1/11/21 - 2/11/21 Flashcards
Presentation of Anterior Uveitis (2 points + bonus)
- Presents with pain and redness. If redness is present → primarily noted at the limbus and patients have a constricted pupil and pain.
Presentation of Posterior Uveitis (3 points)
- More likely to be painless compared to anterior uveitis but can presents with floaters and blurred vision
3 conditions which are associated with uveitis
- Ankylosing Spondylitis
- IBD
- Behcet’s Disease
Clinical Features of Anklylosing Spondylitis (5 points)
- gradual onset < 40yo
- duration of symptoms >3months
- prolonged morning stiffness and night pain
- improvement with physical activity or exercise, and failure to improve with rest
- response to NSAIDs
When to treat granuloma annulare? (3 points)
- lesions persisting for months -> confirm with biopsy if not already performed
- is unsightly or tender
- interferes with function -> e.g if on finger
How to treat granuloma annulare?
Treatment is: betamethasone dipropionate 0.05% ointment BD for a minimum of 4-6 weeks
Diagnosis of Giardia (2 points)
Stool Microscopy for cysts and trophozoites
- a negative test does not preclude an infection → diagnostic yield is increased when 2nd or 3rd test is also tested
Direct Fluorescent Antibody methods to detect antigen are more sensitive
How and when to treat Giardia? (2 points)
Not necessary in immunocompetent patients with asymptomatic Giardia infection
In symptomatic patients → Metronidazole 400mg PO 8hourly for 5/7
4 features on history of acute pancreatitis
- Severe, constant, deep epigastric pain → lasts hours or a days
- Pain may radiate to the back + relieved by sitting forwards
- Nausea + Vomiting
- Sweating and Weakness
Features on examination of acute pancreatitis (2 + 2 bonus)
- Tender in epigastrium
- Fever, Tachycardia +/- shock
- Ecchymotic discolouration → Grey Turner Sign (flank) or Cullen’s Sign (periumbilical) → suggest retroperitoneal bleeding
- Dyspnoea → diaphragmatic inflammation secondary to pancreatitis, pleural effusion or ARDS
Red Flags for New-Onset Headache (9 points)
- Sudden Onset → subarachnoid haemorrhage, arterial dissection, pituitary apoplexy, haemorrhage into mass lesion, reversible cerebral vasoconstriction syndrome
- First ever headache with focal neurological signs or drowsiness or confusion → stroke, venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, meningitis/encephalitis
- Age >50yo → Giant Cell Arteritis, Mass Lesion or Stroke
- Head Trauma → subdural/epidural haemorrhage
- Frequency/Severity increases over weeks to months → mass lesion, subdural haemorrhage, analgesic rebound
- New onset headache in patient with HIV, Cancer or is immunosuppressed → meningitis, abscess, metastases
- Signs of Systemic Illness (fever, rash, neck flexion stiffness) → systemic infection, meningitis, encephalitis, vasculitis
- Papilloedema → mass lesions, raised intracranial hypertension, venous sinus thrombosis
- Positional Headache (worse when lying down) or Cough Headache → space-occupying lesion or posterior fossa lesion, Chiari Malformation
Management of Recurrent Pneumothorax. (2 points)
- If one recurrence ON THE SAME SIDE → refer for pleurodesis
Imaging in the context of Multiple Myeloma (3 points)
- Imaging of the Skeleton → Whole Body CT, MRI or PET Scan to detect lytic lesions and fractures
- bone loss, osteopenia, focal lytic lesions and fractures are defining of MM
- CT + PET are more sensitive than Whole Body XR
Clinical Features of Cervical Spondylosis (6 points - type and location of pain, when is pain worse, what makes pain better or worse, night time pain?, movement restriction)
- Dull, aching suboccipital neck pain
- Worse in the morning on arising and lifting head
- Improves with gentle activity and warmth (e.g warm showers) + Deteriorates with heavy activity
- Usually unilateral pain → pain may be referred to head, arms and scapulae
- May wake patient at night with parasthesia in arms
- Restricted tender movements → especially rotation/lateral flexion
Which vertebrae are most affected in cervical spondylosis? (2 points)
Occurs following disc degeneration and apophyseal joint degeneration → involves C5-6 and C6-7
- Leads to narrowing of the intervertebral foramen with the nerve roots C6 and C7 being at risk of compression
Distribution of Varicella Rash
Everywhere - most in central trunk (scalp, eyelids, nose and mouth)
Distribution of Erythema Infectiosum
SLAPPED CHEEK in a well child
Rash on forearms and thighs
Distribution and Presentation of Rubella
Rash first on face and neck then scattered rash around the body + postauricular lymphadenopathy
Distribution of Scarlet Fever
Circumoral Pallor + Strawberry Tongue
Sandpaper rash
Background erythema with superimposed puncta (scarlet spots)
Distribution and Presentation of Measles
3 C’s -> cough, coryza, conjunctivitis
Blotchy maculopapular rash
Clinical Features of Roseola Infantum (2 points + timeframes)
- Sudden high temperature - lasts between 3-5 days
- Raised, red rash when child’s temperature returns to normal → appears on body, spreads to arms and legs and RARELY seen on the face
- Rash generally lasts for 2 days and blanches when pressed
Isolation period of Roseola Infantum (1 point)
- Children with roseola are only contagious before their symptoms appear → so once the rash and other symptoms appear they can no longer spread the virus to other children
- Rarely affects adults → by age of 2, 95% of people have been infected with roseola
Clinical Features of Atypical Pneumonia -> common responsible pathogen + history features.
- Mycoplasma pneumoniae → typically community acquired and mild
- Gradual Onset
- Low-Grade Fever, Malaise
- Headache
- Sore Throat
- Minimal respiratory symptoms - non-productive cough, pleuritic chest pain or SOB
ABx therapy for atypical pneumonia + duration of therapy plan.
- doxycycline 100mg orally, 12 hourly-
Duration of therapy:
- If patient has significantly improved after 2-3 days of ABx → treat for 5 days - If clinical response is slow → treat for 7 days
Who should receive anti-viral therapy for shingles? (2 points)
- Antiviral therapy is recommended for all patients who present within 72 hours of the formation of the rash or for immunocompromised patients at any time regardless of duration of the rash.
Treatment for Shingles
- valaciclovir 1g TDS for 7/7 (children >2yo -> 20mg/kg up to 1g)
When do people receive the Zostavax and is it a live vaccine?
Live attenuated vaccination
Single Dose → free for people aged >70yo
5 year catch-up program for people aged 71-79 until 31 October 2021
If shingles in the last year, should patients receive the vaccination? What should happen if the patients have had multiple episodes of shingles in the past year?
If had shingles in the last year and immunocompetent → vaccination should be delayed by 1 year
If 2 or more episodes of shingles in 1 year → investigate for underlying cause of immune suppression prior to vaccination
Definition of Diabetic Ketoacidosis (3 points)
- Hyperglycaemia → BGL >11mmol/L
- Presence of Ketonaemia or Ketonuria
- Venous pH <7.3 or bicarb <15mmol/L
Clinical Features of DKA (7 points - give 4)
- Dehydration
- Polyuria + polydipsia, polyphagia
- Weight Loss - due to fluid loss and loss of muscle and fat
- Weakness
- Kussmaul’s Respirations → Hyperventilation of DKA
- Nausea and Vomiting
- Abdominal pain
Clinical Symptoms suggestive of diabetes (6 points)
- lethargy, polyuria, polydipsia
- frequent fungal or bacterial infections
- blurred vision
- loss of sensation (ie touch, vibration, cold)
- poor wound healing
- weight loss.
Risk Factors for PE (6 categories)
- Surgery
- Acute and Chronic Medical Illness
- Malignancy Related
- Known Thrombophilia
- Other - BMI, prolonged immobilisation of Travel, PHX of DVT or PE
- Hormone Related Factors
Wells Score (7 points)
Clinical Signs and Symptoms of DVT
PE most likely diagnosis
Tachycardia >100
Prolonged period of immobilisation (3 days) or surgery within the last
PHx of DVT or PE
Haemoptysis
Malignancy in last 6/12
PERC Rule (what is it and 8 points)
PE Rule-out Criteria - if any are positive, cannot rule out PE
Age <50yo No Oestrogen Use No Tachycardia >100bpm SaO2 > 95% No Haemoptysis No surgery or trauma requiring hospitalisation within 4 weeks No PHx of VTE No unilateral leg swelling
What kind of immobilisation should a patient with a suspected scaphoid fracture have? When should they be placed in this immobilisation?
if definitive diagnosis cannot be determined and scaphoid fracture is determined on clinical grounds EVEN IF RADIOGRAPHS ARE NEGATIVE → patient should be placed in a volar wrist splint or preferably a thumb spica splint/cast until definitive imaging is performed.
Clinical Diagnosis of OA
- Age ≥ 45yo
- Activity Related Joint Pain
- Morning Stiffness lasting <30mins
Examination Findings of Hip and Knee OA + 1 special test and findings.
- Limited ROM of Hip on internal rotation, flexion or knee flexion/extension
- Pain on Hip Internal Rotation and Flexion
-
FABER Test → Flexion-Abduction-External Rotation Test
- Stretches the portion of the gluteus medius/minimus that rotates the hip medially
- Pt supine → examiner lifts knee on affected side (flexion) → places heel onto opposite knee and lets the knee fall to the side
- Pain in lateral hip → Greater Trochanteric Pain Syndrome, Pain in groin → hip joint disease, pain in buttock → sacroiliac joint disease
-
Diagnosis of Acute Bacterial Sinusitis
At least 3 of:
- Fever >38
- Discoloured purulent nasal discharge
- Severe localised pain
- Elevated ESR or CRP
- Double Sickening - patient deteriorates after a period of mild illness
ABx choice in Acute Bacterial Rhinosinusitis and if no improvement, what is the next step?
- amoxicillin 500mg (child 15mg/kg up to 500mg) orally, 8hrly for 5/7
- if no improvement in 5/7 or if symptoms worsen or if features of complicated infection develop → amoxicillin + clavulanate 875+125mg BD for 5/7
Time criteria of diagnosis of undescended testes? Why?
Testis that is not in the scrotum by the AGE OF 3 MONTHS
5% of boys have undescended testes at birth → 1-2% at 3 months old → 1% at 1 year old. UNCOMMON to have testes descend after 3 months
Investigation and Management of Undescended Testes.
Investigations → U/S is NOT helpful prior to referral
Management → Surgery
Features of Severe/Complicated Diverticulitis (5 points) + Management of this.
- positive blood culture result, septis or septic shock, perforation, peritonitis, abscess
- Managed with bowel rest, IV ABx and IV Fluids
How is non-severe/uncomplicated diverticulitis managed? Does everyone need ABx?
- Immunocompetent patients with uncomplicated left-sided diverticulitis do not routinely require ABx
- If immune compromised, R) sided diverticulitis, failure to improve after 72 hours of conservative therapy (no ABx)
- ABx → amoxicillin+clavulanate 875+125mg PO BD for 5 days
ABx management for chlamydia
Doxycycline 100mg PO BD for 7/7
Management points for chlamydia (6 points)
- ABx therapy
- Notify Health Department
- Contact Trace up to 6 months
- No Sexual Contact for 7/7 since starting treatment
- Test for Re-Infection at 3/12
- No sexual contact with partners up to last 6/12 until they have been tested and treated accordingly
When do you need to do a test of cure for chlamydia? Routine or not?
- TEST OF CURE IS NOT ROUTINELY RECOMMENDED → only if pregnant or if ano-rectal chlamydia - retest for cure in 4 weeks time
ABx management for Gonorrhoea. Does it change depending on location of gonorrhoea?
- Anorectal and Genital
- Ceftriaxone 500mg in 2ml of 1% lidocaine IM or 500mg IV Stat
- PLUS Azithromycin 1g PO Stat
- Pharyngeal
- Ceftriaxone 500mg in 2ml of 1% lidocaine IM or 500mg IV Stat
- PLUS Azithromycin 2g PO with food Stat
Management Points for Gonorrhoea (6 points)
- ABx Therapy
- No sexual contact for 7 days after treatment is administered
- No sex with partners for the last 2 months until partners have been tested and treated as necessary
- Contact Tracing - 2 months
- Test of Cure → at 2 weeks with PCR swab (pharyngeal, anal or cervical NOT urethral)
- Retest in 3 months after exposure
What is the difference between a chalazion and a stye?
Chalazion aka Meibomian Cyst → benign lipogranulomatous collection arising from one of the meibomian glands lining the tarsal plate of the eyelid
Stye -> Infected hair follicle on the lid margin
Medical Management of Nasolacrimal Duct Obstruction (4 points)
- Massage the Nasolacrimal Sac
- Keep the Eye Clean - wash with salt water as needed
- Apply Warm Compresses - clean, warm washcloth heal against close eyelid 2-5mins, 2-5 times/day
- Apply Chloramphenicol Eye Drops or Ointment until tears become clear
When do you refer nasolacrimal duct obstriction?
Neonates and younger - refer to ED if severe amounts of discharge
Age 2-12 -> medical management unless skin irritation secondary to discharge
Age >12 months -> if symptoms ongoing for more than 3 months, refer for nasolacrimal probing.
Features that are usually present as part of the diagnosis of Polymyalgia Rheumatica (3 main + 4 others)
- Bilateral Shoulder Pain
- Age >50yo
- Elevated ESR and CRP
- Morning Stiffness lasting >45mins
- Hip Girdle Discomfort or limited ROM
- Absence of involvement of other joints other than the hip and shoulder
- absence of RF and anti-CCP
Pharmacological Management of Polymyalgia Rheumatica
Prednisolone 15mg PO daily for 4 weeks then reduce daily dose by 2.5mg every 4 weeks to 10mg daily, then reduce daily dose by 1mg every 4-8 weeks to stop
