PassMedicine Top 100 Concepts

ADMINISTRATION AND HEALTH INFOMATICS

Controlled drugs

Controlled drugs - it is the quantity supplied which needs to be stated in both figures and words, rather than the
dosage

DERMATOLOGY

Scabies

Scabies - permethrin treatment: all skin including scalp + leave for 12 hours + retreat in 7 days

EAR, NOSE AND THROAT

Aphthous mouth ulcers

Stopping smoking is a risk factor for aphthous mouth ulcers

Epistaxis

Recurrent epistaxis without red flags can be treated with Naseptin (chlorhexidine/neomycin) cream

Laryngopharyngeal reflux

A trial of proton pump inhibitors should be tried in patients with suspected laryngopharyngeal reflux

Globus, hoarseness and no red flags --> ?laryngopharyngeal reflux

Vestibular neuronitis

The HiNTs exam can be used to distinguish vestibular neuronitis from posterior circulation stroke

EVIDENCE BASED CLINICAL PRACTICE

Significance tests

Power = 1 - the probability of a type II error

MEDICINE

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CARDIOLOGY

ACE inhibitors

After starting an ACE inhibitor, significant renal impairment may occur if the patient has undiagnosed bilateral renal
artery stenosis

Angina pectoris: drug management

When treating angina, if there is a poor response to the first-line drug (e.g. a beta-blocker), the dose should be
titrated up before adding another drug

If angina is not controlled with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be
added

Atrial fibrillation: rate control and maintenance of sinus rhythm

Patients who've had a catheter ablation for atrial fibrillation still require long-term anticoagulation as per their
CHA2DS2-VASc score

Chronic heart failure: drug management

As part of the broad lifestyle approach to heart failure, annual influenza vaccine should be offered

When starting ACE-inhibitors and beta-blockers for heart failure with reduced ejection fraction start one drug at a
time

Offer a mineralcorticoid receptor antagonist, in addition to an ACE inhibitor (or ARB) and beta-blocker, to people
who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure

Combination antiplatelet and anticoagulant therapy

In the initial phase following an ACS/PCI patients who also have AF are generally given 2 antiplatelets + 1
anticoagulant

DVLA: cardiovascular disorders

DVLA advice following angioplasty - cannot drive for 1 week

Hypertension: management

For patients of black African or African–Caribbean origin taking a calcium channel blocker for hypertension, if they
require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor

In people with a significant postural drop or symptoms of postural hypotension, treat based on standing blood
pressure

Consider starting antihypertensives in all patients under 60 with stage 1 hypertension (even if estimated CV risk

Loop diuretics

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Loop diuretics may cause ototoxicity

Myocardial infarction: secondary prevention

Following a myocardial infarction sexual activity may resume after 4 weeks

Prosthetic heart valves

Mechanical valves - target INR: - aortic: 3.0 - mitral: 3.5

Pulmonary embolism: management

'Provoked' pulmonary embolisms are typically treated for 3 months

Statins

Statins + erythromycin/clarithromycin - an important and common interaction

Pregnancy is a contraindication to statin therapy

Warfarin: interactions

Warfarin interacts with fluconazole and careful monitoring of INR is required

Warfarin: management of high INR

INR 5.0-8.0 (no bleeding) - withhold 1 or 2 doses of warfarin, reduce subsequent maintenance dose

ENDOCRINOLOGY

Diabetes mellitus: management of type 2

In patients with T2DM, SGLT-2 should be introduced at any point they develop CVD, a high risk of CVD or chronic
heart failure

A second drug should be added in type 2 diabetes mellitus if the HbA1c is > 58 mmol/mol

Diabetic foot disease

Diabetic patients who have any foot problems other than simple calluses should be followed up regularly by the local
diabetic foot centre

DVLA: diabetes mellitus

Patient with diabetes who have had two hypoglycaemic episodes requiring help needs to surrender their driving
licence

Graves' disease: features

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Graves' disease is the most common cause of thyrotoxicosis

Graves' disease: management

Propranolol should be used in new cases of Graves' disease to help control symptoms

Gynaecomastia

GnRH agonists (e.g. goserelin) used in the management of prostate cancer may result in gynaecomastia

Hypothyroidism: management

Iron / calcium carbonate tablets can reduce the absorption of levothyroxine - should be given 4 hours apart

Neuroblastoma

For a child with a palpable abdominal mass or unexplained enlarged abdominal organ: refer very urgently (

Obesity: classification and therapeutic options

Liraglutide should be considered as an adjunct for weight loss in obese class II patients who are prediabetic

Pregnancy: thyroid problems

Women with hypothyroidism may need to increase their thyroid hormone replacement dose by up to 50% as early as
4-6 weeks of pregnancy

Primary hyperparathyroidism

The PTH level in primary hyperparathyroidism may be normal

SGLT-2 inhibitors

Sodium-glucose co-transporter 2 inhibitors are associated with an increased risk of urinary tract infections

GASTROENTEROLOGY

Coeliac disease: investigation

Patients must eat gluten for at least 6 weeks before they are tested

Crohn's disease

Arthritis is the most common extra-intestinal feature in both Crohn's and UC

Haemochromatosis: features

Haemochromatosis is a cause of hypogonadotrophic hypogonadism

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Helicobacter pylori: tests

Urea breath test is the only test recommended for H. pylori post-eradication therapy

Irritable bowel syndrome: management

Insoluble sources of fibre such as bran and wholemeal should be avoided in IBS

Metoclopramide

Metoclopramide is contraindicated in Parkinsonism

Ulcerative colitis: management

In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is topical (rectal) aminosalicylates

INFECTIOUS DISEASES

Lyme disease

In patients with suspected Lyme disease presenting within 4 weeks of symptom onset, the ELISA test should be
repeated after 4–6 weeks if initially negative

Meningitis: management of suspected bacterial meningitis

Suspected meningococcal disease: A child

NEPHROLOGY

ADPKD

Ultrasound is the screening test for adult polycystic kidney disease

Chronic kidney disease: eGFR and classification

Eating red meat the evening before a blood test can invalidate eGFR result

In a patient with CKD who has a 20% increase in serum creatinine when started on an ACE-i, suspect renal artery
stenosis

Chronic kidney disease: features

A sustained decrease in eGFR of 15 mL/min/1.73 m2 or more within 12 months requires referral to a nephrologist

In a patient with an eGFR

Chronic kidney disease: hypertension

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Aim for a lower blood pressure target (

Chronic kidney disease: proteinuria

An ACR of >70 mg/mmol or more requires referral to a nephrologist

An ACR of >3mg/mmol is abnormal

Henoch-Schonlein purpura

Henoch-Schonlein purpura classically presents with abdominal pain, arthritis, haematuria and a purpuric rash over
the buttocks and extensor surfaces of arms and legs

NEUROLOGY

Absent ankle jerks, extensor plantars

Extensor plantars + absent ankle jerk --> mixed UMN + LMN signs- motor neuron disease, subacute combined
degeneration of cord, syringomyelia

Cluster headache

Verapamil is used for long-term prophylaxis of cluster headaches

'Clusters' of cluster headaches typically last from 4 to 12 weeks

DVLA: neurological disorders

A person with a group 2 license and epilepsy can only drive after 10 years of being fit-free without medication

Migraine: diagnostic criteria

Aura usually last between 5-60 minutes

Migraine: management

Offer 10-sessions of acupuncture for the prevention of migraines if both topiramate and propranolol have been
ineffective after 2 months or are unsuitable

Motor neuron disease: features

Eye movements are typically spared in motor neurone disease

Parkinson's disease: management

Consider glycopyrronium bromide to manage drooling of saliva in people with Parkinson's disease

Stroke: management

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Clopidogrel is the preferred antiplatelet for secondary prevention following stroke

If clopidogrel is contraindicated or not tolerated, given aspirin and modified release dipyramidole for secondary
prevention following stroke

Transient ischaemic attack

If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, they should
be admitted immediately for imaging to exclude a haemorrhage

The ABCD2 scoring system is no longer recommended by NICE CKS. If a patient experiences symptoms suggestive
of a TIA within 7 days, then they are to be reviewed in hospital within 24 hours. If the symptoms presented > 7 days
ago, then they are to reviewed within a week

Vestibular schwannoma (acoustic neuroma)

Loss of corneal reflex - think acoustic neuroma

ONCOLOGY

Neoplastic spinal cord compression

Spinal cord compression - back pain is the earliest and most common symptom

PALLIATIVE CARE

Syringe drivers

Syringe drivers: respiratory secretions & bowel colic may be treated by hyoscine hydrobromide, hyoscine
butylbromide, or glycopyrronium bromide

RESPIRATORY

Acute exacerbation of COPD

The most common organism causing infective exacerbations of COPD is Haemophilus influenzae

NICE only recommend giving oral antibiotics in an acute exacerbation of COPD in the presence of purulent sputum
or clinical signs of pneumonia

COPD: stable management

COPD - reason for using inhaled corticosteroids - reduced exacerbations

Azithromycin prophylaxis is recommended in COPD patients who meet certain criteria and who continue to have
exacerbations

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Lung cancer: referral

Over 40, appetite loss, smoker - Urgent CXR

OPHTHALMOLOGY

Herpes zoster ophthalmicus

Hutchinson's sign: vesicles extending to the tip of the nose. This is strongly associated with ocular involvement in
shingles

Subconjunctival haemorrhage

A subconjunctival haemorrhage usually resolves within two weeks

PAEDIATRICS

Calcaneal apophysitis (Sever disease)

Sever's disease is an important differential diagnosis for heel pain in children and adolescents

Febrile convulsions

Antipyretics do not prevent febrile convulsions

Hearing testing in children

If a newborn baby has an abnormal hearing test at birth they are offered the auditory brainstem response test

Laryngomalacia

Laryngomalacia: 99% of cases usually resolve spontaneously by 18-24 months

Scarlet fever

A child with scarlet fever can return to school 24 hours after commencing antibiotics

Undescended testis

Babies found to have bilateral undescended testes at the newborn examination should be reviewed by a senior
paediatrician within 1 day

PSYCHIATRY

Anorexia nervosa

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Anorexia focused family therapy is the first-line treatment for children and young people with anorexia nervosa

SURGICAL AND MUSCULOSKELETAL PROBLEMS

RHEUMATOLOGY

Bisphosphonates

Bisphosphonates are associated with an increased risk of atypical stress fractures

Lateral epicondylitis

Lateral epicondylitis: worse on resisted wrist extension/suppination whilst elbow extended

Psoriatic arthropathy

Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of psoriatic arthritis

Systemic lupus erythematosus: investigations

Over 99% of patients with SLE are ANA positive, therefore it is a useful rule out test

SURGERY

Benign prostatic hyperplasia

Finasteride treatment of BPH may take 6 months before results are seen

Thrombosed haemorrhoids

Thrombosed haemorrhoids are characterised by anorectal pain and a tender lump on the anal margin

WOMEN'S HEALTH

CONTRACEPTION

Combined oral contraceptive pill: contraindications

Current gallbladder disease is UKMEC 3 for the combined oral contraceptive pill

GYNAECOLOGY

Heavy menstrual bleeding: management

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 Menorrhagia - intrauterine system (Mirena) is first-line

Menorrhagia - do an ultrasound if abnormal exam findings, pelvic pain, intermenstrual or postcoital bleeding

Infertility: initial investigations

Male infertility is the cause in 30% of infertile couples

OBSTETRICS

Breastfeeding: contraindications

Cephalosporins in breastfeeding is considered safe to use

Galactocele

Galactocele can usually be differentiated from a breast abscess by clinical history and examination findings alone,
without need for further investigation

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