Asthma + COPD + ENT Flashcards
What is the first line investigation for someone suspected with asthma?
Spirometry with bronchodilator reversibility
Fractional exhaled nitric oxide
If there is diagnostic uncertainty after first line investigations for asthma then what follow up test could be done?
Peak flow diary - measure peak flow several time a day for 2-4 weeks
Direct bronchial challenge test with histamine or methacholine
What additional management should be given to pts with asthma other then the inhalers?
Individual asthma self-management programme
Yearly flu jab
Yearly asthma review
Advise on exercise and stop smoking
What is MART therapy?
Maintenance and reliever therapy - when SABA is stopped and only ICS/LABA (Fostair) is used for both daily preventer and reliever
What inhaler technique is used for aerosol inhalers?
Inhale slow and steady
What inhaler technique is used for DPI?
Inhale quick and deep
What is the aim of asthma treatment?
Control disease with minimal side effects
Control:
- no daytime symptoms
- no night time awakening due to asthma
- no need for rescue medications
- no exacerbations
- no limitations on activity including exercise
- normal lung function
Which conditions are included in atophy?
Asthma
Hay fever
Eczema
Allergic rhinitis
What should children under the age of 5 with asthmatic symptoms be suspected for?
Viral wheeze
Try treatment with SABA inhaler and see if symptoms improve
Monitor closely so see how often the use and if it works. Steroids may be tried for short period of time but if uncertainty then refer to resp paediatrician.
What is the MRC dyspnoea scale?
Used to assess the impact of breathlessness in COPD pts
What are the different grading of the MRC dyspnoea scale?
Grade 1 - breathless on strenuous exercise
Grade 2 - breathless on walking up hill
Grade 3 - breathless that slows walking on the flat
Grade 4 - stop to catch breath after waking 100 m on the flat
Grade 5 - unable to leave the house due to breathlessness
How can the severity of COPD be assessed?
Using the FEV1
Stage 1 - >80% of predicted
Stage 2 - 50-79%
Stage 3 - 30-49%
Stage 4 - <30%
What other investigations other then a spirometry can be done to help diagnosis COPD and exclude other conditions?
Chest x-ray FBC - polycythaemia - raised hb in chronic hypoxia BMI - baseline weight to assess any weight change in the future Sputum culture ECG/ECHO CT thorax Serum alpha-1 antitrypsin TLCO - decreased in COPD
What is the most important intervention in COPD?
Smoking cessation
What should patients with COPD be offered alongside inhalers?
Pts with MRC score > 2 pulmonary rehab
Lifestyle advise + exercise
Vaccinations - flu/pneumococcal
Smoking cessation
What is an exacerbation of COPD defined as?
Change in sputum colour
Increased quantity of sputum
Increased breathlessness
What are additional options available in more severe cases of COPD?
Nebulisers (salbutamol and/or ipratopium)
Oral theophylline
Oral mucolytic therapy to break down sputum (e.g. carbocisteine)
Long term prophylaxis antibiotics - specialist only
Longe term oxygen therapy at home
When is LOT indicated in COPD?
Chronic hypoxia <92%
Polycythaemia
Cyanosis
Heart failure - cor pulmonale
When can LOT not be used in COPD?
If the pt smokes and this is a fire hazard
What is the medical treatment for an exacerbation of COPD if the pt is well enough to stay at home?
Prednisolone 30 mg OD for 7-14 days
Regular inhalers or home nebulisers
Antibiotics if there is evidence of infection
What is the initial management for acute bronchitis?
Smoking cessation
Adequate analgesia
Fluid intake
When are antibiotics indicated in acute bronchitis?
Systemically unwell
High risk of complications
Immunocompromised
What is the first line antibiotic for acute bronchitis in over 18 yrs?
Oral doxycycline: 200 mg on first day the 100 mg for 4 days - don’t give in pregnant women
What are alternative choices of antibiotics for acute bronchitis?
Amoxicillin - 500mg three times a day for 5 days - preferred in pregnant women - first line in 12-17 yr olds
Clarithromycin - 250mg to 500mg twice a day for 5 days
Erythromycin - 250-500mg 4 times a day for 5 days or 500-1000mg 2 times a day for 5 days (preferred in pregnant women)
What tool is used to assess severity of community acquired pneumonia?
CRB-65 / CURB-65
What is the CRB-65 tool?
Confusion
Resp rate >/= 30
Bp systolic < 90 or diastolic <60
65 yrs old
What is the antibiotics of choice if the CRB-65 score is 0 and no hospital assessment is required?
Amoxicillin 500mg 3 times a day for 5 days
If allergic to penicillin then doxycycline or clarithromycin/erythromycin
What safety netting should be given to someone started on antibiotics for pneumonia?
See medical advise if:
- symptoms worsen rapidly or significantly
- symptoms do not start to improve in 3 days or as expected
- become systemically unwell
What is the virus that causes the common cold?
Rhinovirus
What are the complications of the common cold?
LRTI
Sinusitis
Acute otitis media
What is important to assess in suspected allergic rhinitis?
Atophy/ family history
Type, freq and location, severity, housing conditions, pets, occupation
What is the management of allergic rhinitis?
Info about disease
Nasal irrigation with saline
Avoid trigger if identified
Mild to moderate - internasal antihistamine prn
Moderate to severe - internasal corticosteroids
Review in 2-4 weeks if don’t improve
What is the treatment for bacterial tonsillitis?
Penicillin V - 10 days
If allergic the clarithromycin/erythromycin
Arrange urgent bloods in immunodeficiency patient
What are the differential diagnosis for tonsillitis?
Common cold
Glandular fever
Epiglottis
What are the complications of tonsillitis?
Peritonsilar abscess
Acute otitis media
What is the tonsillectomy criteria?
7 episodes in past year
5 episodes in each of past two years
3 episodes in each of past 3 years
What are the causes of acute laryngitis?
Viral Bacterial Fungal Can co-exist Trauma Overuse e.g screaming/singing
What are the causes of chronic laryngitis?
Allergy Reflux Trauma Smoking Medications
What are the differential diagnosis for laryngitis?
Pharyngitis
Malignancy
Laryngeal nerve palsy
Nodule/polyps/cysts on vocal cord
What questions would you ask in a history of someone with suspected laryngitis?
Ask red flags for cancer Symptoms of GORD History of asthma Allergies Trauma Surgical history Medication Family history (autoimmune)
What would you look for on examination in someone with suspected laryngitis?
Lumps in neck
Airway obstructions signs
Lymphadenopathy
Systemic signs of autoimmune(rashes, joint deformity)
When is referral required for laryngitis?
If symptoms persist for 3 weeks or more
What is the management of laryngitis?
Self-limiting
Rest voice
Avoid smoking, alcohol
Remain hydrated
Antibiotics if have fever/sputum or immunocompromised
What should all children with croup receive?
Single dose of oral dexamethsone
If too unwell for oral then inhaled budesonide or IM dexamethsone
What is the management of croup after the steroids?
Managed at home if mild or moderate. Self-limiting, resolve in 48 hours and should give paracetamol/ibuprofen for fever and pain.
Urgent advise if symptoms persist or get worse
What are the three classifications of croup?
Mild - barking cough
Moderate - barking cough with stridor and some sternal/intercostal recession
Severe - all of the above + signs of resp failure and lethargic unwell child - urgent hospital admission required
What are the three types of conjunctivitis?
Allergic
Viral
Bacterial
What are the clinical features of allergic conjunctivitis?
Itching
Watery/mucoid discharge
Conjunctival redness
Oedema of the conjunctiva and eyelid
What non-pharmacological advise should be given for conjunctivitis?
Self care measures such as bathing and cleaning eyelids, cool compresses, lubricating drops or artificial tears and avoid contact lenses
Advise on infection control
What should be prescribed for allergic conjunctivitis?
Topical ocular antihistamines e.g. Azelastine and mast cell stabilisers e.g. Nedocromil sodium
What should be prescribed if bacterial conjunctivitis is suspected?
Topical antibiotics e.g. chloramphenicol or fusidic acid
What advise should be offered to patient presenting with a stye?
Reassurance that it is self-limiting and self care advise:
- apply warm compression to closed eyelid for 5-10 mins, 2-4 times a day until resolves
- advise not to puncture stye
- avoid eye make up or contact lenses until healed
What treatment options are available for a painful external stye in primary care for symptom relief?
Plucking the eyelash from infected follicle to facilitate drainage
Incision and drainage of the stye using a fine sterile needle
What are the causes of otitis externa?
Swimmers ear Topical medication Hearing aid/earplugs Chemicals Hot climates Wax build up Trauma e.g. cotton buds
What are the symptoms of otitis externa?
Itching is main symptom
May have discharge, jaw pain, slight fever, hearing may be impaired
Usually bacterial but if chronic may be fungal
What are the differential diagnosis for otitis externa?
Contact dermatitis Forgiven bodies Impacted wax Otitis media Cholesteatoma Malignancy
What is a life-threatening extension of Otitis externa?
Necrotising otitis externa - extension into the mastoid and temporal bones. Usually in diabetics or immunocompromised
What is the management of otitis externa?
Topical antibiotic/anti fungal drops- Acetic acid, sprays, corticosteroids
Oral antibiotics can be given e.g. flucloxacillin, clarithromycin
Analgesia for pain
What are the clinical features of acute otitis media?
Usually bacterial or viral.
Conductive hearing loss
History of Coryza and affects children
What is the management for acute otitis media?
Self-limiting - 5 days
Pain+fever managed by paracetamol + ibuprofen
Antibiotics may be consider in systemically unwell or immunocompromised. 5-7 day course of amoxicillin, clarithromycin or erythromycin.
What are the potential complication of acute otitis media?
Recurrence
Hearing loss
Tympanic membrane perforation
Rare: mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve palsy.
What measures can be taken to avoid recurrent AOM?
In children - avoid exposure to passive smoking, use of dummies and flat supine feeding, ensure vaccinations up to date
Adults - avoid smoking and passive smoking
What are the clinical features of otitis media with effusion (glue ear)?
Not infectious
Normally resolves over weeks or months
Can lead to hearing impairment
More common in children esp in winter months.
What is the management for otitis media with effusion?
Period of active observation for 3 months
If signs and symptoms persist the refer to ENT
What are the complications of OME?
Conductive hearing loss
Speech and language development issues and communications skills difficulty
Chronic damage to the tympanic membrane
Which children is OME more common?
Cleft palate Down’s syndrome Cystic fibrosis Primary ciliary dyskinesia Allergic rhinitis
What is the most common cause of vertigo?
BPPV
Which manoeuvres are used to diagnose and treat BPPV?
Dix-hallpike to diagnose
Epley to treat
Also pt can do brandt-Daroff exercises
May require referral if can’t perform or doesn’t work and also if severe nausea and can’t tolerate fluids
What are the differential diagnosis for Ménière’s disease?
Acoustic neuroma Otitis media Earwax Ototoxic drugs Intracrainal pathology
What investigation is recommended in suspected Meniere disease?
Audiometry - sensorineural hearing loss - low freq hearing loss or combined high and low freq with normal mid range
What is the management of Ménière’s disease?
Inform DVLA
Acute attacks - antiemetics to alleviate any vertigo or nausea
Life style - low salt diet, avoid caffeine, chocolate, alcohol, tobacco
- Consider trial of betahistine (16mg three times a day) to reduce freq an severity of attacks
- safety advise
- vestibular rehab program
- maintain mobility
- hearing support
- referral to ENT
What is the time frame for acute vs chronic sinusitis?
Acute <12 weeks
Chronic >12 weeks
When is acute sinusitis more likely to be bacterial rather then viral?
Present for more then 10 days or gets better before getting worse
Unilateral dominance
Fever greater then 38 degrees
What is the management for acute sinusitis?
Symptom relief
Saline solutions
Corticosteroid sprays
Antibiotic in bacterial
When should referral be consider in sinusitis?
Freq + reccurent episodes(more then 3 which required antibiotics)
Treatment failure after antibiotic course
Unusual/resistant bacteria
Anatomical defect or immunocompromised
Suspected allergic/immunological cause
Co-morbities that complicated management (e.g. polyps)
What should be prescribed after 10 days of symptoms of acute sinusitis?
Corticosteroid sprays
What is the management of chronic sinusitis?
Advise: Avoid allergic triggers Stop smoking Practice good dental hygiene to reduce risk of infection Avoid underwater diving
Nasal irrigation with saline solution
Consider course of internasal corticosteroid e.g. mometasone or fluticasone for up to 3 months or seek specialist advice for children
What are the potential cause of thyroid nodules?
Thyroid cysts
Chronic inflammation of thyroid - hyper/hypothyroidism
Multinodular goitre
Thyroid cancer
What investigations should be requested for in thyroid nodules?
TFTS
Physical examination
USS
Thyroid scan
What is the management for nasal polyps?
Topical steroids
What are the red flags for nasal polyps?
Unilateral
Children with polyps
What is the management of nasal septum deviation?
Decongestant
Anti-histamine
Nasal steroid sprays
Nasal strips
If airway obstruction referral for septoplasty
What are the complications of nasal fracture ?
Septal haematoma
Deviated septum
Orbital fracture
What is the management of uncomplicated nasal fractures?
Advise on ice packs and simple analgesia
Follow up appoint with ENT in 5-7 days after swelling gone down for manipulation and splinting
2-3 weeks to heal
What are the clinical features of vestibular migraines?
Vertigo, imbalance, nausea, sweating, photophobia, tinnitus, full ears, headache, alter sensation in face - build up over few hours
Family history of migraines
What is the diagnostic criteria for vestibular migranes?
ICHD-3 diagnosis:
>5 episodes, history of migranes, vestibular symptoms between 5 min and 72 hrs, migrane headache or associated symptoms in at least half the episodes
What is the management of vestibular migranes?
Avoid triggers
Eat at regular time and maintain healthy diet
Reduce stress
Regular sleep routine
Regular exercise
Use simple analgesics during episodes, anti-emetics are also available
If preventive drugs necessary the use Amitripytyline
