Diagnostics and Therapeutics Flashcards
What is the cause of oral thrush?
Fungal infection from candida
- antibiotic use can cause
- incorrect inhaler technique can cause
- cancer patients and other immunocompromised groups
Symptoms of oral thrush?
Red mouth with white patches
Can cause nappy rash in babies
Is oral thrush contagious?
It is not contagious from oral to oral transmission but babies can pass it on the the nipple of breastfeeding mothers
How to treat oral thrush?
First line: Miconazole gel 1.25ml QDS for seven days (2.5ml in two years plus)
Nystatin 100,000 units if miconazole not indicated
Why would miconazole gel be contraindicated?
Licensed for 4 months plus, or 5/6 months plus in preterm. Choking risk in younger babies, so nystatin may be preferred.
Liver dysfunction
Drug interactions e.g. warfarin
How to prevent oral thrush?
Good dental hygiene
Inhaler advice if appropriate
What if oral thrush hasn’t resolved after seven days of miconazole?
If there was some response continue miconazole for a further seven days
If no response offer seven day course of nystatin
If still no response seek specialist advice
What is the cause of hand, foot and mouth disease?
Coxsackie virus usually the A16 strain
Symptoms of hand, foot and mouth disease?
Sore throat
Possible fever
Tender lesions in mouth and rash on body
How it hand, foot and mouth disease spread?
Contact with nasal/throat secretions Contact with fluid from blisters Faeco-oral transmission Can spread from mother to foetus Transmissible immediately before and during acute stage of illness
How to treat hand, foot and mouth disease?
Usually self limiting
Maintain fluids as dehydration can occur due to pain in mouth
Advise on possible soft diet with no salty, spicy, hot or acidic foods
Advise on analgesics- paracetamol/ibuprofen
How to prevent hand, foot and mouth disease?
Good hand hygiene
Cover mouth and nose when sneezing
Take care when handling nappies
Do not share cups, utensils, clothes or bedding
Do not pierce blisters as fluid is infectious
Other advice for hand, foot and mouth disease?
Avoid close contact with pregnant women
Children do NOT need to be excluded from school/nursery
What is the cause of threadworms?
A parasitic worm called enterobius vermicularis which infests the human gut
Symptoms of threadworms?
Perianal itching, usually worse at night
Worms may be seen on skin or in faeces
How is threadworm spread?
Faeco-oral route when eggs are ingested
Once ingested eggs mature to adult worms in one to two months in the small intestine
Adult female worms migrate to the anus to lay thousands of eggs, usually at night
Threadworms survive for six weeks
Treatment for threadworms?
Mebendazole 100mg stat for all of the household and two weeks or rigorous hygiene measures unless pregnant or under six months of age.
If mebendazole contraindicated then rigorous hygiene measures must be used for six weeks
What rigorous hygiene measures are needed during threadworm treatment?
Good hand hygiene Cut fingernails regularly Shower each morning Change bed linen and night wear daily for several days after treatment- do not shake these items as may spread eggs around room Wash on a hot cycle Throughly dust and vacuum
Do children need to be excluded from school/nursery if they have threadworms?
No
What causes head lice?
Parasitic insects called pediculus humanus capitis infect hairs on the head and feed on blood from the scalp
Life cycle of head lice?
Eggs are laid close to scalp surface, take 7-10 days to hatch
Baby lice hatch from eggs and take 7-10 days to mature to adult
Female lice lay 50-150 eggs a day
Lice have a 30-40 day life span
How is head lice spread?
Crawling between hair shafts of hosts
Head lice symptoms?
Itching on head
White spots in hair (empty eggs)
Sight of lice
Head lice treatment?
Physical insecticides- silicone or fatty acid ester based products that coat the lice and suffocate them
Chemical insecticides- poisons lice (resistance can occur)
Wet combing- to remove the lice
Treatment depends on needs of the individual patient but dimeticone 4% lotion and wet combing are recommended first line for pregnant/breast feeding, ages 6 months to 2 years and patients with asthma or eczema
Other advice for patients with head lice?
No need to be excluded from school/nursery
What causes chickenpox?
Virus called varicella-zoster
What are the symptoms of chickenpox?
Fever Rash (spots) all over body Itchy Crusting of spots within 5 days of the rash, crusts fall off in 1-2 weeks Nausea Headache Tiredness Loss of appetite
How is chickenpox spread?
Personal contact or droplet spread, very infectious as 90% of susceptible contacts contract disease
Incubation period of 1-3 weeks
Infectious from 1-2 days before rash appears until spots have crusted over
Chickenpox treatment?
Paracetamol for pain and pyrexia (licensed for three months plus) Avoid NSAIDs- can cause skin complications Calamine lotion to relieve itching Chlorphenamine for ages 1 year plus 1-2 years: 1mg BD 2-6 years: 1mg 4-6h max 6mg daily 6-12 years: 2mg 4-6h max 12mg daily 12 years plus: 4mg 4-6h max 24 mg daily
Other advice to patients with chickenpox?
Exclude from school until blisters crust over
Also avoid pregnant women, babies less than 4 weeks old and the immunocompromised
Adequate fluid intake
Dress to avoid overheating or shivering
Smooth, cotton fabrics
Keep nails short
Advise on complications: bacterial superinfection, dehydration
What causes slapped cheek?
Parvovirus B19
Symptoms of slapped cheek?
Low-grade fever Nasal discharge Headache Nausea Diarrhoea Rash on cheeks Rash may also be present on trunk, back and limbs
How is slapped cheek spread?
Droplet spread through respiratory secretions
Incubation period of 14-21 days
Only infectious for a few days before rash appears
Slapped cheek treatment?
Adequate fluids
Paracetamol or NSAID if needed
Do children with slapped cheek need to be excluded from school/nursery?
No
What causes measles?
A morbillivirus of the paramyxovirus family
Symptoms of measles?
Non-vaccinated Cough and cold symptoms Conjunctivitis Fever of 39°C or more Rash Koplik’s spots: on buccal mucosa. 2-3mm red spots with blue/white centres
How is measles spread?
Airborne via respiratory tract- almost all susceptible contacts with contract disease
Incubation period of 10 days
Infectious when symptoms appear (four days BEFORE rash appears) and four days after the onset of the rash
Treatment for measles?
Adequate fluids
Paracetamol/ ibuprofen for symptomatic relief
Other advice for patients with measles?
Excludes from school/nursery until at least 4 days after rash appears Avoid contact with susceptible people Urgent medical advice if: Shortness of breath Uncontrolled fever Convulsions Altered consciousness
What causes impetigo?
Staphylococcus aureus or staphylococcus pyogenes. Some is metacillin resistant
How is impetigo spread?
Close contact with infected person or contaminated object
Incubation period of 4-10 days
Infectious until lesions are crusted over
Symptoms of impetigo?
Lesions usually on face around mouth/nose. Usually have yellow crust Itchy Systemic symptoms may occur: Fever Diarrhoea Weakness
How to treat localised impetigo?
1) Hydrogen peroxide cream 1% cream apply two/three times a day for five days
2) if not appropriate use fusidic acid 2% cream three times a day for five days
3) if fusidic acid resistant use mupirocin 2% three times a day for five days
How to treat wide-spread impetigo?
1) fusidic acid 2% three times a day for five days
2) if resistant use flucloxacillin QDS for five days (dose depends on age/weight)
3) if allergic or unsuitable use clarithromycin BD for five days
4) if unsuitable use erythromycin QDS for five days
For systemic infections higher doses may be required
Other advice for impetigo patients?
Good hygiene
Wash affected areas with soap and water
Avoid scratching
Avoid sharing towel, clothes, utensils etc
Exclude from school/nursery until lesions healed or 48 hours after starting antibiotics
What causes ringworm?
Fungal infection usually caused by trichophyton rubrum of interdigitale
How is ringworm spread?
Direct contact with infected human
Direct contact with infected animal
Indirect contact through objects
Contact with soil (rare)
Symptoms of ringworm?
Itchy, scaly skin
Red ring shaped patches
Ringworm treatment?
In mild prescribe terbinafine or imidazole cream
Consider hydrocortisone 1% cream if inflammation
In severe disease prescribe oral anti fungal such as terbinafine
Topical anti fungal treatment for ringworm?
Terbinafine 1% cream (over 12 years): apply once or twice a day for up to 1-2 weeks
Clotrimazole 1% cream: apply two to three times a day and continue for at least 4 weeks
Miconazole 2% cream: apply twice a day continuing for 10 days after lesions have healed
Econazole 1% cream: apply twice a day until skin lesions heal
Oral anti fungal treatment for ringworm?
Terbinafine 250mg OD for four weeks
Contraindicated in hepatic impairment and severe renal impairment
Make sure to check LFTs
Itraconazole 100mg OD for 15 days or 200mg OD for 7 days
Contraindicated in ventricular dysfunction or heart failure
Other advice for ringworm?
Wear loose fitting clothes to keep moisture away from skin
Maintain good hygiene
Dry thoroughly after washing
Avoid scratching as this will cause spread
Do not share towels
Children do NOT need to be excluded from school/nursery
What causes scabies?
Infestation of a parasite called sarcoptes scabiei
Symptoms of scabies?
Pruritus particularly at night
Wavy, thread-like white/grey lines 2-10mm in length which may have a small vesicle with a black dot at the end
How is scabies spread?
Close skin contact with an infected person
Symptoms via shared clothes and towels
Symptoms begin 3-6 weeks after primary infestation
Therefore contagious before rash develops
Usually linked to overcrowded living conditions
How is scabies treated?
For ages over 2 months:
1st line: permethrin 5% cream
2nd line: malathion aqueous 0.5% if permethrin contraindicated or not tolerated
May also prescribe anti-pruritic cream such as crotamiton 10% cream and a sedating antihistamine such as chlorphenamine or hydroxyzine
Other advice for scabies?
Product should usually be applied to the whole body chin downwards however the immunosuppressed, children and the elderly may also have to apply to the face and scalp
Second application required a week after the first
All household members and sexual partners from the last month should be treated
Bedding, clothes and towels should be decontaminated by washing at 60°C and drying in a hot dryer or by sealing in a plastic bag for at least 72 hours
Itching may persist for up to two weeks after successful treatment
Isolate from school or work for until 24 hours after first treatment
What is urticaria?
Superficial swelling of the skin that results in red raised, and intensely itchy rash
Angioedema is a deeper form of urticaria with swelling of the deeper layers
What causes urticaria?
Release of histamine and other inflammatory mediators from activated mast cells
Acute: less than six weeks, usually self-limiting. Can be spontaneous or in response to a trigger such as a viral infection or allergic reaction
Chronic: has the same causes but lasts longer than six weeks
How to treat urticaria?
Identify triggers if appropriate
Non-sedating antihistamine for up to six weeks
If severe offer a short course of steroids
Refer to specialist if appropriate
Paediatric warning symptoms? (13)
Loss of appetite More than 24 hours without a wet nappy Loss of weight Persistently raised temperature Breathing problems Significant earache Discharge from only one nostril Temperature and sore throat Persistent night cough Blood loss from any orifice Neck stiffness Photophobia Rash which does not blanch on pressure
What are three types of eczema in early years?
Atopic eczema Seborrhoeic eczema (cradle cap/dandruff) Nappy rash (contact dermatitis)
Symptoms of atopic eczema?
Usually starts before first birthday
Children can grow out of it
Skin becomes irritated, itchy, red, cracked and inflamed. It can be weeping, crusting and bleeding in severe cases
What cause atopic eczema?
The protect barrier is reduced
Increased moisture loss from the skin
Bacteria/irritants pass through easier
What is atopy?
Genetic tendency to develop allergic disease, capacity to produce IgE in response to common environmental proteins
What is flexural eczema?
Atopic eczema in sites of creases and skin folds
Common trigger factors of atopic eczema?
Soap and detergents Skin infection House-dust mites and their droppings Animal dander and saliva Pollen Overheating Rough clothes
Treatments for atopic eczema?
Mainly emollients and corticosteroids
What are emollients?
Topical treatments to help soothe, smooth, protect and hydrate the skin
Indicated for all dry disorders
They make the skin waterproof
Reduce itching/scratching to reduce secondary infection
Forms of emollients?
Creams Ointments Gels Bath/shower oils Sprays
Positives of aqueous cream?
Useful as a leave on emollient
Negatives of aqueous cream?
Can cause skin reactions
Causative agent may be the stabiliser and cleansing agent sodium lauryl sulphate (SLS)
Also contains other ingredients that may cause a reaction: chlorocrescol, cetostearyl alcohol and parabens
How should emollients be applied?
Liberally
As often as possible but at least three/four times a day
Apply immediately after bath or shower to trap in the maximum amount of moisture
Apply in downwards motion following the direction of the hairs
Do not rub as can lead to irritation from friction
Warnings with emollients?
Some are SLS contains so irritating
Paraffin containing are flammable
Advice for bath/shower oils?
Do not have the water too hot as this can exacerbate itching
Use a bath mat to prevent slipping
Following the directions
Pat skin dry after use
What is complete emollient therapy?
A way of keeping your skin properly moisturised at all times by using a combination of products liberally and frequently
Do not stop suddenly once things get better as they can quickly get worse again
What does a standard complete emollient therapy include?
Emollient-based cleanser or soap substitute
Creams for any time application
Ointment which are usually preferred at night
How to know how much emollient should be prescribed?
Use section in BNF
How do topical corticosteroids work for eczema?
Suppress production of inflammatory mediators
Forms of topical corticosteroids?
Creams Lotions Gels Mousses/foams Ointments Tapes
Four potencies of topical corticosteroids?
Mild
Moderate
Potent
Very potent
How often to apply topical corticosteroids?
Once or twice a day for one to two weeks to control flare ups
No benefits of applying more often
What is a finger tip dosage unit?
Length of cream/ointment from a tube squeezed from the tip of an adult index finger to the crease
Approximately 0.5g
How much does one finger tip dosage unit cover?
Two adult palms including the fingers
Advice for topical corticosteroid application?
Apply thinly to affected areas only
Apply no more than twice a day
Use least potent formulation that gives full effect
Apply up to 20 minutes after application of emollient
What does topical corticosteroid potency mean?
The degree of vasoconstriction they produce in the skin
Why should an emollient be applied up to 20 minutes before a topical corticosteroid?
Hydrates the skin and highlights areas of redness to make it easier to see where to apply corticosteroid
Removes scales which can affect corticosteroid absorption
Also plumps you the skin to increase the surface area for absorbing corticosteroid
Symptoms of seborrhoeic eczema?
Greasy, yellow or brown scaly patches
Usually on the scalps of young babies but can be face, ears, neck, nappy area, armpits and behind the knees of both children and adults
Usually does not itch or cause discomfort
Not contagious
Affects oily skin
Cause of seborrhoeic eczema?
Unclear but not poor hygiene or allergy
May be high levels of sebum on affected areas
Reaction to yeast called malassezia on the skin
Advice for seborrhoeic eczema?
Common in first two months of babies life and clears up in weeks to months without treatment
Do not pick the scales as can cause infection
Hair loss may occur but this will grow back
Scales can be soften overnight with baby oil, white petroleum jelly, olive or vegetable oil and shampoo in the morning
Gently brush with a soft brush
If this doesn’t work an emollient can be tried
When to refer a patient with cradle cap?
Itchy scalp
Swollen scalp
Bleeding scalp
Spreads to the face or body
What is nappy rash?
When the skin around a babies nappy area becomes irritated
Contact dermatitis caused by urine and faeces
Nappy rash causes?
Mainly prolonged exposure to urine or faeces
Can be a result of infection, trauma or rare skin condition
How to prevent nappy rash?
Keep babies skin clean and dry
Use a barrier cream if needed
Trigger factors for nappy rash?
Weaning Common cold Teething Antibiotics First sleeping through the night Change in diet Diarrhoea
Symptoms of a secondary bacterial infection from nappy rash?
Marked redness with exudate
Vesicular and pustular regions
Pus-like drainage or yellowing coloured crusting
Treatment of a secondary bacterial infection from nappy rash?
Advise on skin care
Apply barrier cream every change
Refer to a doctor for oral antibiotics
Do not use talcum powder, vitamin A, topical antibiotics or oral antifungals
Symptoms of a secondary fungal infection from nappy rash?
Severe bright red patches with fine peripheral scale in nappy region
Especially in skin folds
No exudate
Sometimes co-exists with oral thrush
Treatment of a secondary fungal infection from nappy rash?
Advise on skin care
Antifungal cream such as clotrimazole
No barrier creams until infection has settled
When to refer a patient with nappy rash?
Spreading to other areas
Getting worse or refractory to treatment
Bacterial infection present or suspected
Fungal infection that co-exists with oral thrush
Systemic symptoms
Anaemia definition?
A haemoglobin level two standard deviations below the normal for age and sex. Men: below 130g/l Women: below 120g/l Ages 12-14: below 120g/l Pregnant women: 110g/l Postpartum: 100g/l
What serum ferritin level confirms iron deficiency?
Less than 30mcg/l
Causes of iron deficiency anaemia?
dietary deficiency (rarely a cause on its own as it can take eight years to develop)
Malabsorption (coeliac, gastrectomy, H. Pylori infection)
Increased loss mainly from GI or uterus (NSAID use, colonic carcinoma, gastric carcinoma, gastric ulceration, menorrhagia)
Increased requirement (pregnancy)
Other causes (blood donation, self-harm, haematuria, nose bleeds, medication)
What is the most common type of anaemia?
iron deficiencycy
Complications of iron-deficient anaemia?
Cognitive and behavioural impairment in children
Impaired muscular performance
Heart failure
Adverse effects on the immune system
Complications of iron deficiency anaemia in pregnant women?
Increased morbidity (both mother and child)
Possible low birth weight
Preterm delivery
Maternal postpartum fatigue
Iron deficiency in infant for first three months of life
Symptoms of iron deficiency anaemia?
Dyspnoea Fatigue Headache Cognitive dysfunction Restless leg syndrome Serious symptoms such as ankle oedema, worsening of pre-existing angina pain can occur if level less that 70g/l
Signs of iron deficiency (without anaemia?)
fatigue Lack of concentration Irritability Pallor Atrophic glossitis Dry, rough skin and hair Alopecia Ulceration of corners of the mouth Nail changes (ridges, spoon-like)
How to treat iron deficiency anaemia?
address any underlying causes
Prescribe ferrous sulfate, fumarate or gluconate (all equipment to 65mg iron) OD
Continue for three months after the iron deficiency is corrected to allow stores to replenish
If not tolerate changed to alternate-day dosing or consider alternative preparation
Consider parenteral iron if oral not tolerated, contraindicated or ineffective
Information to give patients taking iron supplements?
adverse effects usually settle down with time
Usually taken on an empty stomach, but if GI disturbances occur, then can try taking with or after food (but lowers absortion) or taking on alternate days
Explain monitoring requirements
Safe storage as overdose can be fatal
Side effects of iron supplements?
constipation Diarrhoea Epigastric pain Faecal impaction GI irritation Nausea Black stools
When may ongoing iron supplementation be appropriate?
recurring anaemia (elderly) and further investigations not indicated Iron poor diet (vegan) Malabsorption (coeliac disease) Monnorhagia Patient with gastrectomy Pregnant women Patients in hemodialysis
Oral iron supplements can reduce the absorption of?
Tetracyclines
Quinolones
Bisphosphonates
Zinc
What can reduce the absorption of oral iron?
Zinc Magnesium Calcium Tannins (in tea, coffee, cocoa) Phytates (cereal grains, legumes, nuts and seeds)
Common oral iron supplement interactions?
methyldopa (reduces antihypertensive effect)
Levodopa (bioavailability may be reduced)
Levothyroxine (effects of thyroxine may be reduced)
Penicillamine (absorption can be reduced by up to two thirds)
What is MCV?
mean corpuscular volume
Average size of the red blood cells
Typing anemia due to MCV?
microcytic (<80fl)
Normocytic (80-100fl)
Macrocytic (>100fl)
Types of microcytic anemia?
iron deficiency
Chronic inflammatory disease
Thalassemia
What are reticulocytes?
premature RBCs
Types of normocytic anaemia with a high reticulocyte count?
Haemolytic anaemia
Blood loss
Types of normocytic anaemia with a low reticulocyte count?
bone marrow disorder (aplastic anaemia)
What are megaloblasts?
large immature RBCs
Types of macrocytic anemia with megalobasts?
Vitamin B12 deficiency
Folate deficiency
Drug-induced (methotrexate etc.)
Types of macrocytic anemia without megalobasts?
alcohol abuse
Hypothyroidism
Pregnancy
Types of anaemia caused by decreased RBC production?
Aplastic anemia CKD due to decreased erythropoietin Hypothyroidism Vitamin B12 deficiency Iron deficiency Chronic inflammatory disease
Types of anaemia caused by increased destruction of red blood cells?
Disseminated fragmented coagulopathy (DIG)
Thrombotic thrombocytopenic purpura (TTP)
Hemolytic uremic syndrome (HUS)
Mechanical heart valves
Hypersplenism
Inherited haemolytic anaemia (sickle cell)
Malaria
Bloods test results in hemolytic anaemia?
increased lactate dehydrogenase
Increased reticulocyte count
Increased bilirubin
Low haptoglobin levels
What are red blood cells broken down to?
lactate dehydrogenase Globin Free haemoglobin Unconjugated bilirubin Iron
What is MHC?
mean haemoglobin concentration
a measure of the concentration of haemoglobin
27-32pg is the normal range
What is a low MHC called?
hypochromic
What types of anemia have a low MHC?
Iron deficiency
Chronic disease
Thalassemia
What is aplastic anaemia?
when the bone marrow fails to produce RBC, WBC and platelets
Blood test results for aplastic anaemia?
low Hb
Low platelets
Low neutrophils
Causes of aplastic anaemia?
Congenital (very rare) Idiopathic Infections Exposure to toxins Drugs Pregnancy Sickle cell Genetic factors
What drugs can cause aplastic anaemia?
chloramphenicol, sulfonamides, gold, penicillamine, indometacin, diclofenac, naproxen, piroxicam, phenytoin, carbamazepine, carbimazole, thiouracil, dosulepin, phenothiazines, chlorpropamide, chloroquine
Aplastic anaemia symptoms?
pallor Headache Palpitations Dyspnoea Fatigue Ankle oedema Skin/mucosal haemorrhage Retinal haemorrhage Petechial rashes
Aplastic anaemia treatments?
remove any underlying causes Haemopoietic stem cell transplant immunosuppressive drug therapies include: ATG (anti-thymocyte globulin) combined with cyclosporin Alemtuzumab Eltrombopag
What is AIHA?
autoimmune hemolytic anaemia
What is autoimmune haemolytic anaemia?
when the body produces antibodies again RBCs, so they are destroyed by the immune system
What causes autoimmune haemolytic anaemia?
idiopathic Infections Cancer Autoimmune conditions Certain drugs
Symptoms of autoimmune haemolytic anaemia?
dyspnoea Fatigue Palpitations Chest pain Headache Pallor Jaundice Dark urine Gallstones Splenomegaly
What do blood test results show in AIHA?
raised bilirubin
Raised lactate dehydrogenase
A Coombs test is used to detect antibodies that act against the surface of your red blood cells
Treatments for AIHA?
treat underlying causes if secondary AIHA (drug-induced, cancer)
Steroids
Rituximab
IVIG
Other immunosuppressive drugs (azathioprine, mycophenolate, ciclosporin, cyclophosphamide)
Splenectomy
What is hematocrit?
percentage of a sample of whole blood occupied by intact red blood cells
Norma hematocrit ranges?
males 40-52%
Females 37-47%
What is RDW?
RBC distribution width
(Standard deviation of RBC volume/ mean cell volume) x 100
Normal range for RDW?
11-15%
What does a high RDW show?
Large variability in sizes of RBCs
How does CKD cause anaemia?
Damaged kidneys means a reduced amount of erythropoietin produces
Patients with CKD also use more iron to make the same amount of haemoglobin as others
Treatment options for CKD associated anaemia?
Use of erythropoietin stimulating agents such as epoetin or darbepoetin
IV iron supplementation
Both of these can be given during dialysis
What is a food allergy?
An abnormal reaction of the immune system to a particular food. It can be IgE mediated or non-IgE mediated
What is a food intolerance?
When the body has difficulty digesting certain substances in food or because certain substances directly affect the body somehow. The immune system is not involved
Time of onset of food allergy?
IgE mediated is immediate
Non-IgE mediated is delayed
