General Practise and Primary Healthcare Flashcards
What is Acne Vulgaris?
Inflammation and obstruction of the pilosebaceous follicle with keratin plugs which results in comedones, inflammation and pustules. Sebaceous glands produce sebum, increased production traps keratin. Comodones can be open (blackheads) or closed
Associated with colonisation of anaerobic bacterium Propionibacterium acnes
Typically affects the face, neck and upper trunk.
Presentation of acne, including the types of scarring
Comedones
- Dilated sebaceous follicle, white if closed, black if open
Inflammatory lesions when follicle bursts, causing papules (small lumps) and pustules (small lumps with yellow pus)
Inflammation may be excessive causing nodules and cysts
Scarring can be:
- Hypertrophic (lumps)
- Ice-pick (indentations)
- Hyperpigmentation (darkening of skin)
What is unique about drug induced acne and what is acne fulminans
Drug Induced - monomorphic
Fulminans - Includes systemic upset, requires hospital admission and responds to oral steroids
Classifications of Acne
Mild: Open and closed comedones, may have sparse inflammation
Moderate: Widespread non inflammatory lesions and nuerous papules and macules
Severe: Extensive inflammation, nodules, pitting, scarring.
Management of mild/moderate/severe acne
Mild - 12 week topical combination therapy
- Topical adapalene and topical benzoyl peroxide
- Topical tretinoin and topical clindamycin
- Topical benzoyl peroxide and topical clindamycin
Moderate/severe - 12 week course of Topical adapalene and benzoyl peroxide with oral lymecycline or doxycycline
Important considerations with oral abx in acne
Tetracyclines contraindicated in women breastfeeding, pregnant or in children under 12. Erythromycin can be used
Topical retinoid or oral benzoyl peroxide should be co prescribed with oral abx to prevent resistance
Using antibiotics for >6 months may cause gram negative folliculitis, treat with oral trimethoprim
Which of these should not be used to treat acne
monotherapy with topical or oral antibiotic, or just both together.
Due to risk of resistance
Other possible treatment options for acne
Oral retinoids (TERATOGENIC)
COCP in women
Co-cyprindiol (most effective COCP but has higher risk of VTE)
Isotretinoin - reduces sebum production. Strongly teratogenic, must be on reliable contraception and stop for a month before pregnancy
Side effects of tretinoin
Dry skin/lips
Photosensitivity
Depression, anxiety, aggression, suicidal ideation
Rarely, stevens johnsons syndrome or toxic epidermal necrolysis
What is Acute Bronchitis?
Self limiting chest infection. Assoicated with oedematous large airways and sputum productions, may cause wheeze but no other focal chest signs (crackles, dullness to percussion, bronchial breathing etc).
How does bronchitis present?
Cough
Sore throat
Rhinorrhoea
Wheeze (not always present)
Investigations and Management of acute bronchitis
Clinical diagnosis
Analgesia, fluid intake.
Only do antibiotics if:
- Systemically very unwell
- Pre-existing comorbidities
- CRP 20-100
What is the most common STI and which one is fastest increasing?
Chlamydia is most common (especially in 15-24 yo) and gonorrhoea is the fastest increasing, with a big concern about antibiotic resistance
What is Chlamydia?
The most prevalent STI in the UK, caused by Chlamydia trachomatis, an obligate intracellular pathogen. Affects ~1/10 young women and has a 7-21 day incubation period.
Risk Factors for Chlamydia
Young
Sexually active
Multiple partners
Clinical Features of Chlamydia
Largely asymptomatic (50% men, 75% women)
Women:
- Cervicitis (pain, discharge, bleeding)
- Dysuria
- Painful sex +- postcoital bleeding
Men:
- Urethral discharge/discomfort
- Dysuria
- Epididymo-orchitis
- Reactive arthritis
What might an examination of chlamydia show?
Pelvic/abdominal tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge
What is the screening for chlamydia?
National Chlamydia Screening Program
Every sexually active person under 25yo screened annually for chlamydia. Positive tests are retested in 3 months, to ensure they havent been reinfected.
Limitation: Opportunistic testing (opt in)
When attending a GUM clinic what is tested for at minimum?
Chlamydia
Gonorrhoea
Syphilis
HIV
What STIs can be investigated with a charcoal swab?
Bacterial vaginosis
Candidiasis
Gonorrhoea (endocervical swab)
Trichomonas (posterior fornix swab)
Group B Strep
What STIs are tested for using NAAT. How are samples collected in men and women
Nucleic acid amplification test
Chlamydia and gonorrhoea
In women, a self vulvovaginal (1), endocervical (2) swab or first catch urine (3) are used.
In men, can be done with first catch urine or urethral swab
Where else can NAAT swabs be done to check for chlamydia
Rectal and pharyngeal NAAT swabs (anal and oral sex)
What is the management for chlamydia?
First line:
- Doxycycline 100mg 2xday for 7 days
- Azithromycin 1g orally (mycoplasma genitalium is resistant so less preferred)
How is chlamydia managed in pregnancy
Doxycycline is inappropriate in pregnancy (fetal tooth/bone development, maternal hepatotoxicity) and breastfeeding
Use:
- Azithromycin 1g STAT
- Erythromycin or amoxicillin could be used.
Test of cure not routinely recommended, but recommended for rectal cases, in pregnancy, and where symptoms persist.
Non Medical Management of chlamydia
Referral to GUM clinic, with partner notification and abstinence.
Men: All contacts since 4 weeks before symptom onset
Women and asymptomatic men: All contacts from last 6 months
Complications of Chlamydia in and out of pregnancy
Out:
- Pelvic inflammatory disease
- Infertility
- Ectopic pregnancy
- Epididymo-orchitis
- Conjunctivitis
- Lymphogranuloma venereum
In:
- Preterm delivery
- Permature ROM
- Low birth weight
- Postpartum endometritis
What is a complication of maternal chlamydia to the neonate, and what is an important differential to investigate
Pneumonia is possible
Main one is conjunctivitis (can be spread hand-to-eye)
- Presents with chronic erythema, irritation, discharge, unilateral and lasting >2 weeks.
What is Gonorrhoea?
Fastest increasing STI (maybe due to antibiotic resistance). Neisseria gonorrhoea (gram neg diplococcus).
Infects mucous membranes with columnar epithelium (endocervix in women, and urethra, rectum, conjunctiva and pharynx)
How does Gonorrhoea present?
More likely than chlamydia to be symptomatic (90% men, 50% women)
Females:
- Odourless purulent discharge (green/yellow)
- Dysuria
- Pelvic pain
Men:
- Same discharge
- Dysuria
- Epididymo-orchitis (test. swelling/pain)
Can cause rectal (anal discharge, itching, painful poo) and pharyngeal (sore throat, difficulty swallowing) infection but usually asymptomatic.
How do prostatitis and conjunctivitis present in chlamydia
Prostatitis:
- Perineal pain, urinary symptoms, prostate tenderness
- Conjunctivitis: Erythema and purulent discharge
Investigations for Gonorrhoea
NAAT used to detect RNA/DNA of gonococcal infection. Endocervical, vulvovaginal or urethral swab, or first catch urine. + Rectal/pharyngeal swabs in MSM
Endocervical charcoal swab MUST be taken for MCS before Abx, due to high rates of antibiotic resistance
Management for Gonorrhoea
Management in pregnancy
Single IM Ceftriaxone 1g if sensitivities not known
Single oral ciprofloxacin 500mg if sensitivities known
Test of cure NEEDED due to high resistance.
- 72 hours after treatment for culture
- 7 days after for RNA NAAT
- 14 days after for DNA NAAT
In pregnancy,
- IM Ceftriaxone 500mg + Oral azithromycin 1g orally
Main complications of Gonorrhoea
women
men
both
Women:
- PID
Men:
- Epididymo-orchitis
- Prostatitis
Both:
Disseminated gonococcal infection (infection spreads to skin and joints)
- Arthritis (migratory polyarthritis)
- Skin lesions (pustular or maculopapular)
- Tenosynovitis
- Fever/Chills
Other general comps of Gonorrhoea
Chronic pelvic pain
Infertility
Conjunctivitis
Septic arthritis
Endocarditis
Gonococcal conjunctivitis in neonate (called ophthalmia neonatorum)
- Medical emergency, associated with sepsis, perforation of eye, blindness
- Can be passed on during vaginal birth (similar to conjunctivitis and pneumonia in the child)
What is Syphillis?
STI caused by spriochete (spiral shape bacteria) called Treponema pallidum. Usually enters through a break in skin or mucous membranes, and has a up to 90 day incubation period
Modes of transmission of syphillis
Oral, vaginal, anal sex
Vertical transmission
IV drug use
Blood transfusion
Stages of Syphillis
Primary - painless ulcer (chancre) at original site of infection and local non tender lymphadenopathy
Secondary (6wk - 6months) - Systemic symptoms
- Symmetrical rash on trunk, palms, soles
- Buccal “snail track” ulcers
- condylomata lata (painless warty lesions on the genitalia)
- 3-12 weeks to latent stage
Latent - Symptoms disappear and patient asymptomatic. Early latent in first 2 years, late latent after that.
Tertiary syphilis - many years later, with the development of gummas (granulomatous lesions of skin and bones)
Neurosyphilis is when infection affects CNS
primary stage of syphillis
Painless genital ulcer (chancre) (resolves over 3-8 weeks)
Local lymphadenopathy
secondary stage of syphillis
Secondary (6wk - 6months) - Systemic symptoms
- Symmetrical maculopapular rash on trunk, palms, soles, face
- Buccal “snail track” ulcers
- condylomata lata (painless warty lesions on the genitalia)
- Alopecia
- Lymphadenopathy
- Oral lesions
tertiary stage of syphillis
Late latent/tertiary - >2 years since infection
- Granulomatous lesions “gummas” affect skin, organs and bones
- Aortic aneurysm
- Neurosyphilis
Late stage involves brain, nerves, eyes, heart, blood vessels, liver, bones, joints.
Signs of neurosyphillis
Tabes dorsalis (demyelination of the spinal cord posterior columns)
Ocular syphilis (blurred vision, eye pain, redness, inflammation)
Argyll-Robertson pupil - Constricted pupil that accommodates to close objects but doesnt react to light. Often irregularly shaped.
Paralysis, altered behaviour, dementia, sensory impairment
How is syphillis diagnosed?
Treponemal specific
- T pallidum particle agglutination assay (TPPA) and enzyme immunoassay (TPEIA). Positive results confirm exposure, but not current/past.
Non treponemal specific
- Rapid Plasma Reagin (RPR) and Venereal Disease Research Laboratory (VDRL) - Can show active disease and monitor disease progression. Sensitive but not specific, as they only assess the quantity of antibodies produced in response to syphilis.
Samples from infection sites can be tested to confirm T.pallidum with
- Dark field microscopy
- Polymerase Chain Reaction
Causes of false positive non-treponemal tests
Pregnancy
SLE, anti-phospholipid syndrome
TB
Leprosy
Malaria
HIV
Management of Syphillis
IM Benzathine benzylpenicillin 1.8g. 2-3 doses, 1 week apart.
- Doxycycline is an alternative
- In pregnancy: Erythromycin
Follow up at GUM clinic every 3 months, avoid sexual contact, contact tracing and partner notification. Test for HIV and full sexual health screen
What ADR is sometimes seen after syphilis treatment
Jarisch-Herxheimer - fever, rash, tachycardia. Differs to anaphylaxis as NO wheeze or hypotension.
No treatment required
How can congenital syphillis present?
Bunted upper incisors (Hutchinsons teeth) and mulberry molars
Rhagades (scars at angle of mouth)
Keratitis
Saber shins
Saddle nose
Deafness
What is Atrophic Vaginitis?
Inflammation and thinning of vulvovaginal tissue due to a decline in oestrogen levels. Most commonly in post-menopausal women.
Oestrogen normally makes epithelium of vagina thick and lubricated. Absence causes it to become thin and dry, making it prone to inflammation and infections, due to alteration of pH and microflora.
Lack of oestrogen can also reduce healthy connective tissue in pelvis, causing pelvic organ prolapse and stress incontinence.
Presentation of Atrophic Vaginitis
Thin/Pale vaginal mucosa
Vaginal dryness/itchiness
Pain during sex and post-coital bleeding
Discharge, loss of pubic hair and pH>4.5
Investigations and management of atrophic vaginitis
Clinical exam including speculum.
Discharge should be infection screened.
- Transvaginal USS and Endometrial biopsy necessary to exclude endometrial cancer.
- pH >4.5
Non hormonal:
- Moisturisers and lubricants
Hormonal:
- Systemic HRT (Estriol cream/ estradiol tablets)
What is Bacterial Vaginosis?
Overgrowth of anaerobic organisms (e.g. Gardnerella vaginalis). Leads to a fall in lactobacilli which produce lactic acid, so vaginal pH rises.
Very commonly sexually active women (NOT sexually transmitted infection).
Presents as grey-whiteish watery discharge and fishy offensive smell.
Criteria of BV diagnosis
Amsel’s criteria (3/4 must be present)
- Thin, white, homogenous discharge
- Clue cells (stippled vaginal epithelial cells) on microscopy
- Vaginal pH >4.5
- Positive whiff test (adding potassium hydroxide causes fishy odour)
Management of BV
Not needed if asymptomatic
Oral metronidazole 5-7 days (could have single oral, 2g metronidazole dose if issues adhering)
What is trichomonas vaginalis and how does it present
Flagellated protozoa parasite (STI)
Vaginal discharge (offensive, yellow/green, frothy)
Vulvovaginitis
Strawberry cervix
pH>4.5
Investigations and management of trichomonas vaginalis
Microscopy of a wet mount shows motile trophozoites
Oral metronidazole 5-7 days/ 2g dose one off
What is Measles?
RNA paramyxovirus, spread by aerosol transmission. Has a 10-14 day incubation period and patient is infective from prodrome until 4 days after rash start.
MMR Vaccine vaccinates against it
How does Measles present?
Prodrome
- Irritable, conjunctivitis, fever
Followed by main features
- Koplik spots (white spots (grains of salt) on the buccal mucosa) appear before the rash
- Rash (Starts behind ears (3-5 days post fever) and spreads to whole body. Discrete maculopapular rash that becomes blotchy and confluent. Desquamation typically spares palms and soles)
Management of measles
Measles is self resolving 7-10 days post symptoms. Isolate until 4 days post symptom resolution
Notifiable disease to UKHSA
Vaccinate contacts within 72 hours
Complications of measles
Otitis media - most common
Pneumonia - most common cause of death
Encephalitis
Diarrhoea
Meningitis
Hearing loss
Vision loss
Death
What is otitis media and what is it caused by?
Inflammation of the middle ear (between tympanic membrane and oval window).
Most commonly secondary to viral URTI (RSV and rhinovirus) but ear infection is bacterial (S. pneumoniae, Moraxella catharallis, H influenzae, S aureus)
How does Otitis media present and what would you see on examination?
Earache and tugging on ear
Fever, hearing loss, discharge
On examination
- Tympanic membrane is red and bulging outwards. Loss of light reflex
- May be perforation and discharge
Management of Otitis media
Usually self limiting (3 days)
Give Abx if:
- >4 days and no improvement
- Systemically unwell
- immunocompromised
- If under 2 and bilateral otitis media
- Discharge or perforation
Define otitis externa with some main risk factors and causative bacteria
Infection of the outer ear canal.
Swimming, hot/humid climate, trauma, use of hearing aids/earplugs
P aeruginosa, S aureus.
Presentation and examination of otitis externa
Ear pain, itching, hearing loss, fullness in ear
Tender pinnus/tragus, normal tympanic membrane
What is glue ear? What can unilateral glue ear suggest?
Otitis Media with Effusion. Chronic ear infection or eustachian tube dysfunction can cause a build up on viscous inflammatory fluid, causing conductive hearing loss.
Unilateral OME can suggest a middle ear tumour.
How does glue ear normally present and what do you see on examination?
Conductive hearing loss and aural fullness
Dull grey tympanic membrane, lack of light reflex, and a bubble trapped behind tympanic membrane
Management of glue ear
Most cases resolve in 3 months. Otherwise, non surgical (hearing aid, autoinflation) or surgical intervention may be needed (Myringotomy and grommet insertion)
What is a grommet, and how is it used in glue ear
Negative pressure in middle ear causes fluid accumulation leading to glue ear. A grommet is a small pipe that is placed into the tympanic membrane to keep pressure the same on either side by allowing air to enter the middle ear.
It is inserted after a myringotomy (incision in tympanic membrane to drain fluid in middle ear).
How long do grommets stay in? What is some lifestyle advice to avoid infection
6-12 months, but some can be long term.
Avoid water! and regular ENT check ups
Give the two types of deafness with possible causes
Conductive - When sound waves not conducted through outer ear to eardrum. Causes: eardrum perforation, fluid in middle ear, earwax buildup.
Sensorineural - Damage to inner ear (cochlea) or to nerve pathways from ear to brain. Causes: Aging, loud sound exposure, Meniere’s disease.
How can the deafnesses be differentiated on examination
Conductive
- Rinnes: Bone conduction > Air conduction (negative result)
- Webers: Heard more in the bad ear
Sensorineural
- Rinnes: Air conduction > Bone conduction (Positive - Normal result)
- Webers: Heard more in the good ear
What are the most common causes of deafness?
Ear wax, otitis media, otitis externa
What is pelvic inflammatory disease
PID is an ascending infection from the endocervix, affecting the uterus, fallopian tubes, ovaries and surrounding peritoneum.
Caused mostly by chlamydia trachomatis, but also N gonorrhoeae, M genitalium, M hominis
Clinical features of PID
Lower abdo pain
Fever
Deep dyspareunia
Dysuria and menstrual irregularities
Vaginal/cervical discharge
Cervical excitation
Investigations of PID
Pregnancy test to exclude ectopic pregnancy
High vaginal swab
Chlamydia and gonorrhoea
Management of PID
Low threshold for treatment
1 - stat IM ceftriaxone + followed by 14 days of oral doxycycline + oral metronidazole
2 - Oral ofloxacin + oral metronidazole
Complications of PID
Perihepatitis (Fitz-Hugh Curtis Sydrome) - RUQ Pain, may be confused with cholecystitis. (Ascending infection causes inflammation of liver capsule without involving liver)
Infertility
Chronic pelvic pain
Ectopic pregnancy
