1 Gp - Seco 1

Front 1

Peptic Ulcer Disease (PUD)

Back 1

-75% associated with Helicobacter pylori
-remainder: medication incl
--aspirin
---NSAID: 5-20% has dyspeptic symptoms; 1 in 1000 has GI bleed
-----NSAID-associated dyspepsia is a red flag and requires endoscopy followup
--often pat will not volunteer info about medication that they have not got from the doctor, need to ask specifically

Front 2

Dyspeptic symptoms

Back 2

-heartburn
-anorexia
-abd pain & distension

Front 3

Risk factors that incr the likelihood of sig. organic disease and are indicators for OGD are:

Back 3

-age50-55/+ at 1st presentation
-age40-45/+ at 1st presentation for people of Maori, Pacifica, or Asian descent
-FmHx of gastric cancer with onset age<50
-Severe or persistent dyspepsia
-prev PUD, particularly if complicated
-ingestion of NSAIDs incl. aspirin!! (check OTC use)
<CUPIDPC>
-chronic GI bleeding
-unexplained weight loss
-persistent or protracted vomiting
-iron def anemia
-dysphasia
-palpable abdominal mass
-coughing spells or nocturnal aspiration

Front 4

OA analgesia

Back 4

-NSAID
-paracetamol
-topical analgesic e.g. capsaicin
-weak opiods
-intra-articular steroids

If NSAID can't be stopped:
-advise the lowest effective dose for the shortest duration
-use least gastro-toxic NSAID - e.g. ibuprofen 1200mg/d
-use with PPI (suppress acid, effective in healing ulcers during continued NSAID use)
-swap to COX2 inhibitor (non-subsidized)

Front 5

Testing for Helicobacter pylori with PUD is worth it if...

Back 5

pat comes from an area of high H. pylori prevalence (>30%)

Front 6

Testicular cancer - key points are..

Back 6

-more common in young adults (15-44), but can occur any age
-Maori>2x>non-Maori, often present at a later disease stage with poorer prognosis
---a higher suspicion is therefore indicated
-Presentation:
--common: change in the "feel" of one testis -80% cases: either pat or his partner notices a change e.g. texture, enlargement or lump
--10% recent trauma hx is common: pat examine himself and finds tumor rather than being the cause of malignant change
--other presentation: gynecomastia from BhCG synth; symptoms from metastatic spread e.g. back pain, breathlessness (10% of initial cases)
-Pain/discomfort is not unusual
--often painless, 1/3 has pain, often a dragging sensation; sometime more severe pain misdx'd as orchitis, there may be associated reactive hydrocoele.
-Any suspicious features should prompt referral to urology w/o delay

Front 7

Causes of a scrotal mass

Back 7

true testicular mass
OR
benign persistent abnormalities e.g.:
-varicocele (abN enlargement of scrotal vein that drains testes)
-spermatocele (cystic enlargement of rete testis or head of epididymis)

Front 8

Examination to differentiate normal from abnormality in the scrotum include

Diagnosis is confirmed by...

Back 8

Transillumination
&
5 Physical exams ("sagcn"):
-scrotum
-abdomen
-gynecomastia
-chest auscultation - lung metastases
-neck lymph node

Dx is confirmed by u/s
-in a non-specialist: don't wait for u/s investigation and result if this will cause a delay in specialist assessment

Tumor markers may provide additional info e.g.:
-AFP
-hCG
-LDH
---if normal, don't rule out cancer

Front 9

Although less than 5% of testicular masses are malignant...

Scrotal findings suspicious for malignancy are:

Back 9

to avoid any delay in definitive tx, any abnormality suspicious for testicular cancer should be referred urgently for urological opinion (within 2wks)

Findings suspicious for malignancy:
-unexplained testicular swelling
-unexplained mass from testis
-scrotal mass that does not transilluminate
-body of testis can't be distinguished

Front 10

Signs & Symptoms of uUTI (uncomplicated UTI)

Back 10

-dysuria
-frequency
-back pain
-costovertebral tenderness

These features and absence of vaginal discharge or irritation makes uUTI highly likely >90-95%.
--vaginal irritation or discharge is more likely to be vaginitis or cervicitis, and reduces cystitis likelihood by 20%

Front 11

Causal organisms of uUTI

Back 11

-E coli (70-95%)
-Staph. saprophyticus (5-10%)
-Klebsiella spp (1-2%)
-Proteus mirabilis (1-2%)

Front 12

Investigation of UTI

Back 12

urine dipstick
-approach is to tx on the basis of findings (+ve results for nitrite &/or leukocytes)
-+ve blood requires microscopic exam to delineate between haematuria and ahemoglobinuria, and for detection of casts to distinguish between lower&upper UTI

urine culture - ndicated if there are:
-clinical features of pyelonephritis
-failure to respond to empirical tx
-pregnancy
-urolithiasis
-other: considered if immunocompromised or diabetic

Front 13

Symptoms of lower vs upper UTI

Back 13

lower UTI (cystitis):
-dysuria
-frequency
-back pain
-costovertebral angle tenderness
-or no significant pain

upper UTI (pyelonephritis)
-fever
-flank pain
-n&v
-& lower UTI symptoms

Front 14

Management of uUTI

Back 14

Empiric tx
-if hx is typical e.g.dysuria, frequency, no vaginal discharge or irritation; presence of risk factors

Med:
-1st line: trimethoprim 300mg od for 3d, except in communities with high resistance
--single dose tx is less effective but has less side effects
-if symptoms persist/worsen, urine culture & prescribe antibiotics according to the results of culture & sensitivity
--others: nitrofurantoin (5-7d), cephalosporins, fluoroquinolone (1-3d)

Upper UTI can be treated with oral antibiotics (fluoroquinolone, ciprofloxacin) for 7-10d, with an early review; or IV antibiotics
---in area of high resistance, ceftriaxone IV

Women who are systemically unwell should be admitted to hospital.

?Non-medical:
-RTs show cranberry or lingoberry juice, cranberry concentrate tablets reduces the risk of symptomatic recurrent infection by 10-20%

Front 15

When giving general advice on UTI, bear in mind study results such as...

Back 15

Studies have shown:
-postcoital voiding doesn't prevent cystitis
-no evidence that poor urinary hygiene predisposes to recurrent infections
-although urine alkalization is traditionally used to relieve UTI symptoms, it lacks evidence
-IRRATIONALE to give advice on freq of urination, timing of voiding, wiping patterns, douching, use of hot tubs or wearing pantyhose

Front 16

UTI in Pregnancy

Back 16

-more concerning due incr'd risk of kidney infection
-progesterone decr muscle tone of ureter&bladder, incr urinary reflux
-kidney infection during pregnancy can result in premature birth or pre-eclampsia

Tx: nitrofurantoin (safer, but avoid 36+wk due hemolytic anemia in newborn)
-trimethoprim (avoid 1st trimester due folic a. antagonist, though no evid of teratogenicity)