General Practice Flashcards
Tx - Trigeminal Neuralgia
1st line - carbamezapine
Surgical Interventions are possible for persistent symptoms
what causes hormonal headaches? how do they present- describe the distribution of the headache? When do they occur?
Hormonal headaches are related to low oestrogen.
They have similar features to migraines, with a unilateral, pulsatile headache associated with nausea. They are sometimes called menstrual migraines.
They may occur:
- Two days before and the first three days of the menstrual period
- In the perimenopausal period
- Early pregnancy (headaches in the second half of pregnancy should prompt investigations for pre-eclampsia)
hormonal headaches - Tx
Triptans and NSAIDs (e.g., mefenamic acid)
What is Cervical Spondylosis and how does it present?
Cervical spondylosis is a common condition caused by degenerative changes in the cervical spine.
Sx :
- neck pain, usually made worse by movement.
- often presents with headaches.
Sponylosis just means spinal degeneration (thinning of intervebral disks), not to be confused with spinal stenosis (narrowing)- spondylosis leads to spinal stenosis , spondylitis (inflammation of vertebra), spondylolisthesis (lateral displacement)
Tension headaches management, including chronic
- Reassurance
- Simple analgesia (e.g., ibuprofen or paracetamol)
Amitriptyline is generally first-line for chronic or frequent tension headaches.
What is a hemiplegic migraine, how can you differ them from a stroke
- The main feature of hemiplegic migraines is hemiplegia (unilateral limb weakness). Other symptoms may include ataxia (loss of coordination) and impaired consciousness.
- strokes have sudden hemiplegia
Rx for migraines
Patients may develop strategies for managing symptoms, often retreating to a dark, quiet room and sleeping.
Medical options for an acute attack are:
- NSAIDs(e.g., ibuprofen or naproxen)
- Paracetamol
- Triptans(e.g., sumatriptan)
- Antiemeticsif vomiting occurs (e.g., metoclopramide or prochlorperazine)
Opiatesarenotused to treat migraines and may make the condition worse.
Presentation of tension headaches
a mild ache or pressure in a band-like pattern around the head.
They develop and resolve gradually.
They do not produce visual changes.
Bell’s Palsy - What are the functions of the facial nerve - 3 parts?
Motor functionfor:
- Facial expression
- Stapediusmuscle in the inner ear
- Posterior digastric,stylohyoidandplatysmamuscles - these are jaw and neck muscles, not throat!!
Sensory functionfortastefrom theanterior 2/3of the tongue.
Parasympatheticsupply to the:
- Submandibularandsublingualsalivary glands
- Lacrimal gland(stimulating tear production)
What is bells palsy and what causes it?
Facial nerve palsy - isolated dysfunction of the fascial nerve causing unilateral facial weakness
it is idiopathic - no apparent cause
recovery several weeks - 12 months, 1/3 patients have residual weakness
what is Ramsay-Hunt syndrome?
Ramsay-Hunt syndrome is caused by the varicella zoster virus (VZV). It presents as a unilateral lower motor neurone facial nerve palsy. Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side. This rash can extend to the anterior two-thirds of the tongue and hard palate.
Tx - Ramsay hunt-syndrome
Treatment is withaciclovirandprednisolone. Patients also requirelubricating eye drops.
What is Guillain-Barré syndrome
Guillain-Barré syndrome is an acute paralytic polyneuropathy that affects the peripheral nervous system. It causes acute, symmetrical, ascending weakness and can also cause sensory symptoms. It is usually triggered by an infection and is particularly associated with to Campylobacter jejuni, cytomegalovirus (CMV) and Epstein-Barr virus (EBV).
Presentation of Guillain-Barré syndrome
Symptoms usually start within four weeks of the triggering infection - campylobacter, EBV, CMV. They begin in the feet and progress upward. Symptoms peak within 2-4 weeks. Then, there is a recovery period that can last months to years.
The characteristic features are:
Symmetrical ascending weakness
Reduced reflexes
There may be peripheral loss of sensation or neuropathic pain. It may progress to the cranial nerves and cause facial weakness. Autonomic dysfunction can lead to urinary retention, ileus or heart arrhythmias.
Severe cases - respiratory failure.
Presentation of BPPV
- A variety of head movements can trigger attacks of vertigo. A common trigger is turning over in bed.
- Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks.
- Often episodes occur over several weeks and then resolve but can reoccur weeks or months later.
- BPPV does not cause hearing loss or tinnitus.
What is otitis externa
- inflammation of the skin in the external ear canal
- it can spread to the pinna (external ear)
- acute or chronic - +/- 3 weeks
what is the most common cause of hypothyroidism in the developed world? Explain what this is?
- hashimoto’s thyroiditis is an autoimmune condition causing inflammation of the thyroid gland
- don’t get confused with De Quervain’s (post-infectious) thyroiditis, both have initial goitre then hypothyroidism period i think
what antibodies are associated with Hashimoto’s thyroiditis?
It is anautoimmunecondition causinginflammationof the thyroid gland. It is associated withanti-thyroid peroxidase(anti-TPO)antibodiesandanti-thyroglobulin(anti-Tg)antibodies.
Other than Hashimoto’s disease, what are the causes of hypothyroidism (6)
-
- Iodine deficiency - developing world
- Hyperthyroidism Tx - LIST THESE?
- other thyroiditis
- Medications - lithium and amiodarone
- De Quivinne’s Thyroiditis - post flu/mumps leads to inital thryotoxicosis followed by hypothyroidism followed by
- past-partum thyroiditis
- Hypopituitism (other pituitary hormones are also decreased )
- pituitary adenomas
- pituitary surgery
- infection
- Sheehan syndrome (postpartum haemorrhage → ischemia)
- radiation
what are the causes of hyperthyroidism
The causes of hyperthyroidism can be remembered with the “GIST” mnemonic:
G – Graves’ disease
I – Inflammation (thyroiditis)
S – Solitary toxic thyroid nodule
T – Toxic multinodular goitre
What is thyroiditis? What causes it (4)
Thyroiditis(thyroid glandinflammation) often causes aninitial periodofhyperthyroidism, followed byunder-activityof the thyroid gland (hypothyroidism). The causes of thyroiditis include:
- De Quervain’s thyroiditis
- Hashimoto’s thyroiditis
- Postpartum thyroiditis
- Drug-induced thyroiditis
Rx for Hyperthyroidism - 5
- 1st line - carbimazole (titrated or block and replace with levothyroxine) - sounds like an antifungal lol
- propylthiouracile
- radioactive iodine + levothyroxine
- thyroidectomy + levothyroxine
- Beta blockers for relief of adrenaline -ike symptoms
what is a thyrotoxic crisis? How does it present and how is it managed?
Thyroid storm is a rare presentation of hyperthyroidism. It is also known as thyrotoxic crisis. It is a rare and more severe presentation of hyperthyroidism with fever, tachycardia and delirium. It can be life-threatening and requires admission for monitoring. It is treated the same way as any other presentation of thyrotoxicosis, although they may need additional supportive care with fluid resuscitation, anti-arrhythmic medication and beta blockers.
Mx of normal thyrotoxicosis:
- carbimazole - 1st line
- propylthiouracil
- radioactive iodine
- surgery
Define allodynia
Allodyniarefers to when pain is experienced with sensory inputs that do not normally cause pain (e.g., light touch).
Physiology of pain - describe the anterolateral system?
For memory Z2F:
- The signal from nociceptors travels in thecentral nervous system, up the spinal cord (mainly in thespinothalamic tractandspinoreticular tract) to the brain where it is interpreted as pain, mainly in thethalamusandcortex.
For understanding - Neuroscientifically challenged video:
- nociceptors send signals to the spinal cord that then ascend to the brain on pathways known as the anterolateral system
- there are 3 pathways that make up the antero lateral system: spinothalamic, spinoreticular and spinomesencephalic tracts
- spinothalamic tract - the main pathway for transmitting pain to the cerebral cortex that is thought to allow for conscious sensation and localisation of pain. Decussates at the spinal level, ascends and synapses in the thalamus. Third order neurones ascends from the thalamus, through the in the internal capsule and terminate at the somatosensory cortex.
- Spinoreticular - same pathway as the spinothalamic tract but also synapses in the reticular formation, neurone throughout the brainstem involved in attention and consciousness. This is thought to play in the emotional response to pain
- Spinomesechephalic tract - same pathway as spinothalamic but synapses in the aqueductal grey in the midbrain that releases endogenous opioids and results in descending inhibition of pain signals in the spinal-cord.
Define neuropathic pain, what are the typical features of neuropathic pain (5) ?
Neuropathic painis caused by abnormal functioning or damage of the sensory nerves, resulting in pain signals being transmitted to the brain. Typical features suggestive of neuropathic pain are:
- Burning
- Tingling
- Pins and needles
- Electric shocks
- Loss of sensation to touch of the affected area
What are the three steps of the analgesic ladder?
The World Health Organisation (WHO) analgesic ladder was originally to help manage cancer-related pain. It is also often used for acute and chronic painful conditions. The idea is that patients with mild pain start on the first step, and when pain is more severe or does not respond to the lower steps, higher steps on the ladder are used until the pain is adequately managed.
There are three steps to the analgesic ladder:
Step 1: Non-opioid medications such as paracetamol and NSAIDs
Step 2: Weak opioids such as codeine and tramadol (tramadol has multiple mechanisms of action, including being an SNRI and agonist of opioid receptors)
Step 3: Strong opioids such as morphine, oxycodone, fentanyl and buprenorphine
What are the ‘adjuvants’ to the analgesic ladder?
Other medications that can may be combined with the analgesic ladder for additional effect (calledadjuvants) or used separately to manage neuropathic pain. These are:
- Amitriptyline– a tricyclic antidepressant
- Duloxetine– an SNRI antidepressant
- Gabapentin– an anticonvulsant
- Pregabalin– an anticonvulsant
- Capsaicin cream(topical) – from chilli peppers
what are the Key side effects of NSAIDs (6)
The key side effects ofNSAIDsare:
- Gastritis with dyspepsia (indigestion)
- Stomach ulcers
- Exacerbation of asthma - prostaglandins inhibit leukotriene release (bronchospasm)
- Hypertension
- Renal impairment
- Coronary artery disease, heart failure and strokes (rarely) - prostaglandins protect vascular endothelium
What are the 5 key side effects of opiods?
The key side effects ofopioidsare:
- Constipation
- Skin itching (pruritus)
- Nausea
- Altered mental state (sedation, cognitive impairment or confusion)
- Respiratory depression (usually only with larger doses in opioid-naive patients)
How are opioids used in palliative care for pain management?
Using opioids to control pain in palliative patients is a specific scenario where the doses are titrated and optimised over time. This involves using a combination of:
Background opioids (e.g., 12-hourly modified-release oral morphine)
Rescue doses for breakthrough pain (e.g., immediate-release oral morphine solution)
The rescue dose is usually 1/6 of the background 24-hour dose. For example, if the patient is getting 30mg in 24 hours of modified-release morphine (15mg every 12 hours), each rescue dose will be 5mg, given every 2-4 hours as required.
If the patient requires regular rescue doses for breakthrough pain, the dose of the background opioid can be increased. The rescue doses will also need increasing so that they remain 1/6 of the background 24-hour dose.
TOM TIP: Remember that each rescue dose is 1/6 of the 24-hour background dose. This is a very common exam question and something that seniors will commonly ask to test your knowledge. The question may be something like, “this patient is on 30mg of modified-release morphine every 12 hours; what would be the correct breakthrough dose?” In this scenario, 10mg is the correct answer, as the patient is getting 60mg background morphine every 24 hours (30mg twice a day).
what is the difference between chronic primary and chronic secondary pain?
Chronic primary pain – where no underlying condition can adequately explain the pain
Chronic secondary pain – where an underlying condition can explain the pain
3 mechanisms of chronic pain
- Sensitisation of the primary afferent nociceptors by frequent stimulation
- Increased activity of the sympathetic nervous system
- Increased muscle contraction in response to pain
- Biological,psychologicalandsocialfactors contribute to the persistence of the pain.
KEY Management of chronic pain - 5 things
- Supervised group exercise programs
- Acceptance and commitment therapy (ACT)
- Cognitive behavioural therapy (CBT)
- Acupuncture
- Antidepressants (e.g., amitriptyline, duloxetine or an SSRI)
What is the appropriate medical management of chronic primary pain (where no underlying condition can adequately explain the pain)?
- Antidepressants (e.g., amitriptyline, duloxetine [SNRI] or an SSRI)
It is worth noting that the NICE guidelines (2021) advise that forchronic primary pain(where no underlying condition can adequately explain the pain), patients shouldnotbe started on:
- Paracetamol
- NSAIDs
- Opiates
- Pregabalin
- Gabapentin
TOM TIP: Chronic pain is incredibly common. It is worth noting these recent guidelines that clearly state to avoid basically all forms of analgesia (other than antidepressants) in patients with chronic primary pain. These guidelines may come up in exams, potentially asking you the most appropriate medication for a patient with chronic primary pain (antidepressants). This is different to chronic secondary pain, where there is an underlying condition that explains the pain.
Management of Osteoathritis
Non-pharmacological management involves patient education and lifestyle changes, such as:
- Therapeutic exercise to improve strength and function and reduce pain
- Weight loss if overweight, to reduce the load on the joint
- Occupational therapy to support activities and function (e.g., walking aids and adaptations to the home)
Pharmacological management recommended by the NICE guidelines (2022) are:
- Oralparacetamol(Short term) and topicalNSAIDs
- Add oralNSAIDs(consider co-prescribing aproton pump inhibitor, such asomeprazole, to protect the stomach)
- Consideropiatessuch ascodeine
They are best used intermittently, only for a short time during flares. Weak opiates and paracetamol are only recommended for short-term, infrequent use. NICE (2022) recommend against using any strong opiates for osteoarthritis.
Intra-articular steroid injections may temporarily improve symptoms (NICE say up to 10 weeks).
Joint replacement may be used in severe cases. The hips and knees are the most commonly replaced joints.
what tool is used to assess for neuropathic pain?
TheDN4 questionnairecan be used to assess the characteristics of the pain and the likelihood of neuropathic pain. Patients are scored out of 10. A score of 4 or more indicates neuropathic pain - hence the name
Douleur neuropathique en 4
What are the 4 first line treatments for neuropathic pain?
There are four first-line treatments for neuropathic pain:
- Amitriptyline– a tricyclic antidepressant
- Duloxetine– an SNRI antidepressant
- Gabapentin– an anticonvulsant
- Pregabalin– an anticonvulsant
NICE recommend using one of these four medications to control neuropathic pain. If it does not help, it can be slowly withdrawn, and an alternative can be tried. All four can be tried in turn. Only one neuropathic medication should be used at a time.
How is trigeminal neuralgia managed?
Trigeminal neuralgiais a type of neuropathic pain. However, NICE recommendcarbamazepineas the first-line medication for trigeminal neuralgia, and if that does not work to refer to a specialist.
classical triad of parkinson’s
There is aclassic triadof features in Parkinson’s disease:
- Resting tremor(a tremor that is worse at rest)
- Rigidity(resisting passive movement)
- Bradykinesia(slowness of movement)
Pathophysiology of parkinson’s - what is the function of the basal ganglia?
Thebasal gangliaare a group of structures situated near the centre of the brain.** They are responsible for coordinating habitual movements such as walking, controlling voluntary movements and learning specific movement patterns**.
Dopamineplays an essential role in the basal ganglia function. Patients with Parkinson’s disease have a slow but progressive drop in dopamine production.
4 features of a parkinson’s tremor
- asymmetrical
- pill-rolling appearance
- resting - worse at rest, improves with movement of that arm
- worse when distracted - performing a task in the opposite hand makes it worse
Features of parkinson’s other than the triad
- Depression
- Sleep disturbance and insomnia
- Loss of the sense of smell (anosmia)
- Postural instability (increasing the risk of falls)
- Cognitive impairment and memory problems
Define bradykinesia - list some examples
Bradykinesiadescribes the movements gettingslowerandsmallerand presents in several ways:
- Handwriting gets smaller and smaller (micrographia)
- Small steps when walking (“shuffling” gait)
- Rapid frequency of steps to compensate for the small steps and avoid falling (“festinating” gait)
- Difficulty initiating movement (e.g., going from standing still to walking)
- Difficulty in turning around when standing and having to take lots of little steps to turn
- Reduced facial movements and facial expressions (hypomimia)
4 Tx options for parkinson’s
The treatment options are:
- Levodopa (synthetic dopamine)- combined withperipheral decarboxylase inhibitors
- COMT inhibitors
- Dopamine agonists
- Monoamine oxidase-B inhibitors
Parkinsons - what is levodopa often combined with
Levodopaissynthetic dopaminetaken orally. It is usually combined with aperipheral decarboxylase inhibitor(e.g.,carbidopaandbenserazide), which stops it from being metabolised in the body before it reaches the brain.
Parkinson’s - what is the main adverse effect of Levodopa
The main side effect oflevodopaisdyskinesia. Dyskinesia refers to abnormal movements associated withexcessive motor activity. Examples are:
- Dystonia(where excessive muscle contraction leads to abnormal postures or exaggerated movements)
- Chorea(abnormal involuntary movements that can be jerking and random)
- Athetosis(involuntary twisting or writhing movements, usually in the fingers, hands or feet)
Amantadineis aglutamate antagonistthat may be used to managedyskinesiaassociated withlevodopa.
Management for Dementia- each of the 4 types, and two aspects of treatment
- Non-pharmacological interventions (promote cognition, independence, and wellbeing) - cognitive stimulation therapy, group reminiscence therapy
Alzheimer’s:
* Acetylcholinesterase (AChE) inhibitors (donepezil, galantamine, and rivastigmine)
* Memantine (a N-methyl-D-aspartic acid receptor antagonist)
Lewy Bodies:
* Donepezil or rivastigmine are recommended first line.
Vascular dementia:
* management of cardiovascular disease - stroke, heart disease, diabetes, HTN, high cholesterol, CKD
* If comorbid alzheimer’s, parkinson’s disease dementia or lewy body then AChE inhibitors or memantine are options, if no comorbid dementia then no!!
Fronto-temporal demmentia:
* People with frontotemporal dementia should not be offered AChE inhibitors or memantine.
**Drug treatments for non-cognitive symptoms (mood disturbance, personality change, agitation, psychosis) may include antipsychotics:
*** Risperidone and haloperidol are the only antipsychotics licensed for treating non-cognitive symptoms of dementia.
Management of behavioural and psychological symptoms of dementia
Antipsychotic medications:
Risperidone or Haloperidol)
These symptoms include agitation, anxiety, wandering, aggression, delusions and hallucinations
What is chronic fatigue syndrome?
Persistant, disabling fatigue lasting >6 months, affecting mental and physical function that significant impaired their ability to engage in usual activities and cannot be explained by another illness.
Plus 4 of:
- myalgia (muscle pain)
- polyarthragia (joint pain)
- memory impairment/cogniftive difficulites
- unrefreshing sleep/sleep disturabance
- post-exertional malaise (slow recovery, low levels of exertion)
- peristant sore throat, cervical/axillary lymph nodes
Management of chronic fatigue syndrome (5+)
Same as Fibryomalgia
- referral to specialist CFS service
- CBT (developing coping strategies)
- manage any underlying causes or contributory factors - stress, chronic conditions, insomnia,
- graded exercise programmes
- manage stress, depressiona dn anxiety
- advice on sleep hygeine - avoid daytime sleeping
- **pain managment **- anti-depressants.
Chronic Fatigue vs Fibromyalgia
- both characterised by chronic symptoms of fatigue and widespread pain
- They are both functional disorders - without a clear pathology, that are managed with support, CBT and graded exercise
- difference is that in fibromyalgia widespread pain is the main feature, whereas in CFS there is persistent disabling fatigue as the main feature
- Think of Iona vs CAS patient - really helpful
Ix for Fibromyalgia
- the same as CFS - all normal, ruling out other causes of pain and fatigue
- FBC, TFTs, CRP/ESR…
What is fibromyalgia and what are the key features? (7+)
A functional disorder where there is chronic (>3 months) and widespread (left and right sides, above and below the waist, and axial skeleton) pain. Basically it is primary chronic pain rather than secondary
- profound fatigue is usually also present
- post-exertional pain and fatigue (small amounts of exertion)
- widespread myofascial trigger points - severe tender points
- paresthesia
- morning stiffness
- poor concentration
- sleep disturbance
- low mood
Mx for Fibromyalgia (3)
-
- graded group exercise programmes
- CBT or Acceptance and commitment (ACT) - develop coping strategies
- consider antidepressants - duloxetine (SNRI), amitriptyline for pain and sleep (not low mood)
- Don’t use Gabapentine or pregabaline!!! NSAIDs, paracetamol or opioids - they don’t work
- lifestyle modification - pacing to avoid over exertion
- some find acupuncture helpful
Ix for glandular fever
Heterophilic antibodies - most people (i think cheaper, takes up to 6 weeks)
- monospot test
- paul brunnel test
EBV serology - faster, used in kids
- EBV viral caspid antigen antibodies - IgM (acute infection) and IgG (after the condition)
What drug can you not to give to someone with infectious mononucleosis
Amoxicillin - Mononucleosis causes an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.
Management of Infecitous mononucleiosis (lifestyle advice?)
Infectious mononucleosis is usually self limiting. The acute illness lasts around 2 – 3 weeks, however it can leave the patient with fatigue for several months once the infection is cleared.
Patients are advised to avoid alcohol, as EBV impacts the ability of the liver to process the alcohol. Patients are advised to avoid contact sports due to the risk of splenic rupture. Emergency surgery is usually required if splenic rupture occurs.
Name 4 causes of Otitis externa
- Bacterial infection
- Fungal infection - especially following topical antibiotics
- Eczema
- dermatitis - Seborrhoeic + Contact
What are the two most common bacterial causes of otitis externa?
Pseudomonas aeruginosa - aminoglycoside Rx (gentamicin)
Staphylococcus aureus
4 Sx of otitis externa
Ear pain
Discharge
Itchiness
Conductive hearing loss (if the ear becomes blocked)
Otitis externa - On examination what is found? Lastly, what about the tympanic membrane?
Examination can show:
Erythema and swelling in the ear canal
Tenderness of the ear canal
Pus or discharge in the ear canal
Lymphadenopathy (swollen lymph nodes) in the neck or around the ear
The tympanic membrane may be obstructed by wax or discharge. It may be red if the otitis externa extends to the tympanic membrane. If it is ruptured, the discharge in the ear canal might be from otitis media rather than otitis externa.
Management of Otitis Externa (4 categories)
Mild - Acetic acid 2% (antifungal and antibacterial effects)
Moderate - topical antibiotic (neomycin or gentamicin) + steroid (dexamethasone).
Topical antibiotics cannot be used if the tympanic membrane is perforated, why?
Severe pain or systemic symptoms (fever is abnormal) - oral flucloxacillin or ENT admission and IV antibiotics
Fungal Infection - clotrimazole
What is malignant Otitis Externa, how does it present and how is it managed?
Malignant otitis externa is a severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull.
Malignant otitis externa is usually related to underlying risk factors for severe infection, such as: Diabetes, Immunosuppressant medications (e.g., chemotherapy), HIV
Symptoms are generally more severe than otitis externa, with persistent headache, severe pain and fever.
Malignant otitis externa requires emergency management, with:
Admission to hospital under the ENT team
IV antibiotics
Imaging (e.g., CT or MRI head) to assess the extent of the infection
Neuro Key concept - What is ataxia, and what are the two main types?
Ataxia
Ataxia is a problem with coordinated movement. It can be sensory or cerebellar.
Sensory ataxia is due to loss of proprioception, which is the ability to sense the position of the joint (e.g., is the joint flexed or extended). This results in a positive Romberg’s test (they lose balance when standing with their eyes closed) and can cause pseudoathetosis (involuntary writhing movements). A lesion in the dorsal columns of the spine can cause sensory ataxia.
Cerebellar ataxia results from problems with the cerebellum coordinating movement, indicating a cerebellar lesion.
The most common bacterial cause of otitis media
The most common bacterial causes of otitis media, as well as other ENT infections such as rhino-sinusitis is streptococcus pneumonia. (It is also the most common alternative cause of bacterial tonsilitis to group A strep)
Other common causes include:
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
what are the most common causes of tonsilitis?
The most common cause of tonsillitis is a viral infection. Viral infections do not require or respond to antibiotics.
The most common cause of bacterial tonsillitis is group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin). The most common cause of otitis media, rhinosinusitis and the most common alternative bacterial cause of tonsillitis is Streptococcus pneumoniae.
Other causes:
Haemophilus influenzae
Morazella catarrhalis
Staphylococcus aureus
Management of Otitis media
Most cases of otitis media will resolve without antibiotics, and NICE guidelines from 2018 highlight the importance of not providing antibiotics for otitis media.
They state that most cases of otitis media will resolve within 3 days without antibiotics, but it can last for up to a week. Complications (mainly mastoiditis) are rare.
- Give simple analgesia to help with pain and fever.
- Antibiotics if given can be delayed prescription - amoxicillin 1st line
Management of Sinusitis - Acute and Chronic
NICE recommend for patients with symptoms that are not improving after 10 days, the options of:
High dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily)
A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line)
Options for chronic sinusitis are:
Saline nasal irrigation
Steroid nasal sprays or drops (e.g., mometasone or fluticasone)
Functional endoscopic sinus surgery (FESS)
Everything you need to know about Croup
define it exactly - structure affected?
Age of patients?
Sx?
classic cause?
management?
Croup is an acute infective respiratory disease affecting young children. It typically affects children aged 6 months to 2 years, however they can be older.
It is an upper respiratory tract infection causing oedema in the larynx.
Sx:
Increased work of breathing
“Barking” cough, occurring in clusters of coughing episodes
Hoarse voice
Stridor
Low grade fever
The classic cause of croup that you need to spot in your exams, is parainfluenza virus.
It usually improves in less than 48 hours and responds well to treatment is steroids, particularly dexamethasone.
What are the symptoms of impacted ear wax
In most people, ear wax does not cause any problems.
Ear wax can build up and become impacted and stuck to the tympanic membrane. This can result in:
Conductive hearing loss
Discomfort in the ear
A feeling of fullness
Pain
Tinnitus
What is Presbycusis? Pathophysiology? Ix? Mx?
Presbycusis is described as age-related hearing loss. It is a type of sensorineural hearing loss that occurs as people get older. It tends to affect high-pitched sounds first and more notably than lower-pitched sounds. The hearing loss occurs gradually and symmetrically.
The causes of reduced hearing in presbycusis are complex. There are several different mechanisms, including loss of the hair cells in the cochlea, loss of neurones in the cochlea, atrophy of the stria vascularis and reduced endolymphatic potential.
Ix - audiometry
Rx - Presbycusis is Irreversible, Hearing aids, or for severe cases, cochlear implants
What scoring system can be used to assess if a sore throat (tonsilitis and pharyngitis) is likely to be bacterial/benefit from antibiotics? How does it affect the management?
The FeverPAIN scoring system can be used to estimate the probability that a sore throat is due to a bacterial infection (streptococcus) and will benefit from antibiotics. A score and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis. Antibiotics are considered for a score of more than 4. A point is awarded for each of the following.
* Fever during previous 24 hours
* P – Purulence (pus on tonsils)
* A – Attended within 3 days of the onset of symptoms
* I – Inflamed tonsils (severely inflamed)
* N – No cough or coryza (inflammation of the mucus membranes in the nose)
Management if not scoring high enough:
Advise simple analgesia with paracetamol and ibuprofen to control pain and fever. Safetynetting - contsider antibiotics if not settled after 3 days or the fever rises above 38.3ºC. Also, consider antibiotics if they are at risk of more severe infections, such as young infants, immunocompromised patients or those with significant co-morbidity, or a history of rheumatic fever.
GP - what does examination involve for tonsilitis (3)
Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils.
There may be anterior cervical lymphadenopathy, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible). The tonsillar lymph nodes are just behind the angle of the mandible (jawbone).
Z2F doesn’t say this, but I’d also examine the ears for signs of otitis media.