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Question 1 - Child with Koplik Spots, Fever, and Rash

1. Prodrome (3-4 days): the "3 Cs" - Cough, Coryza, Conjunctivitis + fever
2. Koplik spots on buccal mucosa (enanthem)
3. Maculopapular rash starting on the head/face, then spreading downward to trunk and extremities (cephalocaudal spread)

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Question 2 - 17-year-old Male with Gynecomastia, Tall Stature, Small Testes, Learning Difficulties

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Question 3 - 55-year-old Male with Nocturia, Weak Stream, Incomplete Bladder Emptying

• Fastest onset of symptom relief
• Well tolerated
• No effect on PSA (important for prostate cancer screening)

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Question 1 - Sudden Severe "Worst Headache of My Life"

• Nausea and vomiting
• Photophobia
• Neck stiffness (meningism) - develops within hours
• Loss of consciousness / sudden collapse
• Focal neurological deficits

1. Non-contrast CT head - first step; detects blood in ~95% if done within 6 hours
2. Lumbar puncture - if CT is negative but suspicion remains; look for xanthochromia (yellow CSF due to bilirubin from lysed RBCs) - appears after 2-4 hours, lasts ~2 weeks
3. CT angiography / MR angiography - to identify the aneurysm

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Question 2 - 16-year-old Girl with Primary Amenorrhea, Short Stature, Webbed Neck

• Growth hormone therapy (to increase final height)
• Estrogen replacement at puberty (induces secondary sex characteristics)
• Annual cardiac screening (risk of aortic dissection)
• Infertility - may need donor egg IVF

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Question 3 - 28-year-old Woman with Cyclic Pelvic Pain, Dyspareunia, Infertility

• Gold standard: Laparoscopy with direct visualization (and biopsy) - "powder burn" or "gun-shot" lesions
• Transvaginal ultrasound - can detect endometriomas ("chocolate cysts")
• CA-125 may be mildly elevated (not diagnostic)

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Q1 - Vaccine Given at Birth (EPI Pakistan)

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Q2 - Depression Screening Tool for Adolescents

• A validated 9-item self-report questionnaire adapted from the adult PHQ-9
• Screens for depression in adolescents aged 12-17
• Scores 0-27; score ≥10 suggests moderate depression
• Also screens for suicidal ideation (item 9)

• PHQ-9 - standard adult depression screening
• Edinburgh Postnatal Depression Scale (EPDS) - postnatal depression
• GMDS / Beck Depression Inventory - research settings

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Q3 - Age to Begin Cervical Cancer Screening (Pap Smear)

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Q4 - PSA Screening Age in Asymptomatic Men

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Q5 - Malar Rash + Joint Pain + Positive ANA

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Q6 - Type 2 DM with eGFR 35 - Drug to Avoid

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Q7 - 80-year-old on Multiple Medications with Acute Confusion

1. Full medication review - identify offending drugs (anticholinergics, benzodiazepines, opioids, steroids, antihistamines, digoxin)
2. Rule out medical causes - sepsis, UTI, hypoglycemia, electrolyte disturbance, hypoxia
3. Assess using CAM (Confusion Assessment Method) to confirm delirium
4. Non-pharmacological management - reorientation, lighting, familiar faces, avoid restraints

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Q8 - Most Specific Antibody for Rheumatoid Arthritis

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Q9 - Gold Standard Test for Cushing's Syndrome

• ACTH level - if suppressed: adrenal source; if elevated: pituitary or ectopic
• High-dose DST - distinguishes pituitary (Cushing's disease) from ectopic
• MRI pituitary / CT adrenal/chest

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Q10 - Tool to Assess Functional Status in Elderly

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Q11 - Hashimoto's Thyroiditis - Associated Antibody

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Q12 - Weight Gain, Cold Intolerance, Constipation, Bradycardia

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Q1 - 6-year-old with Recurrent Tonsillitis (7 episodes/year)

• Obstructive sleep apnoea due to tonsillar hypertrophy
• Peritonsillar abscess (recurrent)
• Suspected malignancy

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Q2 - Traveller with Fever, Rigors, Splenomegaly

1. Thick blood film - most sensitive, detects parasites
2. Thin blood film - identifies species (Plasmodium falciparum, vivax, ovale, malariae, knowlesi)
3. Rapid Diagnostic Test (RDT) - detects P. falciparum antigen (HRP-2); quick bedside test
4. If films negative but suspicion high - repeat every 12-24 hours x3

• P. falciparum is the most dangerous - causes cerebral malaria, blackwater fever
• Splenomegaly develops with repeated infections
• Never delay treatment while awaiting confirmation if P. falciparum is suspected
• Treatment: Artemisinin-based combination therapy (ACT) for uncomplicated falciparum; chloroquine for vivax/ovale (where sensitive)

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Q3 - Sexually Active Woman with Dysuria, Frequency, Positive Nitrites

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Q4 - Sudden Sensorineural Hearing Loss - Best Treatment

• Standard: Prednisolone 1mg/kg/day (max 60mg) for 7-10 days, then taper
• Mechanism: Reduces cochlear inflammation and immune-mediated damage
• Must be started urgently - ideally within 72 hours of onset; efficacy drops significantly after 2 weeks

• Intratympanic (transtympanic) steroids - injected directly into middle ear via tympanic membrane; used as salvage or primary therapy in diabetics/hypertensives

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Q5 - HIV PEP - Ideal Start Time

• PEP must be started within 72 hours - after this window, it is NOT effective
• Duration: 28 days of triple antiretroviral therapy
• Current preferred regimen: Tenofovir + Emtricitabine + Raltegravir (or dolutegravir)

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Q6 - Significant Bacteriuria on Urine Culture

• In symptomatic women, even 10²-10³ CFU/mL of E. coli or S. saprophyticus is significant
• Catheter specimen: ≥10³ CFU/mL is considered significant
• Asymptomatic bacteriuria does NOT require treatment except in pregnancy and pre-urological procedures

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Q7 - Silvery Scaly Plaques on Extensor Surfaces with Nail Pitting

• Well-demarcated erythematous plaques with silvery-white scale
• Extensor surfaces (elbows, knees), scalp, lower back, umbilicus
• Nail changes: pitting, onycholysis, subungual hyperkeratosis, oil drop sign
• Auspitz sign: pinpoint bleeding on removing scale (dilated dermal capillaries)
• Koebner phenomenon: lesions appear at sites of trauma

• Mild: Topical steroids, vitamin D analogues (calcipotriol)
• Moderate-severe: Methotrexate, cyclosporine, biologics (TNF-α inhibitors, IL-17/IL-23 inhibitors)

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Q8 - Tzanck Smear with Multinucleated Giant Cells

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Q9 - 2-year-old with Barking Cough, Stridor at Rest, Low-grade Fever

• Croup (viral) - gradual onset, barking cough, subglottic narrowing ("steeple sign" on X-ray)
• Epiglottitis (bacterial - H. influenzae b) - rapid onset, toxic child, "thumb sign" on X-ray, NO barking cough - do not examine throat

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Q10 - Unilateral Nasal Polyp with Bloody Discharge

1. Squamous cell carcinoma of the paranasal sinuses (most common sinonasal malignancy)
2. Inverted papilloma (benign but locally aggressive; 10% malignant transformation risk)
3. Nasopharyngeal carcinoma (EBV-associated; common in Southeast Asian populations)
4. Olfactory neuroblastoma (esthesioneuroblastoma)
5. Angiofibroma (in adolescent males - highly vascular, no biopsy without embolization)

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Q11 - Diabetic with Chest Pain, ST Elevation on ECG

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Q12 - Painless Genital Ulcer with Indurated Edge + Inguinal Lymphadenopathy

• Painless (key distinguishing feature)
• Indurated (hard, rolled edges)
• Clean base, non-purulent
• Unilateral or bilateral rubbery, non-tender inguinal lymphadenopathy
• Heals spontaneously in 3-6 weeks (even without treatment - disease progresses to secondary stage)

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SECTION A: CHILDHOOD IN FAMILY MEDICINE

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Q1 - Anatomical and Physiological Characteristics of Childhood and Their Importance in Family Medicine

Airway and Respiratory System

• Airway is shorter, narrower, and more compliant than adults
• The larynx is positioned higher (C3-4 vs C5-6 in adults) and the epiglottis is more U-shaped and floppy
• Trachea is softer and more easily compressed
• Chest wall is cartilaginous and compliant - intercostal retractions are more visible and clinically significant
• Clinical significance: Even minor swelling reduces airway diameter substantially (resistance = 1/r⁴); hence croup, epiglottitis, and foreign bodies are far more dangerous in children. Obligate nasal breathers in infancy (nasal obstruction = respiratory distress)

Cardiovascular System

• Heart rate is higher in infancy (normal neonatal HR 120-160 bpm) and decreases with age
• Blood pressure is lower; hypotension is a late and pre-terminal sign of shock in children
• Children compensate for volume loss with tachycardia and vasoconstriction for longer than adults
• Clinical significance: Tachycardia is the earliest sign of shock; by the time hypotension appears, the child is in decompensated shock

Renal System

• Neonatal kidneys have limited concentrating ability (max ~600 mOsm/kg vs 1200 in adults)
• GFR is low at birth and matures by 1-2 years
• Clinical significance: Children dehydrate faster; drug dosing is critical as renal clearance is age-dependent. Fluid and electrolyte balance requires careful monitoring

Immune System

• Physiological immunological immaturity in neonates and infants
• Maternal IgG transferred transplacentally (passive immunity) wanes by 3-6 months - creating the "immunological valley"
• Own IgG production begins but takes years to reach adult levels
• Clinical significance: Neonates and infants under 3 months are at highest risk from encapsulated bacteria (Strep pneumoniae, Hib, Neisseria meningitidis) - hence early vaccination is critical

Nervous System

• Brain grows rapidly: 25% of adult size at birth, 80% by age 2
• Myelination is incomplete until adolescence
• Blood-brain barrier is immature in neonates
• Clinical significance: Fever can cause febrile convulsions (6 months - 5 years); neurological damage from hypoxia/infection is more severe in early childhood; drug CNS toxicity is higher

Gastrointestinal System

• Gastric emptying is slower in infants; lower esophageal sphincter tone is reduced - explains physiological gastro-esophageal reflux
• Intestinal surface area relative to body weight is greater - higher absorption efficiency but also higher susceptibility to toxins
• Clinical significance: Diarrhea causes proportionally greater fluid loss; rotavirus dehydrates infants very rapidly

Growth and Development

• Rapid growth in infancy (birth weight doubles by 5 months, triples by 12 months)
• Growth charts (WHO/CDC) are essential screening tools in family medicine
• Critical periods: First 1000 days (conception to age 2) are the most important for brain and organ development

Importance in Family Medicine

1. Drug dosing must be weight-based (mg/kg)
2. Normal vital signs vary with age - family physicians must know age-appropriate ranges
3. Developmental milestones screening is a core preventive function
4. Children present differently to adults - fever, dehydration, and respiratory distress have unique signs

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Q2 - Common Infectious Diseases in Children: Prevention, Diagnosis, and Management

Vaccine-Preventable Diseases

Other Common Infections

• Neonates: Group B Strep, E. coli, Listeria
• Infants/children: Neisseria meningitidis, Strep. pneumoniae, Hib
• Features: Fever, neck stiffness, photophobia, bulging fontanelle (infants), non-blanching petechial rash (meningococcal)
• Diagnosis: LP (contraindicate if raised ICP), blood cultures
• Treatment: IV Ceftriaxone immediately; dexamethasone reduces neurological sequelae

• Cause: Strep. pneumoniae, Hib, Moraxella catarrhalis
• Features: Ear pain, fever, pulling at ear, bulging tympanic membrane
• Management: Watchful waiting first 48-72h (mild cases); amoxicillin if no improvement or severe

Prevention Principles in Family Medicine

1. Vaccination (primary prevention)
2. Hand hygiene and sanitation education
3. Breastfeeding - provides passive immunity via secretory IgA
4. Surveillance - report notifiable diseases (measles, pertussis, meningitis)
5. Contact tracing and chemoprophylaxis (e.g., rifampicin for meningococcal contacts)

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Q3 - Acute Respiratory Infections (ARIs) in Children

Classification (WHO/IMCI)

Common Conditions

• Age <2 years; RSV (Respiratory Syncytial Virus) most common cause
• Features: rhinorrhoea, wheeze, subcostal recessions, hyperinflation, fine crackles
• Diagnosis: clinical; CXR shows hyperinflation
• Treatment: supportive - nasal suctioning, oxygen if SpO₂ <92%, NG feeds if too breathless to feed; NO steroids, NO bronchodilators routinely (per evidence)

• Parainfluenza virus; ages 6 months - 3 years
• Barking cough, inspiratory stridor, hoarseness
• Treatment: single dose oral/IM dexamethasone (0.15-0.6mg/kg); nebulised adrenaline for moderate-severe

• Under 5: viral (RSV, influenza, parainfluenza) or bacterial (Strep. pneumoniae #1)
• School-age: Mycoplasma pneumoniae ("walking pneumonia") - patchy infiltrates, responds to macrolides
• Neonates: Group B Strep, E. coli
• Treatment:
  • <5 years: Amoxicillin (first choice for typical pneumonia)
  • School-age (atypical): Azithromycin/clarithromycin
  • Severe/hospital: IV Ampicillin + Gentamicin (neonates); Ceftriaxone (older children)

• Hib (though now rare due to vaccination)
• Rapidly progressive, toxic child, drooling, "tripod position," "hot potato voice"
• DO NOT examine throat - risk of complete obstruction
• Management: calm environment, ENT + anaesthesia, secured airway, IV ceftriaxone

Red Flags in ARIs (Refer/Admit)

• Age <3 months with fever
• SpO₂ <92%
• Central cyanosis
• Apnoeas
• Unable to drink/feed
• Severe chest indrawing or grunting
• Fast breathing at rest

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Q4 - Gastrointestinal Diseases in Childhood

Acute Gastroenteritis

• Most common cause of childhood diarrhea: Rotavirus (now vaccine-preventable)
• Other causes: Norovirus, E. coli (ETEC - traveller's diarrhoea), Salmonella, Campylobacter, Shigella, Giardia

• Continue breastfeeding throughout illness
• Zinc supplementation (10-20mg/day for 10-14 days) reduces severity and duration
• Antibiotics only for: Shigella (azithromycin), Vibrio cholerae (azithromycin), Giardia (metronidazole)
• NO anti-motility agents in children (loperamide is contraindicated)

Intussusception

• Telescoping of bowel (ileum into colon most common), peak age 6-24 months
• Features: Episodic colicky pain, drawing up of legs, "redcurrant jelly" stools, sausage-shaped abdominal mass (right side)
• Diagnosis: Ultrasound ("target sign"), AXR
• Treatment: Air/hydrostatic enema reduction (80-90% success); surgery if failed or peritonitis

Pyloric Stenosis

• Males 4:1, age 2-8 weeks, first-born males
• Projectile non-bilious vomiting; palpable olive-shaped mass in epigastrium
• Hypochloraemic, hypokalaemic metabolic alkalosis ("paradoxical aciduria")
• Diagnosis: Ultrasound (pylorus length >14mm, thickness >3mm)
• Treatment: Ramstedt's pyloromyotomy (surgical)

GERD in Infants

• Physiological until 12-18 months; pathological if causing failure to thrive, apnoeas, or oesophagitis
• Management: Positional advice, thickened feeds, alginate (Gaviscon); PPI/H2 blocker for complications

Role of Family Physician

1. First-contact assessment of dehydration severity
2. ORS counselling and initiation (Plan A/B)
3. Identify alarm features requiring referral (bloody stools, surgical abdomen, severe dehydration, failure to thrive)
4. Nutritional rehabilitation post-illness
5. Prevention education (hand hygiene, safe water, rotavirus vaccination)

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Q5 - Allergic and Atopic Conditions in Children

The Atopic March

Atopic Dermatitis (Eczema)

• Affects ~20% of children; most present before age 5
• Features: Pruritic, erythematous, scaly patches; face and extensor surfaces in infants; flexural surfaces in older children
• Diagnosis: Clinical (Hanifin & Rajka criteria: pruritis, typical morphology, chronic/relapsing course, personal/family atopy)
• Management:
  • Emollients (cornerstone - apply liberally and frequently)
  • Topical corticosteroids (mild potency for face/flexures; moderate-potent for body)
  • Topical calcineurin inhibitors (tacrolimus/pimecrolimus) for sensitive areas
  • Antihistamines for sleep disturbance
  • Dupilumab (IL-4/IL-13 inhibitor) for moderate-severe refractory cases

Childhood Asthma

• Most common chronic respiratory disease in children; affects ~10-15%
• Features: Recurrent wheeze, cough (especially nocturnal), breathlessness, triggered by exercise, URTIs, allergens
• Diagnosis: Clinical + spirometry (FEV1/FVC <0.70, reversibility with bronchodilator ≥12%)
• Stepwise management (BTS/SIGN):
  • Step 1: SABA (salbutamol) PRN
  • Step 2: Add low-dose ICS (beclomethasone/fluticasone)
  • Step 3: Add LABA (salmeterol) - not as monotherapy in children
  • Step 4: Increase ICS dose / add leukotriene receptor antagonist (montelukast)
  • Step 5: Specialist referral, biologics (omalizumab for allergic asthma)

Allergic Rhinitis

• Seasonal (hay fever - tree/grass pollen) or perennial (house dust mite, pet dander)
• Features: Sneezing, rhinorrhoea, nasal itching, nasal congestion, "allergic salute," "allergic shiners"
• Management: Intranasal corticosteroids (first-line), non-sedating antihistamines, allergen avoidance, immunotherapy

Food Allergy

• IgE-mediated (immediate - within 2h): peanut, tree nut, milk, egg, fish, shellfish
• Non-IgE-mediated: delayed reactions, eosinophilic oesophagitis, FPIES
• Diagnosis: Skin prick test, specific IgE, oral food challenge (gold standard)
• Management: Strict avoidance + adrenaline auto-injector (EpiPen) prescription for those at risk of anaphylaxis

Prevention

• Primary: Breastfeeding for ≥4-6 months; avoid tobacco smoke exposure
• Secondary: Early introduction of allergenic foods (peanut by 4-6 months in high-risk infants - per LEAP trial)
• Emollient use from birth may reduce eczema risk (ongoing evidence)

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Q6 - Childhood Immunization Schedules and Importance of Vaccination

Why Vaccination is Vital

1. Prevents infection before natural exposure
2. Provides herd immunity - protects unvaccinated individuals when coverage ≥85-95%
3. Has eradicated smallpox (1980) and nearly eliminated polio
4. Cost-effective: prevention far cheaper than treatment
5. Reduces antibiotic use, thereby limiting antimicrobial resistance

WHO Recommended Vaccines (Universal)

• BCG, Hepatitis B, OPV/IPV, DTwP/DTaP, Hib, Pneumococcal (PCV), Rotavirus, MMR, Varicella

Pakistan EPI Schedule (2024)

Contraindications to Note

• Live vaccines (MMR, BCG, OPV, Varicella) contraindicated in immunocompromised children, pregnancy
• Anaphylaxis to previous dose = contraindication to repeating
• Minor illness with low-grade fever is NOT a contraindication (common misconception)

Cold Chain

• Vaccines must be stored at +2°C to +8°C (except OPV/Varicella which need -15 to -25°C)
• Cold chain failures cause vaccine wastage and reduced efficacy

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Q7 - National Vaccination Schedule and Role of Family Medicine

Role of Family Physician in Immunization

1. Education - address vaccine hesitancy; counsel parents about safety and importance
2. Opportunistic vaccination - check and update vaccine status at every visit
3. Catch-up schedules - manage partially vaccinated or unvaccinated children
4. Cold chain maintenance - ensure vaccines are stored and handled properly in clinic
5. Adverse event monitoring - identify and report post-vaccination reactions (AEFI - Adverse Events Following Immunization)
6. Surveillance - report vaccine-preventable disease outbreaks to public health authorities
7. High-risk groups - identify children needing additional vaccines (e.g., pneumococcal, influenza for immunocompromised, asplenic, or those with chronic illness)

Common Barriers to Vaccination (Family Medicine Context)

• Vaccine hesitancy / religious/cultural objections
• Poor access (geographical, financial)
• Missed opportunities at clinic visits
• Cold chain failures
• Family physician's role: Address each barrier at the individual and community level

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Q8 - Dispensary Observation and Preventive Care in Family Medicine

Well-Child Visits (Preventive Care Schedule)

Components of Each Visit (HEADSS adapted for children)

1. Growth monitoring - weight, height, head circumference plotted on WHO growth charts
2. Developmental assessment - gross motor, fine motor, language, social milestones
3. Nutritional assessment - breastfeeding, complementary feeding, micronutrient deficiencies (iron, Vitamin D, iodine)
4. Vision and hearing screening
5. Immunization review and administration
6. Parental education - injury prevention, car seats, sleep safety (SIDS prevention), sun safety, dental care
7. Psychosocial assessment - maternal depression screening, domestic environment

Growth Faltering (Failure to Thrive)

• Weight below 3rd centile or crossing 2 major centile lines downward
• Causes: Inadequate intake, malabsorption, increased requirements, psychosocial
• Management: Nutritional rehabilitation, address underlying cause, community nutrition programs

IMCI (Integrated Management of Childhood Illness)

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SECTION B: ADOLESCENCE

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Q9 - Physiological Features of Adolescence and Clinical Significance

Somatic Growth

• Pubertal growth spurt: Girls peak at 11-12 years (~8 cm/year); Boys peak at 13-14 years (~9-10 cm/year)
• Peak bone mass is achieved during adolescence - calcium and Vitamin D intake is critical
• Clinical significance: Scoliosis, slipped capital femoral epiphysis, Osgood-Schlatter disease all manifest during rapid growth

Nutritional Changes

• Greatly increased caloric and protein requirements
• Iron deficiency anaemia is common - particularly in girls after menarche
• Eating disorders (anorexia, bulimia) emerge in adolescence
• Obesity risk increases with sedentary lifestyles and calorie-dense diets

Cardiovascular and Respiratory

• Lung volumes, cardiac output, and VO₂ max all increase
• Boys develop larger lung volumes and greater muscle mass post-puberty
• BP gradually rises to adult levels

Sleep Physiology

• Circadian rhythm shifts in adolescence (delayed sleep phase) - biological tendency to sleep later
• Clinical significance: Chronic sleep deprivation impairs cognition, mood, and academic performance; family physicians should counsel families

Clinical Significance in Family Medicine

• First visit alone with adolescent (confidentiality) is a key family medicine principle
• HEADSS assessment framework: Home, Education, Activities, Drugs, Sex, Suicide/Depression
• Non-judgmental communication is essential to build trust

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Q10 - Hormonal and Endocrine Changes During Puberty

Initiation of Puberty

1. Hypothalamus releases GnRH (Gonadotropin-Releasing Hormone) in pulsatile bursts
2. Anterior pituitary secretes LH and FSH
3. Gonads produce sex steroids (testosterone in males, oestradiol in females)

Adrenarche

• Precedes gonadal puberty by 2 years
• Adrenal glands secrete DHEA and DHEAS (androgens)
• Causes: axillary/pubic hair, body odour, mild acne

Female Puberty (Average sequence: BREAST-ADRENAL-GROWTH-MENSTRUATION)

• Thelarche (breast budding): first sign, ~age 8-13
• Pubic hair, axillary hair
• Growth spurt
• Menarche (first menstruation): ~2-3 years after thelarche, mean age 12.7 years
• Oestradiol drives breast development, uterine growth, body fat distribution

Male Puberty (Average sequence: TESTICULAR-PUBIC HAIR-GROWTH-VOICE)

• Testicular enlargement (>4ml Prader orchidometer): first sign, ~age 9-14
• Pubic/axillary/facial hair
• Testosterone drives muscle mass, penile growth, voice deepening, spermatogenesis
• Growth spurt (later than girls)
• Spermarche (first ejaculation): ~age 13

Tanner Staging (important for viva)

• Stage I: Prepubertal
• Stage II: First signs of puberty
• Stage III-IV: Progressive development
• Stage V: Adult

Disorders to Know

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Q11 - Psycho-emotional and Behavioral Disorders in Adolescents and Management

Normal Adolescent Psychology

• Identity formation (Erikson's stage: Identity vs Role Confusion)
• Increased risk-taking behaviour (brain prefrontal cortex matures last)
• Peer influence supersedes parental influence
• Abstract thinking develops (Piaget's formal operational stage)

Common Disorders

• Prevalence ~5-15% in adolescents; often underdiagnosed
• Features: Persistent sadness, anhedonia, sleep changes, academic decline, social withdrawal, irritability (more prominent in adolescents than adults)
• Screening: PHQ-A (validated for adolescents)
• Management: CBT (cognitive behavioural therapy) - first-line for mild-moderate; fluoxetine (only SSRI approved for adolescent depression) for moderate-severe; combined therapy is most effective

• Generalised anxiety, social anxiety, separation anxiety, school refusal
• CBT is first-line; SSRIs for moderate-severe

• Inattention, hyperactivity, impulsivity - present in >2 settings, before age 12
• Management: Behaviour therapy first (<6yr); methylphenidate (stimulant) for ≥6 years; lisdexamfetamine is alternative
• Family physician role: initial assessment, referral to paediatric psychiatry, ongoing monitoring

• Anorexia nervosa: BMI <17.5, fear of weight gain, distorted body image; highest mortality of any psychiatric disorder
• Bulimia nervosa: Binge-purge cycles, normal weight, electrolyte disturbances (hypokalaemia, metabolic alkalosis)
• Management: multidisciplinary (physician, dietitian, psychiatrist); family-based therapy (Maudsley approach) is first-line for adolescent anorexia

• Alcohol, cannabis, tobacco, vaping increasingly common
• CRAFFT screening tool (Car, Relax, Alone, Forget, Friends, Trouble) used in adolescents
• Brief motivational interviewing by family physician

• Always ask directly: "Are you having thoughts of harming yourself?"
• Risk factors: depression, previous attempts, substance use, LGBTQ+ identity, abuse, family history
• Immediate safety plan; refer to mental health services; involve parents (with patient's consent where possible)

Family Physician's Role

• Confidentiality (essential for honest disclosure)
• Annual HEADSS assessment
• Non-judgmental, youth-friendly consultation style
• Coordinate with school, parents, and mental health services

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Q12 - Musculoskeletal Disorders Commonly Encountered in Adolescence

Idiopathic Scoliosis

• Lateral curvature of spine >10° (Cobb angle), most common in girls aged 10-16
• Usually detected on school screening or incidentally
• Adam's forward bend test: asymmetric rib hump on bending forward
• Diagnosis: standing AP spine X-ray; measure Cobb angle
• Management:
  • <25°: Observe every 6 months
  • 25-40°: Bracing (Milwaukee/Boston brace) if still growing

  • 40°-50°: Surgical correction (spinal fusion)

• Family physician role: Screen at well-child visits; refer if curve >20° or progressing

Osgood-Schlatter Disease

• Traction apophysitis at tibial tuberosity; boys 12-15, girls 8-12
• Cause: rapid bone growth + repetitive quadriceps stress during sports
• Features: pain and swelling over tibial tuberosity, worsened by running/jumping/kneeling
• X-ray: fragmentation of tibial tuberosity apophysis
• Management: self-limiting (resolves when growth plates close); activity modification, NSAIDs, physiotherapy, patellar tendon strap

Slipped Capital Femoral Epiphysis (SCFE)

• Posterior/medial displacement of femoral head epiphysis through growth plate
• Obese adolescent boys, ages 12-16
• Features: hip/groin pain, limp, obligate external rotation of hip, leg shortening
• X-ray: "ice cream slipping off cone" appearance; Klein's line does not transect femoral head
• Management: Surgical emergency - in situ pinning to prevent avascular necrosis

Patellofemoral Pain Syndrome (Anterior Knee Pain)

• Most common knee complaint in adolescents, especially girls
• Aching pain behind/around patella, worsened by stairs, squatting, prolonged sitting ("theatre sign")
• Cause: malalignment, quadriceps weakness, overuse
• Management: Physiotherapy (VMO strengthening), activity modification, orthotics

Scheuermann's Disease (Juvenile Kyphosis)

• Structural kyphosis due to anterior wedging of ≥3 consecutive vertebrae (>5° each)
• Thoracic or thoracolumbar; adolescent boys
• Features: rigid thoracic kyphosis ("round back"), back pain
• Distinguished from postural kyphosis (which corrects on extension)
• Management: physiotherapy, bracing, surgery if severe (>75°)

Stress Fractures

• Common in adolescent athletes, especially runners and gymnasts
• Tibia (most common), metatarsals (march fracture), femoral neck
• MRI is most sensitive (plain X-ray often normal initially)
• Management: relative rest, address underlying cause (e.g., female athlete triad: disordered eating + amenorrhea + osteoporosis)

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SECTION A: ADOLESCENT HEALTH (continued)

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Q1 - Nutritional Disorders in Adolescents and Preventive Strategies

Why Adolescents are Nutritionally Vulnerable

• Rapid growth increases demand for all macronutrients and micronutrients
• Changing social patterns: eating outside home, skipping meals, peer influence
• Body image concerns drive disordered eating
• Increased physical activity in some, sedentary behaviour in others
• Cognitive immaturity leads to poor long-term food choices

Key Nutritional Disorders

• Most common nutritional deficiency in adolescents worldwide
• Especially girls after menarche (monthly blood loss) and athletes
• Features: fatigue, pallor, reduced exercise tolerance, impaired cognition
• Prevention: dietary iron (red meat, green leafy vegetables, legumes), Vitamin C to enhance absorption; iron supplementation in high-risk groups
• Treatment: ferrous sulphate 200mg TDS for 3 months + dietary counselling

• Prevalence rising globally; associated with sedentary lifestyle, ultra-processed food
• Consequences: type 2 diabetes, hypertension, dyslipidaemia, PCOS, sleep apnoea, psychological issues (stigma, depression)
• Assessment: BMI-for-age (>85th centile = overweight; >95th = obese)
• Prevention: 5-2-1-0 rule (5 fruits/veg daily, <2 hours screen time, 1 hour physical activity, 0 sugary drinks)
• Management: lifestyle modification (diet + exercise), family-based behavioural therapy; pharmacotherapy (orlistat ≥12yr) rarely; bariatric surgery in severe cases in adolescents

• Critical during adolescent bone mass accrual (90% of peak bone mass achieved by age 18)
• Deficiency leads to rickets in younger adolescents, stress fractures, increased osteoporosis risk later
• Requirements: Calcium 1300mg/day; Vitamin D 600 IU/day
• Prevention: dairy products, fortified foods, sunlight exposure, supplements in high-risk groups

• Iodine deficiency - cognitive impairment, goitre (address via iodised salt)
• Zinc deficiency - growth retardation, delayed puberty
• Folate - especially important for adolescent girls who may become pregnant

Preventive Strategies

1. Nutrition education in schools (life skills curriculum)
2. Restrict junk food/sugary drinks in school canteens
3. Screening at well-adolescent visits (BMI, pallor, menstrual history)
4. Family physician-led dietary counselling using MyPlate/balanced diet principles
5. National nutrition programmes (school feeding programmes, iron-folate supplementation)
6. Media literacy - challenge unrealistic body image standards

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Q2 - Prevention of Harmful Habits Among Adolescents

Common Harmful Habits

• Nicotine addiction develops rapidly in adolescents (neurologically vulnerable)
• Risk factors: peer influence, parental smoking, stress, low socioeconomic status
• Consequences: addiction, chronic respiratory disease, cancer, cardiovascular disease
• Prevention: school-based programmes, raise legal age, ban flavoured e-cigarettes, physician brief counselling (5 As: Ask, Advise, Assess, Assist, Arrange)

• Brain development continues until age 25 - alcohol is particularly damaging in adolescents
• Consequences: impaired cognition, risky behaviour, accidents, addiction
• Screening: CRAFFT tool (Car, Relax, Alone, Forget, Friends, Trouble) - score ≥2 = high risk
• Prevention: delayed onset, parental monitoring, school education, counselling

• Cannabis use linked to psychosis, amotivational syndrome, and poor academic outcomes in adolescents
• Prescription drug misuse (opioids, benzodiazepines) increasing
• Prevention: awareness campaigns, peer support programmes, accessible mental health services

• WHO recommendation: <2 hours recreational screen time/day for adolescents
• Consequences: sleep disruption, social isolation, depression, cyberbullying
• Prevention: digital detox strategies, parental controls, balanced screen use education

• Consequences: STIs, unintended pregnancy
• Prevention: comprehensive sex education (abstinence + contraception), HPV vaccination, condom availability, confidential access to sexual health services

• Physical and cyberbullying affect mental health profoundly
• Prevention: school anti-bullying policies, social-emotional learning programmes

Family Physician's Preventive Role

• Incorporate HEADSS (Home, Education, Activities, Drugs, Sex, Suicide) at every adolescent visit
• Provide brief motivational interviewing for substance use
• Maintain confidentiality to encourage disclosure
• Involve parents constructively without breaching trust
• Refer to adolescent mental health services as needed

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Q3 - Promoting a Healthy Lifestyle in Adolescence

Key Domains of Healthy Lifestyle

• WHO recommendation: ≥60 minutes of moderate-to-vigorous activity daily for adolescents
• Benefits: healthy weight, bone density, cardiovascular fitness, improved mood and cognition, reduced depression
• Strategies: school physical education, sports participation, active transport (walking/cycling), family activity

• Balanced diet: carbohydrates (50%), protein (15-20%), healthy fats (30%)
• 5+ portions of fruit and vegetables daily
• Limit: added sugars, saturated fats, ultra-processed foods, sugary beverages
• Adequate iron, calcium, Vitamin D (see Q1)

• Adolescents need 8-10 hours/night
• Delayed circadian phase is physiological - school start times should ideally be later
• Strategies: consistent sleep schedule, no screens 1 hour before bed, dark/cool bedroom

• Stress management skills: mindfulness, relaxation techniques
• Strong social connections and peer relationships
• Reduce academic pressure and promote growth mindset
• Access to school counsellors and mental health services

• Age-appropriate, comprehensive sex education
• HPV vaccination at 11-12 years (before sexual debut)
• Access to confidential contraceptive counselling

• Brushing twice daily, flossing, limit sugary snacks/drinks
• Regular dental check-ups

• Sunscreen use, avoid tanning beds
• Skin cancer prevention begins in adolescence

Framework in Family Medicine

1. Counsel - non-judgmental lifestyle advice
2. Connect - link to community resources (sports clubs, mental health)
3. Collaborate - with schools, parents, peers
4. Champion - advocate for healthy school environments
5. Continue - follow-up and ongoing relationship

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Q4 - Role of the Family Physician in Adolescent Health Care

Unique Aspects of Adolescent Care

• Adolescents are the most underserved age group in healthcare - they are healthy enough not to need frequent GP visits yet have significant health risks
• They are less likely to seek care voluntarily
• Confidentiality, trust, and non-judgmental attitudes are essential

Core Functions

• Annual well-adolescent check using HEADSS framework
• Screening for depression (PHQ-A), substance use (CRAFFT), eating disorders, vision, hearing, BP
• Vaccination completion (MMR, HPV, Tdap, meningococcal, COVID-19)
• Growth and development monitoring

• Manage common adolescent conditions: acne, menstrual disorders, sports injuries, musculoskeletal pain, STIs
• Initial assessment of mental health disorders; prescribe SSRIs if appropriate; refer when needed
• Manage chronic diseases (asthma, diabetes, epilepsy) through adolescent transition from paediatric to adult care

• Moving young people with chronic illness from paediatric to adult services ("transition")
• Should begin at ~14 years; focus on self-management skills, understanding their condition

• See the adolescent alone for part of the consultation
• Explain confidentiality and its limits (serious harm to self/others)
• This is the single most important enabler of honest communication

• Contraceptive counselling, STI testing and treatment, pregnancy testing
• HPV vaccination, cervical screening information

• First-contact mental health care: depression, anxiety, eating disorders, self-harm
• Brief interventions, signposting, referral

• Advocate at system level for adolescent-friendly health services
• School-based health clinics, extended hours, non-judgmental reception staff

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SECTION B: FEMALE REPRODUCTIVE HEALTH

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Q5 - Anatomy and Physiology of the Female Reproductive System

Anatomy

• Mons pubis, labia majora/minora, clitoris, vestibule, Bartholin's glands (lubrication)
• Perineal body: fibromuscular structure between vagina and anus; important in childbirth

• 8-10cm fibromuscular canal; pH 3.8-4.5 (maintained by Lactobacilli)
• No glands - lubricated by transudate + Bartholin's glands
• Relations: anteriorly bladder/urethra; posteriorly rectum/pouch of Douglas

• Pear-shaped, 8cm long, 60g; position: anteverted, anteflexed (normal)
• Layers: perimetrium (peritoneum), myometrium (smooth muscle - contractions), endometrium (responsive to hormones)
• Blood supply: uterine artery (branch of internal iliac); anastomoses with ovarian artery
• Supports: uterosacral ligaments (most important), round ligaments, cardinal (Mackenrodt's) ligaments, pubocervical ligaments

• 10-12cm; four parts: interstitial, isthmus, ampulla (site of fertilisation), infundibulum (fimbriae)
• Lined with ciliated columnar epithelium - cilia beat toward uterus

• 3x2x1cm; dual function: oogenesis + endocrine (oestrogen, progesterone, inhibin)
• Blood supply: ovarian arteries (direct from aorta at L2)
• Lymphatics drain to para-aortic nodes (important in ovarian cancer spread)

• 2.5-3cm; external os (parous vs nulliparous); squamocolumnar junction (transformation zone) - site of cervical dysplasia and cancer
• Endocervical glands produce mucus (changes with menstrual cycle and pregnancy)

Physiology - The Normal Menstrual Cycle

• Rising oestrogen → positive feedback on LH → LH surge → ovulation
• Progesterone in luteal phase → negative feedback on FSH/LH
• BBT (basal body temperature) rises 0.2-0.5°C after ovulation (progesterone effect)

Clinical Relevance in Family Medicine

• Hormonal changes explain cyclical symptoms (premenstrual syndrome, menstrual migraine)
• Understanding the cycle is essential for contraceptive counselling and fertility advice
• Atrophic changes post-menopause (oestrogen withdrawal) cause vaginal dryness, urinary symptoms, bone loss

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Q6 - Menstrual Cycle Disorders

Normal Menstrual Parameters

• Cycle length: 21-35 days
• Duration: 3-7 days
• Volume: 20-80ml
• Character: regular, without severe pain

Classification of Disorders

• PALM (structural): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia
• COEIN (non-structural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified

• Primary: No pelvic pathology; prostaglandin-mediated uterine cramping; starts 1-2 days before flow; peaks day 1-2
  • Treatment: NSAIDs (first-line - inhibit prostaglandin synthesis); COCP; heat pads
• Secondary: Underlying pathology (endometriosis, fibroids, adenomyosis, PID)
  • Treatment: treat underlying cause

• 80ml/cycle; clinically defined as heavy periods that interfere with quality of life

• Causes: fibroids (most common structural cause), adenomyosis, coagulopathy (von Willebrand disease), PCOS, hypothyroidism, IUCD
• Investigation: FBC (anaemia), TFTs, clotting screen, pelvic USS, endometrial sampling if >45yr or risk factors
• Management:
  • Medical: Levonorgestrel-releasing IUS (Mirena - most effective medical treatment), tranexamic acid, NSAIDs, COCP
  • Surgical: endometrial ablation, hysterectomy (definitive)

• Physical and psychological symptoms in luteal phase, resolving with menstruation
• PMDD (Premenstrual Dysphoric Disorder) = severe form with prominent mood symptoms
• Management: lifestyle (exercise, diet), SSRIs (continuous or luteal phase), COCP, GnRH agonists (severe)

• Rotterdam criteria (2 of 3): oligo/anovulation, clinical/biochemical hyperandrogenism, polycystic ovaries on USS
• Features: irregular periods, hirsutism, acne, obesity, infertility, insulin resistance
• Management: lifestyle modification (weight loss restores ovulation in obese PCOS), COCP (regulates cycle, anti-androgenic), metformin (insulin resistance), clomiphene/letrozole (ovulation induction for fertility)

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Q7 - Inflammatory Diseases of the Pelvic Organs

Pelvic Inflammatory Disease (PID)

• Primary: Neisseria gonorrhoeae, Chlamydia trachomatis (most common STI causes)
• Secondary/polymicrobial: anaerobes, E. coli, Gardnerella vaginalis (associated with bacterial vaginosis)

• Uterine tenderness, OR
• Adnexal tenderness, OR
• Cervical motion tenderness ("chandelier sign")
• (in a sexually active woman with no other explanation)

• Surgical emergency cannot be excluded
• Tubo-ovarian abscess
• Pregnancy
• Severe illness (high fever, vomiting)
• Failed oral treatment

• Fitz-Hugh-Curtis syndrome - perihepatitis (right upper quadrant pain, violin-string adhesions)
• Fertility loss - tubal factor infertility (one episode PID = 12% risk; three episodes = 54%)
• Future ectopic pregnancy - 6-10-fold increased risk due to tubal scarring

Other Pelvic Infections

• Obstruction/infection of Bartholin's gland duct; fluctuant painful swelling at 4 or 8 o'clock position on vulva
• Causative organisms: E. coli, Staphylococcus, Gonorrhoea (less common)
• Treatment: Word catheter insertion (marsupialisation); antibiotics if cellulitis present

• Candida albicans; risk factors: antibiotics, diabetes, immunosuppression, pregnancy
• Features: thick white "cottage cheese" discharge, intense vulval pruritus, dyspareunia, no odour
• Treatment: Clotrimazole 500mg pessary single dose, or Fluconazole 150mg PO single dose

• Overgrowth of anaerobes; not an STI but sexually associated
• Features: thin grey-white discharge, fishy odour (amine test positive), no vulval inflammation
• Diagnosis: Amsel criteria (3 of 4): thin discharge, pH >4.5, clue cells on wet mount, positive whiff test
• Treatment: Metronidazole 400mg BD x 5-7 days or 2g single dose

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Q8 - Modern Methods of Contraception

WHO Medical Eligibility Criteria (MEC) Categories

• Category 1: No restriction (method can be used)
• Category 2: Advantages outweigh risks
• Category 3: Risks outweigh advantages
• Category 4: Absolute contraindication (do not use)

Combined Oral Contraceptive Pill (COCP)

• Contains oestrogen (ethinylestradiol) + progestogen
• Mechanism: inhibit ovulation (primary), thicken cervical mucus, thin endometrium
• Efficacy: 99.7% with perfect use
• Benefits: regulates cycle, reduces dysmenorrhoea, treats acne, protects against ovarian/endometrial cancer
• Absolute contraindications (WHO 4): History of VTE/DVT, ischaemic heart disease, stroke, migraine with aura, breast cancer, severe liver disease, hypertension >160/100, age >35 + smoking

Progestogen-Only Pill (POP / Mini-pill)

• Contains progestogen only; mechanism: thickens cervical mucus (mainly), may inhibit ovulation
• Advantages: safe in breastfeeding, cardiovascular disease, hypertension, migraine with aura
• Desogestrel POP has 12-hour window (traditional POP = 3-hour window)
• Side effect: irregular bleeding

Intrauterine Devices (IUD)

Long-Acting Reversible Contraception (LARC) - Gold Standard

• Subdermal rod containing etonogestrel; lasts 3 years
• Efficacy: >99.9% - most effective method available
• Suitable for all ages including adolescents

• 150mg medroxyprogesterone IM every 12 weeks
• Amenorrhoea in 70% by 1 year
• Return to fertility delayed 6-12 months after last injection - counsel accordingly

Barrier Methods

• Male condom: 98% (perfect use), 85% (typical use); only method that also prevents STIs
• Female condom: 95% (perfect use)
• Diaphragm/cervical cap: used with spermicide; less effective; requires fitting

Emergency Contraception

1. Levonorgestrel (Plan B) - within 72 hours; 85% effective
2. Ulipristal acetate (ellaOne) - within 120 hours; more effective (98%)
3. Copper IUD - within 120 hours; >99% effective; can be left in situ as ongoing contraception

Permanent Methods

• Female sterilisation (tubal ligation): bilateral occlusion of fallopian tubes; effective immediately
• Vasectomy: simpler, safer, and more effective than female sterilisation; not immediately effective (needs semen analysis at 8-12 weeks)

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Q9 - Family Planning Services by Family Physicians

Core Services Provided

• Full contraceptive counselling: explain all methods, efficacy, side effects, how to use
• Respect patient autonomy and reproductive intentions
• Address myths and misconceptions (especially in conservative populations)
• Confidential services for unmarried and adolescent women

• Prescribe COCP, POP, DMPA injectables
• Fit and remove subdermal implants (after training)
• Insert and remove IUD/IUS (after training)

• Folic acid 400mcg daily starting 3 months before conception (reduces neural tube defects)
• Optimise chronic conditions (diabetes, epilepsy, hypertension) before pregnancy
• Rubella immunity check and vaccination if needed
• Smoking cessation, alcohol cessation

• Natural Family Planning (NFP): symptothermal method (BBT + cervical mucus)
• Less reliable (91% typical use) but acceptable to some on religious grounds
• Important to teach correctly and acknowledge failure rate

• Lactational Amenorrhoea Method (LAM): >98% effective if fully breastfeeding, amenorrhoeic, and <6 months postpartum - all three criteria must be met
• DMPA: can start immediately postpartum (breastfeeding safe)
• IUS: insert at 6 weeks postpartum
• COCP: delay until 6 weeks postpartum if breastfeeding (oestrogen reduces milk supply)

• Confirm pregnancy, counsel options (continue/adoption/termination)
• Refer to appropriate services; maintain non-judgmental approach

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Q10 - Outpatient Management of Pregnancy in Family Medicine

Antenatal Care Schedule (WHO 2016 - 8+ contacts)

Booking Blood Tests

• FBC, blood group and Rh factor, rubella immunity, syphilis serology, HIV, HBsAg, urine culture, urine protein, thyroid (if symptomatic)

Supplementation

• Folic acid 400mcg/day - until 12 weeks (reduces NTDs); 5mg/day if high risk (previous NTD, anticonvulsants, diabetes)
• Vitamin D 10mcg (400 IU)/day - throughout pregnancy
• Iron - only if anaemic (Hb <10.5g/dL in pregnancy); routine supplementation in iron-deficient populations (Pakistan)

Common Problems Managed in Outpatient Setting

• Nausea/vomiting: lifestyle (small frequent meals, ginger, vitamin B6), ondansetron if severe
• Constipation: fibre, hydration, lactulose
• Heartburn: Gaviscon, omeprazole if refractory
• Anaemia: iron supplementation
• Hypertension in pregnancy: monitor closely; labetalol/nifedipine if treatment required
• Gestational diabetes (GDM): dietary modification first; metformin; insulin if targets not met

Red Flags (Refer/Admit)

• Severe headache or visual disturbance (pre-eclampsia)
• Epigastric pain (HELLP syndrome)
• Reduced fetal movements
• PV bleeding
• Signs of DVT/PE
• Fever with rigors
• Severe vomiting (hyperemesis gravidarum)

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Q11 - Preventive Measures for Oncological Diseases of the Female Reproductive System

Cervical Cancer

• Cause: HPV (types 16 and 18 cause 70% of cervical cancers)
• Primary prevention: HPV vaccination (see Q12)
• Secondary prevention: Cervical screening (Pap smear, HPV testing)
• Tertiary prevention: Early treatment of CIN (cervical intraepithelial neoplasia) with LLETZ/cryotherapy before invasive cancer develops

Endometrial (Uterine) Cancer

• Most common gynaecological cancer in developed countries
• Risk factors: Oestrogen excess (obesity, PCOS, nulliparity, HRT without progestogen, late menopause, early menarche), tamoxifen, Lynch syndrome (hereditary)
• Protective factors: COCP, multiparity, progestogen-containing HRT, breastfeeding
• Screening: No routine population screening; present with postmenopausal bleeding - any PMB requires endometrial assessment (USS + biopsy)
• Prevention: Weight management (most important modifiable factor), COCP, management of PCOS

Ovarian Cancer

• "Silent killer" - presents late (most at Stage III/IV); 5th most common cancer in women
• Risk factors: Nulliparity, BRCA1/2 mutation (lifetime risk 40-60%), Lynch syndrome, HRT, endometriosis
• Protective factors: COCP (50% reduction in risk with ≥5 years use), multiparity, breastfeeding, tubal ligation
• Screening: No proven effective population screening; CA-125 + transvaginal USS not specific enough for mass screening
• High-risk strategy: BRCA1/2 testing for high-risk families; risk-reducing salpingo-oophorectomy at 35-40 years for BRCA carriers after completed family

Vulval and Vaginal Cancers

• Rare; associated with HPV, VIN (vulval intraepithelial neoplasia), lichen sclerosus
• Prevention: HPV vaccination, regular examination in women with known VIN/LS

General Preventive Strategies (Family Medicine)

1. HPV vaccination for all girls and boys aged 11-12 years
2. Smoking cessation counselling (smoking is an independent risk factor for cervical, vulval, and endometrial cancer)
3. Obesity management (reduces endometrial and possibly ovarian cancer risk)
4. Family history assessment - BRCA/Lynch syndrome referral for genetic testing
5. Opportunistic screening at every consultation - any postmenopausal bleeding must be investigated

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Q12 - Cervical Cancer Screening and Prevention Strategies

Epidemiology

• 4th most common cancer in women worldwide; #1 gynaecological cancer in low-income countries
• Virtually entirely preventable through vaccination + screening
• HPV types 16 and 18 account for ~70%; types 31, 33, 45, 52, 58 account for another 15%

Primary Prevention - HPV Vaccination

• Most effective before sexual debut (EPI schedule at 11-12 years in Pakistan, school-based)
• Also recommended for males (protects against HPV-related penile, anal, oropharyngeal cancers)
• Catch-up vaccination up to age 26; shared decision-making 27-45 years

Secondary Prevention - Cervical Screening

• Cells sampled from transformation zone (squamocolumnar junction)
• Technique: liquid-based cytology (LBC) now preferred over conventional smear
• Start age: 21 years (or 1 year after sexual debut, whichever comes first - in some guidelines)
• Frequency: every 3 years (cytology alone); every 5 years (HPV co-test)

• Many countries now use HPV testing as primary screen (more sensitive than cytology)
• HPV negative = reassurance; HPV positive + abnormal cytology = colposcopy

• Magnified examination of cervix with acetic acid (white areas = acetowhite = CIN) and Lugol's iodine (non-staining = abnormal)
• Biopsy taken for histological confirmation

• CIN 1: Surveillance (most regress); treatment if persistent >2 years
• CIN 2-3: LLETZ (loop diathermy excision) - removes transformation zone; cure rate >95%
• Cryotherapy, laser ablation: alternatives in low-resource settings

Tertiary Prevention

• Early-stage cervical cancer (Stage IA1): cone biopsy or simple hysterectomy
• Stage IA2-IIA: radical hysterectomy + pelvic lymph node dissection
• Stage IIB+: Chemoradiotherapy (cisplatin + radiotherapy)

Role of Family Physician in Cervical Cancer Prevention

1. Opportunistic invitation to unscreened women at every consultation
2. HPV vaccination at routine adolescent visits
3. Colposcopy referral for abnormal smears
4. Education about symptoms (postcoital bleeding, intermenstrual bleeding) warranting investigation
5. Follow-up after treatment, ensuring compliance with surveillance
6. Special populations: HIV-positive women need more frequent screening; immunosuppressed women are at higher risk

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SECTION A: MALE REPRODUCTIVE HEALTH

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Q1 - Anatomy and Physiology of the Male Reproductive System

Anatomy

• Paired ovoid organs in the scrotum; ~4x3x2cm; 15-25ml volume
• Descended by 28-32 weeks gestation; cryptorchidism if undescended
• Surrounded by tunica albuginea; divided into ~250 lobules, each containing seminiferous tubules
• Dual function:
  • Spermatogenesis (seminiferous tubules - Sertoli cells support sperm development)
  • Endocrine (Leydig/interstitial cells produce testosterone)
• Blood supply: testicular arteries (from aorta at L2); venous drainage via pampiniform plexus → testicular veins (right = IVC; left = left renal vein - explains why left varicocele is more common)
• Lymphatics: para-aortic nodes (NOT inguinal - important in testicular cancer staging)

• Coiled tubule (~6m uncoiled) on posterior surface of testis
• Head (caput) receives efferent ductules; body (corpus); tail (cauda) connects to vas deferens
• Functions: sperm maturation (transit takes 12-21 days) and storage; sperm acquire motility here

• 30-45cm muscular tube; travels in spermatic cord through inguinal canal into pelvis
• Joins seminal vesicle duct to form ejaculatory duct (enters prostate)
• Site of vasectomy

• Paired glands posterior to bladder; contribute ~70% of seminal fluid
• Contains fructose (energy source for sperm), prostaglandins, and coagulating factors

• Walnut-sized gland (~20g); located below bladder neck, surrounds proximal urethra
• Zones:
  • Peripheral zone (70%) - site of prostate cancer
  • Transition zone (20-30%) - site of BPH
  • Central zone (5%) - surrounds ejaculatory ducts
• Contributes ~30% of semen: zinc, PSA (liquefies semen), citric acid
• Relations: anteriorly pubic symphysis; posteriorly rectum (hence DRE); inferiorly urogenital diaphragm
• Blood supply: inferior vesical artery (branch of internal iliac)
• Innervation: sympathetic (T11-L2) → ejaculation; parasympathetic (S2-4) → erection

• Pre-ejaculatory fluid; alkalinises urethra, lubricates

• 2 corpora cavernosa + 1 corpus spongiosum (surrounds urethra, forms glans)
• Erection: parasympathetic → NO → cGMP → smooth muscle relaxation → vascular engorgement
• PDE-5 breaks down cGMP - hence PDE-5 inhibitors treat erectile dysfunction

Physiology - Spermatogenesis and Hormonal Axis

1. Hypothalamus → GnRH (pulsatile)
2. Anterior pituitary → LH + FSH
3. LH → stimulates Leydig cells → testosterone production
4. FSH + testosterone → stimulates Sertoli cells → spermatogenesis
5. Testosterone + inhibin B (from Sertoli cells) → negative feedback on hypothalamus/pituitary

• Takes ~74 days (64 days spermatogenesis + 10 days epididymal maturation)
• Requires temperature 2-3°C below body temperature (hence scrotum outside body)
• Heat (fevers, varicocele, undescended testis) impairs spermatogenesis
• Daily sperm production: ~200 million

• Development of male secondary sex characteristics
• Maintenance of libido and erectile function
• Spermatogenesis
• Anabolic: muscle mass, bone density, erythropoiesis
• Behaviour: confidence, aggression

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Q2 - Diseases of the Prostate Gland and Management in Primary Care

Benign Prostatic Hyperplasia (BPH)

• Storage (irritative): frequency, urgency, nocturia, urge incontinence
• Voiding (obstructive): weak stream, hesitancy, incomplete emptying, terminal dribbling, straining
• Post-micturition: post-void dribbling

• IPSS (International Prostate Symptom Score): 0-7 mild, 8-19 moderate, 20-35 severe
• DRE: enlarged, smooth, symmetrical, rubbery prostate
• PSA: elevated in BPH but must exclude cancer
• Urine flow rate + post-void residual (PVR) USS
• Renal function (obstructive uropathy risk)

Prostate Cancer

• Gleason 6 (Grade Group 1): low risk, often indolent
• Gleason 7 (GG 2-3): intermediate risk
• Gleason 8-10 (GG 4-5): high risk

• Bone metastases most common (osteoblastic - "hot spots" on bone scan)

• PSA testing with informed consent after discussing risks/benefits
• DRE: hard, irregular, nodular prostate is suspicious
• Urgent 2-week-wait (2WW) referral if PSA elevated for age or hard nodule on DRE

• Active surveillance: low-risk disease (Gleason 6); regular PSA, MRI, biopsy
• Radical prostatectomy (robotic) or Radiotherapy: localised disease
• Androgen deprivation therapy (ADT - GnRH agonist/antagonist): advanced/metastatic
• Docetaxel/enzalutamide/abiraterone: castration-resistant prostate cancer

Prostatitis

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Q3 - Common Reproductive Disorders in Men

Erectile Dysfunction (ED)

• Inability to achieve/maintain erection sufficient for satisfactory sexual activity
• Prevalence: 10% at 40 years; 50% at 70 years

• Vascular (most common): atherosclerosis, hypertension, diabetes - ED is an early marker of cardiovascular disease
• Neurological: diabetic neuropathy, MS, spinal cord injury, post-prostatectomy
• Hormonal: hypogonadism, hyperprolactinaemia, hypothyroidism
• Psychological: performance anxiety, depression, relationship issues
• Drug-induced: antihypertensives (beta-blockers, thiazides), antidepressants (SSRIs), antipsychotics, opioids

• PDE-5 inhibitors (first-line): Sildenafil (Viagra), Tadalafil (Cialis - longer acting, 36h), Vardenafil
  • Contraindicated with nitrates (severe hypotension), recent MI/stroke, hypotension
• Psychosexual counselling (if psychological cause)
• Testosterone replacement (if hypogonadal)
• Second-line: intracavernosal alprostadil (prostaglandin E1), vacuum erection device
• Third-line: penile prosthesis implant

Male Hypogonadism

• Primary (hypergonadotropic): testicular failure - high LH/FSH, low testosterone
  • Causes: Klinefelter, orchitis, trauma, chemotherapy, undescended testes
• Secondary (hypogonadotropic): pituitary/hypothalamic failure - low LH/FSH, low testosterone
  • Causes: hyperprolactinaemia, Kallmann syndrome, pituitary tumour, obesity, opioid use

Male Infertility

• Affects ~7% of men; male factor contributes to 50% of infertile couples

• Pre-testicular: hypogonadism, hyperprolactinaemia, thyroid disease, drugs, alcohol
• Testicular: varicocele (#1 treatable cause), cryptorchidism, orchitis (mumps), Klinefelter, chemotherapy, idiopathic
• Post-testicular: obstruction (epididymis, vas), erectile/ejaculatory dysfunction

• Volume ≥1.4ml; concentration ≥16M/ml; total motility ≥42%; morphology ≥4% (Kruger)

• Treat underlying cause (varicocelectomy, hormonal treatment)
• ART: IUI, IVF, ICSI (intracytoplasmic sperm injection) for severe oligospermia/azoospermia

Testicular Cancer

• Most common cancer in men aged 15-35; highly curable (>95% overall)
• Germ cell tumours: Seminoma (50%, radiosensitive, slower) and Non-seminoma (NSGCT - teratoma, embryonal carcinoma, yolk sac, choriocarcinoma)
• Tumour markers: AFP (raised in NSGCT, NOT seminoma), β-hCG (raised in both), LDH (staging)
• Presentation: Painless testicular mass; rule out epididymo-orchitis
• Diagnosis: Testicular ultrasound; never biopsy trans-scrotally (risks lymphatic spread)
• Management: Orchidectomy via inguinal approach; then chemotherapy (BEP - bleomycin, etoposide, cisplatin) or radiotherapy depending on stage

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Q4 - Infectious and Inflammatory Diseases of the Male Genitourinary System

Urethritis

• Gonococcal (GU): N. gonorrhoeae; purulent urethral discharge, dysuria, within 2-7 days of exposure
  • Treatment: Ceftriaxone 1g IM single dose (resistance to cefixime/fluoroquinolones increasing)
• Non-gonococcal (NGU): Chlamydia trachomatis (most common), Mycoplasma genitalium, Ureaplasma, Trichomonas
  • Mucopurulent/clear discharge, milder symptoms
  • Treatment: Doxycycline 100mg BD x 7 days (chlamydia); azithromycin 1g single dose (alternatives); treat partners

Epididymo-orchitis

• Inflammation of epididymis ± testis
• STI-related (young men): Chlamydia, Gonorrhoea
• Non-STI (older men): E. coli, Pseudomonas (often associated with UTI, bladder outlet obstruction)
• Features: Unilateral scrotal pain and swelling, fever, tender epididymis
• Distinguish from testicular torsion: Torsion presents acutely (hours), extreme pain, absent cremasteric reflex, high-riding testis - surgical emergency; Doppler USS shows increased flow in epididymo-orchitis, decreased in torsion
• Treatment:
  • STI: Ceftriaxone 500mg IM + Doxycycline 100mg BD x 10-14 days + partner notification
  • Non-STI: Quinolone (ciprofloxacin) x 14 days; scrotal support, analgesia

Prostatitis (see Q2 above)

Phimosis and Balanitis

• Phimosis: Inability to retract foreskin; physiological in children (<3yr); pathological if acquired (lichen sclerosus)
  • Treatment: topical steroids (betamethasone 0.05% x 4-6 weeks), circumcision if refractory
• Balanitis: Inflammation of glans; often Candida (diabetics), contact dermatitis, bacterial
  • Treat the cause; clotrimazole for candidal; exclude diabetes

Sexually Transmitted Infections (STIs) in Men

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Q5 - Prevention and Early Detection of Prostate Diseases

PSA Screening Debate

• PSA (Prostate-Specific Antigen) is a serine protease produced exclusively by prostatic epithelium
• Normal: <4 ng/mL (age-adjusted); elevated in cancer, BPH, prostatitis, urinary retention, post-DRE
• Controversy: USPSTF Grade C (shared decision-making 55-69 years); American Cancer Society recommends discussion at age 50 (average risk) or 40-45 (high risk)
• Benefits: earlier detection, reduced cancer-specific mortality
• Harms: overdiagnosis (many low-grade cancers are indolent), overtreatment (incontinence, ED)

• PSA density (PSA/prostate volume): >0.15 suggests cancer
• PSA velocity (PSA rise >0.75 ng/ml/year): more suspicious
• Free/total PSA ratio: lower ratio = higher cancer probability

Prevention Strategies

• No proven dietary prevention for prostate cancer despite research into lycopene, vitamin E, selenium
• Weight management: obesity linked to more aggressive disease
• Regular exercise reduces BPH symptom severity
• Early recognition of LUTS: Counsel men >50 to discuss urinary symptoms with their GP
• Prompt referral for haematuria, LUTS with elevated PSA, hard prostate

Family Physician Role in Prevention

1. Offer PSA discussion at age 50 (or 45 for high-risk)
2. Annual DRE for men with risk factors
3. Counsel on BPH lifestyle measures
4. Screen for complications of untreated LUTS (renal function, PVR)
5. Risk stratify and refer promptly

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Q6 - Role of Family Physician in Men's Reproductive Health

Core Responsibilities

• BP, lipids, glucose (metabolic syndrome risk)
• Testicular self-examination education (young men, 15-35 - testicular cancer awareness)
• PSA discussion (50+)
• STI testing in sexually active men
• Colorectal, lung, and skin cancer screening as per guidelines

• Contraceptive counselling including vasectomy information
• STI testing, treatment, and partner notification
• Erectile dysfunction - identify cardiovascular risk (ED is often the first manifestation)
• Male infertility initial assessment and referral

• Annual LUTS review in men >50
• PSA with informed consent
• IPSS assessment and stepwise management of BPH
• Urgent referral pathway for suspected prostate cancer

• Often under-recognised; present in 2-5% of men >40
• Symptoms: fatigue, low libido, ED, mood changes, reduced muscle mass
• Diagnose: early morning total testosterone x2 + LH/FSH
• Treatment: testosterone replacement after excluding contraindications (prostate cancer, haematocrit >54%, severe heart failure)

• Men are less likely to seek help for depression; higher suicide rates
• AUDIT (alcohol), PHQ-9 (depression) at appropriate visits
• Non-judgmental consultation style; "male-friendly" consultation environments

• Hypertension, diabetes, dyslipidaemia - all affect reproductive function
• Medication review (antihypertensives and antidepressants commonly cause ED)

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SECTION B: GERIATRIC MEDICINE

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Q7 - Physiological Processes of Aging and Clinical Implications

Cardiovascular

• Increased arterial stiffness → isolated systolic hypertension
• Reduced cardiac reserve; maximum heart rate decreases (~220 - age)
• LV hypertrophy (response to afterload); diastolic dysfunction common
• Reduced baroreceptor sensitivity → orthostatic hypotension
• Clinical: Higher risk of heart failure, AF, hypertension; falls due to orthostatic hypotension

Respiratory

• Reduced lung elasticity → increased residual volume, decreased FEV1 (~30ml/year after 30)
• Reduced cough reflex and mucociliary clearance
• Reduced respiratory muscle strength
• Clinical: Higher susceptibility to pneumonia, atypical presentations (no fever), silent aspiration

Renal

• GFR decreases ~1ml/min/year after age 40 (but serum creatinine may remain normal due to reduced muscle mass)
• Reduced tubular function; decreased ability to conserve water and sodium
• Clinical: Drug dosing must be based on eGFR (CKD-EPI/MDRD); dehydration risk; NSAID/nephrotoxic drug caution

Gastrointestinal

• Reduced gastric acid → bacterial overgrowth, reduced B12/iron absorption
• Reduced GI motility → constipation
• Reduced hepatic blood flow and Phase 1 metabolism → prolonged drug half-lives
• Clinical: Anaemia (B12/iron deficiency); avoid drugs with high hepatic first-pass metabolism

Musculoskeletal

• Sarcopenia: Loss of muscle mass and strength (begins age ~40; accelerates after 70)
• Osteoporosis: reduced bone mineral density (women post-menopause; men >70)
• Joint cartilage loss → osteoarthritis
• Clinical: Falls, fractures, functional decline; screen with DEXA scan

Neurological

• Brain volume decreases (neuronal loss, white matter changes)
• Reduced neurotransmitter synthesis (dopamine, acetylcholine, serotonin)
• Slowed processing speed; mild forgetfulness (normal aging vs dementia)
• Reduced pain sensitivity → silent MI, silent pneumonia
• Clinical: Cognitive decline, Parkinson's disease, altered drug pharmacodynamics

Immune System (Immunosenescence)

• Reduced T-cell function, impaired vaccine response, chronic low-grade inflammation ("inflammaging")
• Clinical: Higher susceptibility to infections; atypical presentations; poor vaccine efficacy (need high-dose flu vaccines)

Endocrine

• Reduced insulin sensitivity → type 2 diabetes risk
• Reduced testosterone/oestrogen (late-onset hypogonadism/menopause)
• Subclinical hypothyroidism increases in prevalence

Pharmacokinetic Changes (Critical for Prescribing)

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Q8 - Multimorbidity in Elderly Patients

• Affects >80% of people over 65
• The rule, not the exception in geriatric medicine

Why Multimorbidity is Challenging

• Multiple guidelines conflict when applied simultaneously (each written for single disease)
• Risk of overtreatment and polypharmacy
• Patient priorities may differ from clinician targets
• Each condition affects others (e.g., NSAIDs for osteoarthritis worsen heart failure and CKD)
• Functional decline is as important as disease control

Common Multimorbidity Clusters in Elderly

• Cardiometabolic: Hypertension + DM + CKD + dyslipidaemia + heart failure
• Neuropsychiatric: Dementia + depression + Parkinson's disease
• Musculoskeletal: Osteoarthritis + osteoporosis + sarcopenia
• Respiratory: COPD + heart failure + sleep apnoea

Approaches to Management

• Ask "What matters most to you?" rather than "What is the matter with you?"
• Prioritise conditions based on patient values, not guideline targets
• Address functional status and quality of life as primary outcomes

• Medical: disease inventory, medications
• Functional: ADL (Barthel), IADL (Lawton-Brody)
• Cognitive: MMSE, MoCA
• Nutritional: MNA (Mini Nutritional Assessment)
• Psychological: GDS (Geriatric Depression Scale)
• Social: living situation, carer support
• Frailty: Fried phenotype or Clinical Frailty Scale (CFS)

• Unintentional weight loss (>4.5kg in last year)
• Self-reported exhaustion
• Weakness (grip strength)
• Slow walking speed
• Low physical activity

• Multidisciplinary team: GP + geriatrician + pharmacist + physiotherapist + OT + social worker + nurse
• Single care coordinator for complex patients
• Regular case conferences

• Prioritise treatments with proven benefit in elderly (e.g., antihypertensives, statins, anticoagulation for AF)
• Question guidelines designed for younger patients without multimorbidity
• Regular medication reviews (see Q9)

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Q9 - Polypharmacy in Older Adults

Why Polypharmacy is Harmful

• Drug-drug interactions (e.g., warfarin + NSAIDs = bleeding)
• Drug-disease interactions (e.g., NSAIDs + heart failure = decompensation)
• Cascade prescribing: drug causes side effect → new drug prescribed for side effect
  • Example: NSAID → elevated BP → antihypertensive added → ankle oedema → diuretic added
• Age-related pharmacokinetic changes amplify toxicity (see Q7)
• Non-adherence increases with pill burden
• Falls and cognitive impairment from inappropriate medications

High-Risk Medications in Elderly - Beers Criteria (AGS)

STOPP/START Criteria (European Tool)

• STOPP (Screening Tool of Older People's Prescriptions): 80 criteria for drugs to stop
• START (Screening Tool to Alert to Right Treatment): drugs that should be started but are omitted (undertreatment is also a problem)

Deprescribing Framework

1. List all medications including OTC and supplements
2. Identify inappropriate drugs (no indication, risky, low benefit)
3. Prioritise drugs to stop based on patient goals, risk-benefit analysis
4. Taper (not abrupt cessation) where needed (e.g., benzodiazepines, SSRIs, corticosteroids)
5. Monitor for withdrawal effects and disease recurrence
6. Document shared decision-making

• Brown bag review: ask patient to bring all medications to every visit
• Involve pharmacist in medication review
• Use SMCNA/MUR (Medicines Use Review) or Structured Medication Review (SMR)

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Q10 - Cognitive Impairment and Dementia in Elderly Patients

Normal Aging vs Mild Cognitive Impairment vs Dementia

Dementia - Types and Features

Assessment

• MMSE (Mini Mental State Examination): 0-30; <24 = cognitive impairment; quick, widely used
• MoCA (Montreal Cognitive Assessment): 0-30; <26 = impairment; more sensitive for MCI
• ACE-III (Addenbrooke's Cognitive Examination): more detailed; 0-100

• FBC, U&E, LFTs, TFTs (exclude reversible causes: hypothyroidism, B12/folate deficiency, uraemia, liver disease)
• Calcium, glucose, syphilis serology
• Brain MRI (preferred over CT): exclude structural causes, assess vascular changes, atrophy pattern

Management

• Mild-moderate: AChE inhibitors - Donepezil (most used), rivastigmine, galantamine
• Moderate-severe: Add Memantine (NMDA antagonist)
• BPSD (Behavioural and Psychological Symptoms): Risperidone (short-term, cautiously - stroke risk); avoid antipsychotics in DLB (sensitivity reaction)

• Cognitive stimulation therapy
• Music therapy, reminiscence therapy
• Structured daily routine, safe environment
• Carer support and education (carer burnout is common)

• Capacity assessment (Mental Capacity Act principles)
• Lasting Power of Attorney (LPA) - arrange early while capacity remains
• Advance care planning, DNAR discussions
• Driving: inform DVLA; advise patient to stop driving

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Q11 - Prevention of Falls in Older Adults

• 30% of community-dwelling adults >65 fall each year; 50% of those >80
• Falls cause 40% of all injury deaths in elderly
• Hip fracture: 30-day mortality ~10%; 1-year mortality ~30%; 50% never return to previous function

Risk Factors (Intrinsic vs Extrinsic)

• Muscle weakness (sarcopenia) - most important modifiable factor
• Balance/gait impairment
• Visual impairment (cataracts, glaucoma)
• Cognitive impairment
• Orthostatic hypotension
• Incontinence (rushing to toilet)
• Foot problems (bunions, neuropathy, inappropriate footwear)
• Previous falls (strongest predictor of future falls)

• Poor lighting
• Loose rugs, slippery floors
• Lack of grab rails/handrails
• High bed height
• Inadequate footwear

• Sedatives/hypnotics (benzodiazepines, opioids, antihistamines)
• Antihypertensives (orthostatic hypotension)
• Anticholinergics
• Antipsychotics (Parkinsonism, sedation)
• Diuretics (nocturia, dehydration)

Assessment - Falls Risk Tools

• TUG (Timed Up and Go): >12 seconds = high risk; >20 seconds = significant impairment
• Berg Balance Scale: 0-56; <45 = fall risk
• FRAX score: Fracture risk assessment (osteoporosis screening)

Multifactorial Falls Prevention (Evidence-Based)

Post-Fall Assessment (SPLATT mnemonic)

• Symptoms at time of fall
• Previous falls
• Location (where did it happen)
• Activity at time of fall
• Time of fall
• Trauma (injuries)

• DEXA scan for all women >65, men >70, or younger with risk factors
• Treatment: Calcium 1000-1200mg + Vitamin D 800 IU daily + Bisphosphonate (alendronate - first-line) if T-score ≤-2.5

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Q12 - Organisation of Care and Palliative Assistance for Elderly Patients

Models of Care for Elderly

• Family physician as coordinator of all care ("medical home" concept)
• Regular comprehensive reviews, medication management, preventive care
• Home visits for housebound patients (proactive community care)

• Inpatient CGA-based multidisciplinary assessment
• Evidence: CGA reduces mortality and nursing home placement by ~25%
• Acute Care for Elders (ACE) units: designed to prevent hospital-acquired deconditioning

• Day hospitals: assessment, rehabilitation, social stimulation without admission
• Home care services: personal care, meals on wheels, district nursing
• Respite care: temporary relief for family carers

• Residential care: personal care, no nursing needs
• Nursing homes: qualified nurses on-site; for those with complex needs
• Specialist dementia care units

Palliative Care in the Elderly

1. Relief from pain and distressing symptoms
2. Support psychological, social, and spiritual wellbeing
3. Neither hasten nor postpone death
4. Support family during illness and bereavement

Identifying Palliative Care Needs - "Surprise Question"

• If No → palliative approach should be initiated
• Tools: SPICT (Supportive and Palliative Care Indicators Tool), Gold Standards Framework (GSF)

Advance Care Planning (ACP)

• Documented discussions about future care wishes before loss of capacity
• Components:
  • DNAR (Do Not Attempt Resuscitation) order - decision about CPR
  • Advance Decision to Refuse Treatment (ADRT) - legally binding refusal of specific treatments
  • Lasting Power of Attorney (LPA) - designates decision-maker
  • Preferred place of care/death - home, hospice, hospital

Symptom Management at End of Life

The Liverpool Care Pathway Principles (now replaced by NICE Guidelines NG31)

• NICE guideline on care in the last days of life:
  • Recognise dying (clinical assessment)
  • Communicate sensitively with patient and family
  • Stop non-essential medications and investigations
  • Ensure comfort: mouth care, positioning, pressure area care
  • Meet spiritual/cultural needs
  • Support carers before and after death

Role of Family Physician in End-of-Life Care

1. Lead the conversation - initiate ACP early; do not wait for crisis
2. Prescribe anticipatory medications ("just in case box" at home: morphine, midazolam, haloperidol, glycopyrronium)
3. Coordinate care between district nurses, hospice, social services, out-of-hours GP
4. Support carers - recognise carer burden; arrange respite
5. Death certification and bereavement support - a follow-up call or letter after bereavement is valued and improves carer grief outcomes

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SECTION A: AUTOIMMUNE DISEASES

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Q1 - Definition and Classification of Autoimmune Diseases

Definition

Classification

• Rheumatological: RA, SLE, Sjögren's, scleroderma, myositis, vasculitis
• Endocrine: Hashimoto's, Graves', Type 1 DM, Addison's, autoimmune hypophysitis
• Neurological: MS, myasthenia gravis, Guillain-Barré, NMOSD
• Gastrointestinal: Coeliac disease, IBD (Crohn's/UC), autoimmune hepatitis, PBC
• Haematological: Autoimmune haemolytic anaemia, ITP, pernicious anaemia
• Dermatological: Psoriasis, pemphigus vulgaris, vitiligo

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Q2 - Pathogenesis and Risk Factors of Autoimmune Diseases

Mechanisms of Self-Tolerance (and How They Break Down)

• In the thymus, T cells with high affinity for self-MHC/peptide complexes are clonally deleted (negative selection)
• In bone marrow, autoreactive B cells undergo receptor editing or deletion
• Failure: some autoreactive lymphocytes escape into the periphery

• Anergy: autoreactive T cells become functionally unresponsive without co-stimulation
• Regulatory T cells (Tregs - CD4+CD25+FoxP3+): suppress autoreactive cells
• Peripheral deletion via apoptosis (Fas-FasL pathway)

Pathogenic Mechanisms in Autoimmunity

• Pathogen antigen (viral or bacterial) shares structural similarity with a self-antigen
• Immune response against pathogen cross-reacts with self-tissue
• Example: Group A Streptococcus M protein → anti-cardiac antibodies → rheumatic fever; Campylobacter jejuni ganglioside mimicry → Guillain-Barré syndrome

• Infection causes local inflammation and tissue damage → release of normally sequestered self-antigens
• Innate immune activation → upregulates co-stimulatory molecules → activates previously anergic autoreactive T cells

• Initial immune response to one antigen → tissue damage → exposure of new self-antigens → expanding autoimmune response over time

• Reduced Treg number or function allows autoreactive lymphocytes to become activated
• Key mechanism in many AIDs (SLE, T1DM, MS)

• Some pathogens (EBV, bacterial superantigens) activate B and T cells non-specifically, including autoreactive clones

Risk Factors

• HLA associations (strongest genetic link): HLA-DR3, DR4 → Type 1 DM, RA, SLE; HLA-B27 → ankylosing spondylitis, reactive arthritis; HLA-DQ2/DQ8 → coeliac disease
• Non-HLA genes: PTPN22 (RA, T1DM, SLE), CTLA4 (T1DM, thyroid diseases), IL-2R

• Female predominance (75-80% of AID patients are women); oestrogen enhances B-cell activity
• Exacerbations during pregnancy and post-partum (SLE, MS)
• Testosterone is immunosuppressive; low levels increase AID risk in males

• Infections: EBV (SLE, MS), Helicobacter pylori (gastric autoimmunity), CMV
• Sunlight/UV radiation: Triggers SLE flares (DNA damage releases autoantigens)
• Smoking: Independent risk factor for RA (citrullination of proteins - anti-CCP), SLE, MS
• Diet: Gluten triggers coeliac; low Vitamin D associated with MS and T1DM
• Drugs: Drug-induced lupus (hydralazine, procainamide, isoniazid - induce ANA)
• Microbiome: Gut dysbiosis linked to multiple AIDs

• SLE more severe in African-Caribbean and South Asian populations
• MS highest prevalence in northern latitudes (Vitamin D deficiency)

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Q3 - Major Clinical Forms of Autoimmune Diseases in Family Medicine

Systemic Lupus Erythematosus (SLE)

• Young women (F:M = 9:1); peak onset 15-45 years
• Features: malar rash, discoid rash, photosensitivity, oral ulcers, arthritis (non-erosive), serositis (pleuritis, pericarditis), renal disease (lupus nephritis), CNS disease, haematological (haemolytic anaemia, thrombocytopenia, lymphopenia), immunological (positive anti-dsDNA, anti-Sm, antiphospholipid), positive ANA
• SLICC criteria: ≥4 clinical/immunological criteria for diagnosis
• Family physician role: monitor for flares, screen for organ damage (renal function, BP, urine protein), check for drug toxicity (hydroxychloroquine → eye toxicity)

Rheumatoid Arthritis (RA)

• F:M = 3:1; any age but peak 40-60 years
• Symmetric polyarthritis of small joints (MCPs, PIPs, wrists) - morning stiffness >1 hour
• Extra-articular: rheumatoid nodules, pleural effusions, pericarditis, vasculitis, Felty's syndrome (RA + splenomegaly + neutropenia), secondary Sjögren's
• Serology: RF (70% sensitive), anti-CCP (98% specific)
• 2010 ACR/EULAR criteria: Score ≥6/10 (joint distribution, serology, acute phase reactants, symptom duration)
• Family physician role: early diagnosis and referral, DMARDs (methotrexate - anchor drug), monitoring for joint damage and extra-articular disease

Hashimoto's Thyroiditis

• Most common autoimmune disease; most common cause of hypothyroidism in iodine-sufficient countries
• Anti-TPO antibodies (>95%) and anti-Tg antibodies
• Progressive thyroid destruction → hypothyroidism
• Family physician: TSH monitoring annually, levothyroxine replacement

Type 1 Diabetes Mellitus

• Autoimmune destruction of pancreatic beta cells (T-cell mediated)
• Anti-islet cell antibodies (ICA), anti-GAD65, anti-IA-2, anti-ZnT8
• Presents with DKA or classic hyperglycaemia symptoms
• Family physician: insulin management, HbA1c monitoring, complication screening

Multiple Sclerosis (MS)

• Demyelination of CNS white matter; young adults (F:M = 3:1)
• Relapsing-remitting (most common), primary progressive, secondary progressive
• Features: optic neuritis (visual loss, pain on eye movement), internuclear ophthalmoplegia, limb weakness/spasticity, sensory disturbance, bladder dysfunction, Uhthoff phenomenon (worsening with heat)
• Diagnosis: McDonald criteria (MRI showing lesions disseminated in time and space); oligoclonal bands in CSF
• Family physician: recognise symptoms, refer neurology, monitor disease-modifying therapies (interferons, natalizumab, ocrelizumab)

Sjögren's Syndrome

• Exocrine gland destruction; primary or secondary (complicating RA, SLE)
• Features: dry eyes (keratoconjunctivitis sicca - Schirmer's test), dry mouth (xerostomia), parotid enlargement, arthritis, vasculitis, interstitial lung disease
• Antibodies: anti-Ro (SSA), anti-La (SSB)
• Complications: non-Hodgkin's lymphoma (40x increased risk)
• Treatment: symptomatic (artificial tears, saliva substitutes, pilocarpine)

Myasthenia Gravis

• Anti-AChR antibodies block neuromuscular junction
• Features: fluctuating, fatigable weakness - ptosis, diplopia, dysphagia, dysarthria, proximal limb weakness, respiratory failure (myasthenic crisis)
• Diagnosis: anti-AChR antibodies, repetitive nerve stimulation (decremental response), edrophonium (Tensilon) test
• Associated: thymoma (10%) - CT chest in all patients
• Treatment: pyridostigmine (AChEI), steroids, azathioprine, plasmapheresis/IVIg for crisis, thymectomy

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Q4 - Methods of Early Diagnosis of Autoimmune Diseases

Clinical Suspicion (Pattern Recognition)

• Young woman with multisystem involvement
• Unexplained fatigue + joint pain + rash
• Symmetric small joint arthritis with morning stiffness >1 hour
• Recurrent miscarriages (antiphospholipid syndrome)
• Raynaud's phenomenon (SSc, SLE, mixed CTD)
• Dry eyes + dry mouth in middle-aged woman (Sjögren's)
• Family history of autoimmune disease

Laboratory Tests

• ESR, CRP, ferritin, fibrinogen
• FBC (anaemia, leucopenia, thrombocytopenia)
• U&E, LFTs, urine protein:creatinine ratio (renal involvement)
• Complement levels C3/C4 (low in SLE, especially during flares)

Imaging

• Ultrasound: joints (synovial thickening, effusion in RA), thyroid (Hashimoto's, nodules), salivary glands (Sjögren's)
• X-ray: erosive joint disease (RA - juxta-articular osteoporosis, periarticular erosions, joint space narrowing)
• MRI: CNS (MS plaques - periventricular, juxtacortical, infratentorial), joint/soft tissue inflammation
• DEXA: bone density loss in chronic inflammatory disease or steroid use

Biopsy

• Kidney: lupus nephritis classification (ISN/RPS classes I-VI)
• Skin: Lupus, vasculitis
• Salivary gland (lip): Sjögren's - focal lymphocytic infiltration
• Temporal artery: giant cell arteritis
• Nerve/muscle: vasculitis, myositis

Family Physician's Approach

1. Systematic clinical history: symptom onset, systems review, family history, medications
2. Targeted autoantibody testing based on clinical suspicion
3. Baseline organ function before referral
4. Do NOT over-test: ANA as a screening test in non-specific fatigue → high false-positive rate and patient anxiety without benefit
5. Urgent referral for organ-threatening disease (renal involvement, cytopenias, serositis)

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Q5 - Principles of Follow-Up and Long-Term Management

Treatment Goals

1. Remission or lowest possible disease activity
2. Prevent organ damage
3. Maintain quality of life and function
4. Minimise treatment toxicity
5. Address comorbidities (cardiovascular risk in SLE/RA; infection risk with immunosuppression)

Disease Monitoring Tools

Disease-Modifying Therapies

• Hydroxychloroquine: First-line in SLE; anti-inflammatory, anti-malarial; reduces flare frequency and mortality; monitoring: annual ophthalmology (macular toxicity)
• Methotrexate: Anchor DMARD in RA; also used in SLE, psoriasis, myositis; monitoring: FBC + LFTs monthly initially, 3-monthly when stable; folic acid supplementation; contraindicated in pregnancy
• Azathioprine: SLE maintenance, IBD, myositis; check TPMT activity before starting (risk of myelosuppression if deficient)
• Mycophenolate mofetil (MMF): Preferred for lupus nephritis maintenance; monitoring FBC

• Anti-TNF (etanercept, infliximab, adalimumab): RA, psoriasis, ankylosing spondylitis; contraindicated in TB (screen with IGRA before starting), heart failure, demyelinating disease
• Rituximab (anti-CD20): RA, SLE, vasculitis; B-cell depletion
• Belimumab (anti-BAFF): SLE (reduces flares); first biologic approved specifically for SLE
• Abatacept: RA (T-cell co-stimulation blocker)
• JAK inhibitors (tofacitinib, baricitinib): RA, psoriatic arthritis; oral; risk of VTE, infections, reactivation of herpes zoster (vaccinate before starting)

• Used for acute flares and bridge therapy; minimise long-term use
• Long-term complications: osteoporosis (give calcium + Vit D + bisphosphonate if >3 months), diabetes, hypertension, adrenal suppression, cataracts, infections
• Steroid-sparing strategy: always aim to add DMARD to reduce steroid dose

Long-Term Monitoring for Treatment Toxicity

• Methotrexate: FBC, LFTs, renal function 3-monthly; annual CXR in some protocols
• Hydroxychloroquine: annual retinal screening
• Azathioprine: FBC + LFTs regularly
• Biologics: TB screening before initiation; infection monitoring; malignancy surveillance

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Q6 - Interdisciplinary Collaboration in Autoimmune Disease Management

Multidisciplinary Team (MDT) Structure

Family Physician's Coordination Role

1. Primary-secondary care interface: Implement specialist recommendations; monitor for drug toxicity between specialist appointments
2. Comorbidity management: Cardiovascular risk reduction (statins, antihypertensives), vaccination (patients on immunosuppressants need annual flu vaccine, pneumococcal, shingles - AVOID live vaccines on high-dose immunosuppression)
3. Transition care: Support young patients transitioning from paediatric to adult services
4. Patient education: Disease understanding, drug adherence, recognising flares, when to seek help
5. Shared care protocols: Clear documentation of monitoring responsibilities between primary and secondary care

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SECTION B: ENDOCRINOLOGY

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Q7 - Hormonal Regulation and Importance in Endocrine Diseases

Principles of Hormonal Regulation

1. Hypothalamus releases releasing hormones (TRH, GnRH, CRH, GHRH, dopamine)
2. Anterior pituitary releases tropic hormones (TSH, LH, FSH, ACTH, GH, prolactin)
3. Target glands (thyroid, gonads, adrenal cortex) release final hormones (T3/T4, sex steroids, cortisol, IGF-1)
4. Negative feedback: Final hormones suppress hypothalamus and pituitary (except oestrogen mid-cycle → positive feedback)

• Peptide/protein hormones (insulin, PTH, GH, TSH): water-soluble, bind cell-surface receptors, act rapidly via second messengers (cAMP, IP3)
• Steroid hormones (cortisol, sex steroids, Vitamin D): lipid-soluble, cross cell membrane, bind nuclear receptors, alter gene transcription (slower action)
• Amine hormones (thyroid hormones, catecholamines): thyroid hormones act like steroids; catecholamines act like peptides

• Negative feedback (most common): product inhibits its own production (e.g., T3/T4 suppresses TSH; cortisol suppresses ACTH; insulin reduces when glucose normalises)
• Positive feedback (rare): product stimulates more production (e.g., rising oestrogen → LH surge)
• Feed-forward: Neural stimulation (e.g., stress → CRH → ACTH → cortisol)

Importance in Endocrine Disease

• Deficiency: Gland failure (primary - high tropic hormone, low final hormone) vs central failure (secondary - low tropic hormone, low final hormone)
  • Example: Primary hypothyroidism - TSH high, T4 low; Central hypothyroidism - TSH low/normal, T4 low
• Excess: Autonomous gland production, tropic hormone excess (pituitary adenoma), or ectopic hormone production (paraneoplastic)
• Resistance: Normal/high hormone levels but impaired receptor response (e.g., type 2 DM = insulin resistance; pseudohypoparathyroidism = PTH resistance)

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Q8 - Diabetes Mellitus: Classification, Clinical Manifestations, Diagnosis, and Management

Classification

Diagnostic Criteria (WHO/ADA)

Clinical Manifestations

Management of Type 2 DM

• Weight loss (7% body weight reduces HbA1c by ~1%)
• Mediterranean/low-glycaemic diet
• Exercise: 150 min/week moderate aerobic
• Smoking cessation

• General: <53 mmol/mol (7%)
• Elderly/frail: <58-64 mmol/mol (7.5-8%) - avoid hypoglycaemia
• Pregnancy: <42 mmol/mol (6%)

• Basal-bolus insulin regimen: Long-acting insulin (glargine/detemir) once/twice daily + rapid-acting insulin (lispro/aspart/glulisine) with meals
• Carbohydrate counting to match mealtime insulin
• Continuous glucose monitoring (CGM) + insulin pumps in motivated patients

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Q9 - Complications of Diabetes and Their Prevention

Microvascular Complications (specific to DM)

• Leading cause of blindness in working-age adults worldwide
• Mechanism: capillary basement membrane thickening, pericyte loss, increased permeability
• Stages:
  • Background: microaneurysms, dot-blot haemorrhages, hard exudates
  • Pre-proliferative: flame haemorrhages, cotton wool spots, venous beading, IRMA
  • Proliferative: new vessel formation (NVD/NVE), vitreous haemorrhage, tractional retinal detachment
  • Diabetic maculopathy: macular oedema → central vision loss (most common cause of vision loss in DM)
• Screening: annual dilated fundoscopy or digital retinal photography from diagnosis (T2DM) or 5 years post-diagnosis (T1DM)
• Treatment: tight glycaemic and BP control (primary prevention); laser photocoagulation (proliferative); intravitreal anti-VEGF (macular oedema)

• 25-40% of diabetics develop nephropathy; leading cause of ESKD worldwide
• Stages (Mogensen): hyperfiltration → microalbuminuria (ACR 3-30 mg/mmol) → macroalbuminuria → declining GFR → ESKD
• Screening: Annual urine ACR + eGFR from diagnosis (T2DM); 5 years post-diagnosis (T1DM)
• Treatment: ACEi/ARB (first-line - reduce proteinuria and slow progression); SGLT-2 inhibitors (proven renoprotective - reduce eGFR decline); BP target <130/80mmHg; glycaemic control

• Affects ~50% of diabetics
• Types:
  • Distal symmetric peripheral neuropathy (most common): "glove and stocking" sensory loss, paraesthesia, neuropathic pain
  • Autonomic neuropathy: gastroparesis, postural hypotension, cardiac denervation, erectile dysfunction, diabetic diarrhoea, bladder dysfunction
  • Mononeuropathy: cranial nerve palsy (CN III - pupil-sparing), carpal tunnel syndrome
• Treatment: tight glycaemic control (primary prevention); neuropathic pain: duloxetine (first-line), pregabalin, amitriptyline; foot care

• Combination of neuropathy (painless injury) + peripheral vascular disease (poor healing) + infection
• SINBAD scoring system for risk
• Prevention: annual foot examination, patient education (inspect feet daily, appropriate footwear), podiatry
• Management: debridement, antibiotics, revascularisation if PVD; amputation in severe cases

Macrovascular Complications (accelerated atherosclerosis)

• Coronary artery disease (2-4x increased risk; often silent MI)
• Peripheral arterial disease (claudication, critical ischaemia)
• Stroke/TIA (2x increased risk)

• Statin therapy: ALL T2DM >40 years regardless of baseline lipid (atorvastatin 10-20mg)
• Aspirin: only if established CVD (not primary prevention due to bleeding risk)
• ACEi: if proteinuria or hypertension; BP target <130/80
• SGLT-2 inhibitors + GLP-1 agonists: proven CV mortality benefit (EMPA-REG, LEADER trials)
• Smoking cessation

Acute Complications

• Triad: hyperglycaemia (>11 mmol/L), ketonaemia (>3 mmol/L), acidosis (pH <7.3, bicarbonate <15)
• Precipitants: infection (most common), missed insulin, new-onset T1DM
• Management: IV fluids (0.9% saline), fixed-rate IV insulin infusion (FRIII), potassium replacement, treat precipitant; monitoring glucose + ketones hourly

• Very high glucose (often >35 mmol/L), high osmolality (>320), no significant ketosis, severe dehydration
• Management: cautious rehydration (risk of cerebral oedema), insulin once fluids given, anticoagulation (thrombosis risk)

• Causes: excess insulin, sulphonylurea, missed meals, alcohol, exercise
• Symptoms: autonomic (sweating, tremor, palpitations) then neuroglycopenic (confusion, seizure, coma)
• Rule of 15: 15g fast-acting glucose → wait 15 min → recheck; if conscious; glucagon IM/IV dextrose if unconscious

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Q10 - Hypothyroidism: Diagnosis and Treatment

Causes

• Primary (most common): Hashimoto's thyroiditis (iodine-sufficient countries), iodine deficiency (worldwide), post-radioiodine/surgery, drugs (amiodarone, lithium, carbimazole overdose)
• Secondary (central): Pituitary adenoma/surgery/infarction (Sheehan's syndrome)
• Transient: Postpartum thyroiditis, subacute thyroiditis (recovery phase)

Clinical Features

• Metabolic: Weight gain, cold intolerance, fatigue, constipation
• Cardiovascular: Bradycardia, pericardial effusion, hypertension (diastolic), hypercholesterolaemia
• Dermatological: Dry skin, hair loss, brittle nails, non-pitting oedema (myxoedema), loss of outer third of eyebrows (Queen Anne's sign)
• Neurological: Delayed relaxation of ankle reflexes (pathognomonic), carpal tunnel syndrome, depression, cognitive slowing
• Reproductive: Menorrhagia, anovulation, infertility

• Life-threatening; precipitated by cold, infection, surgery
• Hypothermia, altered consciousness, bradycardia, respiratory depression
• Treatment: IV T4 (and/or T3), hydrocortisone (exclude adrenal insufficiency first), supportive ICU care

Diagnosis

• TSH (first-line screening): Elevated in primary hypothyroidism; low/normal in central
• Free T4: Low in overt hypothyroidism; normal in subclinical hypothyroidism (TSH elevated, FT4 normal)
• Anti-TPO antibodies: Confirm Hashimoto's aetiology
• Subclinical hypothyroidism: TSH 4-10 mU/L + normal FT4; treat if: symptoms + positive anti-TPO, TSH >10, pregnancy, planning pregnancy, age <65

Treatment

• Levothyroxine (T4 replacement):
  • Dose: 1.6 mcg/kg/day (adults); start low in elderly and cardiac disease (25-50 mcg; increase 25 mcg every 4-6 weeks)
  • Take 30-60 minutes before breakfast (calcium, iron, antacids reduce absorption)
  • Monitor TSH 6-8 weeks after each dose change; 6-12 monthly when stable
  • Target TSH: 0.5-2.5 mU/L (narrower in pregnancy: 0.1-2.5 in T1; 0.2-3.0 in T2-3)
• Pregnancy: Increase dose by 25-30% as soon as pregnancy confirmed; check TSH every 4 weeks in first trimester

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Q11 - Hyperthyroidism and Management in Primary Care

Causes

Clinical Features

• Metabolic: Weight loss despite good appetite, heat intolerance, sweating
• Cardiovascular: Tachycardia, AF (especially elderly), palpitations, systolic hypertension, heart failure
• Neurological: Anxiety, tremor, emotional lability, insomnia, brisk reflexes
• Muscular: Proximal myopathy (difficulty rising from chair/stairs)
• GI: Diarrhoea/loose stools, increased bowel frequency
• Dermatological: Warm moist skin, hair thinning, onycholysis (Plummer's nails)
• Graves' specific: Exophthalmos, lid retraction/lag, chemosis, diplopia; pretibial myxoedema

• Treatment: PTU (blocks synthesis AND conversion T4→T3) + β-blocker + iodine (Lugol's) + hydrocortisone (blocks conversion) + supportive ICU

Diagnosis

• TSH: Suppressed (<0.1 mU/L) - most sensitive
• Free T4 and Free T3: Both elevated in overt; FT3 elevated alone in T3 thyrotoxicosis
• TRAb (TSH-receptor antibodies): Confirms Graves' disease
• Radionuclide thyroid scan (Tc-99m): Diffuse uptake (Graves') vs hot nodule(s) (toxic MNG/adenoma) vs suppressed uptake (thyroiditis)

Management

• Carbimazole (preferred in UK; 20-40mg/day initially): blocks thyroid peroxidase → reduced T4/T3 synthesis; titrate-to-euthyroid or block-replace regimen
• Propylthiouracil (PTU): Used in first trimester of pregnancy (carbimazole teratogenic in T1) and thyroid storm (blocks peripheral conversion)
• Side effects: Agranulocytosis (0.3%) - WARN patient to report sore throat/fever immediately and stop drug; rash; hepatotoxicity (PTU)
• Propranolol: Symptom control (tachycardia, tremor, anxiety) while awaiting euthyroid state; also reduces peripheral T4→T3 conversion

• Results in permanent hypothyroidism (desired; then levothyroxine)
• Contraindicated: pregnancy, breastfeeding, active severe Graves' ophthalmopathy (may worsen - give steroids prophylactically)
• Isolation precautions for 5-7 days post-treatment

• Large goitre causing compression, suspected malignancy, failed ATDs, patient preference
• Complications: recurrent laryngeal nerve palsy (hoarseness), hypoparathyroidism (hypocalcaemia - tetany)

• Recognise symptoms; perform TSH + FT4 +FT3
• Start propranolol for symptom control; refer to endocrinology
• Monitor for AF (anticoagulate with CHA₂DS₂-VASc ≥2)
• Lifelong levothyroxine monitoring after definitive treatment

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Q12 - Thyroiditis and Thyroid Nodules

Thyroiditis

• Most common thyroiditis; autoimmune (anti-TPO, anti-Tg antibodies)
• Lymphocytic infiltration + Hürthle cell change on histology
• Typically presents with hypothyroidism; occasionally early transient hyperthyroidism ("Hashitoxicosis")
• Risk of B-cell lymphoma (rare); do not biopsy diffuse Hashimoto's goitre unless rapid enlargement
• Management: levothyroxine for hypothyroidism; no treatment if euthyroid

• Viral (post-viral, often post-URTI); granulomatous inflammation
• Features: painful, tender goitre; fever; transient hyperthyroidism → euthyroid → transient hypothyroidism → recovery (months)
• ESR very elevated; anti-TPO negative; scan shows reduced uptake
• Management: NSAIDs (mild); prednisolone 30-40mg if severe; beta-blockers for symptomatic hyperthyroid phase; thyroid recovers in >90%

• Autoimmune; affects 5-10% postpartum women; anti-TPO positive
• Painless; similar biphasic pattern to subacute (hyperthyroid → hypothyroid → recovery) but painless
• 50% remain permanently hypothyroid - follow up annually with TSH
• May be misdiagnosed as postnatal depression during hypothyroid phase

• Rare; fibrous replacement of thyroid extending to adjacent structures (trachea, oesophagus, vessels)
• Hard, "woody" fixed goitre; may cause stridor, dysphagia
• Associated with IgG4-related disease; treat with steroids + surgery to relieve compression

• Bacterial (Staph, Strep); very rare
• Severe pain, fever, erythema, fluctuant goitre; requires IV antibiotics + surgical drainage

Thyroid Nodules

• Age <20 or >70 years
• Male sex
• Rapid growth, hard consistency, fixation
• Cervical lymphadenopathy
• History of neck irradiation
• Family history of thyroid cancer, MEN2, or Cowden syndrome
• Solitary cold nodule

1. TSH: If low → autonomous function → radionuclide scan (hot nodule = almost certainly benign; cold nodule = 10-15% malignant)
2. Thyroid Ultrasound: Characterise nodule (size, echogenicity, calcification, margins, vascularity)
   • TIRADS classification (Thyroid Imaging Reporting and Data System): guides need for FNAC
3. Fine Needle Aspiration Cytology (FNAC): For nodules ≥1cm with suspicious features (or ≥1.5cm if intermediate risk)
   • Bethesda Classification:
     • I: Non-diagnostic (repeat)
     • II: Benign (thyroid cyst, colloid nodule, Hashimoto's) - discharge to surveillance
     • III: AUS/FLUS (atypia of undetermined significance) - repeat or molecular testing
     • IV: Follicular neoplasm - hemithyroidectomy (cannot distinguish benign from malignant on cytology alone)
     • V: Suspicious for malignancy - surgery
     • VI: Malignant - total thyroidectomy

1. Palpate thyroid at routine examination, especially in women over 40
2. Request TSH + thyroid USS for any palpable nodule
3. Refer urgently if: rapid growth, stridor, hoarseness, fixation, lymphadenopathy, or TIRADS 5/Bethesda VI
4. Follow-up benign nodules per radiologist recommendation (typically USS at 12 months, then 2-3 years)

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