21/11/21 Flashcards
Causes of Genital Ulcer Disease (3)
Herpes Simplex Virus → most common cause
- Syphillis
- Chemical Burns or Contact Dermatitis from topical treatments
- Skin infections by Gram-Postive Bacteria
- Aphthous Ulcers
- Malingancy
- Autoimmune Conditions
- In MSM → consider lymphogranuloma venerum
General management principles of paediatric asthma (6 points)
- Try identify what triggers asthma symptoms → allergens
- Manage comorbid symptoms that affect asthma → allergic rhinitis
- Show parents and children (if old enough) when and how to take reliever medication
- Monitor regularly and adjust treatment accordingly to maintain good control of symptoms and prevent flare-ups, while minimising the dose of inhaled corticosteroids as well
- Written asthma action plan to be provided to parents
- Reduce tobacco smoke in the household
- Healthy eating, physical activity, healthy weight
- Immunisations - influenza
Risk factors for severe-life threatening exacerbation of asthma in children
- *Asthma Related Factors**
- Poor Asthma Control
- Admission to hospital in the last 12 months
- History of intubation for flare-up of asthma
- Overuse of SABA reliever
- Poor Adherence to asthma action plan
- Poor Adherence to preventer or Incorrect inhaler technique for preventer
- Exposure to Tobacco Smoke
- Exposure to clinically relevant allergens
- *Other Clinical Factors**
- Allergies to foods, insects or medicines
- Obesity
- *Family Related Factors**
- Failure to attend consultations or lack of follow-up after an acute flare-up
- Significant parental psychological or socioeconomic issues
- Parent/Carer unequipped to manage asthma emergency
Steps to management of asthma in a child aged >6yo.
Step 1: SABA as required
Step 2:
- ICS (low dose)
- Montelukast 5mg
Step 3:
- ICS (high dose)
- ICS + LABA
- ICS (low-dose) + Montelukast
Step 4: Refer to Specialist
Indications for preventer treatment in a child with asthma >6yo.
Frequency
- Frequent Intermittent → flare-ups once every 6 weeks and no symptoms between flareups
- Persistent → Symptoms between flare-ups
- Daytime symptoms >1 per week
- Nighttime symptoms >2 per month
- Symptoms restrict activity
- Symptoms restrict sleep
Severity
- Moderate to Severe Flare-Ups → >2 ED presentations or >2 episode requiring oral corticosteroids
- Life-threatening Flare-Ups requiring hospitalisation or PICU admission
Discussion points re: adverse effects of inhaled corticosteroid use in children. 4 points
- Local Adverse Effects → hoarseness and pharyngeal candidiasis are NOT commonly reported but can be reduced by the use of spacer devices and by mouth-rinsing and spitting after use
- Systemic Adverse Effects → dose-dependent but uncommon
- Growth → short term suppression of growth, effect is dose dependent, children most likely still achieve normal adult height or 1cm less
- Note that uncontrolled asthma itself reduces growth and final height
- ~~Bone Density~~ → NOT associated with decrease in bone density or fractures
- Adrenal Suppression → can occur even at low doses. Risk is high in children using concomitant intranasal steroids and children with lower BMI.
What is the only ICS + LABA combination that can be used in children >6yo? What age group does the TGA approve this drug for?
Use for children aged 5-12yo (only medicaiton approved by TGA)
Fluticasone propionate + salmetorol 50+25 microg, 2 actuations by inhalation via pMDI with spacer BD
Key Points in approach to youth-friendly preventative care consultation (3 points)
- Validate concerns
- Negotiate time alone with the young person if they attend with the parent/intimate partner/guardian
- Usually avoid asking personal/sensitive questions in front of parent/intimate partners/guardian
- Discuss confidentiality and its exceptions → risk of harm to oneself, harm to others
- Explain purpose of asking lifestyle questions → effect on health and wellbeing
- Ask permission before asking personal/sensitive questions + give permission to decline answering the lifestyle questions
Causes of Genital Ulcer Disease
- Herpes Simplex Virus
- Syphillis
- Aphthous Ulcers
- Contact Dermatitis or Chemical Burn from Topical Treatment
- Malignancy
- Autoimmune Disease
- Gram-Positive Bacterial Skin Infection
Antiviral Therapy for Genital Herpes
valaciclovir 500mg PO BD for 10 days → if clinical response is rapid, can cease treatment after 5 days
Do I wait for microbiological testing prior to commencing treatment? Why or Why Not?
- Take swab of lesion and immediately start treatment, DO NOT wait for microbiological test results to commence treatment
Other than anti-virals, what are other management points for management of genital herpes (6 points)
- Simple Analgesia and Anti-Pyretics
- Topical Lignocaine reduces pain from erosions
- Urinating in bath or shower → relieves superficial dysuria
- Encourage condom use with ongoing partners
- NOT notifiable condition
- NO NEED for contact tracing
- After 1 week - complete sexual health screening
Investigations for Post-Coital Bleeding (2)
- Endocervical Swab for STI including Chlamydia
- Co-Test (HPV + LBC)
Treatment points including pharmacological management of Genital Warts (3 points)
- Human Papillomavirus Infection is transmitted by genital-to-genital contact BUT the HPV types that cause genital warts, are not directly associated with cancer.
- Should screen those with genital warts for STI
- Latency of HPV is not known so it may not be possible to determine who the sexual contact was → contact tracing is not required
- Topical Preparations
- Imiquimod 5% cream topically, 3 times/week on alternate days at bedtime until warts resolve (usually for 8-16 weeks)
- Podophyllotoxin 0.5% pain topically, twice daily for 3 days followed by a 4 day break, repeat weekly for 4-6 cycles until warts resolve
- Cryotherapy → repeated at intervals of 1-2 weeks
BLS Steps
DRSABCD D - Dangers + Move bystanders away R - Responsive S - Send for Help A - Assess Airway (open airway) B - Assess Breathing C - Assess circulation (pulse) -> Start CPR 30:2 D - Attach defibrillator (AED)
Management of Opiate Overdose (2 points)
Oxygen + Respiratory Support for Acute Management
- use Guedel Airway to open airway. High-Flow O2 as required.
Naloxone IV boluses (100-400microg), titrated to clinical effect
If long-acting - may need naloxone IV infusion
Can consider activated charcoal for gastrointestinal decontamination
- 2 hours after immediate release preparation
- 6 hours after extended release preparation
Supportive Care
- IV rehydration
- Re-warming in hypothermia
- Maintenance of Euglycaemia
In who and how often should TFTs be conducted? In women with post-partum thyroiditis, how often and for how long should we be testing TFTs?
Women with Antithyroid Peroxidase Antibodies in early pregnancy → 50% will develop post-partum thyroiditis
- TFTs should be conducted at 3 and 6 months following delivery in those with known autoimmune disease, PHx of postpartum thyroiditis or chronic viral hepatitis
Annual TSH for 5-10 years → in women with history of post-partum thyroiditis as they have increased risk of developing permanent overt hypothyroidism.
Pathogenesis of Graves Disease
TSH receptor Ab increases thyroid hormone production → thyroid hyperplasia
Lab Results of Graves Disease
TSH receptor Ab increases thyroid hormone production → thyroid hyperplasia
Course of Disease of Post-Partum Thyroiditis
Typically 1-6 months after delivery
Thyrotoxicosis for 1-2 months followed by hypothyroidism for 4-6 months.
Hypothyroidism may be permanent (20%)
Lab Results of Post-Partum Thyroiditis
TPO Ab High
Normal ESR
Management of Post-Partum Thyroiditis. When do you use thyroxine?
- Beta-Blocker for symptoms
2. Thyroxine if the hypothyroid phase is prolonged, symptomatic, if breast-feeding or attempting further pregnancies.
Radionuclide Scan of Graves Disease
Normal or Elevated Diffuse uptake pattern
Radionuclide Scan of Postpartum Thyroiditis
Near absent uptake
Red Flags of Crying in an Infant (4 points)
- Sudden Onset of Irritability and Crying
- DDx → Middle Ear Disease, Infection, Raised ICP, Hair Touniquet of finger or toes, Corneal Abrasion, Inguinal Hernia
- Post-Natal Depression (PND)
- Excessive crying is a Risk Factor for Abusive Head Trauma (aka Shaken Baby Syndrome)
- Signs or Symptoms of Cows Milk Protein Allergy or Soy Protein Allergy
Normal Crying characteristics in an infant. Age and time/day. Peak. Time during the day.
- at 6-8 weeks of age → a baby cries 2-3 hours per 24 hours
- increases in early weeks of life and peaks at around 6-8 weeks and usually improved by 3-4 months of age
- usually worse in late afternoon or evening but can occur at any time
- infant may draw legs up as if in pain → but NO EVIDENCE that this is due to intestinal pathology
Definition of excessive crying in an infant.
- defined as crying 3 hours/day, at least 3 times/week for at least 3 weeks, in a baby that is well and thriving.
History questions for the crying infant. (5_
- Infant feeding, vomiting, stools, urinating and sleeping patterns
- Psychosocial Factors in mother/parents
- Pre-natal and Perinatal risk factors of sepsis
- When does crying occur?
- How long does the crying occur for?
- How and what do you feed the baby?
- What do you do when the baby cries?
- How does the crying make you feel?
- How has the crying affected the family?
Differential Diagnosis of Unsettled and Crying Infant.
TIM CRIESS
| T | Trauma |
| M | Maternal/Parental Stress, Anxiety or Depression |
| C | Cardiorespiratory Disease |
| R | Reflux, Reaction to Medication, Reaction to Formula, Rectal Fissure |
| I | Intracranial Hypertension, Immunisations, Intolerance of Lactose or Cow’s Milk Protein Allergy |
| E | Eye → Corneal Abrasion, Occular Foreign Bodies, Glaucoma, Retinal Haemorrhage |
| S | Surgical → Volvulus, Intussuception, ‣, Testicular Torsion (‣) |
| S | Strangulation (Hair/Fibre Torniquet) |
I | Infection |
Clinical Features of Cows Milk/Soy Protein Allergy.
- Significant feeding problems that persist day and night
- frequent vomiting (exclude pyloric stenosis)
- diarrhoea with blood or mucus
- poor weight gain
- wide-spread eczema
What does PURPLE Crying mean?
| U | Unexpected - crying can come and go and you won’t know why |
| R | Resists soothing - crying may not stop not matter what you try |
| P | Pain-Like Face - babies may look like they are in pain even when they are not |
| L | Long-Lasting - crying can last as much as 5 hours/day or more |
| E | Evening Cluster - baby may cry more in the late afternoon or evening |
P | Peak → baby may cry more each week, the most at 2 months and less at 3-5 months
Clinical Triad for Intussusception + Age Range
- TRIAD → Intermittent abdominal pain + palpable abdominal mass + red currant jelly stools
- occurs in only 1/3 of children
- May occur at any age → most commonly 2 months to 2 years
Clinical Features of Intussusception (5)
- Intermittent Pain or Distress -> Episodes can recur within minutes to hours and may increase in frequency of the next 12-24 hours
- Child may appear very well between episodes
- Pallor especially during episodes
- Lethargy → profound, episodic or persistent
- Vomiting → bile stained vomiting is a late sign and indicates bowel obstruction
- Diarrhoea → common initially, rectal bleeding or classic red currant jelly stools are a late sign
Clinical Features of Meniere’s Disease including hearing loss
- Spontaneous
- Time Course: Minutes to Hours
- Episodes accompanied by unilateral aural fullness, tinnitus, hearing loss.
- Low frequency sensorineural hearing loss
- Usually nausea/vomiting
Risk Factors - FHx, Autoimmune Disease, Recent Viral Illness
Examination Findings in Meniere’s Disease
- Peripheral Nystagmus - unidirectional
- Fukuda stepping test - localises to affected side
- Romberg Test - Positive
- Heel-To-Toe → inability to walk heel-to-toe in a straight line
Management of Meniere’s Disease (3 points)
- Reduce salt intake to no more than 2-3g/day
- Avoid Caffeine
- Amplification and Assistive Hearing Devices can be used to treat hearing loss → consult a neurologist
- Exercise Physiologist for Vestibular Rehabilitation program
- Prophylaxis → Hydrochlorothiazide 25mg PO daily, increase up to 50mg daily
- If patient remains asymptomatic for 6 months → diuretics can be tapered and re-started if required
- Intratympanic injections of gentamicin or corticosteroid Positive Pressure Therapy
- Surgery → endolymphatic sac decompression, vestibular nerve section
Causes of Peripheral Vertigo (5 points)
BPPV Meniere's DIsease Ramsay Hunt Syndrome Labyrinthitis Vestibular Neuritis Acoustic Neuroma Superior Semicircular Canal Dehicense Cholesteatoma
Causes of Central Vertigo (3 points)
Cerebellar Infarction Cerebellar Haemorrhage Vertebrobasilar Insufficiency Vestibular Migraine Multiple Sclerosis Hereditary Ataxia
Approach to examination of vertigo (5 points)
Neuro (+gait, balance, Rombergs, Heel-to-Toe, Fukada Step Test)
Eye/Visual Examination - Nystagmus
Otological Examination
CV Examination
Special Tests -> Dix-Halpike, Orthostatic Hypotension, Head Impulse Test
