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Topical Steroids:
Mild Hydrocortisone

Moderate CLobetasaone butyrate (Eumovate), Betametasone 0.025% (Betnovate RD)

Potent Fluticasone (Cutivate), Betametasone 0.1% (Betnovate)

Very Potent Clobetasol Proprionate (Dermovate)

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SEM= SD/root(n)

95CI = Mean - 1.96*SEM

Mean + 1.96 * SEM

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Incontinence

Stress

Stress - leaking when coughing laughing. Weakness of detrusor muscle

Inv
Bladder diary
VE r/o prolapse
Urinalysis urodynamic studies

Stress incontinence
Strenghtening of pelvic floor muscles.
Kegels contracttion 8 x at leats 3 x a day for 3 months.

Surgical repair if unsuccessful

If surgical repair declined = Duloxetine. Increases noradrenaline at synaptic

juncton an increases contractility of muscles,

Urge Incontinence
Cant hold it. Bladder muscle intability/tone

Bladder training x 6 weeks

Antimuscarinics - relax bladder muscle.

Oxybutinin tolteridine (iR) Darifenacin 1 OD.
If antumuscarininc effects not tolerated (eg elderly) = Mirabegron.

Desmopressin may also be used but mostly for night problems or to control urinary
frequency during the day but should never be used more than once in 24 hours
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Rhinne and Weber 24:00

Rhinne +ve: Normal: Air > Bone (Tuning fork on mastoid (bone) then move to front
of ear(bone))
Weber: in sensorineural lateralises to opposite side

If Rhinne -ve: Bone > air : Weber will lateralise to same side

Webers: ConDuctive hearing loss: sound louder in Deaf ear

: SensoriNeural hearing loss sound louder in Normal ear

Audiogram
in sensorineural hearing loss both air and bone conduction are impaired
in conductive hearing loss only air conduction is impaired
in mixed hearing loss both air and bone conduction are impaired, with air
conduction often being 'worse' than bone

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Gonorrhoea
IM ceftriaxone 1g stat
ciprofloxacin 500mg stat (if sensitivities known)
Cefixime 400mg (single dose) + oral azithromycin 2g (single dose) (if ceftriaxone
is refused (e.g. needle-phobic))

Chlamydia
Doxycycline 100mg BD x 7 days
Azithromycin 1 g sta then 500mg OD for 2 days.
Ofloxacin 200mg BD x 7 days

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Colorectal cancer: referral guidelines

NICE updated their referral guidelines in 2015. The following patients should be
referred urgently (i.e. within 2 weeks) to colorectal services for investigation:
patients >= 40 years with unexplained weight loss AND abdominal pain
patients >= 50 years with unexplained rectal bleeding
patients >= 60 years with iron deficiency anaemia OR change in bowel habit
tests show occult blood in their faeces (see below)

An urgent referral (within 2 weeks) should be 'considered' if:

there is a rectal or abdominal mass
there is an unexplained anal mass or anal ulceration
patients < 50 years with rectal bleeding AND any of the following unexplained
symptoms/findings:
-→ abdominal pain
-→ change in bowel habit
-→ weight loss
-→ iron deficiency anaemia

Faecal Occult Blood Testing (FOBT)

This was one of the main changes in 2015. Remember that the NHS now has a national
screening programme offering screening every 2 years to all men and women aged 60
to 74 years. Patients aged over 74 years may request screening.

In addition FOBT should be offered to:

patients >= 50 years with unexplained abdominal pain OR weight loss
patients < 60 years with changes in their bowel habit OR iron deficiency anaemia
patients >= 60 years who have anaemia even in the absence of iron deficiency

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Dyspepsia Referral Guidelines:

Urgent

All patients who've got dysphagia

All patients who've got an upper abdominal mass consistent with stomach cancer

Patients aged >= 55 years who've got weight loss, AND any of the following:
upper abdominal pain
reflux
dyspepsia

Non-urgent

Patients with haematemesis

Patients aged >= 55 years who've got:

treatment-resistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following: nausea, vomiting, weight loss,
reflux, dyspepsia, upper abdominal pain
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper
abdominal pain

Managing patients who do not meet referral criteria ('undiagnosed dyspepsia')

This can be summarised at a step-wise approach

1. Review medications for possible causes of dyspepsia
2. Lifestyle advice
3. Trial of full-dose proton pump inhibitor for one month OR a 'test and treat'
approach for H. pylori
if symptoms persist after either of the above approaches then the alternative
approach should be tried

Testing for H. pylori infection

initial diagnosis: NICE recommend using a carbon-13 urea breath test or a stool
antigen test, or laboratory-based serology 'where its performance has been locally
validated'
test of cure:
there is no need to check for H. pylori eradication if symptoms have resolved
following test and treat
however, if repeat testing is required then a carbon-13 urea breath test should be
used

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Referral to a nephrology specialist is normally required for people with:

An eGFR of less than 30 ml/min/1.73 m2. These people are usually under specialist
care, but monitoring of blood tests may take place in primary care as part of
shared care arrangements
A sustained decrease in eGFR of 25% or more within 12 months and a change in eGFR
category
A sustained decrease in eGFR of 15 ml/min/1.73 m2 or more within 12 months.
A urinary ACR of 70 mg/mmol or more, unless known to be caused by diabetes and
already appropriately treated
A urinary ACR of 30 mg/mmol or more, together with persistent haematuria (two out
of three dipstick tests show 1+ or more of blood) after a urinary tract infection
has been excluded

The need for oxygen therapy should be assessed in:

All patients with severe airflow obstruction (FEV1 < 30% predicted)
Patients with cyanosis
Patients with polycythaemia
Patients with peripheral oedema
Patients with a raised jugular venous pressure
Patients with oxygen saturations < 92% breathing air.
Assessment should also be considered in patients with moderate airflow obstruction
(FEV1 30–49% predicted).
Many patients tolerate mild hypoxaemia well, but once the resting artierial oxygen
partial pressure (PaO2) falls below 8 kPa patients begin to develop signs of cor
pulmonale, principally peripheral oedema. Once this occurs the prognosis is poor
and if untreated the five year survival is less than 50%.

The assessment of patients for LTOT should include the measurement of arterial
blood gases on two occasions at least three weeks apart in patients who have a
confident diagnosis of COPD, who are receiving optimum medical management and whose
COPD is stable.

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Infection with H.pylori is the most important known risk factor for any type of
gastric cancer as it increases risk by two-fold.

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Diarrhoea:

Staph A, Bacillus Cereus 1-6

Salmonella, eColi 24- 48H

Shigella, campylobacter 48-72H

Giardia, Amoebiasis > 7 days

Staph A severe vomitting

Shigella vomitting, bloody diarrhoea Rx ciprofloxaxin
Campylobacter bloody diarrhoea, flu -like prodrome Rx Clarithromycin

Giardia Long term Rx Metronidazole

Amoebiasis long term bloody

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Drugs in Urine Deteectable time:

Cannabis 27 days with chronic heavy use.
Diazepam 7 days.
Methadone 1–2 days as a single dose, 7–9 days as a stable maintenance dose.
Cocaine for 12–36 hours.
Opiates 3 days.

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Drug induced lupus

"SLAP HIM"

Sulfasalazine
Losartan
Anti-convulsants
Procainamide
Hydralazine
Isoniazid
Minocycline
Chlorpromazine

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Cyclo-oxygenase-2 selective inhibitors and diclofenac (150 mg daily) are associated

with an increased risk of thrombotic events. Naproxen (1000 mg a day or less) and
low-dose ibuprofen (1200 mg a day or less) are considered to have the most
favourable thrombotic cardiovascular safety profiles of all NSAIDs.

cyCLO diCLo CLOtting

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Genetics: All the aemia and uria are autosomal recessive

Autosomal dominant: MND, Fam hypercholesterolaemaia, HNPCC, ADPKD

X-linked mother carrier only sons will have disease -cant pass it on as in X
chrmosome

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When diagnosed in an HIV positive patient, carcinoma of the cervix, non-Hodgkin’s

lymphoma and Kaposi’s sarcoma classify the patient as suffering from acquired
immuno deficiency syndrome (AIDS).

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prednisone for asthma exacerbation is 10 mg of prednisolone for children under two

years of age, a dose of 20 mg for children aged 2–5 years and a dose of 30–40 mg
for children older than five years.

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HBP in pregnancy
labetalol, nifedipine, methyl dopa

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Lactational mastitis
Fluclox. If no improvement in 48H give co-amoxiclav. If no improvement in 14 days
refer to breast surgeon.
Metronidazole can be given for mastitis in non-lactating women.
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Varicella in pregnancy

fetal varicella syndrome => learning diff, limb hypoplasia:

<20 weeks High chance
>20 weeks Reduced chance
>28 weeks Smaller chance
Neonatal varicella => chickenpox in mother <5 d before or 2 d after delivery - can
be fatal. Give acyclovir

Prophylaxis: If exposed and varicella status not known, check status.

If not immune and <20 weeks give VZIG within 10 days.
If not immune and >20 weeks give VZIG or oral acyclovir within 10 days
If outside 10 days window advise to seek specialist advice if rash develops.

Treament:
Confirmed chicken pox in pregnancy:
> 20 weeks give oral acyclovir within 24 hours of onset of rash
< 20 weeks refer for specialist advice.

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ssri switching
childhood rashes

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#

crohns uc management

UC

Relapses Mild moderate severe

Mild < 4 stools per day
Moderate 4-6 stools per day
Severe > 6 stools per day sith systemic symptoms (tachycaria, fever raised CRP).

Remission

Mild -Moderate (Review each step after 4 weeks)

Proctitis:
Topical ASA
Topical ASA + oral ASA
Topical ASA + oral ASA + steroid

L sided Colitis:
Topical ASA
Topical ASA + Oral ASA
Oral ASA + Oral steroid

Widespread Colitis:
Topical ASA + Oral ASA
Oral ASA + Oral steroid

Severe
Admit + IV steroids or IV cyclosporin if steroid not tolerated.

Maintenance

Mild - Moderate
Topical ASA + Oral ASA

Severe or >= 2 exacerbations in 1 year

Azathioprine or Mercaptopurine

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CROHNS

Remission

Steroid
Enteral feeding if steroids not tolerated
ASA
Mercaptopurine, Azathioprine, Methotrexate
Infliximab
Metronidazole for isolated peri-anal

Maintenance
Azathioprine, Mercaptopurine
Methotrexate
ASA

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#

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ssri switching
childhood rashes
finger tip units
AnteNatalCare
Breast CA
ogtt igt

im adrenaline 1 in 1000
0-6 150 6-12 300 12+ 600

suspected meningococcal septicaemia

im benpen: 0-1 300mg 1-9 600mg 10+ 1200mg 2nd lne IM Cefotaxime 1G 3rd
line Chloramphenicol
acute severe asthma
status epilepticus
med3 timeframes

Box and whisker plot: value considered outlier if >1.5x interquartile range above
upper or below lower limit.

dvla
snellen
group 1 6/12 in one eye
group 2 6/7.5 in on eye and 6/60 in other eye

psa 50-69 3ng/ml

70+ 5ng/ml

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#

For GAD treatment is

1. SSRI
2. If no help SNRI
3. If not better - pregabaline
benzo can be used for short period only for crisis.

For Panic disorders

1. SSRI
2. If no better- imipramine or clomipramine
benzos are not used at all.

Health promotion is defined by the World Health Organisation as 'the process of

enabling people to increase control over, and to improve, their health.'
Write a learning log about the fat guy with the ulcer.