11 people will get renal stones and more than half will suffer a recurrence. More common in patients with HT, DM and obesity and patients taking calcium supplements.Indications for admission & invx taken from BMJ 2012 as well as this articleInvestigations – BMI, BP, FBC, Hba1c, Cr&Es, uric acid and adjusted calcium, urine dip test (90% of pts with renal colic have haematuria), MSU (40% of patients with flank pain and haematuria do not have renal stones) and if possible stone analysis or 2 x 24 urine collections for urine calcium, oxalate, uric acid and PH. Arrange CT KUB within 7 daysDiagnostic uncertainty, age over 60 or known arteriopathy (risk of AAA), Inadequate pain control, Fever >37.5, solitary or transplanted kidney, suspected bilateral stones, impending renal failure, inability to arrange early investigation or urological assessment.Rx = Renal colic – Diclofenac +/- Tamsulosin (? Value of Tamsulosin now debated).For stone prevention in recurrent stone formers - ?Increased fluid intake (but not sweetened drinks), low meat intake, thiazides for calcium stones and potassium citrate in uric acid and calcium stones.Type 1 DM - The bolus dose for food coverage is prescribed as an insulin to carbohydrate ratio. The insulin to carbohydrate ratio represents how many grams of carbohydrate are covered or disposed of by 1 unit of insulin. Usually around 1 to 1.5 units per 10g of CHO.High blood sugar correction (also known as insulin sensitivity factor)The bolus dose for high blood sugar correction is defined as how much one unit of rapid-acting insulin will drop the blood sugar (mmol/l). Usually 1 unit for 2.5 mmol/l.A very rough estimate - Total Daily Insulin Requirement (in units of insulin)?= 0.55 X Total Weight in Kilograms. Basal/background Insulin Doseis usually 40-50% of Total Daily Insulin Dose.March 5thZika – Symptoms – Low grade fever, flu like symptoms, conjunctivitis and maculopapular rash. Men with suspected Zika should use condoms for 6 months. Men who have been asymptomatic while travelling in a Zika risks areas should use condoms for 1 month on their return to the UK. Women who have been asymptomatic while travelling in a Zika risks areas should avoid pregnancy for one month after their return to the UK.If a pregnant woman returns from an at risk country – If infection > 2 weeks prior refer obstetrics consider base line USS and they normally arrange four weekly USS throughout pregnancy, microcephaly usually become evident around 20/40. If possible Zika symptoms within 2 weeks of return consider blood and urine testing (PCR test) but this becomes negative after 2 weeks. IGM/IGG testing not currently available in UK.Feb 27thInterstitial Lung Disease in Connective Tissue Disorders – Commoner than you might think. Rheumatoid arthritis with ILD is the commonest due to Rh A prevalence but regards individual risk ILD is more common in scleroderma and less common in SLE. 19% of all Rh A patients will have some pulmonary changes on HR CT scanning. ?ILD may be the first presentation of a CTD. Drugs for CTDs, ?such as Methotrexate, anti TNF and Leflunomide also cause ILD. Diagnosis = spirometry and HR chest CT scan. Rx evidence base is poor?azathioprine? and or corticosteroids may help.Smoking cessation – Little evidence that Varenicline actually does have neuropsychiatric or cardiac events. NRT should be delivered as a patch with prn short acting NRT (combined Rx), Buprion consistently has a seizure rate of 1 in 1000 users. Varenicline and combine NRT for 12 weeks are the first line treatments.Feb 20thAntidepressant cessation – After a single episode consider cessation after 6 to 12 months. If hx or previous relapse consider Rx cessation after 2 years with an offer of CBT prior to discontinuation.Taper antidepressant dose over 4 weeks but sometimes longer if withdrawal effects are experienced.Feb 13th Adult Polycystic Kidney Disease – A GP with a list of 1800 patients would expect to have 1 to 2 patients with APKD. Autosomal dominant, 90% have FH. De novo mutation with no FH does occur in 10%. Median age of ESRF is 55. Rate of disease progression varies, even within the same family. It’s associated with intracranial aneurysms (10%) and liver cysts (80%) and HT (60%).Age > 40 – USS can be used to screen family membersAge 16- 40 – MRI of the kidney or genetic testing can be used to screen family membersAll patients should be under consultant care (nephrologist).Tolvaptan is a drug with halves the rate of total kidney volume increase and changes outcomes – it is now used in the UKFeb 6thRheumatoid?arthritis - Patients have a 20% increased risk of BCC and a doubling of risk for SCC. TNF inhibitor drugs have no effect on BCC risk but increase SCC risk by 30%.Jan 29thLumbar spinal stenosis - ?LSS is common > 60 years. Can be due to facet joint hypertrophy, osteophytes, disc protrusion and degenerative spondylolisthesis. It may occur with or without back pain. Pain is often cramping or burning and may be in the sacroiliac area, posterior lateral thigh or a radiculopathy. Classically worse with standing and walking and relieved by bending forward or sitting. May have patchy sensory loss and reduced knee or ankle reflexes. They may also have problems with balance and weakness in some muscle groups. If the diagnosis is uncertain then NCS may help. The diagnostic test of choice is MRI. Surgery is the best intervention and decompression is usually better than spinal fusion or inter-spinous spacers.Jan 16thExercise induced bronchospasm – May occur in the presence of asthma or in its absence. EIB in the absence of asthma is wheeze usually occurring after intense aerobic exercise, developing 15 mins after exercise, lasting up to an hour. In half of patients, if they exercise within 1-3 hours the subsequent symptoms are reduced. Diagnosis = a fall in FEV1 > 12% after heavy aerobic exercise (FEV1 measured pre and after exercise at 5, 10, 15 and 20 mins). Rx is with a SABA not corticosteroids. Also warming up with bursts of high intensity exercise may help.Jan 9th? 2016Chronic refractory cough – a persisting cough when all remedial causes have been excluded. It’s common, usually an intermittent dry cough throughout the day originating in the laryngeal region.Rx –? techniques which can be taught = Cough control breathing and cough suppression swallow. Drugs such as Pregabalin may help. Ipratropium and Tiotropium inhalers may also help.Conditions which cause chronic cough = asthma, COPD, reflux, sinusitis, OSA, ACE inhibitors and eosinophilic bronchitis, HF and serious pulmonary disease.?Eosinophilic bronchitis, a variant of asthma, is a common cause of chronic cough and responds well to inhaled corticosteroids.Dec 5th 2015Nausea in palliative care - Drugs, gastric stasis, chemical disturbance, intestinal obstruction and constipation ?are the common causesCheck for constipation and Cr&Es and calciumYou can use a regular anti emetic with a prn anti-emetic if it works via a different pathwayCyclizine acts via the vestibular systemMetoclopramide via the chemo receptor trigger centre in the brain?Metoclopramide and Domperidone act directly on the gut as a pro-kineticDrug and metabolic causes = Haloperidol and/or Metoclopramide?GI tract causes (stasis) - Domepridome or MetoclopramideDon't use drugs together that have a similar action e.g. Domperidone and MetoclopramideDon't use drugs together that competing MOA e.g. Metoclopromide and CyclizineLevomepromazine acts via a number of pathways and is an excellent second line agentDec 12th Diagnosis of rheumatological disorders - Rh Factor +ve in 70 to 80% of pts with RA, so 30% of patients with RA are Rh factor -ve, 10 % of healthy people will be Rh Factor +ve. If you consider RA and the Rh factor is negative then opt for anti CCP antibodies. Anti CCP antibodies have 67% sensitivity and 95% specificity. So if the patient if Rh factor -ve and anti CCP negative they are very unlikely to have Rh arthritis.Diagnosis of Rh arthritis1 large joint effected = 1pt, 1-3 small joints = 2pts, 4-10 joints effected = 3pts, >10 joints = 5ptsDuration > 6 weeks = 1 ptLow +ve Rh Factor or Anti CCP = 2 pointsHigh +ve Rh factor or Anti CCP = 3 pointsIt total is = or > 6 points you can make a diagnosis of Rh arthritis ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download