8 - Minor Illnesses Flashcards
How should you manage a pregnant woman who has never had chicken pox before and she comes into contact with chicken pox from her other child at nursery?
- Test IgG for varicella zoster with results within 2 days
- If no antibodies and <20 weeks administer VZIG
- If not antibodies and >20 weeks administer either VZIG or acyclovir
- Advise woman to contact if she develops a rash
Need this as otherwise may have fetal varicella syndrome or neonatal chicken pox
How can you tell the difference between a viral and bacterial URTI?
Viral: runny nose, cough, low grade fever, trouble sleeping, shorter duration
Bacterial: higher fever that gets worse a few days into illness rather than better, longer course over 10-14 days, possible pus on tonsils
How can you tell the difference between influenza and other viral URTIs?
- Influenza may have muscle aches and high fever
- Give oral oseltamivir or inhaled zanamivir if person in an at risk group within 48 hours
- Give oseltamivir if not at risk but could have complications e.g pregnancy
- If healthy treat conservatively. Will take 1-2 weeks of rest and fluids
What are some URTIs you should either give no antibiotic prescribing or delayed prescribing to?
- Reassure patient they do not need as will not improve symptoms and side effects of abx e.g n+v
- Only prescribe immediately if patient systemically unwell, immunocompromised such as CF or patient at risk of complications
What are some self care tips you can give patients with a cough that you are not prescribing an antibiotic for?
- Steam inhalation if adult
- Gargle salt water
If prescribing antibiotics for an acute cough, what are the antibiotics of choice?
If prescribing antibiotics for a sore throat (e.g pharnygitis or tonsillitis), what are the antibiotics of choice?
- Only prescribe immediately when fever pain >4/5 and absence of cough
- Explain usual course of sore throat is around 1 week
- Suggest paracetamol, NSAIDs, medicated lozenges with an NSAID/antiseptic/local anaesthetic (non-medicated have no evidence)
What is the fever pain score?
Who is more likely to benefit from antibiotic prescribing with otitis media?
- Under 18 with ottorhoea
- Under 2 with infections in both ears
- Usual course 3 days to 1 week so give paracetamol or ibuprofen, no evidence for anything else
- Give amoxicillin or clarithromycin then co-amoxiclav if not improving after 2 days
When should you prescribe antibiotics for acute sinusitis?
- Usual course around 2-3 weeks so tell them to seek help if not improving after 3 weeks as may be dental infection or resistant bacteria
- At 10 days give nasal corticosteroid
- If systemically unwell or intracranial complications like mastoiditis or intraorbital complications give antibiotics
When are UTIs classed as complicated?
- Immunosuppresed
- Recurrent (>2 in 6/12, >3 in 12/12)
- Children
- Men
- Pregnancy
- Impaired renal function
- Abnormal urinary tract
- Virulent organism e.g S.Aureus
How would you investigate a suspected UTI?
- Take patients vital signs, check for any red flags like haematuria/loin pain/rigors.
Women
- If under 65 and non-complicated take dipstick. If + for blood, leukocytes and nitrates likely UTI
- If complicated, catheterised, or over 65 then MSU/CSU culture in boric acid or refrigerated up to 4 hours
Man
- MSU or CSU culture before antibiotics
- Check sexual history and rule out other causes e.g prostatitis
Child
- Dipstick if >3months and if leucocyte and nitrate +ve treat as UTI
- If <3 years send MSU
- If <3months, fever or at risk of complications refer urgently to paed specialist
- If cannot obtain sample don’t delay prescribing
What questions do you need to ask a child with a UTI?
How are UTIs managed once diagnosed?
Child
- For atypical arrange ultrasound in acute infection and DMSA within 4-6 months after infection
- Under 3 months refer to specialist
- Trimethoprim or Nitrofurantoin 1st line
Woman uncomplicated
- See image
- Do not give pregnant women trimethoprim
Man
- Nitrofurantoin 100mg BD 7 days or Trimethoprim 200mg BD 7 days (only if low risk of resistance)
- Check up after 48 hours
- Admit to hospital if systemically unwell
- Consider referral to urology
- Consider cancer nephrology referral if haematuria
What self care advice can be given to people with a UTI?
No evidence for cranberry products
How is pyelonephritis investigated?
- MSU culturing organism with fever and/or loin pain with other excluded causes is pyelonephritis
- Triad: usually unilateral flank pain, fever, N+V
How is pyelonephritis treated?
- Admit to hospital if signs of sepsis or systemically unwell
- Urgent cancer referral if over 45 and haematuria
- If catheter consider changing/removing catheter and check not blocked
How is community acquired pneumonia diagnosed (non-covid)?
Virtual consultation:
- Temp >38
- Resp rate >20
- HR>100
- New confusion
- Cough, chest pain, breathlessness, anorexia
- If O2 <92% very serious
How can bacterial pneumonia be distinguished from viral COVID pneumonia?
How is non-covid community acquired pneumonia managed?
- Decide whether a hospital admission is necessary for CXR, mucus sample, blood tests using CRB65
- Give antibiotics if bacterial within 4 hours of diagnosis (see image)
- Drink plenty of fluids and rest
- Safety net
What are some complications of community acquired pneumonia?
- Sepsis
- Pleurisy
- Lung abscess (risk higher with other co-morbities and alcohol abuse)
What is the difference between the presentation of acute bronchitis and community acquire pneumonia?
- No x-ray changes with bronchitis
- URTI signs with bronchitis e.g runny nose
- No pleuritic chest pain with bronchitis
- No fever, rigors, tachypne with bronchitis
How do we manage acute bronchitis?
- Advise self care like analgesia, fluids, honey, Pelargonium, cough medicines containing guaifenesin as self limiting over 3 to 4 weeks
- Advise patient to stop smoking
- Advise patient to come back in 3 to 4 weeks if not resolved
- Consider delayed antibiotic prescribing if person at risk e.g diabetic, heart failure. Same antibiotics as pneumonia
- Do not offer inhaler or corticosteroids
What are some differentials for a boil/carbuncle?
- Cystic acne
- Folliculitis
- Epidermoid cyst
- Dental abscess
- Hidradenitis suppurativa
- Anthrax
How do boils and carbuncles present?
Boil
- Painful lump usually in hair bearing sites that are subject to friction and perspiration e.g axilla, neck
- Firm, tender, erythematous nodules with possible cellulitis, which enlarge and become painful and fluctuant and shiny
- May rupture spontaneously, draining pus or necrotic material. - Heal and leave a violaceous macule or scar.
Carbuncle
- Very painful usually on neck, back thighs
- Malaise and systemic symptoms common
- Develop yellow-grey irregular crater centrally, caused by necrosis of the intervening skin
How are boils and carbuncles managed?
Non-fluctuant:
- Advise moist heat QDS for pain and to localise infection
- Maintain good hygeine
- Tell pt to come back if systemically unwell or turns fluctuant
- 7 day Flucloxacillin if carbuncle, cellulitis, fever, on face, in pain
Fluctuant:
- Same day incision and drainage unless small and may drain
- Consider admission and IV antibiotics if cellulitis or systemically unwell
- Consider swabs for MRSA
When should you swab a boil/carbuncle for MRSA and how should this be treated if positive for staphylococcal carriage?
- Do not start decolonisation until acute infection resolved
- Naseptin cream for 10 days QDS or Mupirocin 5 days TDS
- Antiseptic preparation 5 days e.g chlorhexadine 4%
- Tell patient about hygeine whilst decolonising, e.g changing bed sheets/towels daily, vaccuming
How is oral candidiasis diagnosed?
- Clinical features and exclude differentials as swabs will be positive in most healthy people as commensal
- Lots of different types
- Common in HIV, neonates, elderly, diabetics, poor diet, poor dental hygeine, smoking, hyposalivation
How is oral candidiasis treated?
Mild: topical miconazole 1st line (or nystatin 2nd) for 7 days
Severe: oral fluconazole 50mg 7 days and follow up
- Consider referral for biopsy if chronic plaque like
- Advise good dental hygeine, diabetic control, encourage to stop smoking
How is vulval candida diagnosed?
- Symptoms: vulval itching, dysuria, dysparaunia, vaginal discharge, vaginal soreness
- Consider UTI and STI also
- Can do high vaginal swab or vaginal pH but not necesary if isolated uncomplicated
How is vulval candidiasis treated?
- Pessary: clotrimazole, econazole, miconazole, or fenticonazole
- Oral antifunal: fluconazole or itraconazole
Vulval Symptoms: Clotrimazole 1% or 2% cream applied 2/3DS
- Tell patient not to douche, use soap in the vagina, wear tight clothing, use probiotics topically
- Get patient to return if not cleared up in 7-14 days
- Take culture and sensitivity if severe
How is a candidal skin infection diagnosed?
Clinical features no swabs
- Soreness and itching
- Thin-walled pustules with a red base
- Scales may accumulate, producing a white-yellow, curd-like substance over the infected are
In flexural areas skin fold is typically red and moist.
How is a candidal skin infection treated?
- Topical imidazole (clotrimazole, econazole, miconazole, or ketoconazole) or terbinafine
- If itch or inflammation give mild potency topical corticosteroid BD 7 days
- Give oral fluconazole for 2 weeks if immunocompromised, topical not working or wide spread
- Keep affected area dry and free of tight clothing e.g nappies
How does mechanical back pain present and how is it managed?
How does spondylosis/spinal stenosis back pain present and how is it managed?
- OA of the spine where there is degeneration narrowing spinal canal
- Common over 40, in manual labour, acromegaly
How does spondylolisthesis and a herniated disc present and how are they treated?
- Persistent lower back pain worse on moving and relieved by rest
- Radicular leg pain
- Possible weakness of legs
What is ankylosing spondylitis?
Chronic inflammatory disease of spine and SI joint. Associated with HLA-B27
- Chronic back pain and stiffness that improves with exercise, not rest.
- Sacroiliac joint and spinal fusion. Formation of syndesmophytes (bony growths in intervertebral joint ligaments)
- Arthritis and enthesitis mainly in lower limbs
- Dactylitis (swelling of a finger or toe).
- Fatigue.
- Extra-articular manifestations (uveitis, psoriasis, IBS).
How is ankylosing spondylitis investigated and managed?
- ESR/CRP may be raised
- X-ray and MRI of spine/SI joint to look for sacroiliitis, sclerosis (thickening of bone), erosions, and partial or total ankylosis (fusion of joints
- Test for HLA-B27 and if positive refer to rheumatologist
What are some criteria for referring a patient with suspected ankylosing spondylitis for a HLA-B27 test?
How do you investigate a patient presenting with dyspepsia?
- Ask about stress/anxiety
- Check for any red flags for GI cancers e.g weight loss
- Review meds for anything that can precipitate (aspirin, alpha blockers, CCBs, benzos, beta blockers, anticholinergics NSAIDs, nitrates, corticosteroids)
- Take FBC, CRP and U’s and E’s for anaemia and platelet count
- Ask about lifestyle factors e.g obesity, smoking, trigger foods, alcohol consumption
How is dyspepsia managed?
- Lifestyle: weight loss, avoid triggers, smoking cessation
- H.Pylori test (ensuring no PPI or antibiotics 2 weeks before and no antacids 48 hours before)
- H.Pylori -ve then 1 month PPI trial or H2RA
- H.Pylori +ve then PPI, amoxicillin, clarithromycin/metronidazole BD for 7 days
- Still not improving or recurrent then refer for endoscopy
What is the difference between a sprain and a strain?
Sprain: stretch and/or tear of a ligament. Usually ankles, knees, wrists, thumbs.
Pain especially when weight bearing, tenderness, swelling, joint instability, decreased function
Strain: stretch and/or tear of muscle fibres or tendon. Usually back, hamstrings, foot.
Muscle pain, cramping, bruising, muscle weakness
How are sprains and strains investigated and managed?
Ix:
- Take Hx with mechanism of injury, usual activity level and previous history
- Examine joint instability and neurovascular status
- Take x-ray if Ottawa suspects fracture
Mx:
- Topical NSAID or paracetamol
- PRICE for 48-72 hours
- Possible review after 5 to 7 days
- Will feel better after 2 weeks but avoid strenous exercise and running for up to 8 weeks
- Refer to physio or orthopaedics if not improving with self management
What are Ottawa rules?
What are the differentials for a transient loss of consciousness and how do you distinguish between them?
Vasovagal Syncope: 3Ps of posture, pain, prodromal
Orthostatic Hypertension: medication or conditions related to it, lightheadedness, symptoms worse on standing, tunnel vision. Drop of 20 sys or 10 dia after standing for 3 mins diagnoses
Cardiac abnormalities: FH of sudden death before 40, abnormal ECG, occurs during exertion, palpatations before LOC
Epilepsy: head turning, prodromal deja vu, shaking/jerking, tongue biting
How is a pilonidal sinus investigated and managed?
- Clinical features and risk factors e.g men and prolonged sitting, aid diagnosis
- If asymptomatic watch and wait and good hygeine
- Give antibiotics if abscess forms
- If acute send for same day I+D with paracetamol/NSAID.
- If discharging needs surgical excision leaving open and heal for 6-8 weeks
How are haemorrhoids diagnosed?
- Ask about red flags, family history and symptoms
- Look at perianal area
- Look for any skin tags, fissures etc
- Possible DRE
- Proctoscopy
- Consider FBC for anaemia
How are haemorrhoids treated in primary care?
- Refer to specialist or via cancer pathway if red flags
- Ensure stools are soft and easy to pass by eating more fruit, veg and lots of fluids
- Advise importance of anal hygeine
- Advise against stool withholding
- Refer to secondary care if conservative not working
How are migraines diagnosed?
- Unilateral pulsating headache
- Photo/phonophobia
- N+V
- Aura
- Allodynia
- Prodrome of yawning, changes in sleep, food cravings
How are migraines managed?
Acute
- Ibuprofen, paracetamol or aspirin
- Possible triptan when headache starts e.g sumatriptin
- Consider antiemetic e.g metoclopramide or prochlorperazine)
Prophylaxis
- Avoid triggers e.g cheese, stress, lack of sleep
- Consider propanolol, amitriptyline or topiramate to reduce frequency
- Suggest CBT, acupunture and riboflavin if not pregnant
How are tension headaches managed in primary care?
- Simple analgesia (no opioids) and control other disorders e.g stress
- 10 session of acupuncture over 5-8 weeks
- Possible low dose amitriptyline
How are cluster headaches managed in primary care?
Need to confirm with neurologist if first attack
Acute Confirmed
- 100% O2 for 15 mins
- 6mg sumatriptin SC or IN
- Do not offer paracetamol, NSAIDs etc
Prophylaxis
- Verapamil
What is a medication overuse headache and how is it managed?
Due to overtaking opioids, triptans, ergots etc
How is trigeminal neuralgia managed?
Carbamazepine if no red flags!
How is constipation managed in primary care? (less than 3 stools a week with ?impaction if hard stools every 7-10 days or going a small amount every 2-3 days)
Non-pharmacological
- Increase fibre intake to 30g daily gradually
- Lots of fruit and veg particularly those high in sorbitol e.g prunes, apples
- Increase fluid intake
- Increase activity levels
- Healthy toilet routine and posture
Pharmacological
1st line (unless opioid constipation): Bulk forming laxative like Ispaghula with lots of fluids
2nd line: osmotic like macrogol
3rd line: if soft but tough to pass use stimulant
Reduce once 3 soft stools a week or if not improving manual evacuation
How is BV diagnosed and managed?
Ix:
- Abdominal/pelvic exam
- Test vagina pH
- Speculum and high vaginal swab
- Test for chlamydia, gonorrhoea, trichomonas to rule out others
Mx:
- Metronidazole PO BD 5-7 days
- Intravaginal metronidazole possible for 5 days
What are some investigations that should be done into chronic diarrhoea?
- CA125 testing
- C.Diff testing
- Faecal calprotectin (if raised suggests inflammation so IBD not IBS)
- C.Diff testing
- Examine for ova, cysts and parasites if travel history
- Test for blood in faeces
- HIV serology
How should you explain how to collect a stool sample to a patient?
- Make sure poo doesn’t touch inside of toilet or wee so use clean sterile container
- Fill out details on pot and fill pot to 1/3 full
- Refrigerate or hand in straight away
How should you investigate and manage glandular fever (EBV)?
- Arrange FBC and EBV monospot test in the second week of illness. Look at LFTs
- If negative do EBV viral serology test
- Advise will last 2-4 weeks, tiredness will last longest, take analgesia, avoid contact sports, avoid spread by kissing/sharing utensils
- Admit to hospital if stridor, dehydration or complications
What vaccinations are given from aged 0-18?
1 year: Hib/MenC, MMR, PCV, Men B
2-10 years: flu vaccine
3 years: MMR, 4-in-1 booster
12-13 years: HPV
14 years: 3-in-1 booster, MenACWY
What is the 6-in-1, 4-in-1, 3-in-1 vaccination?
3: Diphtheria, Tetanus, Poliomyelitis
4: Above plus whooping cough
6: Above but Hep B, HiB, Pertussis (Whooping cough)
What is congenital rubella syndrome?
- When mother has rubella infection this can happen to the baby
- Often miscarriages and stillbirths also
How does rubella (German measles) present and how is it diagnosed?
- 2-3 weeks after exposure generic symptoms like rash, lymphadenopathy, arthritis/arthralgia, low grade fever, headache
- Can cause encephalopathy, neuritis, orchitis, thrombocytopenia
- Use viral serology
- Inform PHE, avoid pregnant people, avoid work/school for 5 days after rash, self limiting treatment such as paracetamol
What is Fifth disease and how is it diagnosed? (Childhood exanthem meaning eruptive skin rashes with fever and other symptoms)
- Slapped cheek syndrome caused by parvovirus B19
- Incubation of 1-2 weeks with prodrome of flu like symptoms and then rash across cheeks, trunks, arms and legs that may be red and itchy and resolve in 2 weeks
- Diagnosis on clinical features but can be viral serology for IgM
- If pregnant need to do a blood test to rule out rubella
How is Fifth disease/Erythema Infectiosum treated?
- Self limiting e.g fluids and analgesia
- Not contagious after rash appears so can return to work/school. Also don’t need to avoid pregnant women
- Check rubella vaccination status
How is conjuctivitis diagnosed and managed?
Dx:
- Usually viral
- Conjunctival erythema
- Discomfort in eye e.g grittiness, burning
- Purulent discharge that may cause eyes to stick together on waking and cause transient vision blurring
- Should be no photophobia!
Mx:
- Reassure self limiting 7-10 days viral
- Advise cold compress and bathing in saline/sterile water
- Lubricating eye drops
- Inform pt it is contagious so don’t share towels
- If bacterial and not clearing after 3 days give chloramphenicol or fusidic acid eye drops
How is a stye diagnosed and managed?
Dx
- Bacteria infecting eyelash follicle/gland, more likely if have recurrent blepharitis
- Acute-onset painful, localized swelling near the eyelid margin that develops over several days
- Unilateral
- May be watery eyes
- Can be internal or external
Mx
- Arrange admission if signs of orbital cellulitis
- Apply a warm compress to enourage drainage
- Do not try to puncture
- Avoid wearing makeup and contact lenses
- I+D in GP and pluck eyelash from follicle if really painful external
- Chloramphenicol if spreading infection
What are some signs of orbital cellulitis?
Dx:
- Systemic features of fever and malaise
- Often due to Strep species from ethmoidal sinus if behind orbital septum. If in front often S.Aureus
- Diplopia
- Difficulty moving eye
Mx:
- Emergency referral to hospital and co-amoxiclav or clindamycin if allergy
- CT of orbit and brain particularly in children to check for intracranial abscess
How is an aphthous ulcer managed?
- Often due to damage in the mouth e.g braces, biting cheek, and not associated with systemic disease
- Do FBC, Vit B12, Ferritin, Folate, IgA transglutaminase, viral serology for EBV/HIV if diagnosis uncertain
- Self limiting 10-14 days but avoid trigger foods. If painful can give topical corticosteroid e.g hydrocortisone oro-mucosal tablets, beclomethasone spray, or topical local anaesthetics
- If recurrent can give short course PO prednisolone.
- Refer for malignancy if doesn’t clear in 3 weeks
How do you diagnose scabies?
- Caused by parasite Sarcoptes scabiei that burrows into the epidermis of the skin
- Linear burrows on several parts of the body that are itchy particularly at night
How is scabies managed?
1st Line - Permethrin 5% cream
2nd line - Malathion aqueous 0.5% cream if above not tolerated
- Apply to whole body on cold dry skin and allow to dry before dressing. Wash off 12 hours later and apply 2nd application a week later
- All household members and sexual partners need treatment even if asymptomatic
- Wash all clothes and bedding at 60 degrees and dry in hot dryer
- Itch may still occur for 2 weeks but if still present 2-4 weeks later see GP
How is nappy rash managed in primary care?
Self care:
- Use high absorbency nappies
- Leave nappies off for as long as possible to air out
- Change nappies every 3-4 hours and do not use soap
Pharmacological:
- If mild and asymptomatic advise OTC barrier protection e.g Sudocrem, every nappy change
- If inflamed and discomfort give topical 1% hydrocortisone cream for a max of 7 days
- If persists and candida topical clotrimazole and miconazole
- If persists and bacterial give flucloxacillin 1/52
How does plantar fascitis present and how is it diagnosed?
Hx:
- Intense heel pain during first steps after waking or after inactivity
- Pain that reduced with moderate activity but worse at the end of the day or after long walking
- Risk factors: aged 40-60, obese, running, woman
Dx: (clinical features)
- Positive Windlass test
- Tenderness on palpation of plantar heel
- Tightness of Achille’s tendon
- Antalgic gait
How is plantar fascitis managed?
- Reassure most will resolve in a year
- Rest the foot where possible
- Wear shoes with good arch support or consider insoles
- Lose weight if obese
- Analgesia and ice packs
- Self physiotherapy to stretch
- If persisting then corticosteroid injection
- If still persisting physio, podiatrist and then surgeon to divide plantar fascia
How does impetigo present?
Bullous caused by S.Aureus, Nonbullous can be S.Pyogenes
May swab for MRSA if recurring but usally off of clinical features
Red blisters that quickly pop and form a crust. Lasts for 7-10 days and is very contagious
How is impetigo managed?
- Reassure will heal with no scarring. Stay away from schools and work until crusted over or till 48 hours after start of treatment
Localised non bullous:
- Topical hydrogen peroxide 1% 2-3x a day for 5 days
- If unsuitable can give topical antibiotic like mupriocin or fusidic acid for same time
Widespread non bullous or bullous:
- Oral flucloxacillin 500mg QDS for 5 days or clarithromycin 500mg QDS for 5 days
How does rheumatic heart disease present?
- Usually 1-6 weeks after strep throat
What is the likely diagnosis and what are some other symptoms?
Post Op Ileus: need to rearrange admission
- Distension
- Lack of bowel sounds
- Accumulation of gas
- Delayed flatulence and stool
- Common after abdominal surgery
D
SHOULD AVOID ALL ANTIHISTAMINES IN ELDERLY EVEN NON-SEDATING DUE TO THE RISK OF FALLS
