Gastro, Dermatology & Infectious diseases emergencies Flashcards

Question 1

Q

Can you describe the Rash of Lyme’s disease?

CKS NICE 2018

Answer

A

erythema migrans lesion-typically 5cm diameter - annular homogenous with central clearing and a bulls eye lesion

Question 2

Q

How would you make the diagnosis of Lyme’s disease in the presence of erythema migrans lesion vs no lesion ( if there is no rash with the typical lesion )?

CKS NICE 2018

Answer

A

Erythema Migrans lesion on examination:
in the presence of the erythema migrans lesion- no diagnositc tests are necessary and will unnecessarily delay commencing treatment.

No Erythema Migrans Lesion on examination:
If Lyme disease is suspected in people without erythema migrans, offer an enzyme-linked immunosorbent assay (ELISA) test for Lyme disease (NICE CKS, 2018)

if the ELISA result is positive- offer immunoblot test

Question 3

Q

What is the 3 serious complications of Lyme’s disease?

Answer

A

Severe neurological symptoms.
* encephalitis
* meningitis
* impaired concentration and memory
* paraesthesia and numbness of the limbs
* Bell’s Palsy
cardiac- myocarditis, arrythmias
Joints - Lyme Arthritis
Skin - Acrodermatitis chronica atrophans.

Question 4

Q

What is the first line treatment specific for Lyme’s disease in adults vs children?

Answer

A

all children above age 12 and adults- doxycycline 100mg Po BD for 21d ( or amoxicillin 1g po tds for 21d )

all children under the age of 12 years - amoxicillin 30mg/kg po tds for 21d

Question 5

Q

Why is doxycycline contra-indicated in children under age 12 for treatment fo Lyme’s disease?

Answer

A

doxycycline can cause yellow tooth discolouration and dental enamel hypoplasia

Question 6

Q

When can Jarisch-herxheimer reaction occur?
what is the pathophysiology of the reaction
what are the symptoms?

Answer

A

A Jarisch-Herxheimer reaction may develop (in up to 15% of people) in the first 24 hours of treatment with any antibiotic for Lyme disease.
This is a systemic reaction thought to be caused by the release of cytokines when antibiotics kill large numbers of bacteria (NICE CKS, 2018).
Symptoms include a worsening of fever, chills, muscle pains and headache. It may be mistaken for an allergic reaction and the person may stop their antibiotics (NICE CKS, 2018). The reaction can start between 1-12 hours after antibiotics are started, but can also occur later and can last for a few hours or 1-2 days (NICE CKS, 2018).

Question 7

Q

Name 4 other patholiges that can mimic the changes of pneumonia on chest xray?

Answer

A

pulmonary haemorage
pulmonary aspiration
SLE
carcinoma
contusion secondary to trauma
pulmonary infarction

Question 8

Q

If CURB 65 scores > 3, what is the next test that should be requested?

Answer

A

pneumococcal urine antigen testing

Question 9

Q

What are the 10 risk factors in red flag sepsis?

Answer

A

Brain - GCS only V/P/U AND non-blanching rash

CVS - BP < 90mmhg AND HR > 130bpm

RESP - RR > 24 AND Spo2 < 92% on air

Renal - not passed urine in 18hours or < 0.5ml/kg/hour

Skin - mottled/ashen skin colour/cyanosis/non-blanching rash

OTHER: lactate >2, recent chemotherapy

Question 10

Q

You recognize that a patient has red flag sepsis. What are the components of sepsis 6?

Answer

A

Send blood cultures
IV fluid resuscitation
IV antibioitcs
serial lactate measurements
monitor urine output hourly
administer oxygen to maintain spo2 > 94%

Question 11

Q

in treating redflag sespsis - other than sepsis 6, what other 6 management steps need to be followed in the ED &later on the Ward?

Answer

A

sepsis 6 within 60 minutes within 60 minutes
review by senior st4 + within 60 minutes
repeat observations half hourly in ED
repeat lactate within 2 hours
if septic shock or organ dysfunction - arrange review by critical care team
arrangement to repeat laboratory bloods in 14 hours
review y admitting consultant within 14hours

Question 12

Q

What are the 6 management principles of patients recognized to have septic shock , according to the NICE sepsis toolkit 2016?

Answer

A

sepsis 6 As soon as possible and within 60 minutes
immediate review by senior ST4 + ED doctor
Immediate referral to critical care outreach team
ED duty consultant to be informed
assembled the appropriate staff to initiate invasive monitoring and vasoactive therapy where necessary within 60 minutes of recognition
where ventilatory support is required- attendance of appropriately skilled staff within 30 minutes of recognition

Question 13

Q

A 26-year old Indian male presented to ED after being unwell for 5 days. He had generalized body weakness, fever and headache. In the last two days he had developed loose bowel motions and non-productive cough with dyspnoea. He had 7 episodes of loose stools and with no blood in the stool. In addition he had chills, rigors and calf pain.

He denied any vomiting; chest, abdominal or backache.

On examination he was not in any obvious respiratory distress but appeared unwell. His initial vital signs were BP 96/37, HR 119, temp 39.3, RR 26, Spo2 99% in room air and GCS 15/15. He had no jaundice, pallor, his chest was clear and abdominal exam was unremarkable. There was no rash but he had significant calf tenderness. what is the diagnosis?

Answer

A

In its mild form, leptospirosis may present as an
influenza-like illness with headache and myalgia.
Severe leptospirosis, characterized by jaundice, renal
dysfunction, and hemorrhagic diathesis, is referred to
as Weil’s syndrome. it isoften associated with viral flu like illness and calf tenderness.

Question 14

Q

In a patient with septic shock - you use noradrenaline infusion - what is the mechanism of action and what dose ?

Answer

A

Mechanism of Action: endogenous catecholamine with strong alpha and weak beta adrenoceptor stimulation. dose 0.025mcg/kg/min.

Question 15

Q

In a patient with septic shock - what are the unwanted side effects of noradrenaline?

Answer

A

peripheral vasoconstriction
reflex bradycardia
hypertension
hyperglycaemia

Question 16

Q

In a patient with necrotizing fasciitis - what are the components of the LRINEC score? ( lab results in nec fac)

Answer

A

Serum Sodium <135
Glucose >10.0mmol/l
Creatinine >140umol/L
Haemoglobin <13.5g/dL
WCC>15 x 10000/uL
CRP >150

SCORE: of > 6 is the cut-off to rule in Nec Fac, but a score < 6 does not necessarily rule it out and 10% cases had nec fac with score < 6 in the study!

LRINEC score was used to distinguish NecFac from severe cellulitis/abscess.
this score was poorly validated in 2017 ( MDCALC resource )

Question 17

Q

Indications for prescribing oral/iv thiamine to dependent alcohol drinkers?

Answer

A

if they are malnourished or at risk of malnourishment or
if they have decompensated liver disease or
if they are in acute withdrawal or
before and during a planned medically assisted alcohol withdrawal.

Question 18

Q

What clinical features would suggest that a patient has alcoholic keto-acidosis?

Answer

A

The clinical features that suggest this are:

History of heavy alcohol abuse, such that this man is malnourished. An alcohol binge, followed by abrupt cessation because of intercurrent illness is characteristic. Patients are invariably dehydrated at presentation.
A pronounced metabolic acidosis with a normal blood glucose. If his serum chloride was available, then you could work out his anion gap which would be raised. This is rarely clinically useful.

Question 19

Q

What is the role of prescribing a carbohydrate rich diet as part of the management of a patient with alcoholic keto-acidosis?

Answer

A

Carbohydrates are required to stimulate endogenous insulin production. This is important to turn off the ketone production.

Question 20

Q

A patient presents witha human bite. you test him for Hepatitis B.

Interpret the following results:

HBsAG -negative
Anti-HBs -positive
Anti-HBc -negative

Resource:
https://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf

Answer

A

This patient has immune due to hepatitis B vaccine

HBsAG
A protein on the surface of hepatitis B virus; it can
be detected in high levels in serum during acute or
chronic hepatitis B virusinfection. The presence of
HBsAg indicates that the person is infectious.
In this case he is not infectious.
Anti-HBs
The presence of anti-HBs is generally interpreted as
indicating recovery and immunity from hepatitis B
virus infection. Anti-HBs also develops in a person
who has been successfully vaccinated against
hepatitis B.
Anti-HBc -

Appears at the onset of symptoms in acute
hepatitis B and persists for life. The presence of
anti-HBc indicates previous or ongoing infection with
hepatitis B virus in an undefined time frame.

if it were positive - then in order to determine wether it is from a recent ( in last 6/12 )infection - send blood for IgM anti-HBc levels - and if the levels are high - it is a recent acute infection

HBeAG -
if present - it indicates that the virus is replicating and the infected person has high levels of HBV and is highly infectious

Question 21

Q

A 10 year old boy is in ITU. he developed an extensive rash after complaining of coryzal symptoms. the rash likes partial thickness burns to 80% of his body surface area.

What would your differential diagnosis be?

Answer

A

Differential diagnosis for partial thicnkness burns:

Staphylococcus scalded skin syndrome
Bullous impetigo
Vasculitis
Phemphigus and phemphigoid
Kawasaki’s disease
Urtricaria
Burns
Scarlet fever
SLE
Erythroderma/ Exfoliative dermatitis
Toxic shock syndrome
Herpetic infection- HSV and varicella - zoster

TABLE ON FRCEMSUCCESS website for causes of a mac-pap-erythematous rash:

measles - morbillivirus
rubella ( german measles ) - rubella virus
scarlet fever -streptococcus pyogenase
Fifths disease /infectiosum - parvovirus
sixth disease / roseola infantum - HHV 6

Question 22

Q

What are the causes of Toxic epidermal necrolysis ( 10-30% skin involvement )

Answer

A

CAUSES OF TEN’S:

INFECTION-
Herpes simplex virus, Mycoplasma, TB, Cytomegalovirus, HIV, Adenovirus, Hepatitis, EBV, Histoplasmosis

DRUGS
Antibiotics- Sulphonamide, Penicillin, Chloramphenicol, Macrolides-Erythromycin, Quinolones-Ciprofloxacin
Anticonvulsants :-Barbiturates, Phenytoin, arbamazepine, Valproic acid, Lamotrigine
NSAIDs- Ibuprofen, Indomethacin, Oxicam.

Question 23

Q

What is Nikolsky sign?

Answer

A

Nikolosky sign- Lateral pressure with finger on normal skin adjacent to bullous lesions dislodges the epidermis producing denuded dermis.

Question 24

Q

What are the complications of Toxic epidermal necrolysis?

Answer

A

Sepsis - staphylococcal and pseudomonal species.

Hypovolaemic shock

Multiorgan failure

Disseminated intravascular coagulopathy

Thrombo-embolism

Respiratory failure- Pneumonia

Question 25

Q

What is erythema multiforme?

Answer

A

This is an acute inflammatory skin condition. The spectrum of skin disorder could range from papular eruption of the skin (EM minor) to a severe multisystem illness Steven Johnson’s syndrome (EM major).

Steven johnsons syndrome <10% epidermal detachment.

Question 26

Q

WHat are the possible causes of erythema multiforme?

Answer

A

Causes -

INFECTION:

Herpes simplex virus,
Mycoplasma
TB
Cytomegalovirus and
HIV

DRUGS

1.Antibiotics- Sulphonamide, Penicillin
2.Anticonvulsants -Barbiturates, phenytoin,
carbamazepine
3.Nsaids

MALIGNANCY

·VACCINATIONS

·Radiation therapy

·Idiopathic.

Question 27

Q

What are the clinical features of erythema multiforme?

Answer

A

Malaise, fever, Myalgias, arthralgia and pruritis.
Rash features - variable hence the name multiforme. Maculopapular rash and target or iris lesions. Erythematous papules on dorsum of hand and feet, extensor surfaces of extremities. This rash evolves into the classic target lesions.
Vesicobullous lesions may appear this is pruritic and painful.
Steven Johnson’s syndrome -Vesicobullous lesions on the mucosal surfaces, mouth, eyes, vagina, urethra and anus.
Ocular involvement in 9% of EM minor

Question 28

Q

What conditions are associated with pyoderma gangrenosum?

Answer

A

Crohns
Ulcerative colitis
Rheumatoid Arthrtitis
Haematological malignancy-
* Multiple myeloma ,
* leukaemia
Hepatitis

Question 29

Q

What is the differential diagnosis for pemphigus vulgaris?

Note : the incidence of PV = 3 in 100 000

Answer

A

Bullous pemphigoid
Pemphigus drug induced
Pemphigus herpetiformis
Herpetic lsions
Apthous ulcers
Bullous insect bite
Bullous impetigo
Epidermolysis bullosa
Erythema multiforme
Urtricaria
Dermatitis herpetiformis
Lichen planus

Question 30

Q

What is bullous pemphigoid?

http://pemfriends.co.uk/pemphigoid/bullous-pemphigoid/

Answer

A

BP is the most common immunobullous disease in Western Europe with a reported incidence of 43 per million per year in the U.K. It is a blistering skin disease that tends to affect the elderly.

Question 31

Q

What are the symptoms of Bullous Pemphigoid?

http://pemfriends.co.uk/pemphigoid/bullous-pemphigoid/

Answer

A

Pruritus is frequent and can occur weeks before rash.
Rash- erythematous or urticarial rash
Tense blisters or bullae on skin flexures or may be widespread
mucosal erosions in upto 25%
Intact pruritic fluid filled blisters

Bullous pemphigoid typically starts with a red, ITCHY rash that looks a bit like eczema or hives. This tends to last several weeks or months.

Then, groups of large, itchy blisters usually appear on the red patches, just beneath the surface of the skin. They can be up to 5cm in diameter and full of fluid, with the thick skin of the blisters stretched tightly.

The fluid inside is usually clear, but can turn cloudy or blood stained.

Blisters last a few days before healing without leaving a scar, but a cycle develops in which more form.

The rash and blisters are usually seen on the upper arms and thighs, sometimes spreading to body folds and the abdomen (tummy).

Question 32

Q

Can you describe the mouth and skin lesions of pemphigus vulgaris?

http://pemfriends.co.uk/pemphigus/pemphigus-vulgaris/

Answer

A

the blisters and erosions start first in the mouth, and appear later on the skin. In a few, the skin is affected first.

Other sites affected include the conjunctiva, oesophagus, labia, vagina, cervix, penis, urethra and anus. Most patients get erosions in their mouth at some time; but some never get blisters or erosions on their skin.

MOUTH:

blistering superficial and often appears as erosions
widespread involvement in the mouth
painful and slow to heal
may spread to the larynx causing hoarseness when talking
may make it difficult to eat or drink

SKIN:

o Skin lesions are flaccid - intact blisters not found ( whereas in bullous pemphigus - tense blisters )

o PAINFUL skin rarely pruritic. ( In BP - it is itchy)

o Nail lesions may be present

o Mucous membrane lesions- painful erosions or
blisters and heal slowly - conjunctiva,
oesophagus or genetalia may be involved

Question 33

Q

How treatment would you prescribe for treating pemphigus vulgaris?

Answer

A

Mild oral disease - Topical therapy
Majority are treated with systemic steroids - high doses
Plasmapheresis to remove antibodies - along with
Cytotoxic drug azathioprine
i.v immunoglobulin

Question 34

Q

What are the casues of erythema nodosum?

Answer

A

CAUSES OF ERYTHEMA NODOSUM:

Streptococcal infection, including scarlet fever and rheumatic fever

• Sarcoidosis

• Viruses implicated Epstein-Barr virus, hepatitis B
and hepatitis C and HIV.

Lymphogranuloma venerum
Tuberculosis.
Leprosy
Sulfonylurea’s, gold and oral contraceptives.
crohn’s disease or Ulcerative colitis.

Question 35

Q

How can you differentiate between pemphigus vulgaris and bullous pemphigoid?

Answer

A

Bullous Pemphigoid rash is the commonest autoimmune rash- associated with tense blisters. very itchy

Pemphigus Vulgaris - Flaccid rash- no intact blisters found . ( and the lesions are painful

Question 36

Q

Which drugs are associated with bullous pemphigoid?

Answer

A

Antibiotics( penicillamine)
captopril,
nsaids
furosemide

Bullous Pemphigoid is the most common autoimmune blistering disorder. This is characterised by sub epidermal blistering.

Incidence is higher in elderly population age> 65.

Question 37

Q

In Bullous Pemphigoid-

What immediate treatment measures would commence in the ED?

Answer

A

High potency topical corticosteroids have been shown to be effective in localised disease and is better tolerated in elderly eg dermovate cream
Extensive Disease requires immunosuppression with systemic steroids- prednisolone 30-60mg/day
Azathioprine , plasma exchange use - needs further evidence
Antibiotics for Secondary bacterial infection.
For resistant disease consider Methylprednisolone Cyclophosphamide , cyclosporin, methylpentolate chlorambucil and plasmapheresis
Mucosal disease requires difflam and tetracycline mouth washes

Question 38

Q

What are the potential causes of erythroderma?

http://www.pcds.org.uk/clinical-guidance/erythroderma

Answer

A

Eczema
Psorisasis
Lymphoma and leukaemia. Sezary syndrome t-cell
lymphoma associated with Erythroderma.
Dermatitis- Atopic, seborrhoeic and contact
5 Drug reaction –
*penicillin,
*phenytoin,
*captopril,
*sulphonamide etc.
Idiopathic

Question 39

Q

How do you diagnose scabies?

http://cks.nice.org.uk/scabies#!backgroundsub

Answer

A

History and examination. 2/3 burrows appear on
hand and wrists.
Borrow ink test
Parasitology – scraping of skin and microscopic
examination- sensitivity very low- most diagnosis
is clinically done.

Question 40

Q

What immediate treatment would you consider in your management of scabies?

Answer

A

Simultaneously treat all household members and close contacts (sexual) with Permethrin 5% 1st line or Malathion aqueous liquid 0.5%.
Treat itch- Topical crotamiton, chlorphenamine(limited evidence)
Advice on close contact
Inform HPA if outbreak in schools, nursing home or prisons.

Question 41

Q

Describe the rash of the scabies?

2. What are the complications of scabies?

Answer

A

Small burrows underneath the skin &
Skin excoriation- Acrodermatitis
Untreated scabies can cause secondary bacterial
infections:
Cellulitis, boils, Folliculitis, Impetigo or lymphangitis

Question 42

Q

What is the name of the condition when there is hyperinfestiation with millions of mites in patients with insufficient immune systems?
Which specific patient groups are at risk?
What causes the intense itch?

Answer

A

Norweigian scabies
Chronic corticosteroid use, HIV, Malnutrition, Human
T cell lymphocytic virus type 1, Learning difficulty ,
Dementia and Down’s syndrome
Symptoms of scabies are from immune reaction
(immediate or delayed) to Saliva, eggs or faeces.

Question 43

Q

Who is more likely to get staphylococcal scalded skin syndrome?
Which sign is positive on examination?
what is the name of the toxin?
How do you make the diagnosis?

Answer

A

children under age 5, and immunocompromised patient
Nikolsky sign
Epidermolytic toxins A&B
diagnosis is made on history, examination, Tsank smear, skin biopsy and bacterial culture

Question 44

Q

WHat complication commonly occurs in pregnant woman exposed to chicken pox?

Answer

A

varicella pneumonitis occurs commonly.

other infections include cellulitis, impetigo, furuncles, NECFAC

also neurological: Reyes syndrome, meningo-encephalitis

RIsk to fetus in the first 28 weeks of pregnancy: Intrau-uterine infections and FVS

Question 45

Q

what is the difference on clinical examination between measles and german measles ( Rubella )

Answer

A

MEASLES:

*more severe disease and in child age 3-5yrs
*3 C’s - cough, coryza and conjunctivitis
*1 K - Koplik spots in buccal mucosa (which are tiny
grains of white sand, each surrounded by a red
ring
*Morbili virus
*morbilliform rash usually confluent

RUBELLA:

*milder disease, and in older children & adolescents & adults
* a macular, papular pruritic rash start behind the ears
* examination: lymphadenopathy & FORSCHHEIMER
SPOTS!
* usually no Koplik spots and rash is not confluent
* viurs = rubella virus

Question 46

Q

Name 3 cancers regarded as AIDS defining?

Answer

A

Cervical cancer
Karposi’s sarcoma
Burkitt’s Lymphoma

Question 47

Q

Can you name any MAJOR AIDS Defining opportunistic infections?

Reference:http://cks.nice.org.uk/hiv-infection-and-aids#!diagnosissub

Answer

A

Major AIDS-defining opportunistic infections

Candidiasis of the oesophagus or airways
Pneumocystispneumonia
Atypical or disseminated tuberculosis
cytomegalovirus retinitis

Question 48

Q

What are the common infectious causes of any maculopapular rash?

Answer

A

Common infectious causes of Maculopapular rash

Scarlet fever
Enterovirus and echovirus infection
Fifth disease (erythema infectiosum)
Roseola infantum (sixth disease)
EBV infection (infectious mononucleosis)
Cytomegalovirus infection
Scarlet fever

Uncommon causes

HIV-seroconversion exanthema
Acute hepatitis B virus infection
Acute hepatitis C virus infection
Rubella (German measles)
Rubeola (measles)
Meningococcaemia
Staphylococcal scalded skin syndrome
Toxic shock syndrome (Staphylococcus exotoxin)
Rocky Mountain spotted fever or Mediterranean spotted fever
Kawasaki disease (mucocutaneous lymph node syndrome)
Syphilis (secondary)

Question 49

Q

What are 4 of the clinical symptoms and 4 signs of HIV sero conversion?

Answer

A

SYMPTOMS:

Fever
rash
headache
sore throat
diahroea
malaise
arthralgia

SIGNS:

Clinical Signs

A blotchy maculopapular rash on the trunk, which may
spread to the palms of the hands and soles of the feet.
Oro-genital ulceration.
Ulcers in the orogenital or perianal areas.
Meningism (headache, neck stiffness, and
photophobia) .
lymphadenopathy.
Oral candidiasis.
Shingles.

Question 50

Q

Name 5 travel related infectious diseases?

Answer

A

African tick fever
Brucellosis
Chikungunya fever
East African trypanosomiasis (sleeping sickness)
Enteric fever (typhoid and paratyphoid fever)
Hepatitis
HIV seroconversion
Leptospirosis -
Acute schistosomiasis (katayama fever)
Viral haemorrhagic fevers:
Dengue

Other viral haemorrhagic fevers, such as yellow fever (Africa, South America), Lassa fever (western Africa), and Crimean-Congo haemorrhagic fever (Eastern Europe, Asia, Africa).

Question 51

Q

What are the clinical features of SEVERE malaria?

https: //cks.nice.org.uk/malaria#!diagnosisSub
http: //cks.nice.org.uk/malaria#!topicsummary

Answer

A

Features of severe or complicated malaria in adults include:

Parasitaemia >10%.

Cerebral malaria — impaired conscious level (Glasgow coma score less than 11) or seizures.

Renal impairment (may present with oliguria).

Acidosis (may present with acidotic breathing).

Hypoglycaemia (<2.2 mmol/l) — common in pregnant women.

Respiratory distress which may be due to pulmonary oedema or acute respiratory distress syndrome (ARDS) — common in pregnant women.

Severe anaemia (may present with pallor).

Spontaneous bleeding/disseminated intravascular coagulation.

Shock (BP < 90/60 mmHg).

Sepsis — more common in pregnant women.

Haemoglobinuria — falciparum can cause severe haemolysis with dark red urine (‘blackwater fever’).

Question 52

Q

WHat are the Complications of Malaria infection?

Answer

A

Plasmodium falciparum Malaria complications:
COMPLICATION OF MALARIA INFECTION:

Cerebral malaria (nearly always fatal without
treatment) .
Severe anaemia.
Renal failure.
Pulmonary oedema.
Hypoglycaemia.
Hypovolaemia.
Disseminated intravascular coagulation.
Metabolic acidosis.
Complications during pregnancy.
Plasmodium falciparum Malaria complications:

Question 53

Q

A patients blood test confirms malaria. How would you treat this patient in the ED?

Answer

A

If the person is shocked: cefotaxime should be given intravenously as the patients may have secondary bacterial infection.
Treatment for confirmed non-falciparum malaria will usually be advised by a specialist and includes:

Chloroquine.

For people with malaria due to Plasmodium vivax or Plasmodium ovale:

Primaquine

Paracetamol or ibuprofen for fever.
All cases of malaria should be notified to the public health authorities.

Question 54

Q

What are the indications to admit patients with Malaria?

Answer

A

Malaria is a medical emergency and immediate admission should be arranged for:

People with suspected severe or complicated malaria.
People with suspected falciparum malaria.
Pregnant women.
Children.
People who are older than 65 years of age.

Question 55

Q

What specific drugs would you consider prescribing in patients with confirmed malaria?

https://cks.nice.org.uk/malaria#!scenario

Answer

A

Antimalarial drugs recommended in the UK malaria treatment guidelines 2016 [Lalloo et al, 2016] include:

ARTESUNATE:

Parenteral artesunate is used treat severe or complicated malaria. Intravenous artesunate can cause haemolysis and follow-up blood tests are required.

2.QUININE:

Quinine may be used initially to treat severe or complicated malaria if artesunate is unavailable.

ARTEMISININ combination therapy (ACT):

ACT may be used to treat uncomplicated malaria and is the preferred treatment for mixed infection.

if ACT is unavailable:

Atovaquone-proguanil, OR
Quinine plus doxycycline

CHLOROQUINE

Chloroquine may be used to treat uncomplicated P. malariae, P. ovale and P. knowlesi and most cases of P. vivax malaria but use depends upon patterns of resistance and tolerance.

PRIMAQUINE

Primaquine is the only currently effective drug for the eradication of hypnozoites (dormant parasites which persist in the liver after treatment of P. vivax and P. ovale).

Question 56

Q

What 4 pathogens can cause necrotising fasciitis?

Answer

A

monomicrobial pathogens including:
(i) streptococci especially Streptococcus pyogenes (approximately 10% are caused by group A streptococcus alone)

(ii) Clostridium perfringens (gas gangrene) and other clostridial species,
(iii) Staphylococcus aureus,
(iv) Vibrio vulnificus and other Vibrio species,
(v) Aeromonas hydrophila

polymicrobial synergistic gangrene involves:
(i) mixed aerobe-anaerobe bacterial flora (eg Escherichia coli, Bacteroides fragilis, streptococci and staphylococci)

Question 57

Q

A 34 year old presents to ED he has recently arrived from Saudia Arabia pursuing his graduate studies. He has fevers and myalgia.

What is the organism implicated in MERS- Middle east respiratory syndrome.
what complication can occur?

Answer

A

Coronavirus

2. ARDS

Question 58

Q

What are the estimated percutaneous seroconversion risks for HIV infected blood and Non immune individual to HBeAg positive source. Please answer in Percentage

http://www.nhsemployers.org/~/media/Employers/
Documents/Retain%20and%20improve/Needlestick20injury.pdf

Answer

A

0.3% for HIV infected blood

30% for percutaneous exposure of Non –immune individual to HBeAg +ve source.

Question 59

Q

A 84 year old lady presents with a history of left loin and groin pain. She has a wound in the left loin area following a fall at nursing home 1 week back .

You suspect Necrotising fasciitis List any 2 risk factors for developing this condition.

Answer

A

Skin injury including insect bite, trauma and surgical wounds.
alcohol abuse,
intravenous drug abuse,
chronic liver or renal disease,
diabetes,
malignancy,
immunosuppression and possibly, tuberculosis

Question 60

Q

A patient with alcoholic ketoacidosis presents with metabolic alkalosis. explain the change in the blood gas state?

Answer

A

Prolonged Vomiting, Volume depletion and Hyperventilation (delirium tremens)

Question 61

Q

What is the pathophysiology of diabetic keto-acidosis?

Answer

A

the poor oral intake results in decreased glycogen stores, a decrease in insulin levels and an increase in glucagon levels

Insulin deficiency results in increased mobilisation of free fatty acids from adipose tissue.

ActeylcoA is produced in excess and this forms Acetoacetate and Ketoacid.

Question 62

Q

Other than Diabetic ketoacidosis and Alcohol ketoacidosis. Give an important differential for ketoacidosis.

Answer

A

Starvation keto-acidosis

Question 63

Q

What is the Initial fluid of choice in the treatment of Alcohol Ketoacidosis? explain

Answer

A

5% Dextrose as Saline may paradoxically worsen acidosis in initial stages of treatment.

Question 64

Q

A young female presents with Crohns disease.

what gynaecological features may she have ?
what are the diagnostic features on colonoscopy?

Answer

A

1.  Gynae featuers of crohns disease:
amenorhea
menorhoegia
dysmenorhoea
pyoderma gangrenosum of the vulva

2. colonoscopy features of Crohns: 
skip lesions
 rectal sparing
cobblestone appearance
foecal ulceration
strictures

Answer 65

A

Charcot’s triad (fever, jaundice and right upper quadrant pain)

with

hypotension and altered mental status.

Answer 66

A

The bacteria that cause leptospirosis are spread through the urine of infected animals i.e. rats, cattle,

2.  High fever
Headache
Chills
Muscle aches
Vomiting
Jaundice (yellow skin and eyes)
Red eyes
Abdominal pain
Diarrhea
Rash

Answer 67

A

haemorage
jaundice
renal failure

Answer 68

A

Hepatic Encephalopathy Clinical staging.

Stage I drowsy but coherent not confused: mood
change

Stage II drowsiness, confused, asterixis

Stage III Stupor with hyperreflexia, extensor plantar reflexes,restless, screaming

stage IV Coma

Answer 69

A

Ranson criteria (non-gallstone pancreatitis)

Used for prediction of severe acute pancreatitis - not diagnosis.

Criteria on admission:

age >55 years
glucose >11.1 mmols/L (200 mg/dL)
WBC count >16 x 10^9/L (16 x 10^3/microlitre)
serum AST (SGOT) >250 units/L
serum LDH >350 units/L.

Number of criteria and approximate mortality (%):

0 to 2 = 0%
3 to 4 = 15%
5 to 6 = 50%
>6 = 100%.

Answer 70

A

Grey Turner’s sign - bruising in the flanksis an uncommon and late finding in pancreatitis.It indicates retroperitoneal and intra-abdominal haemorrhage seen in severe necrotizing pancreatitis.

Answer 71

A

Rockall score components:

Age > 60
shock ( HR > 100 )
co-morbidities

Answer 72

A

Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices.
Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation
baloon tamponade with sengstaken blakemore tube

Answer 73

A

Management of Variceal bleeding

Transfuse with Blood, Platelets and clotting factors 2. Activate massive transfusion protocol if available.
Terlipressin
Prophylactic antibiotics

Answer 74

A

a erythematous macular papular vesicular rash confined to a single dermatone that does not cross the midline.

Answer 75

A

Dusky dark red centre with a blister , a pale pink raised middle ring and an outer bright red ring- most common cause is herpes simplex virus

Answer 76

A

Age 2-10 year olds developed:

Face: facial flushing ,
Peri-oral: Forscheimers spots on hard and soft pallate
Pharynx: exudative pharyngotonsillitus
Neck: cervical lymphadenopathy
CHest: sandpaper rash starting on trunk spread to
extremities

FLUSH THE FACE WITH FORSCHEIMERS
FEEL FOR NECK LYMPH NODES AND WIPE THE TRUNK WITH SANDPAPER!

Answer 77

A

Commonest causative organism of travellers diahroea:

Enterotoxigenic escherichia coli. it can also cause bloody diahroea.

travellers diahroea is defined as 3 or more unformed stool passed by a traveller in 24 hours.

Answer 78

A

INFECTIVE CAUSES:

shigella
salmonella (salmonella typhi&paratyphi =enteric fevers)
Shistosomiasis
Clostridium dificile
enteroinvasive Escherichia Coli

NON-INFECTIVE CAUSES:

inflammatory bowel disease
colonic carcinoma

Answer 79

A

CLINICAL features:

1st week - feel weak and lethargic , cough, fever, headache, abdominal pain,initially constipation then diahroea, epsitaxis

2nd week- so tired cant stand up ( prostration ) , prominent diahroea, confusion, abdominal distension, mild tenderness, splenomegaly.

3rd week- complications occur- intestinal haemorage, perforation, secondary pneumonia, myocarditis, encephalitis, septic shock

pathognomonic features:

ROse spots( crops of red macules) on the upper third
of the chest
Fagets sign - typhoid fever occurs with a relative
bradycardia

TREATMENT: azithromycin or flouroquinolones

Answer 80

A

Ebola virus - viral haemorragic fever from West Africa, natural reservoir is in the fruit bat. spread is via contact with bodily fluids & SExual intercourse. incubation period between4-10 days but also up to 3 weeks.
IMMEDIATE STEPS IN THE ED:

immediately isolate the patient
Inform consultant in charge of the department
inform local infectious deisease expert
contact health protection team
wera appropriate PPE
organise immediate transport of patient to a HLIU ( High -Level Isolation Unit

Answer 81

A

That measles is usually a self-limiting condition
s likely to cause unpleasant symptoms
Symptoms usually resolve over the course of a week.
Rest, drink adequate fluids, and take paracetamol or ibuprofen for symptomatic relief
To stay away from school or work for at least 4 days after the initial development of the rash (ideally until full recovery to reduce the risk of infective complications).
To avoid contact with susceptible people (that is, people who are not fully immunized through vaccination or natural exposure, infants, pregnant women, or immunosuppressed people).
To seek urgent medical advice if they develop signs of a complication of measles

Answer 82

A

A protocol or checklist is recommended. The initial care should include:

o A risk assessment for the transmission of blood borne viruses and discussion
with the patient of those risks.
o Taking blood for baseline hepatitis B, C and HIV status with consent.
o Provision of the first dose of hepatitis B vaccine, if required.
o Provision of the first doses of post exposure prophylaxis for HIV in the form
of triple therapy antiretrovirals, if required.
o Availability of microbiology advice to support decision making.

Answer 83

A

Truvada®one tablet twice a day, plus
Kaletra® two tablets twice daily.
course of 28 days

advise:

If they choose to have sex, to practise safe sex and to ensure that they follow such advice for a period of three months.
Not to donate blood until all necessary screening tests are clear.
To see their GP if they develop a fever.

Answer 84

A

A deep injury.
Terminal HIV-related illness in the source patient.
Visible blood on the device which caused the injury.
Injury with a needle which had been placed in a source patient’s artery or vein.

Answer 85

A

Stage 1 - localised infection
*fever, EM target lesions at site of bite the &
lymphadenopathy

Stage 2 - Early disseminated infection ( weeks to months after initial infection )

Erythema migrans - multiple spreading lesions
Secondary (disseminated) erythema migrans
Lymphadenopathy
Neuroborreliosis (acute neurological problems) occurs in 10-15% of untreated individuals and includes CN palsy, bell’s palsy, meningitis and encephalitis
Borrelial lymphocytoma -a purplish lump that may develop on the ear lobe, nipple or scrotum
Irregular pulse/tachycardia

*Radiculopathy – radicular pain, weakness, numbness, or difficulty controlling specific muscles

Stage 3- Late Disseminated Infection- years later:

Joint involvement – oligoarthritis (also known as Lyme arthritis)
Skin involvement – acrodermatitis chronica atrophicans (figure 4)
Peripheral and central nervous system involvement (NICE CKS, 2018).