16/10/21 Flashcards
Typical presentation of allergic rhinitis. (5 points)
Presents with recurrent episodes of sneezing, pruritis, rhinorrhoea, nasal congestion and lacrimation
Diagnosis of Acute Bacterial Rhinosinusitis (5 points)
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
Diagnosis of Chronic Rhinosinusitis (2 points)
- Presence of ≥ 2 symptoms persisting for more than 12 weeks
- 1 must be either nasal congestion/blockage/obstruction or nasal discharge (anteriorly or posteriorly)
- Plus Facial Pain/Pressure and/or reduction or loss of smell
Red Flags of Acute Rhinosinusitis (7 points)
- Unilateral Symptoms
- Bleeding
- Cacosmia → perceived malodourous smell
- Signs of meningitis → photophobia, phonophobia, neck stiffness
- Altered Neurology
- Frontal Swelling
- Eye/Orbital Involvement
- Diplopia
- Decreased Visual Acuity
- Painful ophthalmoplegia
- Peri-orbital oedema and erythema
- Globe Displacement
Investigations for Acute Rhinosinusitis. When are these indicated?
If no improvement with below management of Acute Rhinosinusitis with symptomatic and ABx as deemed fit
- can completed RAST testing → to identify possible allergic triggers via serum specific IgE tests
- CT scan of the sinuses
Symptomatic Management of Acute Rhinosinusitis. (5 points)
- Regular Oral Analgesia → paracetamol + NSAIDs
- Saline Nasal Preparations → sprays, rinses and drops
- Intranasal Corticosteroids
- Intranasal and Systemic Decongestants → recommended for short-term use for up to 5 days especially if congestion if prominent symptom
- Intranasal Ipratropium → beneficial if rhinorrhoea is main symptoms
Antibiotic Therapy for Acute Bacterial Rhinosinusitis. Be Specific
- amoxicillin 500mg (child 15mg/kg up to 500mg) orally, 8hrly for 5/7
What constitutes a HEADS assessment?
H - home, E - education and employment, E - exercise and eating, A - activities, D - drugs and alcohol, S - safety, S - self-harm, suicide, depression, S - sexuality and gender
Points to discuss in the H in a HEADS Asssesment.
Who Where Recent Changes (moves or new people) Relationships Stress or Violence Smartphone or Computer Use (in home vs room)
Points to discuss in the E (education/employment) in HEADS assessment.
Where, Years/Work Details Attendance + Performance + Disciplinary Actions Relationships + Bullying Supports Future Plans
Points to discuss in the E (exercise and eating) of a HEADS assessment.
Weight + Body Shape (BMI) Relationship to Weight and Body Shape Eating Habits and Dieting Exercise Habits Menstrual History
Points to discuss in the Sexuality of a HEADS asssement
Gender Identity
Romantic Relationships
Sexuality + Sexual Experiences
Sexual Abuse + Harassment/Awkward Situations
Previous pregnancies + Risk of Pregnancy + Contraception + STI
Points to discuss in the Suicide/Self-Harm/Depression of a HEADS Assessment.
Mood
Sleep
Online Bullying
Thought of self-harm/hurting others + suicide risk
Points to discuss in the safety of a HEADS assessment.
Serious Injuries
Online Safety
Riding with Intoxicated Driver
Exposure to Violence - school, community or home
High Risk - weapons, criminal behaviours, justice system
Diagnosis of Migraine without Aura. (3 points)
Recurring Headache with at least 5 attacks fulfilling the following criteria:
- Headaches lasting 4-72 hours (treated or unsuccessfully treated
- Headache has at least 2 of the following 4 characteristics:
- Unilateral Location
- Pulsating Quality
- Moderate or Severe Pain Intensity
- Aggravation by or causing avoidance of routine physical activity
- At least one of the following during the headaches:
- Nausea and/or vomiting
- Photophobia and phonophobia
Migraine Treatment in Children (3 points)
- Ibuprofen 10mg/kg (max 400mg) PO → wait 4-6 hours before repeating dose if needed (max 30mg/kg in 24/24)
- OR paracetamol 15mg/kg (max 1g) PO → wait 4-6 hours before repeating dose if needed (max 60mg/kg in 24/24)
- Ibuprofen 10mg/kg (max 400mg) PO → wait 4-6 hours before repeating dose if needed (max 30mg/kg in 24/24)
- ≥ 10yo → sumatriptan intranasally into 1 nostril 10-20mg → can be repeated once after at least 2 hours if headache recurs
- Nausea → ondansetron 0.1 - 0.15 mg/kg (up to 8mg) PO
Points in Wells Criteria for DVT (10 points)
- Active Cancer - Treatment of Palliation within 6 months
- Bedridden recently >3 days or major surgery within 12 weeks
- Calf Swelling >3cm compared to other leg
- Collateral (non-varicose) superficial veins present
- Entire leg swollen
- Localised tenderness along the deep venous system
- Pitting oedema - confined to symptomatic leg
- Paralysis, paresis or recent plaster immobilisation of the lower extremity
- Previous DVT
- Alternative diagnosis to DVT as likely or more likely (-2 points)
Discuss management of DVT based on pre-test probability using Wells Score.
if low pre-test probability -> d-dimer. negative D-dimer rules out DVT. positive D-Dimer -> imaging
if high pre-test probability -> U/S + d-dimer.
if negative U/S + negative d-dimer -> rule out DVT
if negative U/S + positive d-dimer -> repeat U/S 1/52
if positive U/S -> treat DVT
Definition of Complex Regional Pain Syndrome
Defined as a disorder of the extremitis characterised by regional pain → disproportionate in time or degree to the usual course of any known trauma or other lesion
How does a patient with Complex Regional Pain Syndrome present? (5 points)
Usually present with pain, motor impairment, autonomic impairment, sensory changes and tropic changes of the affected limb
Diagnosis of Complex Regional Pain Syndrome
- Continuing pain which is disproportionate to any inciting event
- Patient must report at least 1 symptoms in 3 of the following 4 categories:
- Sensory: reports of hyperesthesia and/or allodynia
- Vasomotor: reports of temperature asymmetry and/or skin colour changes and/or skin colour asymmetry
- Sudomotor/Oedema: reports of oedema and/or sweating changes and/or sweating asymmetry
- Motor/Trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
- Patient must display at least 1 sign at time of evaluation in 2 of the 4 categories:
- Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or temperature sensation and/or deep somatic pressure and/or joint movement
- Vasomotor: evidence of temperature asymmetry (>1 degree) and/or skin colour change and/or asymmetry
- Sudomotor/Oedema: evidence of oedema and/or sweating changes and/or sweating asymmetry
- Motor/Trophic: evidence of decreased ROM and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
Medication used in management of CRPS.
Oral opioids
Gabapentinoids - pregabalin 25-75mg PO nocte initially (increase in 3-7 day intervals)
Tricyclic Antidepressants - amitriptyline 5-12.5mg PO nocte (increase every 7 days)
SSRIs or SSRIs - duolextine 30mg PO mane (increase every 7 days)
Prevention → ascorbic acid (Vit C) 500-1000mg, daily from day of injury for 50 days
Clinical Presentation of TMJ Dysfunction/Syndrome (4 points)
- Main presenting complaint is pain in the TMJ or mandible → refer to scalp or neck, exacerbated by yawning, mastications, talking for extended periods of time.
- Difficulty opening the mouth or brief locking of the mandible on opening or closing.
- Clicking, popping or crepitus within the TMJ itself
- Pain worse with mandibular movements - particularly when eating
Symptoms of Giant Cell Arteritis (GCA) (6 points)
- Jaw Claudication
- Severe Headache
- Polymyalgia Rheumatica
- Visual Symptoms (commonly diplopia or visual loss)
- Scalp Tenderness
- Malaise
Examination and First-Line Investigations of GCA
Examination
- Temporal Artery Abnormality → artery is tender, enlarged, difficult to compress, nodular or pulseless
### Investigations
- ESR + CRP
Management of Giant Cell Arteritis (4 points)
- Urgent referral to specialist for temporal artery biopsy
- WITH visual loss -> - methylprednisolone sodium succinate 0.5-1g IV, over 1 hour, daily for 3 days → switch to oral pred as below
- WITHOUT visual loss -> - prednisolone 40-60mg PO daily for minimum of 4 weeks → continue until symptoms and inflammatory markers resolve then wean.
- To prevent ischaemic events (including ophthalmic vascular thrombosis): aspirin 100mg PO daily (concurrently with corticosteroid therapy)
Risk Factors for Open Angle Glaucoma (7 points)
- Age
- Race → 3x higher in African-Americans
- Family History
- Diabetes
- Hypertension
- Elevated Intraocular Pressure
- Glucocorticoids
Management Options for Open Angle Glaucoma
- Prostoglandin Analogues
- Topical Beta-Blocker
- Topical Alpha-Adrenoceptors
- Carbonic Anhydrase Inhibitor
Management of suspected melanoma.
Excisional Biopsy with 2 mm lateral margin and as deep as the subcutaenous fat
Investigations for Paediatric Weight Loss (8 points)
- FBE
- LFTs
- Fe Studies
- Thyroid Function Tests
- Inflammatory Markers
- Stool MCS
- Coeliac Serology
- Faecal Calprotectin → differentiates between funcitonal and inflammatory bowel disorder
Life-Threatening and Common Causes of Weight Loss in Paediatrics.
## Life-Threatening Conditions Diabetes Mellitus Adrenal Insufficiency Eating Disorders with complications → body image, excessive intake, restrictive intake of food Dehydration
## Common Conditions Viral Gastroenteritis Depression Inflammatory Bowel Disease → Family History of IBD Acute Infections Coeliac Disease Lactose Intolerance Drug Use → amphetamine Child Neglect Malnutrition and Failure to Thrive Irritable Bowel Syndrome
In regards to vaccinations, what titres should all newly diagnosed children with IBD have? Following commencement of immunomodulators, what vaccinations are contraindicated?
- minimise this risk by optimising live vaccinations at diagnosis or 2 months before commencing immune modulators or biologics
- All new diagnosed children test titres for Hepatitis B, Hepatitis C, Varicella and Quantiferon TB
- Once commenced on immunomodulators → use of live vaccinations (MMR, varicella and yellow fever vaccinations) are contraindicated. Response to non-live vaccinations such as hep B is attenuated.
Delirium Screen (10 points)
- FBE
- UEC
- Calcium
- LFTs
- CRP
- Blood Glucose
- Urine Dipstick → urine MCS
- ECG
- CT Brain
- Chest X-Ray
ABx therapy for UTI or Cystitis
- trimethoprim 300mg orally, daily for 3 days
Diagnosis of Vestibular Neuronitis (2 points)
Diagnosis:
- History of Acute or Subacute Onset of Severe Rotatory Vertigo, Nausea, Postural Imbalance WITHOUT HEARING LOSS
- Unidirectional mixed horizontal and torsional nystagmus and positive head impulse test
Management of Vestibular Neuronitis (2 points)
- Usually self-limiting → improves over hours to days
- Corticosteroid can hasten clinical recovery
- Prednisolone 1mg/kg (up to 75mg) PO, daily in the morning for 5 days, then taper dose over 15/7 and cease
in the assessment of severity of croup, what 5 points are used in this assessment? Discuss gradation of these points from mild to moderate and severe croup.
Behaviour, Accessory Muscle Use, Respiratory Rate, Stridor, Oxygen Saturation
Behaviour: Normal -> Agitation -> increased agitation/drowsiness
Accessory Muscle Use: Increased chest wall retraction
Resp Rate: increasing resp rate, marked decrease in RR in severe croup
Stridor: None or just when upset or active-> intermittent stridor -> persistent stridor at rest
Oxygen: Hypoxia in severe croup
Management of Mild - Moderate Croup
- Prednisolone 1mg/kg (up to 50mg) PO stat
If improves following prednisolone stat dose → can return home, if child develops stridor at rest later the same day → present to hospital as management for severe croup will be required.
Management of Acute Cardiogenic Pulomary Oedema (5 points)
- Remain upright
- Urgent ambulance transfer to hospital
- Frusemide 20-80mg IV or IM repeated 20/60 later
- if having oral frusemide → may need increased dose of parenteral frusemide
- if O2<94% → high-flow O2 via oxygen mask
- If no response to frusemide + O2 → add Glyceryl Trinitrate 400microg sublingually → repeat dose every 5 mins up to max 1200 microg
- use nitrates with caution in patients with systolic BP <100mmHg, symptomatic hypotension or signs of poor perfusion
Definition of Fixed Drug Eruption. Which medications commonly cause Fixed Drug Eruptions?
Distinctive cutaneous allergic reaction → recurs at the same site on re-exposure to the medication of other chemical agent
- typically secondary to oral medications → commonly antimicrobials and NSAIDs
Clinical Features and Timeline of Fixed Drug Eruption (acute and long-term timeline)
- Typically presents as a single (or a small number of) well-defined, round or oval red or violaceous patch or plaques which may blister or ulcerate
- asymptomatic but can be itchy or painful
- Over few days and weeks → surface may become scaly or crusted before peeling → colour fades to leave post-inflammatory hyperpigmentation
- Eruption may develop after weeks to years of regular ingestion of the drug, but the subsequent episodes develop within minutes to hours of recommencing the implicated drug
Investigations for Macroscopic Haematuria (6 points)
- Urine Dipstick → Urine MCS
- UTI needs to be ruled out before any further investigations for haematuria
- CT-IVP
- only use U/S if CT is not available → pregnant , children and low risk patients
- CT KUB → identifying ureteric and renal stones but much lower sensitivity in identifying genitourinary malignancies and lesions
- Urine Cytology
- FBE
- Renal Function
- PSA (in men)
Indications for referral to Urology in the context of macroscopic haematuria (5 points)
- macroscopic haematuria
- persistent microscopic haematuria
- abnormal urine cytology
- irritative lower urinary tract symptoms
- recurrent UTI
