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Morning inGP Dr Milena Nossen, Dr Sophia Hwai, and Dr Aeron RaphaelLearningOutcomes To revise the main presentations within GP including: ● Acute vs chronic conditions in primary care ● Common presentations: Back pain, cough, fatigue ● Preventative care: Screening, immunization, lifestyle advice ● Managing common chronic diseases: Hypertension, diabetes, asthma ● Mental health in primary care: Depression, anxiety, referrals ● Managing complex cases: Multimorbidity, polypharmacyWelcome to theTickle family Molly Tickle, mother of Daphne and Tom for O&G/ contraception questions Evan Tickle, father of Daphne and Tom(big smoker) Daphne Tickle (born during Millie’s questions -> toddler in Sophia’s questions -> teenager, likes socialising as she grows older) immune system, more outdoorsy). Allergic to penicillin. He likes football. Has a girlfriend by the time he’s 19. Ian Tickle, father of Evan, grandfather to Daphne and Tom. Has diseases to pass on to Evan eg. for genetic questions and feels depressed Caroline Tickle, mother of Evan, grandfather to Daphne and Tom. For gynae questions Cookie, the dog, who bites for infection questionsMeetyour patients…familyTickleMeetyour patients…MollyTickle Molly Tickle is a 22-year-old woman, registered at your GP practice. Molly She has a past medical history of epilepsy, takes levetiracetam and has no known drug allergies. She is currently in university, studying psychology. She lives with 3 other women in a shared flat, drinks every weekend when going out but does not smoke. Question 1 Molly presents with a 2-day history of increased vaginal discharge. The discharge is thin, white-grey of colour and smells offensively of fish. pH of the discharge is 5. She denies any urinary or systemic symptoms. What diagnosis is most likely? A. Bacterial vaginosis B. Vaginal candidiasis C. Trichomonas vaginalis D. Physiological discharge E. Neisseria gonorrhoea Question 1 Molly presents with a 2-day history of increased vaginal discharge. The discharge is thin, white-grey of colour and smells offensively of fish. pH of the discharge is 5. She denies any urinary or systemic symptoms. What diagnosis is most likely? A. Bacterial vaginosis B. Vaginal candidiasis C. Trichomonas vaginalis D. Physiological discharge E. Neisseria gonorrhoeaBacterial vaginosisBacterialvaginosis Overgrowth of anaerobic organisms, e.g. Gardnerella vaginalis Decreased number of lactobacilli Features: asymptomatic, thin, white, ‘fishy’ vaginal discharge pH >4.5, clue cells on microscopy, positive whiff test Management: Asymptomatic – no treatment Symptomatic – PO metronidazole – 2g stat dose or 500mg for 5-7 days Pregnancy – consider treating even if asymptomatic as increased risk for preterm labour, low birth weight, late miscarriage, chorioamnionitisBacterialvaginosis Overgrowth of anaerobic organisms, e.g. Gardnerella vaginalis Decreased number of lactobacilli Features: asymptomatic, thin, white, ‘fishy’ vaginal discharge pH >4.5, clue cells on microscopy, positive whiff test Management: • Asymptomatic – no treatment • Symptomatic – PO metronidazole – 2g stat dose or 500mg for 5-7 days • Pregnancy – consider treating even if asymptomatic as increased risk for preterm labour, low birth weight, late miscarriage, chorioamnionitisBacterialvaginosis Question 2 4 months later, Molly is in a new relationship with Evan. They are currently using condoms, but Molly is keen to start another form of contraception. Molly is keen to start the Depo-Provera injection. Which of the following is NOT a recognised adverse effect? A. Weight gain B. Reduced bone mineral density Molly C. Delayed return to fertility D. Amenorrhoea E. Increased risk of ovarian cancer Question 2 4 months later, Molly is in a new relationship with Evan. They are currently using condoms, but Molly is keen to start another form of contraception. Molly is keen to start the Depo-Provera injection. Which of the following is NOT a recognised adverse effect? A. Weight gain B. Reduced bone mineral density Molly C. Delayed return to fertility D. Amenorrhoea E. Increased risk of ovarian cancerContraceptionDepot injection Medroxyprogesterone acetate MOA: Inhibits ovulation, thickens cervical mucus Administration: every 12-13 weeks, effective for 14 weeks Side effects: amenorrhoea, irregular bleeding, weight gain, delayed return to fertility, increased risk of osteoporosis Contraindications: breast cancer Cautions: high BMI, osteoporosis Question 3 5 years later, Molly and Evan are now married. Molly has recently found out that she is pregnant. Her last menstrual period was 8 weeks ago. PMH: epilepsy, DH: levetiracetam, NKDA SH: Non-smoker, occasional alcohol consumption prior to pregnancy Which of the following supplements is indicated? MollyEvan A. Vitamin A 1mg B. Vitamin B12 (cyanocobalamin) 1mg C. Ferrous fumarate 210mg D. Folic acid 400mcg E. Folic acid 5mg Question 3 5 years later, Molly and Evan are now married. Molly has recently found out that she is pregnant. Her last menstrual period was 8 weeks ago. PMH: epilepsy, DH: levetiracetam, NKDA SH: Non-smoker, occasional alcohol consumption prior to pregnancy Which of the following supplements is indicated? MollyEvan A. Vitamin A 1mg B. Vitamin B12 (cyanocobalamin) 1mg C. Ferrous fumarate 210mg D. Folic acid 400mcg E. Folic acid 5mgAntenatal careAntenatal care Nutritional supplements Recommend: folic acid & vitamin d Indicated if deficient: iron Avoid: vitamin A (teratogenic) Alcohol Avoid alcohol consumption until birth Smoking Advise smoking cessation, NRT can be considered Diet Avoid raw eggs/ meat (salmonella) Avoid unpasteurised milk, ripened soft cheese, pate, uncooked meat (listeriosis) Work Consider possible occupation hazards, e.g. traumaAntenatal care Nutritional supplements Air travel Recommend: folic acid & vitamin d Avoid >37 for singleton, >32 for Indicated if deficient: iron multiple pregnancy Prescribed medications Avoid: vitamin A (teratogenic) Alcohol Review and stop if not indicated/ Avoid alcohol consumption until birth contraindicated Smoking OTC medications Advise smoking cessation, NRT can be Avoid as much as possible considered Exercise Diet Mild to moderate exercise acceptable, Avoid raw eggs/ meat (salmonella) avoid high impact sports and scuba Avoid unpasteurised milk, ripened soft diving cheese, pate, uncooked meat (listeriosis) Sexual intercourse Work No known adverse outcomes Consider possible occupation hazards, e.g. trauma Question 4 Molly is now 16 weeks pregnant. She presents with a 2-day history of vulval itching and increased vaginal discharge. She has mild, central abdominal pain. She denies any urinary or systemic symptoms. Given the most likely diagnosis, what treatment should you offer Gina? A. PO 200mg BD itraconazole for 1 day B. Topical clotrimazole/ hydrocortisone BD for 7-14 days C. PO stat 150mg fluconazole Molly D. Clotrimazole (vaginal pessary) 500mg for 7 days E. Advise this is self-limiting and give hygiene advice Question 4 Molly is now 16 weeks pregnant. She presents with a 2-day history of vulval itching and increased vaginal discharge. She has mild, central abdominal pain. She denies any urinary or systemic symptoms. Given the most likely diagnosis, what treatment should you offer Gina? A. PO 200mg BD itraconazole for 1 day B. Topical clotrimazole/ hydrocortisone BD for 7-14 days C. PO stat 150mg fluconazole Molly D. Clotrimazole (vaginal pessary) 500mg for 7 days E. Advise this is self-limiting and give hygiene adviceVaginal candidiasisVaginal candidiasis Risk factors: diabetes mellitus, pregnancy, immunosuppression, HIV, drugs (steroids, antibiotics) Features: white, clumpy, thick vaginal discharge (‘cottage cheese’), itching, vulvitis, vulval erythema Management: st 1 : Oral fluconazole 150mg STAT – contraindicated in pregnancy! 2 : Clotrimazole 500mg intravaginal pessary STAT – longer course needed in pregnancy Topical creams can be added for vulval symptoms Question 5 Evan’s mother, Caroline Tickle, a 50-year-old woman, is complaining of urinary incontinence. For 4 months, she has experienced ‘leaking’ of small amounts of urine when laughing or jumping on the trampoline with her grandson. Nil increased urgency or dysuria. PMH: hypertension, pre-diabetes. DH: ramipril. Gynae PMH: G3P2 (2 vaginal deliveries, 28 and 26 years ago. 1 miscarriage). Given the most likely diagnosis, which is the first-line Caroline treatment? A. Oxybutynin B. Bladder retraining C. Pelvic floor muscle training D. Duloxetine E. Mid-urethral tape procedure Question 5 Evan’s mother, Caroline Tickle, a 50-year-old woman, is complaining of urinary incontinence. For 4 months, she has experienced ‘leaking’ of small amounts of urine when laughing or jumping on the trampoline with her grandson. Nil increased urgency or dysuria. PMH: hypertension, pre-diabetes. DH: ramipril. Gynae PMH: G3P2 (2 vaginal deliveries, 28 and 26 years ago. 1 miscarriage). Given the most likely diagnosis, which is the first-line Caroline treatment? A. Oxybutynin B. Bladder retraining C. Pelvic floor muscle training D. Duloxetine E. Mid-urethral tape procedureUrinaryincontinence Urinaryincontinence Stress incontinence Features: leaking small amounts when coughing or laughing Management: 1. Lifestyle measures (weight loss, reducing caffeine), pelvic floor strengthening 2. Surgical 3. Duloxetine (SNRI) Urinaryincontinence Stress incontinence Urge incontinence Features: leaking small amounts Features: urge to urinate, when coughing or laughing followed by incontinence Management: 1. Lifestyle measures (weight Management: 1. bladder retraining loss, reducing caffeine), pelvic 2. Antimuscarinics (e.g. floor strengthening oxybutynin) 2. Surgical 3. Duloxetine (SNRI) 3. Mirabegron in elderly patients Question 6 6 months later, Caroline (51) presents to you with hot flushes, vaginal dryness and mood swings. Her periods have become irregular and heavier. Her last menstrual period was 3 months ago. You explain to Genevieve that she is likely peri-menopausal. She is keen to try out some medications to help manage her symptoms. Which of the following are you most likely to recommend? A. Cyclical oestrogen-only HRT Caroline B. Cyclical combined HRT C. Combined oestrogen-only HRT D. Continuous combined HRT E. Lifestyle advice only Question 6 6 months later, Caroline (51) presents to you with hot flushes, vaginal dryness and mood swings. Her periods have become irregular and heavier. Her last menstrual period was 3 months ago. You explain to Genevieve that she is likely peri-menopausal. She is keen to try out some medications to help manage her symptoms. Which of the following are you most likely to recommend? A. Cyclical oestrogen-only HRT Caroline B. Cyclical combined HRT C. Combined oestrogen-only HRT D. Continuous combined HRT E. Lifestyle advice onlyHormone replacement therapyMenopause • Perimenopause - reduced ovarian function ○ Reduced oestrogen levels & other hormones ■ Change in periods - frequency, duration ■ Vasomotor - hot flushes, night sweats ■ Urogenital changes - vaginal dryness, atrophy, urinary frequency ■ Psychological - anxiety, depression, short-term memory impairment ■ Long-term complications - osteoporosis, IHD • Menopause - average 51 years ○ >50 years - 12 months amenorrhoea ○ <50 years - 24 months amenorrhoeaHormone replacement therapy Components • Oestrogen – for symptom relief (replaces diminished levels) • Progesterone – to reduce risk of endometrial cancer Route • Oral vs transdermal (latter does not increase VTE risk) Timing • Cyclical – during perimenopause • Continuous – post-menopauseHormone replacement therapy Side effects • Nausea, breast tenderness, fluid retention, weight gain Complications • Increased risk of breast cancer – by progestogen • Increased risk of endometrial cancer – by oestrogen, none if progestogen given • Increased risk of VTE/ stroke – by progestogen, not when transdermal application • Increased risk of IHD – if taken >10 after menopause Question 7 Molly’s son, Tom, 6-weeks old, is brought to the GP for his routine check-up. On examination, the right testis is palpable within the scrotum, but the left testis is not palpable in the scrotum or along the inguinal canal. The baby is feeding well and meeting developmental milestones. There are no other abnormalities noted. What is the most appropriate next step in management? A. Arrange an urgent scrotal ultrasound B. Reassure the parents and review at 3 months Tom C. Refer immediately to a paediatric endocrinologist D. Initiate hormonal therapy to stimulate testicular descent E. Refer urgently to a paediatric surgeon for orchidopexy Question 7 Molly’s son, Tom, 6-weeks old, is brought to the GP for his routine check-up. On examination, the right testis is palpable within the scrotum, but the left testis is not palpable in the scrotum or along the inguinal canal. The baby is feeding well and meeting developmental milestones. There are no other abnormalities noted. What is the most appropriate next step in management? A. Arrange an urgent scrotal ultrasound B. Reassure the parents and review at 3 months Tom C. Refer immediately to a paediatric endocrinologist D. Initiate hormonal therapy to stimulate testicular descent E. Refer urgently to a paediatric surgeon for orchidopexyUndescended testisUndescended testis In 2-3% of male infants Often can be palpated in initial canal region Complications: infertility, torsion, testicular cancer, psychological issues Management: • Unilateral – referral at 3 months – surgery around 1 yr of age • Bilateral (25%) – review by paediatrician within 24h – may need urgent endocrine/ genetic investigations Question 8 Molly’s daughter, Daphne, a 3-week-old infant attends the GP following a collapse at home. The mother describes that the baby appeared cyanotic and seemed to have difficulty breathing. The infant's colour has normalised upon examination, but an ejection systolic murmur is audible at the left sternal edge. What is the most likely diagnosis? A. Coarctation of the aorta Daphne B. Patent ductus arteriosus C. Tetralogy of Fallot D. Transposition of the great arteries E. Ventricular septal defect Question 8 Molly’s daughter, Daphne, a 3-week-old infant attends the GP following a collapse at home. The mother describes that the baby appeared cyanotic and seemed to have difficulty breathing. The infant's colour has normalised upon examination, but an ejection systolic murmur is audible at the left sternal edge. What is the most likely diagnosis? A. Coarctation of the aorta Daphne B. Patent ductus arteriosus C. Tetralogy of Fallot D. Transposition of the great arteries E. Ventricular septal defectCongenital heart disease Congenital heart disease Acyanotic 1. Ventricular septal defect Pansystolic murmur 2. Atrial septal defect Ejection systolic murmur Presents later than VSD 3. Patent ductus arteriosus Continuous, ‘machine-like’ murmur 4. Coarctation of aorta Mid-systolic murmur 5. Aortic valve stenosis Ejection systolic murmur Congenital heart disease Acyanotic Cyanotic 1. Ventricular septal defect 1. Tetralogy of Fallot Pansystolic murmur Ejection systolic murmur 2. Atrial septal defect Presents at 1-2 months Ejection systolic murmur 2. Transposition of the great Presents later than VSD arteries 3. Patent ductus arteriosus Continuous, ‘machine-like’ murmur Presents at birth 4. Coarctation of aorta 3. Tricuspid atresia Mid-systolic murmur 5. Aortic valve stenosis Ejection systolic murmurT etralogyof Fallot Features • Cyanosis – tet spells • Right-to-left shunt • Ejection systolic murmur (pulmonary stenosis) • Right sided aortic arch (25%) • CXR – ‘boot-shaped’ heart • ECG - RVH Management • Surgical repair • Beta blockers for cyanotic episodesT etralogyof Fallot Features • Cyanosis – tet spells • Right-to-left shunt • Ejection systolic murmur (pulmonary stenosis) • Right sided aortic arch (25%) • CXR – ‘boot-shaped’ heart • ECG - RVH Management • Surgical repair • Beta blockers for cyanotic episodes Question 9 A 5 weeks, Daphne is brought to the GP by his parents due to concerns about noisy breathing. The parents report that the infant has intermittent high-pitched sounds when breathing in, particularly noticeable when he is lying on his back or during feeding. There are no signs of respiratory distress or cyanosis, and the infant is feeding well and gaining weight appropriately. On examination, the infant appears well with normal oxygen saturation levels. What is the most likely diagnosis? A. Laryngomalacia Daphne B. Tracheomalacia C. Vocal cord paralysis D. Subglottic stenosis E. Choanal atresia Question 9 A 5 weeks, Daphne is brought to the GP by his parents due to concerns about noisy breathing. The parents report that the infant has intermittent high-pitched sounds when breathing in, particularly noticeable when he is lying on his back or during feeding. There are no signs of respiratory distress or cyanosis, and the infant is feeding well and gaining weight appropriately. On examination, the infant appears well with normal oxygen saturation levels. What is the most likely diagnosis? A. Laryngomalacia Daphne B. Tracheomalacia C. Vocal cord paralysis D. Subglottic stenosis E. Choanal atresiaLaryngomalaciaLaryngomalacia Most common, congenital laryngeal abnormality ‘floppy and soft’ larynx – collapses when breathing Features • Inspiratory stridor – high-pitched, intermittent (e.g. supine position, feeding or agitated) • 60-70% of congenital stridor cases • Symptoms increase for first 8 months -> resolve by 18-24 months Complications: respiratory distress, failure to thrive, cyanosis Question 10 Tom is now 5-years-old. He presents to the clinic with a limp that has been gradually worsening over the last few weeks. He has no history of trauma. On examination, he has a reduced range of motion in his left hip, particularly with internal rotation and abduction. X-ray reveals flattening of the femoral head. His parents are concerned about his long-term prognosis and ask what the best course of action would be. Given the likely diagnosis, what is the most appropriate management for this child? A. Immediate surgical intervention B. Non-weight-bearing with the use of a Petrie cast Tom C. Observation with regular follow-up D. Oral corticosteroids E. Referral for bed rest and traction Question 10 Tom is now 5-years-old. He presents to the clinic with a limp that has been gradually worsening over the last few weeks. He has no history of trauma. On examination, he has a reduced range of motion in his left hip, particularly with internal rotation and abduction. X-ray reveals flattening of the femoral head. His parents are concerned about his long-term prognosis and ask what the best course of action would be. Given the likely diagnosis, what is the most appropriate management for this child? A. Immediate surgical intervention B. Non-weight-bearing with the use of a Petrie cast Tom C. Observation with regular follow-up D. Oral corticosteroids E. Referral for bed rest and tractionPerthes’diseasePerthes’disease Temporal loss of blood supply to femoral head -> avascular necrosis Features: hip pain, limp, stiffness, reduced range of hip movement Investigations: x-ray – widening of joint space -> flattening of femoral head Management: • <6 yrs – observation • >6 yrs – surgical intervention Complications: osteoarthritis, premature fusion of growth platesPerthes’disease Temporal loss of blood supply to femoral head -> avascular necrosis Features: hip pain, limp, stiffness, reduced range of hip movement Investigations: x-ray – widening of joint space -> flattening of femoral head Management: • <6 yrs – observation • >6 yrs – surgical intervention Complications: osteoarthritis, premature fusion of growth platesBreaktime !Infection questions PLAN 1. Bronchiolitis/ resp 2. Otitis media 3. Tonsillitis 4. Dog bite 5. Tick bite 6. Skin infections 7. CAP 8. UTIQuestion 11 Baby Daphne is 3-months-old now and Molly is concerned that Daphne has been generally unwell for the past two days with a dry cough and is eating less than usual. She states that Tom, Daphne’s older brother has been coughing recently and is concerned the bug was passed on. On examination, her RR is 42/min, HR 160bpm, no cyanosis, saturating 92% RA, temp 38.1degC and a widespread wheeze can be heard. Given the presentation what is the most appropriate next step? A. Give oxygen and refer for paeds outpatient review B. Take blood, cultures, lactate and give amoxicillin C. Give amoxicillin and ask to return in 5 days if no improvement D. Reassure and encourage oral feeds as management is supportive E. Send to paeds A&EQuestion 11 Baby Daphne is 3-months-old now and Molly is concerned that Daphne has been generally unwell for the past two days with a dry cough and is eating less than usual. She states that Tom, Daphne’s older brother has been coughing recently and is concerned the bug was passed on. On examination, her RR is 42/min, HR 160bpm, no cyanosis, saturating 92% RA, temp 38.1degC and a widespread wheeze can be heard. Given the presentation what is the most appropriate next step? A. Give oxygen and refer for paeds outpatient review B. Take blood, cultures, lactate and give amoxicillin C. Give amoxicillin and ask to return in 5 days if no improvement D. Reassure and encourage oral feeds as management is supportive E. Send to paeds A&EQuestion 11-Explanation Being 3 months old or younger with a fever immediately puts baby Faye in the high risk category. The likely diagnosis is bronchiolitis for which management is supportive, but her high risk features mean that she needs to be treated in hospital and monitored closelyBronchiolitis This is a common infection affecting 1-12 month olds, caused by RSV. Clinical features: - Preceding coryzal symptoms for 1-3 days, Cough, Tachypnoea,, wheeze or crackles on auscultation, Fever (typically < 39C), Reduced oral intake, Apnoea Differentials: - Viral induced wheeze, asthma - Pneumonia, croup, epiglottitis, cystic fibrosis, Laryngomalaycia, primary ciliary dyskinesia - Foreign body aspiration Investigations: - Pulse oximetry, throat swab, CXR Management: - Ribavirin antiviral therapy(target >90% if >6wks old), paracetamol - Palivizumab prevention therapyBronchiolitisBronchiolitisQuestion 12 Tom, Daphne’s 6-year-old older brother, is recovering from his cough but starts complaining of ear pain a couple days later. He’s unable to sleep due to the pain and tugs on his ear all day. On presentation at the GP, he is irritable with a mild fever. You notice a red bulging tympanic membrane in his left ear. He’s allergic to penicillin and has a PMH of [... immunocompromised] What is the most appropriate management given the likely diagnosis? A. Reassure and give calpol B. Prescribe amoxicillin 5 days C. Prescribe clarithromycin 5 days D. Give a delayed prescription of clarithromycin E. Send to paeds A&EQuestion 12 Tom, Daphne’s 6-year-old older brother, is recovering from his cough but starts complaining of ear pain a couple days later. He’s unable to sleep due to the pain and tugs on his ear all day. On presentation at the GP, he is irritable with a mild fever. You notice a red bulging tympanic membrane in his left ear. He’s allergic to penicillin and has a PMH of [... immunocompromised] What is the most appropriate management given the likely diagnosis? A. Reassure and give calpol B. Prescribe amoxicillin 5 days C. Prescribe clarithromycin 5 days D. Give a delayed prescription of clarithromycin E. Send to paeds A&EQuestion 12-Explanation He likely has otitis media. There is no evidence of severe unwellness or complications such as meningitis, mastoiditis, or facial nerve palsy to warrant an emergency admission. NICE do not recommend antibiotics routinely. However, he is immunocompromised is more likely to develop severe infection. Therefore immediate antibiotics must be given.Otitis media Middle ear infection, typically in children after URTI. Viral 60% RSV, rhinovirus, enterovirus. Bacterial 40% strep. pneumoniae, H. influenzae,M. catarrhalis Clinical features: - Coryza, otalgia, hearing loss +/- N&V Investigations: - Otoscopy (bulging TM, loss of light reflex, +/- perforation), MC&S if discharge, CT Management: 1. Analgesia + delayed prescription/ review if >3 days 2. Immediate abx (oral amox 500mg TDS for 5-7 days. Doxy if pen allergic) if >4 days, 3. Consider abx steroid drops eg. ciprodex <2yrs old with bilat. AOM, AOM + perf Complications: CSOM (if >6wks), hearing loss, labyrinthitis, mastoiditis, facial nerve paralysis, petrositis, tympanosclerosis, meningitis, brain abscess, lateral sinus thrombosisOtitis mediaQuestion 13 Tom does really well in school and becomes head boy. He’s 11 years old now and is preparing to go to secondary. 3 days after their school disco, he complains of a sore throat, neck pain, headache, and fever. HIs vaccinations are up to date. He is allergic to penicillin. His obs are normal except for a high temp 39.2degC. On examination, his tonsils are sore and enlarged, covered in pus, and he has tender lymph nodes. His abdomen is SNT. He admits to pecking his new girlfriend on the cheek. What is the most appropriate management step? A. Reassure and send home B. Give phenoxymethylpenicillin and send home C. Give clarithromycin and advise no contact sports for 4 weeks D. Urgent referral to a specialist E. Encourage fluids, analgesia, and advise no contact sports for 4 weeksQuestion 13 Tom does really well in school and becomes head boy. He’s 11 years old now and is preparing to go to secondary. 3 days after their school disco, he complains of a sore throat, neck pain, headache, and fever. HIs vaccinations are up to date. He is allergic to penicillin. His obs are normal except for a high temp 39.2degC. On examination, his tonsils are sore and enlarged, covered in pus, and he has tender lymph nodes. His abdomen is SNT. He admits to pecking his new girlfriend on the cheek. What is the most appropriate management step? A. Reassure and send home B. Give phenoxymethylpenicillin and send home C. Give clarithromycin and advise no contact sports for 4 weeks D. Urgent referral to a specialist E. Encourage fluids, analgesia, and advise no contact sports for 4 weeksQuestion 13-Explanation He meets the CENTOR criteria for antibiotics, so we should treat for tonsillitis. We can’t rule out infectious mononucleosis however as the symptoms overlap, so we should safety net.T onsillitis Infection of palatine tonsils, 70% viral, 30% bacterial Group A strep beta-haemolytic. Clinical features: - Sore throat, odynophagia, systemic upset, bilateral cervical lymphadenopathy. - If quinsy -> hot potato voice, trismus, uvular deviation Investigations: Monospot test, Bloods (FBC, U&Es, LFTs, CRP). Centor criteria/ FeverPAIN score. Management: 1. IV fluids, abx (benzylpenicillin), analgesia (regular IV/PO paracetamol, ibuprofen + PRN topical 2. Refer for tonsillectomy if meet criteria 3. Admit if quinsy for aspiration Complications: Quinsy, parapharyngeal/ retropharyngeal abscessCENTOR/ Fever PAIN criteria Fever >38 Tonsillar exudate Give abx if >2 criteria. (Modified: +1 if Age 3-14 years old) Tender anterior cervical lymphadenopathy No cough T onsillectomycriteria (SIGN 2010) Indications: - >7/year for 1 year; >5/year for 2 years, >3/year for 3 years - Obstructive sleep apnoea/ dysphagia 2ary to enlarged (adeno)tonsils - Refractive quinsy (best to avoid in acute infection) - Severely disablingQuestion 14 It’s the school holidays so Molly brings Tom and Daphne on a walk with their dog, Cookie. Whilst playing, Cookie accidentally bites Molly. The wound is small but deep and on presentation to the GP it appears to have become red and inflamed. What is the most appropriate initial management? A. Reassure, clean the wound, and advise tetanus vaccination if not up to date B. Prescribe oral flucloxacillin for 7 days C. Prescribe oral co-amoxiclav for 7 days D. Give rabies post-exposure prophylaxis E. Send a wound swab for culture and await results before starting antibioticsQuestion 14 It’s the school holidays so Molly brings Tom and Daphne on a walk with their dog, Cookie. Whilst playing, Cookie accidentally bites Daphne. The wound is small but deep on Daphne’s left hand. On presentation to the GP it appears to have become red and inflamed. What is the most appropriate initial management? A. Reassure, clean the wound, and advise tetanus vaccination if not up to date B. Prescribe oral flucloxacillin for 7 days C. Prescribe oral co-amoxiclav for 7 days D. Give rabies post-exposure prophylaxis E. Send a wound swab for culture and await results before starting antibioticsQuestion 14-Explanation The most likely bacteria is pasteurella multocida which is a gram-negative penicillin-sensitive bacillus. NICE recommends co-amoxiclav for animal and human bites as first line.Infections from animals Most common in GP is Pateurella multocida from Dog - Rabies, cats or dogs. Human bites tend to be a mix of aerobic and anaerobic bacteria. pasteurella Cat - Toxoplasmosis, Investigations: cat scratch disease - Vaccination history Birds - Bird fanciers’ - Risk of viral infections eg. HIV, hepC lung Management: Farm animals - - Clean wound but do not suture Leptospirosis, anthrax, - Co-amoxiclav farmers lung - Doxycycline + metronidazole if pen allergicQuestion 15 While at the GP, Molly brings up that she also noticed some redness just behind her shin after coming back from a walk last week. It’s hot to touch but not too tender. What is the most likely causative organism? A. Plasmodium vivax B. Borrelia burgdorferi C. Staphylococcus aureus D. Bartonella henselae E. Capnocytophaga canimorsus Source: Premier HealthQuestion 15 While at the GP, Molly brings up that she also noticed some redness just behind her shin after coming back from a walk last week. It’s hot to touch but not too tender. What is the most likely causative organism? A. Plasmodium vivax B. Borrelia burgdorferi C. Staphylococcus aureus D. Bartonella henselae E. Capnocytophaga canimorsus Source: Premier HealthQuestion 15-Explanation The picture shows erythema migrans which is associated with lyme disease. It is caused by tick bites. Plasmodium vivax is a non-falciparum type of malaria and unlikely to present in the UK. Staph aureus can cause cellulitis but the distinct bulls eye lesion is more indicative of lyme disease. Bartonella henselae is associated with cat scratch disease which is not mentioned in the question stem. Capnocytophaga canimorsus is associated with dog bites but does not show with bulls eye lesion appearance.Lyme disease Lyme disease is caused by spirochaete Borrelia Management: Burgdorferi and is spread by tick bites in woodlands. Clinical features: - If asymptomatic -> remove - Stage 1 (<30 days): Bulls-eye rash at the tick bite tick with special fine-tipped site developing over 1-4 weeks, headaches, tweezers and wash fever, flu-like illness - If symptomatic/ bulls-eye - Stage 2 (>30 days): Heart block, myocarditis, rash present -> doxycycline - Stage 3: arthritis, acrodermatitis chronicaain atrophicans, polyneuropathy (amoxicillin as alternative) - If disseminated disease -> IV Investigations: ceftriaxone - If rash present -> no investigations required -> move onto management Complications: - In no rash present -> ELISA test for B. burgdorferi. If -ve after 4-6 wks -> repeat ELISA. - Jarisch-herxheimer reaction If still -ve after 12 weeks -> immunoblot testQuestion 16 Daphne is now 6 years old and she has a rapidly worsening painful rash on her face and neck. What is the most likely diagnosis? A. Exacerbation of atopic dermatitis B. Impetigo C. Molluscum contagiosum D. Herpes zoster E. Eczema herpeticum Source: The LancetQuestion 16 Daphne is now 6 years old and she has a rapidly worsening painful rash on her face and neck. What is the most likely diagnosis? A. Exacerbation of atopic dermatitis B. Impetigo C. Molluscum contagiosum D. Herpes zoster E. Eczema herpeticum Source: The LancetQuestion 16-Explanation Given the rapidly worsening rash, we can reasonably suspect eczema herpticum. It is described as monomorphic punched out erosions, typically 1-3mm in size.Eczema herpticum in patients with underlying atopic eczema. It is a dermatological emergency due to the risk of systemic spread, encephalitis, or multi-organ failure. Clinical Features: - Painful vesicular rash on eczematous skin, Punched-out erosions with crusting, Fever, malaise, lymphadenopathy, Rapidly worsening despite standard eczema treatment Investigations: - Tzanck smear → Multinucleated giant cells - HSV PCR or viral swab (confirmatory) Management: 1. Admit for IV aciclovir (severe cases) 2. Oral aciclovir (mild cases after discussion with senior for step down) 3. Avoid topical steroids alone (may worsen viral replication) 4. Monitor for secondary bacterial infection (may need flucloxacillin) Complications: HSV encephalitis, Sepsis & multi-organ failure, Ophthalmic involvement (keratitis, blindness)Skin infections THERE ARE A LOT! Bacterial, Viral, Fungal, Parasitic https://dermnetnz.org/topics/bacterial -skin-infections https://gp-training.hee.nhs.uk/cornwa ll/wp-content/uploads/sites/86/2021/0 4/School-Exclusion-Criteria.pdfSkin infections-bacterialSkin infections-bacterial Impetigo Cellulitis Erysipelas Golden, honey coloured Red, hot tender skin, commonly Well-defined raised rash (often crusts on legs of people with diabetes on face) flucloxacillinusidic acid/ oral Rx: oral flucloxacillin Rx: oral flucloxacillinSkin infections-viralSkin infections-viral Herpes simplex Molluscum contagiosum Verrucae/ warts Painful vesicles that crust over Small dome shaped pearly Rough, scaly outgrowths on papules with central hands and feet Rx: oral aciclovir umbilication Rx: salicylic acid, cryotherapy Rx: self-limitingSkin infections-fungalSkin infections-fungal Tinea capitis/corporis/pedis Candidiasis Red, scaly, annular rash with central Oral thrush, white plaques in the clearing mouth. Vaginal thrush, cottage cheese discharge ketoconzole shampoo/ oral topical Rx: (topical clotrimazole) oral terbinafine/ oral fluconazole fluconazole if severeSkin infections-parasiticSkin infections-parasitic Scabies Head lice Widespread pruritis, Itchy scalp with nits especially on side of fingers. Rx: web comb, dimeticone Rx: permethrin, malathionQuestion 17 Daphne gets treated for eczema herpeticum in hospital and recovers well. In the meantime, Grandpa Ian, now 78 years old, starts developing a chesty cough and feels more out of breath than usual. When he presents to the GP, you can hear bronchial breath sounds and crackles in the right lower zone. His obs are as follows: HR 60bpm, RR 28/min, BP 156/80mmHg, 97% RA, 38.1degC. He’s orientated to time, place and person. He has a PMH of COPD, He is allergic to penicillin. What is the most appropriate next step in management? A. Give amoxicillin for 5 days B. Order pneumococcal and legionella urinary tests and give clarithromycin for 5 days C. Give doxycycline for 5 days and steroids D. Admit to hospital E. Take bloods and and CXR decide management depending on resultsQuestion 17 Daphne gets treated for eczema herpeticum in hospital and recovers well. In the meantime, Grandpa Ian, now 78 years old, starts developing a chesty cough and feels more out of breath than usual. When he presents to the GP, you can hear bronchial breath sounds and crackles in the right lower zone. His obs are as follows: HR 60bpm, RR 28/min, BP 156/80mmHg, 97% RA, 38.1degC. He’s orientated to time, place and person. He has a PMH of COPD, He is allergic to penicillin. What is the most appropriate next step in management? A. Give amoxicillin for 5 days B. Order pneumococcal and legionella urinary tests and give clarithromycin for 5 days C. Give doxycycline for 5 days and steroids D. Admit to hospital E. Take bloods and CXR and decide management depending on resultsQuestion 17-Explanation This gentleman’s CRB-65 score is 1 due to his age. NICE recommends amoxicillin, clarithromycin or doxycycline as first line. He also has COPD and we cannot rule out infective exacerbation, so he would need prednisolone 30mg for 5 days too.Communityacquired pneumonia CAP is common and can be caused by a variety of pathogens, most commonly streptococcus pneumoniae. Clinical features: - Fever, SOB, chest pain, sputum Investigations: - Observations - Bloods (FBC, U&Es, CRP) + sputum culture +/- pneumococcal and legionella urinary antigen test - CXR + follow up CXR in 6 weeks Management: - Amoxicillin. If penicillin allergic -> macrolide/ tetracycline for 5 days - If moderate-severe -> amox + clari OR co-amox OR pip-taz + clarithromycin for 7 days Infective exacerbations of COPD are most commonly caused by haemophilus influenza. Treatment involves prednisolone 30mg 5 days + increased use of bronchodilator therapy +/- antibiotics if there are clinical signs of pneumonia. All pneumonia should have repeat CXR after 6 weeksCommunityacquired pneumonia Source: BMJbestpracticeQuestion 18 Grandpa Ian comes back feeling well from his chest infection but now feels a burning sensation whenever he tries to pee. This is the 3rd time this year. He hasn’t noticed any blood or frothiness in his pee. He doesn’t complain of urinary hesitancy or frequency. He notes some pain around the base of his penile area but there hasn’t been any abnormal discharge and he denies fevers. What is the appropriate management given the likely diagnosis? A. Treat as prostatitis and give antibiotics B. Give antibiotics and refer to urology C. Take a urine culture then give antibiotics D. Do a dipstick then give antibiotics E. Advice good hygiene and preventative methodsQuestion 18 Grandpa Ian comes back feeling well from his chest infection but now feels a burning sensation whenever he tries to pee. This is the 3rd time this year. He hasn’t noticed any blood or frothiness in his pee. He doesn’t complain of urinary hesitancy or frequency. He notes some pain around the base of his penile area but there hasn’t been any abnormal discharge and he denies fevers. What is the appropriate management given the likely diagnosis? A. Treat as prostatitis and give antibiotics B. Give antibiotics and refer to urology C. Take a urine culture then give antibiotics D. Do a dipstick then give antibiotics E. Advice good hygiene and preventative methodsQuestion 18-Explanation He is likely to have a UTI, for which all men need a urine culture and antibiotics for 7 days.Urinarytract infection Infections are most commonly due to E.coli. Clinical features: - Dysuria - Nocturia - Increased urinary frequency - Haematuria - Urinary urgency Investigation: - Urine dipstick - Urine culture - Bloods (FBC, U&Es, CRP)Urinarytract infection Management - Non-pregnant women: trimethoprim OR nitrofurantoin for 3 days + urine culture if aged > 65 years or visible or non-visible haematuria - Pregnant women: urine culture + nitrofurantoin OR amoxicillin/ cefalexin if near term for 7 days + urine culture test of cure - Men: urine culture + trimethoprim OR nitrofurantoin for 7 days - Catheterised patients: do not treat if asymptomatic. Give 7 days abx if required and replace catheter - Acute pyelonephritis: hospital admission + quinolone OR cephalosporin if pregnant for 10-14 daysLearning outcomes/topics HTN meds - starting Asthma - new guidelines Screening - AAA size ereferral ABPI vascular disease interpretation Bell’s palsy - treatment/mechanism why(?) Coeliac - explain what and why Smoking cessation Angina - starting GTN spray counselling Depression - starting SSRI 1/52 followup COPD -referral to pulm rehab ( a) Proportion of people with stable COPD and a score of 3 or above on the MRC dyspnoea scale who are referred to a pulmonary rehabilitation programme.Question 19 A 45M presents to your clinic with increasing shortness of breath, which is affecting their quality of life. On further questioning his symptoms have been progressing over the past 6 months, and his usual medications are no longer having effective control. He is on Trelegy, as well as a PRN Salbutamol inhaler. When asked what his usual exercise tolerance is, he says that 6 months ago he was able to walk to the shops and back (>100m) without feeling breathless, but recently he has had to take breaks after <100m. This is now affecting his quality of life as his family are struggling to support his ADLs. He is Afebrile, Sats 94% on room air, 95 BPM with clear lung and heart sounds on examination. What is the next best step in management for the GP? a) LTOT b) Pulmonary rehab referral c) Increase SABA frequency d) Prescribe oral steroids e) Refer to the Acute Medical Unit for assessmentCOPD-pulmonaryrehab referral criteria Evan Tickle (55M) presents to your clinic with increasing shortness of breath, which is affecting their quality of life. On further questioning his symptoms have been progressing over the past 6 months, and his usual medications are no longer having effective control. He is on Trelegy, as well as a PRN Salbutamol inhaler. When asked what his usual exercise tolerance is, he says that 6 months ago he was able to walk to the shops and back (>100m) without feeling breathless, but recently he has had to take breaks after <100m. This is now affecting his quality of life as his family are struggling to support his ADLs. He is Afebrile, Sats 94% on room air, 95BPM with clear lung and heart sounds on examination. What is the next best step in management for the GP? a) LTOT b) Pulmonary rehab referral c) Increase SABA frequency d) Prescribe oral steroids e) Refer to the Acute Medical Unit for assessmentCOPD NICE guidelines mMRC scale At every review, GPs should: Used to quantify the degree of baseline Offer smoking cessation; functional disability due to dyspnoea. Offer pneumococcal and influenza vaccinations Offer personalised treatment plans Offer pulmonary rehab if patient qualifies Start inhaled therapies if breathless and exercise limitationQuestion 20 Evan Tickle (55M) has a second appointment for a health check. In this consultation the patient’s observations are taken as follows: RR 12; Sats 96%; HR 100; BP 140/90; T 37.6C; CRT <2. He currently takes amlodipine 10mg once a day, as well as Levothyroxine, salbutamol and Trelegy inhalers. What is the next best step in management for the patient? a) Increase Amlodipine to 20mg OD b) Start Furosemide 20mg OD c) Start Ramipril 5mg OD d) Advise lifestyle changes e) Check inhaler techniqueModifying anti-HTN medications (long-term) Evan Tickle (55M) has a second appointment for a health check. In this consultation the patient’s observations are taken as follows: RR 12; Sats 96%; HR 100; BP 148/94; T 37.6C; CRT <2. He currently takes amlodipine 10mg once a day, as well as Levothyroxine, salbutamol and Trelegy inhalers. What is the next best step in management for the patient? a) Increase Amlodipine to 20mg OD b) Start Furosemide 20mg OD c) Start Ramipril 5mg OD d) Advise lifestyle changes e) Check inhaler techniqueHypertension management -NG 136 Based on patient demographics and comorbidities Evan is white caucasian, 55, and non diabetic. He is on Amlodipine (CCB) but this is not controlling his blood pressure adequately. Escalate to CCB + ACEi (or ARB if ACEi contraindicated/S/E profile adverse)Question 21 You receive a phone call from a patient during telephone clinic. He states that he had an appointment with the ultrasound department for his aorta. On review of the letter you note that his AAA was 4.6cm with <1cm change from the previous annual scan. He asks you what this means for him. What is follow-up should be offered to this patient? a) Monthly AAA screening b) Yearly AAA screening c) Urgent referral to vascular d) 3-monthly AAA screening e) Book for elective AAA repairScreening-AAAsize You receive a phone call from a patient during telephone clinic. He states that he had an appointment with the ultrasound department for his aorta. On review of the letter you note that his AAA was 4.6cm with <1cm change from the previous annual scan. He asks you what this means for him. What is followup should be offered to this patient? a) Monthly AAA screening b) Yearly AAA screening c) Urgent referral to vascular d) 3-monthly AAA screening e) Book for elective AAA repairAbdominal aorticaneurysm Condition characterised by an abdominal aorta diameter greater than 3cm. 3-4-5 rule Diagnosis based on USS screening programme with ● 3 cm-4.4 cm - Yearly repeat follow-up based on the observed size and ● 4.5 cm-5.4 cm - 3 monthly change between scans. ● >5.5 cm 2-week referral to Vascular Elective repair if: Symptomatic (pulsatile, expansile abdominal mass with abdominal pain radiating to the back) The AAA has grown by more than 1 cm in 1 year and is larger than 4 cm The AAA is 5.5 cm or largerQuestion 22 Molly’s boyfriend, a 23M presents to your afternoon clinic as an add-on case. He reports waking up this morning unable to smile or make faces on this right hand side. He walked to this appointment and has no other symptoms. On examination he can puff his cheeks out, and scrunch his eyes only on the left hand side. When asked to raise his eyebrows he cannot raise his right eyebrow. This is distressing for him and he asks why this has happened. What is the anatomical relation explaining this presentation? a) UMN lesion affecting the pre-central gyrus b) LMN lesion affecting CN VII c) Local damage to the frontalis muscle d) Vascular supply damage to the anterior face e) Pathology in the globus pallidusQuestion 22 Molly’s boyfriend, a 23M presents to your afternoon clinic as an add-on case. He reports waking up this morning unable to smile or make faces on this right hand side. He walked to this appointment and has no other symptoms. On examination he can puff his cheeks out, and scrunch his eyes only on the left hand side. When asked to raise his eyebrows he cannot raise his right eyebrow. This is distressing for him and he asks why this has happened. What is the anatomical relation explaining this presentation? a) UMN lesion affecting the precentral gyrus b) LMN lesion affecting CN VII c) Local damage to the frontalis muscle d) Vascular supply damage to the anterior face e) Pathology in the globus pallidusBell’s Palsy Unilateral, lower motor neuron facial weakness. Typically idiopathic in cause, but can be associated with viral illness. Classically affects the forehead - due to dual nervous supply of CN VII Utilise this to differentiate between a stroke and Bell’s Palsy; Forehead sparing indicates UMN lesion, non-forehead sparing indicates a LMN lesion in exams.Coeliac-counselling on long-term sequelae Daphne, who is now 16, presents a few weeks later complaining of abdominal pain and bloating and cramping. On further questioning she mentions that this typically happens after eating foods such as toast and pastries at breakfast, or after pasta at dinner. Given the likely diagnosis what is a long term complication that is essential to warn for? a) Increased susceptibility to infections due to hyposplenism b) Increased risk of gastroenteritis due to inflammation of the gut c) Increased risk of short growth from malabsorption d) Increased risk of maternal complications in pregnancy e) Increased risk of cardiac diseaseCoeliac-counselling on long-term sequelae Daphne, who is now 16, presents a few weeks later complaining of abdominal pain and bloating and cramping. On further questioning she mentions that this typically happens after eating foods such as toast and pastries at breakfast, or after pasta at dinner. Given the likely diagnosis what is a long term complication that is essential to warn for? a) Increased susceptibility to infections due to hyposplenism b) Increased risk of gastroenteritis due to inflammation of the gut c) Increased risk of short growth from malabsorption d) Increased risk of maternal complications in pregnancy e) Increased risk of cardiac diseaseCoeliacdisease Immune-mediated sensitivity to dietary In this case: gluten. Hyposplenism - theorised from the development of functional splenism, and/or splenic atrophy. Mediated by T-cells Leads to an increased risk of infection from encapsulated organisms Genetics: HLA-DQ2 allele and association with autoimmune conditions ‘SHIN’ organisms Disease control: Streptococcus pneumoniae Avoidance of gluten-containing foods, Haemophilus Influenzae prophylactic vaccinations and management of Neisseria meningitidis sequelae (Dermatitis herpetiformis, recurrent infections; Enteropathy-associated T cell Hence will need annual flu and one-off pneumovax vaccinations to prevent these infections lymphoma)Question 24 Ian Tickle (68M) presents to your clinic for a review of their non healing venous right leg ulcer. On examination you note that his known venous ulcer is largely unchanged since the last review by the practice nurse. On examination his right foot is cool, and he reports intermittent tingling when walking. You measure his brachial pulse with a doppler and measure 120mmHg; with a pulse at the dorsalis pedis of 88 mmhHg and posterior malleolus of 70 mmHg. What type of vascular disease does this result indicate? a) Venous insufficiency b) Severe arterial disease c) Moderate arterial disease d) No venous or arterial disease e) Mixed vascular diseaseABPI interpretation from results Ian Tickle (68M) presents to your clinic for a review of their non healing venous right leg ulcer. On examination you note that his known venous ulcer is largely unchanged since the last review by the practice nurse. On examination his right foot is cool, and he reports intermittent tingling when walking. You measure his brachial pulse with a doppler and measure 120 mmHg; with a pulse at the dorsalis pedis of 88 mmhHg and posterior malleolus of 70 mmHg. What type of vascular disease does this result indicate? a) Venous insufficiency b) Severe arterial disease c) Moderate arterial disease d) No venous or arterial disease e) Mixed vascular diseaseVascular disease-ABPI ABPI is a useful screening tool for ruling in/out the presence of peripheral arterial disease. First-line investigation, using a Doppler probe to measure the systolic brachial blood pressures of the arms and compare them with the ankle blood pressures. Use the highest measured on each side (DP or PT)/Brachial pressure.Question 25 Ian Tickle (68M) presents a few months later to the GP clinic with a cough. He mentions that this has been ongoing for the past 6 months and has streaks of blood when expectorating phlegm. Previous sputum cultures have returned no organisms, with viral swabs also returning negative. He is awaiting a 6 week repeat CXR following empirical treatment for a CAP. What is the next best step in management? a) Continue empirical Mx - PO Doxycycline b) Urgent CT Thorax c) 2-week wait respiratory referral d) Prescribe oral steroids e) Start PRN salbutamolQuestion 25 Ian Tickle (68M) presents a few months later to the GP clinic with a cough. He mentions that this has been ongoing for the past 6 months and has streaks of blood when expectorating phlegm. Previous sputum cultures have returned no organisms, with viral swabs also returning negative. He is awaiting a 6 week repeat CXR following empirical treatment for a CAP. What is the next best step in management? a) Continue empirical Mx - PO Doxycycline b) Urgent CT Thorax c) 2-week wait respiratory referral d) Prescribe oral steroids e) Start PRN salbutamolLung cancer Small cell and non-small cell In GP the referral guidelines are: > Also ‘screened’ for in Community Acquired Pneumonia - with the 6-week follow up chest x-ray on discharge. CXR findings on report: Increased opacification (consistent with a lung mass); Bulky hilum, lobar collapse in advance cases, or a new pleural effusionQuestion 26 An 18F calls into your clinic with low mood over the past 4 weeks. On questioning she describes feeling unmotivated and low in energy when trying to start tasks; her sleep has been erratic and her appetite is markedly reduced. The GP diagnoses more-severe depression and start her on SSRIs and CBT. What is an important followup to book on starting this medication? a) Routine observations b) Regular height and weight c) 1 week follow up to review change in mood d) Routine bloods in 4 weeks e) ECG in 2 weeksDepression-starting SSRI counselling An 18F calls into your clinic with low mood over the past 4 weeks. On questioning she describes feeling unmotivated and low in energy when trying to start tasks; her sleep has been erratic and her appetite is markedly reduced. The GP diagnoses more-severe depression and start her on SSRIs and CBT. What is an important followup to book on starting this medication? a) Routine observations b) Regular height and weight c) 1 week follow up to review change in mood d) Routine bloods in 4 weeks e) ECG in 2 weeksDepression NG 222 - now differentiates between ‘less Starting SSRIs severe and more severe depression’ In 18-25 year olds - If starting SSRIs they will Less severe - formerly subclinical or mild need a review after 1 week or if there is a specific risk of suicide Self-help, CBT, Individual Behavioural GP counselling points: Actions, SSRIs, Counselling - *When the first review will be* More severe - formerly moderate or severe - How long until the will feel an effect depression from the medication - How to take the medications As above but with border range of - Any regular monitoring and reviews anti-depressants (SSRIs and SNRIs); CBT and - How to self monitor Sx - The typical course length antidepressants; - Withdrawal SxQuestion 27 Ian Tickle (now 68M) presents some months later with progressive abdominal pain after meals. He reports that this is especially bad after large meals, with an associated burning sensation in his throat. He describes it as a burning epigastric pain, which does not radiate and is relieved by OTC gaviscon. You see that his clothes seem slightly looser, and he reports that he has been feeling more fatigued after a day’s work in an office as a manager. What is the next best step in management? a) Urgent AXR b) Endoscopic tests under gastroenterology c) 2ww for suspected gastric cancer d) Routine bloods (FBC, U&Es, LFTs, Bone profile) e) Referral to general surgery for further investigation2wwGastro referral Ian Tickle (now 68M) presents some months later with progressive abdominal pain after meals. He reports that this is especially bad after large meals, with an associated burning sensation in his throat. He describes it as a burning epigastric pain, which does not radiate and is relieved by OTC gaviscon. You see that his clothes seem slightly looser, and he reports that he has been feeling more fatigued after a day’s work in an office as a manager. What is the next best step in management? a) Urgent AXR b) Endoscopic tests under gastroenterology c) 2ww for suspected gastric cancer d) Routine bloods (FBC, U&Es, LFTs, Bone profile) e) Referral to general surgery for further investigationGastro 2WWcriteria Oesophageal and Gastric cancer 2-week wait referral criteria Both require Upper GI endoscopic investigation Shared/ common symptoms of malignancies - unexpected/unexplained weight loss, lethargy, appetite loss. SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching