1
Q
What is tonsilitis?
A
Inflammation of the tonsils- specifically an infection of the parenchyma of the palatine tonsils
2
Q
Which group is acute tonsillitis most common in?
A
Children 5-15 years old
3
Q
What are the 2 types of causes of tonsilitis?
A
Viral and bacterial
4
Q
What is viral tonsilitis caused by? (4)
A
- Rhinovirus
- Coronavirus
- Adenovirus
- Mono (EBV)
5
Q
What is bacterial tonsilitis caused by?
A
Streptococcus pyogenes
6
Q
How is tonsilitis spread?
A
Infectious condition and can be spread by exposure to an infected person (hence predominantly a disease of school children)
7
Q
How does viral tonsilitis present
A
- Low grade fever
- Cough
- Rhinorrhoea
8
Q
How does bacterial tonsilitis present
A
- High grade fever
- Sore throat
- Odynophagia, dysphagia
9
Q
What is 1st line investigation for bacterial tonsillitis?
A
Throat culture
10
Q
What limits throat culture’s usefulness
A
Delay in results (>48 hours)
11
Q
Alternative investigation for bacterial tonsilitis if suspicion of GABHS (group A beta haemolytic strep pyogenes)
A
Rapid streptococcal antigen test- lower sensitivity than culture but provides immediate results
12
Q
What is the criteria for likelihood of GABHS? (4)
A
Centor Criteria
- Presence of tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- Fever 38°C
- Absence of cough
(1 point for each and 3 or more indicates strep pyogenes)
13
Q
How do we manage acute tonsillitis without GABHS?
A
Analgesics (paracetamol main one or ibuprofen/aspirin/naproxen)
14
Q
How do we manage acute tonsillitis with GABHS or 3/4 on Centor Criteria? (3) What do we give if penicillin allergy?
A
Analgesics + 7-10 days Abx (phenoxymethylpenicillin) + corticosteroids (dexamethasone)
-Clarithromycin
15
Q
What do we do if recurrent episodes of tonsillitis?
A
Tonsillectomy
16
Q
What is the most common complication following tonsillitis and what do we do if it happens?
A
Haemorrhage- if within 24 hours we need immediate return to theatre due to risk of further, more extensive bleeding
17
Q
What if the haemorrhage happens 5-10 days after tonsillectomy?
A
Give Abx (indicative of infection)
18
Q
Complications of tonsilitis (3)
A
- Scarlet fever
- Acute sinusitis
- Acute otitis media
19
Q
Prognosis of tonsilitis?
A
Acute tonsillitis is an acute, self-limiting infective condition that normally resolves completely within 1 week with no sequelae. However, some patients may develop recurrent tonsillitis; tonsillectomy may be considered in these cases
20
Q
NICE recommend that tonsilectomy should be considered only if the person meets all of the following criteria: (4)
A
- sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
- the person has five or more episodes of sore throat per year
- symptoms have been occurring for at least a year
- the episodes of sore throat are disabling and prevent normal functioning
21
Q
What is dehydration?
A
State of reduced total body water volume
22
Q
Causes of dehydration (7)
A
- Insufficient water intake- particularly in the elderly and the critically ill
- Diuretics
- DI
- Diarrhoea
- Vomiting
- Burns
- Sweating
23
Q
Clinical features of dehydration
A
- Thirst
- Headache
- Weakness
- Dizziness
- Fatigue
- Dry cool skin, dry mucus membranes, delayed CRT, reduced skin turgor
24
Q
Clinical features of dehydration in infants
A
- Sunken fontanelle
- Irritability
- Lethargy
25
What electrolyte abnormality would be found in dehydration?
Hypernatraemia
26
What would happen to urine osmolality in dehydration?
increased
27
What is the management plan in dehydration? (2)
Oral rehydration therapy to patients who can sit up and drink
IV fluid resuscitation-Correction of hypernatraemia too quickly can lead to cerebral oedema
28
Complications of dehydration (3)
- Hypovolaemic shock → Pre-renal AKI
- Thrombosis
- Increased risk of UTIs
29
How common is breast cancer?
Second most common malignancy in women
30
When is the peak incidence for breast cancer? (2)
- Postmenopausal
- Incidence increases with age
- 50% of breast cancers are diagnosed in women >65
31
Risk factors of breast cancer (5)
- Increased exposure to oestrogen
- Smoking
- Alcohol consumption
- FH of breast cancer
- Increasing age
32
Increased exposure to oestrogen- caused by? (6)
- Not having kids
- Early menarche <13 yrs
- Late menopause >51 yrs
- Obesity
- COCP
- HRT
33
Name 2 genes associated with breast cancer
- BRCA-1
- BRCA-2
34
What are the different types of breast cancer? (2)
- Invasive ductal carcinoma → Most common
- Ductal carcinoma in situ → Non-invasive
35
What does the NHS breast screening programme involve?
Mammogram every 3 years for women 50-70 years old
36
Clinical features of breast cancer
- New irregular lump in the breast or underarm
- Thickening or swelling of part of the breast
- Irritation or dimpling of skin
Paget’s disease of the breast (sign of underlying cancer, mostly invasive)
- Itching or burning
- Pain and sensitivity
- Flattening of nipple
- Yellow or bloody nipple discharge
- Unilateral
37
Paget’s disease of the nipple- what’s this and what causes it?
- Eczema like hardening of the skin on the nipple
- Usually caused by ductal carcinoma in situ infiltrating the nipple
38
Breast lump- describe it (5)
- Non-tender
- Poorly defined margins
- Painless
- Hard mass located in upper outer quadrant
- May be fixed to deep tissue
39
What are signs of metastasis in bone?(3)
- Bone pain
- Pathological fractures
- Spinal compression
40
What are signs of metastasis in liver? (3)
- Abdo pain, distension
- Nausea
- Jaundice
41
What are signs of metastasis in lung? (4)
- Cough
- Haemoptysis
- Dyspnoea
- Chest pain
42
What are signs of metastasis in brain? (3)
- Headaches
- Seizures
- Cognitive deficits, focal neurological deficits
43
Main investigation of breast cancer depending on age?
- Women <35 → Breast ultrasound (Mammogram difficult due to denser breast tissue)
- Women >35 → Mammography
44
What are the two ways of taking a biopsy in breast cancer?
- Fine needle aspiration → cytological information
- Core needle biopsy → histological and cytological information
45
- Which investigations are used to stage breast cancer? (3)
- Core needle biopsy **(T)**
- Sentinel node biopsy **(N)**
- PET scan **(M)**
46
- How else do we check for mets? **(6)**
- Bone scan
- CXR
- FBC
- LFTs
- Calcium levels
- CT chest + abdo
47
Name a marker for breast cancer
CA 15-3
48
What’s 1st line most of the time for breast cancer?
Surgery
49
What is a mastectomy?
Removal of the entire breast and possibly other structures such as lymph nodes & muscles
50
List indications for a mastectomy (4)
- Multifocal tumour
- Central tumour
- Large lesion in small breast
- Ductal carcinoma in situ
51
What is a wide local excision?
Removal of just the area of cancer, aims to keep most of the breast tissue
52
In which patients do we do wide local excision
For smaller, solitary lesions which are peripherally located
53
What is recommended after a woman has had a wide local excision?
Whole breast radiotherapy- may reduce risk of recurrence by two-thirds
54
What is the treatment for clinical (palpable) axillary lymphadenopathy?
Axillary lymph node clearance
55
What can axillary lymph node clearance cause?
Lymphoedema and cause functional arm impairment
56
What if the patient doesn’t want Axillary lymph node clearance with their breast cancer treatment?
Axillary radiotherapy
57
Who is hormonal therapy offered to in breast cancer?
Adjuvant therapy to women who are oestrogen receptor positive
58
Which drug is used in pre-menopausal women for breast cancer?
Tamoxifen (Oestrogen receptor modulator/antagonist)
59
Which drug is used in pre-menopausal women in hormone therapy?
Tamoxifen (Oestrogen receptor modulator/antagonist)
60
What is a risk of using Tamoxifen
Venous thromboembolism
61
Which drug is used in post-menopausal women in hormone therapy?
Anastrazole (Aromatase inhibitor)
62
What is a risk of using Anastrazole
May cause osteoporotic fractures due to reduced oestrogen
63
Who is biological therapy offered to in breast cancer?
If HER2 positive
64
What drug is given if HER2 positive in breast cancer?
Trastuzumab (Herceptin)
65
Side effect of Herceptin
Cardiac toxicity → do echo before giving it
66
What do we give for chemo-induced nausea and vomiting? (2)
A 5HT-3 antagonist → Ondansetron (+ metronidazole)
67
What else is used to treat breast cancer?
Chemotherapy → can be given as a neoadjuvant or adjuvant
68
List complications of breast cancer (4)
- Pleural effusion
- Paraneoplastic syndromes
- High recurrence rate
- Lymphoedema of the arm
69
What is the most important factor for prognosis of breast cancer?
Stage at time of diagnosis
- Earlier stages have significantly better prognosis due to less spread
70
Define obesity
- Chronic adverse condition due to an excess amount of body fat
- Defined as BMI ≥30kg/m², can be grouped into classes 1-3
71
What are the three obesity classes
- Class 1 → 30-34.9 kg/m²
- Class 2 → 35-39.9 kg/m²
- Class 3 → ≥40 kg/m²
72
How prevalent is obesity in adults and adolescents?
40% of adults and 20% of adolescents (12-19 years)
73
What are the categories of causes of obesity?
- Genetics
- Behavioural
- Environmental
- Hormonal
74
What are the behavioural causes of obesity
- larger portion sizes
- sedentary lifestyles
- poor dietary habits
75
What are the hormonal causes of obesity
- hypothyroidism
- hypercortisolism
- insulinoma
76
What is the main clinical feature of obesity?
Large waist circumference
77
What comorbid conditions may you see in obesity? (9)
- T2DM
- CVD
- Hypertension
- Hyperlipidaemia
- GORD
- OSA
- Gout
- Cancer
- Gallbladder disease
78
What is the main investigation done in obesity?
BMI → (weight in kg) / (height in m)²
79
Who is BMI not accurate in obesity? (2)
- Pregnant women
- People with large muscle mass e.g. athletes
80
What’s 1st line for managing Class 1 obesity? (2)
Dietary changes + increase in physical activity
81
What main medication can we consider in obesity?
Orlistat (pancreatic lipase inhibitor)
82
What are the criteria for giving Liraglutide in obesity? (2)
- BMI of at least 35 kg/m²
- prediabetic hyperglycaemia (e.g. HbA1c 42 - 47 mmol/mol)
83
How do we manage Class 2 obesity with comorbidities OR Class 3 OR other measure ineffective?
Bariatric surgery → sleeve gastrectomy
84
Complications of obesity? (13)
- post-surgical DVT
- PE
- bleeding
- wound infection
- vitamin deficiency
- Peri-operative death
- ACS
- T2DM
- hypercholesterolaemia
- hypertension
- non-alcoholic fatty liver disease
- metabolic syndrome
- cancer
85
Define malnutrition
NICE defines malnutrition as the following:
a Body Mass Index (BMI) of less than 18.5; or
unintentional weight loss greater than 10% within the last 3-6 months; or
a BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months
86
How to screen for malnutrition
MUST (Malnutrition Universal Screen Tool)
- it should be done on admission to care/nursing homes and hospital, or if there is a concern. For example an elderly, thin patient with pressure sores
- it takes into account BMI, recent weight change and the presence of acute disease
- categorises patients into low, medium and high risk
87
What diseases can cause malabsorption? (3)
- IBD
- Coeliac
- Lactose intolerance
88
Define global malabsorption
In diseases causing diffuse mucosal damage or reduction in absorptive surface e.g. Coeliac
89
Define partial malabsorption
Localised absorption impairment resulting in deficiencies of specific nutrients e.g. Vit B12 deficiency in patients with disease of terminal ileum
90
Define maldigestion
Malfunction of the intestinal wall resulting in insufficient absorption of breakdown products
91
What can cause maldigestion? (2)
Exocrine pancreas insufficiency or cholestasis
92
Clinical features of malabsorption
- Diarrhoea
- Steatorrhoea → floating and foul smelling stool
- Abdominal distension
- Weight loss and fatigue
- Partial malabsorption- symptoms specific to individual nutrient deficiencies
93
What do we see on bloods for malabsorption?
Anaemia and vitamin deficiencies
94
How do we assess absorptive function of upper small intestine?
D-xylose absorption test
95
How do we manage malabsorption normally?
- Oral supplementation of fluid, nutrients and vitamins
- Calorie and protein enriched diet
96
How do we manage malabsorption if it’s severe?
IV nutrition
97
Define malabsorption
Malfunction of the intestinal wall resulting in insufficient absorption of breakdown products
98
What is COVID-19?
Potentially severe acute respiratory infection caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
99
How does transmission of Covid-19 occur?
Primarily via respiratory droplets
100
How long is the average incubation period for covid 19?
5 days
101
- Clinical features of covid 19? (7)
- Fever
- Cough
- Dyspnoea
- Altered sense of smell/taste
- Headache
- Sore throat
- Nasal congestion
102
What are the main investigations of covid? (3)
- Real-Time Reverse Transcription Polymerase Reaction (RT-PCR)
- Isolated from a nasopharyngeal swab
- Pulse oximetry
- CXR
103
When do we do CXR for covid
If suspected pneumonia
104
Management plan for mild/moderate covid?
- Isolation
- Supportive measures
- antipyretic/analgesic
105
Management plan for severe covid? (4)
- Hospital admission
- VTE prophylaxis
- Oxygen therapy
- Mechanical ventilation
106
List complications of COVID-19 (6)
- Thrombosis
- AKI
- Long covid
- Cardiac arrest
- Sepsis
- DIC
107
Describe the prognosis of COVID-19
Leading cause of death is respiratory failure from ARDS
108
Define conjunctivitis
V common inflammation of conjunctiva (mucus membrane lining inside of eyelids and sclera)
109
What is conjunctiva caused by
bacteria, viruses, allergic reactions, mechanica irritation, medicines
110
Is bacterial or viral causes of conjunctiva more common in adults?
virus
111
Name some bacteria in conjunctiva
- Staph aureus
- Haemophilus influenzae
- Pneumococcus
- Moraxella catarrhalis
112
Name some viruses in conjunctiva
- Adenovirus
- Herpes simplex
- Epstein-Barr
- Varicella zoster
- Molluscum contagiosum
- Coxsackie
- Enteroviruses
113
Common clinical features of conjunctiva (5)
- Red eye due to ocular hyperemia
- Discharge and crust formation
- Itching (most intense in seasonal allergic conjunctivitis)
- Eyelid swelling
- Photophobia
114
What do we see in bacterial conjunctivitis? (2)
- Unilateral, thick purulent discharge (yellow crusting)
- Eyes may be stuck together in morning
115
What do we see in viral conjunctivitis? (2)
- bilateral (begins unilateral), clear watery discharge
- Recent URTI
116
- What do we see in allergic conjunctivitis? (3)
- Clear watery discharge
- Itchiness
- May be seasonal or due to specific allergen (patient will have history of atopy- eczema, asthma etc)
117
What are the main 2 investigations in conjunctiva?
Cell culture & gram stain
Rapid adenovirus immunoassay
118
Management for viral conjunctivitis?
- Topical antivirals
- Antihistamine drops
- Supportive care
119
Management for bacterial conjunctivitis?
- topical broad spectrum antibiotics- chloramphenicol or topical fusidic acid for pregnant women
- Topical fluoroquinolone
120
Management for allergic conjunctivitis?
- Topical antihistamines
- Avoid allergen
- Cold compress
If unresolving - topical steroids or topical sodium cromoglycate
121
What other general advice is there for conjunctivitis ? (2)
- Don’t share towels/household items, itching/touching, touching things between eyes, don’t wear contact lenses
- Wash hands and face regularly and clean eyes with cotton wool (in to out)
122
Complications of conjunctivitis? (3)
- Dry eyes
- Keratitis
- Subepithelial corneal infiltrates
123
Define uveitis
Inflammation of 1 or all parts of uvea (middle vascular layer of eye between retina and sclera)
124
What type of uveitis is the most common
Anterior uveitis
125
What parts of the uvea does anterior uveitis affect?
Iris (iritis) and ciliary body
126
What gene is Anterior uveitis associated with?
HLA-B27
127
What are the causes of Anterior uveitis? (2)
- Idiopathic
- Non-infectious (autoimmune systemic disease) e.g. reactive arthritis, ankylosing spondylitis, IBD, sarcoidosis, MS
128
What parts of the uvea does posterior uveitis affect?
Choroid, retina and retinal vasculature
129
What are the causes of posterior uveitis?(5)
Infections
- Herpes simplex virus
- Varicella zoster virus
- HIV
- Lyme disease
- TB
130
What parts of the uvea does intermediate uveitis affect?
Posterior ciliary body and pars plana
131
What parts of the uvea does panuveitis affect?
Inflammation in all 3 segments
132
What risk factors are there for uveitis ? (4)
- Inflammatory diseases
- HLA-B27 positivity
- Ocular trauma
- Immunosuppression
133
What are the symptoms for anterior uveitis? (8)
- Acute progressive dull pain in orbital region
- Red eye with no discharge
- Photophobia
- Decreased visual acuity (blurred)
- Increased lacrimation
- Hypopyon (pus accumulation in anterior chamber resulting in visible fluid level)
- Constricted & fixed oval pupil
- No pain on eye movement as with scleritis, orbital cellulitis and optic neuritis
134
- What are the symptoms for posterior uveitis? (3)
- Painless visual disturbances
- Floaters
- Decreased visual acuity (blurred)
135
How is uveitis usually diagnosed?
Clinical diagnosis
136
- What is first line for uveitis? (2)
- Corticosteroid eye drops (prednisolone) to reduce inflammation
- Urgent review by ophthalmologist
137
How do we help with photophobia and pain?
Cyclopegic eye drops (e.g. atropine)- dilates pupil
138
How do we deal with infection in uveitis?
Antibiotic or antiviral
139
Complications of uveitis? (5)
- Cataract
- Macular oedema
- Glaucoma
- Band keratopathy
- Synechiae
140
Prognosis of uveitis?
variable and depends upon the aetiology, location, and severity of uveitis. In a large study of uveitis patients, 35% had visual loss of >20/60 in at least one eye, whereas 22% became unilaterally or bilaterally blind.
141
Chronic fatigue syndrome is also known as
Myalgic encephalomyelitis
142
Define chronic fatigue syndrome
≥4 months of disabling fatigue affecting mental and physical function more than 50% of the time
143
Which demographics is chronic fatigue syndrome most common in? (3)
- F>M (3:1)
- Adolescence
- 30-50 years
144
What are the clinical features of chronic fatigue syndrome? (9)
- Persistent disabling fatigue → may be present for >6 months
- Post-exertional fatigue
- Short-term memory or concentration impairment
- Sore throat
- Arthralgia - joint stiffness
- Headache
- Unrefreshing sleep
- Flu-like symptoms (may precede fatigue)
- Painful lymph nodes
145
Post-exertional fatigue- what is this?
Significant exhaustion and impairment following minimal physical or cognitive effort
146
Flu-like symptoms (may precede fatigue) in chronic fatigue syndrome, such as? (3)
malaise, myalgia, fever
147
What is first line investigation in chronic fatigue syndrome?
DePaul symptom questionnaire
148
Give examples of bloods we do and why do we do them in chronic fatigue syndrome?
- FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening, urinalysis
- exclude other diagnoses
149
What’s first line management for chronic fatigue syndrome?
Individualised therapy → manage symptoms and to improve functional capacity
150
What are some options for management as part of individualised therapy for chronic fatigue syndrome? (5)
- CBT - very effective
- Graded exercise therapy
- Low dose amitriptyline
- Referral to pain management clinic if pain predominant feature
- Mindfulness, sleep hygiene, occupational therapy
151
Complications of chronic fatigue syndrome?
Major depressive disorder
152
Prognosis of chronic fatigue syndrome?
longitudinal studies indicate that 17% to 64% of patients improve with treatment; however, less than 10% meet criteria for full recovery, and up to 20% of patients may worsen over time
153
What are pressure sores
Damage to skin usually over bony prominence, as a result of pressure
154
Why causes pressure sores
Constant pressure limits blood flow to skin leading to tissue damage
155
What risk factors are there for pressure sores? (4)
- Immobility
- Recent surgery or intensive care stay
- Diabetes
- Malnutrition
156
Who/where are pressure sores most common in?
Hospitals and elderly population
157
How do we screen for patients at risk of pressure sores?
Waterlow score- takes BMI, nutritional status, skin type, mobility and continence into account
158
Clinical features of pressure sores (5)
- Location- over bony prominences, typically sacrum or heel
- Focal area of nonblanchable erythema
- Evidence of decreased skin perfusion (increased CRT)
- Painful (unlike neuropathic ulcers which are painless)
- Signs of wound infection- purulent drainage, foul smell
159
What are the 4 stages of pressure sores?
- Stage 1 ⇒ nonblanchable erythema of intact skin
- Stage 2 ⇒ loss of dermis +/- epidermis. Superficial ulcer
- Stage 3 ⇒ loss of all skin layers (full thickness)
- Stage 4 ⇒ extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures
160
What predisposing factors can we evaluate for pressure sores? (3)
- blood glucose
- HbA1C
- Serum albumin (malnutrition)
161
What is obstructive sleep apnoea
Sleep-related breathing disorder in which airflow significantly decreases or ceases due to an upper airway obstruction
162
What is the pathophysiology of obstructive sleep apnoea?
Sleep → Decreased Muscle Tone → Upper Airway Collapse → Apnoea (Intermittent Hypoxia) → Arousal (Fragmented Sleep, Sleepiness and Cognitive Dysfunction) → Airway Reopens
163
What groups does obstructive sleep apnoea happen most in? (3)
- M>F
- Prevalence increases with age
- Classically in overweight middle aged men
164
What classification is there for obstructive sleep apnoea?
- Mild (5-15 events/hr)
- Moderate (15-30 events/hr)
- Severe (>30 events/hr)
165
Causes of obstructive sleep apnoea? (6)
- Obesity
- Acromegaly (causes macroglossia)
- Hypothyroidism (causes macroglossia)
- Large tonsils
- Alcohol
- Smoking
166
Clinical features of obstructive sleep apnoea (4)
- Excessive daytime sleepiness
- Episodes of apnoea and gasping
- Restless sleep
- Chronic, loud snoring
167
Excessive daytime sleepiness- how is this measured?
Epworth sleepiness scale (14 is moderate sleepiness and 18 is severe)
168
Signs of complications of obstructive sleep apnoea- such as? (4)
- Impaired cognitive function
- Depression
- Decreased libido
- Hypertension with increased pulse pressure
169
What is the definitive test for obstructive sleep apnoea ?
Polysomnography (PSG)
170
How do we assess risk of obstructive sleep apnoea ?
STOP-BANG score (>3 means you should do PSG)
171
What risk factors do we address for obstructive sleep apnoea?
Weight loss
172
first line for moderate or severe OSAHS?
Continuous positive airway pressure (CPAP) at night
173
What do we use if CPAP not tolerated in sleep apnea?
Intra-oral devices (e.g. mandibular advancement)
174
Which people need to be informed and when for osa?
DVLA if OSA is causing excessive daytime sleepiness
175
Complications for osa? (6)
- impaired glucose metabolism
- cardiovascular disease
- depression
- motor vehicle accidents
- cognitive dysfunction
- increased mortality
176
Prognosis of osa?
patients efficiently treated may report improvements in alertness and some improvement in quality of life, mood, and cognitive function
177
How do we check for infection for pressure sores?
Raised WCC and CRP
178
What are the main ways of managing the pressure sore? (4)
- Pressure relief over affected area
- Frequent position changes (every 2 hrs) for immobile patients
- Moist wound environment (encourages ulcer healing)
- Ensure good nutrition
179
What do we give for pain in pressure sores?
Analgesia (paracetamol, ibuprofen)
180
What do we do with stage 3 or 4 pressure sores if suitable vs not suitable for surgery?
- Surgical debridement and reconstruction with flap formation (if suitable for sugery)
- Debridement of necrotic tissue (if not suitable for surgery)
181
What complications are there for pressure sores?
sepsis, cellulitis, osteomyelitis → if pressure ulcer becomes infected, infection can spread → all can be treated with systemic antibiotics
182
What’s the prognosis for pressure sores?
good, as long as appropriate treatment and wound care is provided promptly
183
What is malaria
a disease caused by Plasmodium protozoa
184
What is the most life-threatening species which cause malaria disease in man?
Plasmodium Falciparum
185
Protective factors against malaria (4)
- Sickle cell trait
- G6PD deficiency
- HLA-B53
- absence of Duffy antigens
186
Where in the world is malaria prevalent?
Through tropical and subtropical regions - travellers account for majority of disease in Western countries
187
How is malaria transmitted? (3)
- via a bite by an infected female anopheles mosquito
- Potentially blood transfusion
- Potentially organ transplant
188
Risk factors of malaria? (3)
- travel to an endemic area
- inadequate chemoprophylaxis
- non-use of an insecticide-treated bed net when in an endemic area
189
What are clinical features of malaria? (9)
- Cyclical (alternating days) fevers with chills and rigors (shivering)
- Haemolytic anaemia
- Splenomegaly
- Headache
- Weakness
- Myalgia
- Arthralgia
- Anorexia
- Diarrhoea
190
Haemolytic anaemia - how does this present? (2)
- jaundice
- dark urine
191
What’s the first line investigation for malaria and what would we see?
Giemsa stained thick and thin blood smears
- Thick detects parasites present
- Thin detects species
192
Other investigations for malaria? (2)
- FBC
- Rapid diagnostic tests (RDTs)
193
Whats the point of doing fbc for malaria
check for anaemia
194
Whats the point of doing Rapid diagnostic tests (RDTs) for malaria
rapid detection of parasite antigen or enzymes
195
What drugs do we give for malaria?
Chloroquine (ok during pregnancy) or hydroxychloroquine
196
What do we give once symptoms are resolved to prevent relapse for malaria?
Primiquine
197
What do we give for prevention of malaria? (2)
- Avoid exposure (nets/repellent/protective clothing)
- Prophylaxis
198
Complications of malaria? (6)
- AKI (due to dehydration + hypovolaemia)
- Hypoglycaemia
- Metabolic acidosis
- Severe anaemia
- Seizures
- ARDS
199
Prognosis of malaria?
Groups at risk of severe disease include low host immunity, pregnancy, age <5yrs, immunocompromise, older adults
200
Define surgical site infection
Infection that occurs in the incision created by an invasive surgical procedure- major cause of morbidity and mortality
201
When may surgical site infection occur?
Following a breach in tissue surfaces allowing normal commensals and other pathogens to initiate infection
202
How common is surgical site infection?
Make up 20% of all healthcare-associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result
203
Risk factors of surgical site infection? (8)
- Old age
- Poor glucose control
- Obesity
- Smoking
- Renal failure
- Immunosuppression
- Preoperative shaving
- Length of operation
204
What are clinical features of surgical site infection? (4)
- Spreading erythema
- Localised pain
- Pus or discharge from the wound
- Pyrexia
205
What are the main investigations for surgical site infection? (4)
- Wound swabs
- Blood tests- to check for Markers of infection
- Blood cultures- to check for Evidence of sepsis
- Cross-sectional imaging- to assess deeper collections or necrotising fasciitis
206
What is the main management for surgical site infection?
Remove any sutures or clips to allow pus to drain + empirical antibiotic therapy
207
What is the preoperative management for surgical site infection? (3)
- Don’t remove body hair routinely (if you do, use electrical clippers instead of razors)
- Antibiotics prophylaxis → if placement of prosthesis or valve
- Patient advice- encourage weight loss, smoking cessation, optimise nutrition, and ensure good diabetic control
208
What is the intraoperative management for surgical site infection? (2)
- Prep skin with alcoholic chlorhexidine
- Cover surgical site with dressing
209
What are breast cysts
A well-defined collection of fluid within the breast that is influenced by hormonal changes
210
How common are breast cysts?
Very Common → 25% of all breast masses
211
Who are breast cysts most common in?
perimenopausal women, peak incidence 35-50 yrs old
212
How do breast cysts usually present? (4)
- Usually presents as small discrete breast lump (soft fluctuable swelling)- describe
- Single or multiple breast masses
- May be painful or tender
- Variable size & texture
- Usually moveable
213
What scan do we do for breast cysts?
Breast Ultrasound or Mammography → depending on woman’s age (Ultrasound in younger patients, <35)
214
What would we see on mammography for breast cysts?
Halo appearance- confirms fluid filled nature of cyst
215
How do we manage breast cysts usually?
aspiration
216
How do we manage blood stained or persistently refilling cysts?
Biopsy or excision
217
What do we do if cyst is large, painful and has infection signs?
Ultrasound-guided FNA
218
What do we do if we find complex cysts that look like they may be able to develop into breast cancer?
Ultrasound-guided core needle biopsy
219
What presentations do we refer on the 2WW for breast cancer?
- Age ≥30 with unexplained breast lump with or without pain
- Age ≥50 with discharge, retraction or other concerning changes in 1 nipple only
220
Who do we do routine non-urgent referral to breast clinic for?
Age <30 with unexplained breast lump with or without pain
221
List of currently notifiable diseases
- Acute encephalitis
- Acute infectious hepatitis
- Acute meningitis
- Acute poliomyelitis
- Anthrax
- Botulism
- Brucellosis
- Cholera
- COVID-19
- Diphtheria
- Enteric fever (typhoid or paratyphoid fever)
- Food poisoning
- Haemolytic uraemic syndrome (HUS)
- Infectious bloody diarrhoea
- Invasive group A streptococcal disease
- Legionnaires’ disease
- Leprosy
- Malaria
- Measles
- Meningococcal septicaemia
- Monkeypox
- Mumps
- Plague
- Rabies
- Rubella
- Severe Acute Respiratory Syndrome (SARS)
- Scarlet fever
- Smallpox
- Tetanus
- Tuberculosis
- Typhus
- Viral haemorrhagic fever (VHF)
- Whooping cough
- Yellow fever
222
What do we do if there’s a notifiable disease as a doctor?
The 'Proper Officer' at the Local Health Protection Team needs to be notified by the medical practitioner
They in turn will notify the Health Protection Agency on a weekly basis
223
What is the guidance on when to notify about the notifiable disease?
'immediately on diagnosis of a suspected notifiable disease' and not to 'wait for laboratory confirmation of a suspected infection or contamination before notification'
224
What is a notable exception from this list of notifiable disease?
HIV (due to historic reasons)
225
Define hospital acquired infections
aka nosocomial Infections, are infections that are contracted 48 hours after hospitalisation and that were not present or incubating at the time of admission
226
Risk factors of hospital acquired infections? (6)
- Age >70 years
- Lengthy hospital stays
- Foreign bodies
- Catheters
- Mechanical ventilation
- Recent antibiotic use
- Metabolic diseases (esp diabetes)
- Immunosuppression
227
What are the common causative pathogens for Surgical Site Infections (2)
- E.coli
- S.aureus
228
What are the common causative pathogens for Nosocomial Pneumonia (2)
- S.aureus
- P.aeruginosa
Can also get Ventilator-associated pneumonia
229
What are the common causative pathogens for Nosocomial UTIs
E.coli
230
What are the common causative pathogens for Bloodstream Infections
S.aureus
231
What are the common causative pathogens for GI infections
C.difficile
232
What is the main multidrug-resistant organism?
Methicillin-Resistant Staphylococcus Aureus (MRSA)
233
Define hernias
Where part of an organ is displaced and protrudes through the wall of the cavity containing it
234
Define Inguinal hernias (superiomedial to pubic tubercle)
Abdominal or pelvic contents protrude through inguinal canal → most common hernia (75%)
235
Direct inguinal hernia- what is it?
Protrusion directly through posterior wall of inguinal canal and medial to inferior epigastric vessels
236
How is Direct inguinal hernia developed?
Over time due to straining and weakness in abdominal muscles
237
Who does Direct inguinal hernia occur in?
Older men, rare in children
238
Indirect inguinal hernia- what is it?
Protrusion into inguinal canal through deep inguinal ring lateral to inferior epigastric vessels
239
How is indirect inguinal hernia caused
Defect in abdominal wall typically present since birth
240
Who does indirect inguinal hernia occur in?
May occur in infants
241
How do direct and indirect inguinal hernias differ on palpation?
When reduced and pressure is applied to deep inguinal ring, indirect hernia will remain reduced but direct hernia reappears
242
Risk factors of hernia? (10)
- Male
- Prematurity
- Age
- Obesity
- Raised intra-abdominal pressure (chronic cough)
- Constipation
- Family history
- AAA
- Marfan’s syndrome
- Ehlers-Danlos syndrome
243
Femoral hernias (inferiolateral to pubic tubercle) - how common and in who?
- only 5% of hernias
- More common in women
244
Define incarcerated hernias
Hernias that can’t be reduced and no systemic features
245
Define strangulated hernias
Blood supply cut off to hernia leading to ischaemia - more common with femoral hernias
246
How may patients present for strangulated hernias? (5)
- Tender, distended abdomen with guarding
- absent bowel sounds
- systemic features
- Bowel obstruction e.g. distension, nausea, vomiting
- Bowel ischaemia e.g. bloody stools
247
What are the features of an inguinal hernia? (4)
- Pain (dull, heaviness, dragging)
- Visible and palpable groin mass (may enlarge with standing/coughing) → is reducible
- Nausea and vomiting
- Constipation
248
What are the features of a femoral hernia? (2)
- Typically non-reducible
- Cough impulse more likely to be absent than inguinal, but still can be +ve
249
How is diagnosis usually made for hernias?
Via observation and palpation
250
What scans may be useful and when for hernias? (2)
- Ultrasound of groin when diagnostic uncertainty
- CT can be useful in very obese patients
251
What do we look for in bloods when suspecting a strangulated hernia? (2)
- Leukocytosis
- Raised lactate
252
What is the main method of management for hernias?
Surgical (mesh) repair even in medically fit patients even if they’re asymptomatic
253
How are unilateral vs bilateral/recurrent inguinal hernias dealt with?
- Unilateral inguinal hernias are repaired with open approach
- Bilateral/recurrent inguinal hernias are repaired laparoscopically
254
When can inguinal hernias be left?
If patient not fit for surgery - can use Truss support belt
255
What hernias defo need repair?
Femoral hernias due to risk of strangulation
256
What do we do if the hernia is obstructed/strangulated?
Emergency laparotomy
257
What post-op complications are there for hernias? (5)
- Urinary retention
- Wound seroma (fluid collection)
- Inguinal wound haematoma
- Wound infection
- Bowel obstruction
258
What operative complications are there for hernias?
Vas deferens division or vascular injury
259
What’s prognosis like for hernias?
Excellent after surgical repair
260
What is umbilical hernia
Symmetrical bulge under umbilicus
261
What is Paraumbilical hernia
Asymmetrical bulge directly above or below umbilicus
262
What is Epigastric hernia
Lump in midline between umbilicus and xiphisternum
263
Risk factors for epigastric hernias
extensive physical training or coughing
264
What is Obturator hernia
- Passes through obturator foramen
- Typically presents with bowel obstruction
265
What is strangulation in context of hernias
where the blood supply to the herniated tissue becomes compromised risking ischaemia and necrosis, leading to pain
-DO NOT manually reduce strangulated hernias, as this can cause more generalised peritonitis.
266
Define hiatus hernia
Protrusion of abdominal contents into thorax, usually the stomach
267
Sliding hiatus hernia - what is it?
- Most common type (95%)
- Gastro-oesophageal junction moves above diaphragm
268
Rolling hiatus hernia - what is it?
GOJ remains below diaphragm but a separate part of stomach e.g. fundus herniates through the oesophageal hiatus
269
Why do Rolling hiatus hernias need more urgent treatment?
As volvulus can result in ischaemia and necrosis
270
What risk factors are there for hiatus hernias? (3)
- Obesity
- GORD
- Increased intra-abdominal pressure
271
Increased intra-abdominal pressure - causes? (4)
- pregnancy
- ascites
- chronic cough
- constipation
272
What is Multi-Organ Dysfunction Syndrome
A clinical syndrome characterised by the development of progressive and potentially reversible physiologic dysfunction of 2 or more organs or organ systems that is induced by a variety of insults, including sepsis
273
What does Multi-Organ Dysfunction Syndrome usually result from? (4)
- Infection
- Injury
- Hypoperfusion
- Hypermetabolism
274
Flowchart of MODS progression
SIRS + infection → sepsis → severe sepsis → MODS
275
MODS score- what are the 4 stages of it?
- **Stage 1** - increased volume requirements, mild respiratory alkalosis, oliguria, hyperglycaemia, increased insulin requirements
- **Stage 2** - tachypnoea, hypocapnia, hypoxaemia, moderate liver dysfunction and haematologic abnormalities
- **Stage 3** - shock, azotaemia (high nitrogen in the blood), acid-base disturbance, significant coagulation abnormalities
- **Stage 4** - vasopressor dependent, oliguria or anuria, development of ischaemic colitis and lactic acidosis
276
What are the main investigations we’d want to do for MODS?
- Monitor vital signs
- ABG may be necessary to look at hypoxaemia, lactic acidosis etc
277
Define mastitis
inflammation of the breast with or without infection
278
When with infection, what 2 types are there for breast mastitis?
Lactational and non-lactational
279
Who does lactational mastitis occur in?
10% of nursing mothers usually 2-4 weeks post partum
280
Most common causative agent in lactational mastitis ?
Staph aureus
281
What is a breast abscess?
a localised area of infection with a walled-off collection of pus → main complication of mastitis
282
Biggest risk factor of breast abscess/mastitis?
Breastfeeding
283
What are the cliical features of breast abscess/mastitis? (4)
- Tender, firm, swollen erythematous breast
- Pain during breastfeeding (also decreased milk outflow) → usually a sharp breast pain
- Flu like symptoms: fever, malaise, chills, myalgia
- Nipple Discharge → purulent discharge is associated with infection
284
What does an abscess look like?
fluctuant, tender mass with overlying erythema
285
What scan can we do for breast abscess/mastitis to show what?
Breast US to show pus collection
286
What more invasive techniques are there for breast abscess/mastitis? (2)
- Diagnostic Needle Aspiration Drainage → purulent fluid indicates a breast abscess
- Fine Needle Aspiration
287
How can we identify the infectious agent for breast abscess/mastitis?
Breast milk cultures
288
With uncomplicated mastitis what can we do for management?
Breastfeeding with alternative breasts every few hours (first line mx is to continue breastfeeding)
289
What else can we give the mother for uncomplicated mastitis?
Analgesics (e.g. ibuprofen)
290
What antibiotics is first line for breast abscess/mastitis and for how long?
flucloxacillin for 10-14 days (as s. aureus is most common causative organism)
291
How do we manage a breast abscess?
Needle aspiration, incision and drainage
If there’s a suspected abscess we refer to secondary care
292
Complications for breast abscess/mastitis? (5)
- cessation of breast feeding
- abscess
- sepsis
- scarring
- fistula
293
Prognosis for breast abscess/mastitis?
When treated promptly and appropriately, most breast infections, including abscess, will resolve without serious complications
Resolution of mastitis after 2-3 days of appropriate antibiotic therapy is expected among most patients
294
What 2 strains of HSV are there in humans?
HSV-1 and HSV-2
295
How is either HSV strain transmitted?
Via direct contact with mucosal tissue or secretions of another infected person
296
How is HSV-1 usually acquired?
In childhood via saliva
297
How is HSV-2 usually spread?
Through genital contact
298
What diseases does HSV-1 cause? (2)
- Herpes labialis i.e. cold sores (oral herpes)
- HSV encephalitis
299
What disease does HSV-2 cause?
Genital herpes
300
What risk factors are there for hsv? (2)
- HIV
- Immunosuppressive medications
301
What are the clinical features of HSV? (4)
- Painful genital ulcer(s)
- Tender inguinal lymphadenopathy
- Oral ulcer
- Erythema multiforme
302
Oral ulcer- what do you feel before the appearance of the cold sore?
Tingling sensation
303
what other symptoms of genital herpes are there? **(2)**
- Dysuria
- Pruritus
304
How does the primary infection of HSVpresent?
may present with a severe gingivostomatitis (erythema and painful ulcerations on the perioral skin and oral mucosa)
305
What is eczema herpeticum?
severe primary infection of the skin by herpes simplex virus 1 or 2- potentially life threatening
306
Who is eczema herpeticum commonly seen in?
Commonly seen in children with atopic eczema
307
How does eczema herpeticum present? (2)How is it treated?
- rapidly progressing painful rash
- Punched out erosions
IV aciclovir
308
How does herpes simplex keratitis present? (4)
- Red painful eye
- Photophobia
- Epiphora (watery eye)
- Fluorescein staining showing linear branching epithelial ulcer
309
What do we order when HSV lesions are present?How else do we detect the type of virus?
Viral PCR
Viral culture
310
What do we do with suspected genital herpes?
nucleic acid amplification tests (NAAT) (after obtaining swab of the base of the ulcer)
311
What is first line for HSV?
Oral aciclovir
312
What do we give for HSV symptoms? (5)
- IV fluids
- Barrier creams
- Pain relief
- Antipyretics
- Antibiotics
313
How do we manage a pregnant woman during 3rd trimester with genital herpes?
Oral aciclovir until delivery and do C section delivery
314
What complications are there for HSV? (5)
- oesophagitis
- meningitis
- encephalitis
- hepatitis
- bell’s palsy
315
What’s the prognosis like for HSV patients?
genital herpes and oral herpes are chronic viral infections with a highly variable course. Some people may have frequent outbreaks of disease, whereas others will be completely asymptomatic
316
What disease does Varicella Zoster (Human Alpha Herpes Virus) cause?
Varicella (chickenpox)
317
who does Varicella (chickenpox) infect? Which groups are at high risk of complications? (4)
Exclusively human virus- over 80% of people have been infected by the age of 10 years
- Adults
- Pregnant women
- Immunosuppressed patients
- Neonates
318
How is VZV spread?
When susceptible person is exposed to VZV either by direct contact with lesions or through airborne spread from respiratory droplets
Incubation period is 14 days
319
What happens after primary infection of VZV?What can happen later in life?
Can become latent in dorsal root ganglia and trigeminal ganglia
In 1/3 cases it may reactivate to produce shingles
320
Risk factors of shingles? (2)
HIV or immunocompromise (e.g. steroid use or chemo)
321
Risk factors of VZV? (4)
- Exposure to VZV
- Age 1-9 years
- Unimmunised status
- Occupational exposure
322
Describe Ramsay Hunt Syndrome
LMN facial nerve palsy due to reactivation of varicella zoster virus in geniculate ganglion of facial nerve
323
What are the clinical features of Ramsay Hunt Syndrome in order? (3)
- First is auricular pain
- Then unilateral facial nerve palsy and vesicular rash around ear (may also get blisters on anterior 2/3 of tongue)
324
How do we treat Ramsay Hunt Syndrome? (2)
Oral aciclovir and corticosteroids (prednisolone)
325
Define Herpes Zoster Ophthalmicus
Reactivation of varicella zoster virus in area supplied by ophthalmic division of trigeminal nerve
326
Clinical features of Herpes Zoster Ophthalmicus? (2)
- Vesicular rash around eye
- Hutchinson’s sign (rash on tip or side of nose) → indicates likely ocular involvement e.g. anterior uveitis
327
Management of Herpes Zoster Ophthalmicus? (2)
- Urgent opthalmology review
- Oral antivirals for 7-10 days
328
clinical features of VZV
- Fever
- Vesicular rash- where does it start and then spread to?
Appears centrally first then spreads to extremities
- Vesicles on mucous membranes e.g. nasopharynx
- Pruritus
- Headache
- Fatigue/malaise
- Sore throat
329
What are the clinical features of shingles?
- Acute, unilateral, painful blistering rash- describe it
Erythematous, macular, vesicular rash
- Prodromal period of burning pain over affected dermatome for 2-3 days
330
When are shingles patients infectious until?
Until vesicles have crusted over → usually 5-7 days from onset
331
What is the treatment for shingles? (3)
- Paracetamol
- NSAIDs
- Can give antivirals within 72 hours
332
Which groups should infected shingles people avoid? (2)
Pregnant women and immunocompromised whilst infectious
333
What is the main investigation for VZV?
What do we do in pregnant women?
PCR- positive for virus DNA
US- screen for foetal consequences of infection
334
What supportive care do we give for VZV?
Paracetamol
335
What do we give for risk of moderate-severe VZV disease?
Oral aciclovir
336
What do we give for risk of severe VZV disease?
IV antiviral therapy
337
Which groups of VZV patients should take post-exposure prophylaxis? (3)
What is the prophylaxis?
- Significant exposure to chickenpox or varicella zoster
- Immunosuppression, neonates, pregnant
- no antibodies to varicella virus
varicella-zoster immunoglobulin (VZIG)
338
What do we give for a common complication of shingles?
Antivirals to reduce chances of post herpetic neuralgia, especially in old people
339
What are the complications for VZV? (5)
- Varicella pneumonia
- Encephalitis
- Meningitis
- Hepatitis
- Severe infection in the newborn
340
Which cancers most commonly form Bone metastases? (3)
- Breast cancer
- Lung cancer
- Prostate cancer
341
What are the most common sites of bone metasteses (from most to least common)? (5)
- Spine- most common
- Pelvis
- Ribs
- Skull
- Long bones- least common
342
What are symptoms are spine metastases associated with? (3)
- Back pain worse when sneezing/coughing
- Worse at night
- Associated with tenderness
343
Clinical features of bone metasteses? (4)
- Bone pain
- Pathological fractures
- Hypercalcaemia
- Raised ALP
344
Treatment options of bone metasteses? (4)
- Pain management (radiotherapy)
- Chemotherapy
- Bisphosphonates for pain (inhibit bone resorption)
- Surgery (if pathological fractures or spinal cord compression)
345
How do you manage neoplastic spinal cord compression while awaiting imaging?
High dose oral dexamethasone
346
Common causes of brain metasteses? (5)
- Lung cancer- most common
- Breast cancer
- Bowel cancer
- Melanoma
- Renal cell carcinoma
347
Features of brain metasteses? (4)
- Seizures
- Focal neurological deficits
- Cognitive deficits
- Headaches
348
Management options of brain metastases? (3)
- Surgical resection
- Stereotactic radiosurgery
- Patients with poor functional status may be treated palliatively
349
Most common causes of lung metasteses? (6)
- Breast cancer
- Colorectal cancer
- Renal cell carcinoma
- Prostate cancer
- Bladder cancer
- Melanoma
350
What would a CXR show for lung metasteses?
Multiple rounded lesions → “Cannonball metastases”
351
What type of cancer is cannonball metastases in lung most commonly due to?
Renal cell cancer → Investigate using CT CAP
352
Define Epistaxis
Nosebleeds
353
What is the most common site of nose bleeding?
Kiesselbach plexus (Little’s Area- where vessels supplying nasal mucosa anastomose with each other)
354
Who is epistaxis most common in?
Children and older people
355
What are the 2 types of epistaxis?
- Anterior epistaxis (90% of cases)- blood flowing out nostrils
- Posterior epistaxis- rare- blood running down throat- high risk of aspiration and airway compromise
356
Risk factors of epistaxis? (6)
- Dry weather
- Minor nasal trauma (nose picking or rubbing)
- Primary coagulopathy (haemophilia)
- Familial hereditary haemorrhagic telangiectasia
- Granulomatosis with polyangiitis
- Thrombocytopenias
357
- Granulomatosis with polyangiitis- what features? **(6)**
- Epistaxis
- Sinusitis
- Dyspnoea
- Saddle shaped nose
- Rapidly progressive glomerulonephritis
- cANCA positive
358
Familial hereditary haemorrhagic telangiectasia- what is it?
- autosomal dominant condition
- Characterised by multiple telangiectasia (small dilated broken blood vessels) over skin and mucous membranes
- Causes spontaneous, recurrent nosebleeds
- First degree relative will also have it
359
Thrombocytopenias- give 2 examples
- Idiopathic thrombocytopaenia purpura (ITP)- features and treatment?
It’s isolated thrombocytopaenia in a well person
- Also causes petechiae and purpura
- Treatment with oral prednisolone
- Thrombotic thrombocytopaenia purpura (TTP)- features? **(3)**
It’s isolated thrombocytopaenia in an unwell person
- HUS (haemolytic anaemia, thrombocytopaenia, AKI)
- Fever
- Neurological signs
360
What are the clinical features of epistaxis? (3)
- blood in 1 nostril or on both sides of nose
- Recurrent epistaxis → suggests anterior vessel on affected side- common in children
- Septal deviation- increased likelihood for epistaxis
361
What’s the main investigation for epistaxis?
Clinical diagnosis- bleeding from nose or back of throat
362
What do we do if epistaxis patient is haemodynamically unstable?
Begin fluid resus
363
What is first stage of management for epistaxis?
Pinch the cartilaginous (soft) area of the nose firmly and bend their head forward (NOT BACK as blood may go into pharynx and cause haematemesis)
364
What is 1st and 2nd line if blood doesn’t stop after 10-15 mins for epistixis?
- 1st line → nasal cautery
- 2nd line or if bleeding point difficult to localise → nasal packing
365
What do we give for recurrent epistaxis?
Naseptin (antiseptic cream)
366
What do we do for posterior epistaxis?
ENT specialist will manage it
367
Complications of epistaxis?
- Acute bacterial rhinosinusitis
- Aspiration pneumonia
- Recurrent epistaxis
368
Prognosis of epistaxis?
Most patients respond to treatment, particularly to nasal packing
369
what is Infectious mononucleosis aka
Mono or kissing disease or glandular fever
370
What is Infectious mononucleosis caused by?
Epstein Barr Virus (EBV)
371
How is Infectious mononucleosis spread?
Highly contagious and spreads via bodily secretions esp saliva (hence kissing disease)
372
What is peak incidence for Infectious mononucleosis?
15-24 year olds
373
Risk factors for infectious mononucleosis? (2)
Kissing and sexual activity
374
How long is the incubation period of Infectious mononucleosis?
6 weeks
375
How long are symptoms shown for Infectious mononucleosis in adults vs children?
- 2-4 weeks in adults
- Asymptomatic in children
376
Features of Infectious mononucleosis? (8)
- Fever
- Fatigue/malaise
- Splenomegaly
- Tonsilitis (sore throat) or pharyngitis
- Bilateral cervical lymphadenopathy
- Abdo pain
- Hepatomegaly and jaundice
- Maculopapular rash- develops in who?
99% of patients who take ampicillin/amoxicillin while they have mono
377
What is the main test forInfectious mononucleosis?
Monospot test (heterophile antibody test) → positive heterophile antibodies
378
What other antibodies test is there forInfectious mononucleosis ?
Positive EBV-specific antibodies → IgG to EBV nuclear antigens appears 6-12 weeks after infection and are lifelong
379
What bloods do we do for Infectious mononucleosis?(3)
- LFTs- showing?
Raised AST and ALT
- FBC- showing?
Lymphocytosis and neutropenia
- Blood film- showing?
Atypical lymphocytes
380
What is the main management like for Infectious mononucleosis? (3)
Supportive care
– Rest, fluids, analgesia/antipyretics (paracetamol ± NSAIDs)
Avoid contact sports
– For at least 3–4 weeks (risk of splenic rupture)
Corticosteroids only if severe complications
– e.g. airway obstruction, severe haemolytic anaemia, thrombocytopenia
381
what drugs can we give for Infectious mononucleosis? (2)
- Analgesics / Antipyretics → acetaminophen (paracetamol)
- Corticosteroids in severe cases (prednisolone)
382
Complications of Infectious mononucleosis? (2)
- Antibiotic-induced rash if given amoxicillin
- Chronic fatigue
383
Prognosis of Infectious mononucleosis?
very good for healthy people. Death occurs rarely, and is caused by airway obstruction, splenic rupture, neurological complications, haemorrhage, or secondary infection
384
Define Rhinosinusitis
Symptomatic inflammation of the lining of the nasal cavity (rhinitis) and paranasal sinuses (sinusitis)
385
Which groups does Rhinosinusitis happen in? (2)
- F>M
- Peak incidence tends to occur in colder months
386
What are the 2 types of causes of Rhinosinusitis?
- Viruses- which ones? **(3)**
- Rhinovirus
- Coronavirus
- Adenovirus
- Bacteria- which ones? **(2)**
- Strep pneumoniae
- Haemophilus influenzae
387
What are the 3 categories of Rhinosinusitis based on how long it lasts?
- Acute ≤4 weeks
- Subacute 4-12 weeks
- Chronic ≥12 weeks
388
Risk factors of Rhinosinusitis? (4)
- pre-existing viral URTI can lead to superimposed bacterial infections
- atopy (hay fever/asthma)
- nasal obstruction
- smoking
389
What are the clinical features of Rhinosinusitis? (7)
- Frontal facial pain/pressure worse on bending forwards
- Purulent nasal discharge- discoloured nasal mucus
- Nasal obstruction (congestion/stuffiness/blockage)
- Cough
- Myalgia
- Sore throat
- Anosmia
390
How do we know the cause of Rhinosinusitisbased on how long symptoms last?
- symptoms <10 days → viral
- Symptoms >10 days but <4 weeks → bacterial
391
What is the main way we diagnose rhinosinusitis?
Clinical diagnosis
392
What do we do if we suspect complications for Rhinosinusitis?
sinus CT
- What may we see? **(4)**
- Opacification
- Mucosal thickening
- Air-fluid levels
- Soft tissue swelling
393
What other visualising investigation is there for Rhinosinusitis?
Nasal endoscopy- provides good visualisation for the nasal cavity and sinuses
394
What investigation can help in planning appropriate Rhinosinusitis management?
Sinus culture
395
What supportive management is there for Rhinosinusitis?
Analgesics or antipyretics (paracetamol/ibuprofen)
396
What drugs can we give for Rhinosinusitis? (3)
- Decongestants
- Intranasal corticosteroid- when?
If lasted >10 days
- Ipratropium (anticholinergics)
397
What other management for Rhinosinusitis do we do alongside the drugs?
Nasal irrigation with intranasal saline
398
What do we give if severe Rhinosinusitis?
Antibiotics- phenoxymethylpenicillin- alongside above measures
399
Complications of Rhinosinusitis? (4)
- chronic sinusitis
- bacterial meningitis
- brain abscess
- peri-orbital or orbital cellulitis
400
prognosis ofRhinosinusitis
generally self-limiting and resolves within 1 month. Complications are more commonly seen in the paediatric population, and occur due to direct extension of the infection into neighbouring structures.
401
Define scleritis
Transmural inflammation of sclera
402
Which demographics does scleritis happen to?
- F>M
- 40-60 years
403
What other conditions are commonly found along with scleritis? (4)
Underlying systemic disorder or infection
- Commonly RA
- SLE
- IBD
- gout
404
What are the clinical features of scleritis? (4)
- Deep, aching, boring eye pain exacerbated by eye movement and palpation, may radiate to rest of face
- Red eye
- Photophobia
- Lacrimation
405
What do we see in episcleritis (inflammation more superficial)?
Painless red eye
406
What do we give to distinguish between scleritis and episcleritis?
Phenylephrine drops- if eye redness improves after then it’s episcleritis
407
What scans can we do for scleritis and why? (2)
- US to see posterior scleritis
- Orbital CT/MRI to differentiate between orbital lesions
408
What else do we need to investigate for scleritis?
Systemic diseases e.g. RA, ANA
409
Who do we needa call for scleritis?
Urgent referral to opthalmologist (threat to sight)
410
What’s first line for scleritis in mild-moderate cases?What do we give if they don’t work?
NSAIDs
Systemic glucocorticoids
- What do we give if unresponsive to steroids?
Systemic immunosuppressive therapy (azathioprine, methotrexate)
411
What is the threshold for hypertension? (2)
- Blood pressure that is persistently ≥140/90 mmHg
AND
- 24 hour blood pressure average reading (ABPM/HBPM) ≥135/85 mmHg
412
What is primary/essential hypertension?
Hypertension with no identifiable cause
413
What is secondary hypertension?
Hypertension caused by an identifiable underlying cause
414
What is the most common cause of secondary hypertension?
Conn’s syndrome- primary hyperaldosteronism
415
Give examples of other causes of hypertension (4)
- renal stenosis
- cushing’s syndrome
- phaeochromocytoma
- acromegaly
416
Risk factors of secondary hypertension? (6)
- Age >65 years
- Alcohol intake
- Lack of exercise
- Obesity
- DM
- Black ancestry
417
How does secondary hypertension usually present?
Usually asymptomatic unless blood pressure is very high
418
List non-specific symptoms of hypertension (3)
- Headache
- Blurred vision
- Dizziness
419
When can orthostatic hypertension be diagnosed?
When there is a drop in SBP of at least 20 mmHg and/or a drop in DBP of at least 10 mmHg after 3 minutes of standing
420
What is the confirmatory investigation for hypertension?
Ambulatory blood pressure measurement (ABPM)- measures BP at fixed intervals over 12-24 hours allowing average to be taken
421
If ABPM is declined for secondary hypertension, what is the next step?
Home blood pressure monitoring, measured by individual at periodic intervals
422
If new BP is ≥180/120mmHg for secondary hypertensioj, then what is the first step of investigation?
Urgent assessment for end-organ damage
Before chasing the cause (secondary hypertension), you must check organ status
423
List investigations for secondary hypertensionto assess end organ damage (3)
- Fundoscopy- what we looking for?
retinopathy
- Urine dipstick- what we looking for?
Renal disease
- ECG- what we looking for?
LVH
424
What lifestyle advice can you give patients to reduce hypertension? (5)
- Weight loss
- Decrease dietary sodium
- Decrease alcohol intake
- Exercise
- Smoking cessation
425
What is 1st line management for hypertension if <55 years old or diabetic?
ACEi’s
- Give examples of ACEi’s **(2)**
- Lisinopril
- Enalapril
426
In what case should a hypertensive patient with CKD be started on ACEi?
If ACR >30 or 3.0 (regardless of age)
427
List side effects of ACEi (3) What can you swap the ACEi for?
- Angioedema
- Cough
- Elevated potassium
ARB
428
What is ACEi the most common cause of?
Drug induced angioedema
429
When is ACEi contraindicated and why? Which patient should this always be considered for?
Renal artery stenosis- starting ACEi may cause significant renal impairment (deranged U&Es)
A patient with risk factors for, and evidence of, atherosclerotic vascular disease
430
What is the preferred medication for black hypertensive patients?
ARB (Losartan)
431
What is 1st line management for hypertension if >55 years old (and not diabetic) or black ethnicity?What is offered if QRISK score is >10%?
Amlodipine/nifedipine
A statin e.g. atorvastatin
432
side effects of Amlodipine/nifedipine
- Ankle swelling (Peripheral oedema)
- headache
- flushing
433
What thiazide like diuretics could we give for hypertension? (3)
In what condition are they contraindicated?
- Indapamide
- Hydrochlorothiazide
- Chlorthalidone
Gout
434
What side effects are there for thiazide like diuretics? (5)
- Hypercalcaemia
- Hyponatraemia
- Hypokalaemia
- Impaired glucose tolerance
- Can cause erectile dysfunction
435
- Hypokalaemia- what does this look on ECG? **(5)**
- T wave flattening
- U waves
- long QT
- prolonged PR interval
- ST depression
436
What can you add on if patient has poorly controlled hypertension, already taking ACEi, CCB and standard dose thiazide like diuretic?
Alpha blocker
437
What do you do if new BP ≥180/120 and no worrying signs for hypertension?
Urgent investigations for end organ damage e.g. ECG, urine dipstick and bloods
438
What if there are worrying signs for hypertension e.g. confusion/chest pain/HF signs/AKI?
Refer for acute medical admission
439
Prognosis for hypertension?
Even modest reductions in blood pressure decrease morbidity and mortality due to complications
440
Define gangrene
Complication of necrosis characterised by the decay of body tissues
441
What are the two types of gangrene?
- Infectious gangrene (wet)
- Ischaemic gangrene (dry)
442
Infectious gangrene (wet)- causes? (2)
- Necrotising fasciitis
- Gas gangrene- clostridium perfringes
443
Ischaemic gangrene (dry)- what is it caused by?
Peripheral artery disease (critical limb ischaemia) due to atherosclerosis (arterial obstruction) or venous obstruction
444
Compare PAD with Buerger’s disease (thromboangiitis obliterans) (2)
- Leg pain with strenuous exercise in PAD, however not commonly associated with Raynauds’s phenomenon
- Buerger’s is a small and medium vessel vasculitis strongly associated with smoking & causes Raynaud’s phenomenon
445
What do we see on angiogram for Buerger’s?
rkscrew shaped collateral blood vessels
446
Risk factors of gangrene? (3)
- Diabetes
- Atherosclerosis
- Smoking
447
What are the general clinical features of gangrene? (3)
- Painful black tissue
- Feeling of heaviness in affected area
- Oedema and swelling
448
List clinical features of wet gangrene (3)
- Sudden onset of pain
- Low grade fever & chills
- Poorly demarcated necrotic area
448
List clinical features of dry gangrene (3)
- Diminished pulses & ABPI (no signs of infection)
- Well demarcated necrotic area
- History of chronic claudication (pain in arms or legs when moving/walking)
449
List clinical features of gas gangrene (4)
- Darkened skin
- Crepitus may be heard due to escaping gas
- Infective area gives off distinct and potent smell
- May be able to visualise gas on radiograph
450
What would you do if infectious gangrene is suspected?
Blood cultures
451
How can you detect the presence and severity of arterial or venous obstruction?
Doppler ultrasonography
452
What is the definitive method to make diagnosis of gangrene? (2)
- Surgical exploration
- Skin biopsy
453
What is the management for wet gangrene (nec. fasc. and gas gangrene)? (2)
- Surgical debridement
- Broad spectrum antibiotics
454
What is the management for dry gangrene? (2)
- IV heparin
- Surgical revascularisation
455
What should you consider if the limb is non-viable in gangrene?
Amputation
456
What are the two key factors for improving outcomes in this life- and limb-threatening condition? (2)
- Early recognition
- Aggressive antibiotic and surgical management
457
Define fibroadenoma
A benign breast tumour with fibrous and glandular tissue
458
Who is Fibroadenoma most common in?
Most common in women between 15-35 yrs old (most common breast tumour in women <35 yrs old)
459
What is the cause of Fibroadenoma
Unknown but increased oestrogen during pregnancy or menstruation may stimulate growth
460
What is the risk of malignancy of Fibroadenoma compared to a cyst?
No increase in risk of malignancy (unlike cyst)
461
What are the clinical features of Fibroadenoma? (5)
A ‘breast mouse’
- Well defined, mobile mass
- Smooth
- Most commonly solitary
- Non-tender
- Rubbery consistency
462
What scans do we do in who and what would we see for Fibroadenoma? (2)
- US <35 years → well defined mass
- Mammography >35 years → well defined mass which may have popcorn like calcifications
463
What more invasive investigation techniques are there for Fibroadenoma? (2)
Core Needle Biopsy or Fine Needle Aspiration
464
What are the 2 main parts of management for Fibroadenoma?
- Regular check-ups
- If >3cm ⇒ surgical excision
465
Prognosis of fibroadenoma?
good, most fibroadenomas are not associated with an increased risk of breast cancer
Year 3
flashcards
Decks in class (18)
# Cards
-
🫀Cardiac conditions224
-
GP:)466
-
🫁Respiratory conditions218
-
🍔Gastroenterological conditions398
-
Endocrinology477
-
Psychiatry51
-
Immunological91
-
MSK223
-
Urological369
-
Emergency116
-
Dermatology169
-
Pharmacological52
-
Neurological358
-
Haematological357
-
Presentations17
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Blublub Part 1507
-
Blublub Part 2262
-
Blublub part 314
