GP day cases Flashcards
Describe each of the conditions:
- CMV
- VZV
- EBV (HHV-4)
- CMV = M for mascara/eye
- VZV = Z with the rash like like a zoo animal Chickenpox, shingles
- EBV = B looks like the top lip
Saliva and genital secretions
Infect/latency in B cells
Children: asymptomatic
Adolescent: pharyngitis, lymphadenopathy, splenomegaly, hepatomegaly, or rash
Get better in 2-4wks. However, some people may feel fatigued for several weeks or even months.
(fluid, rest, para)
Pityriasis rosea
- What is it?
Epidemiology
Aeitiology
Symptoms
- raised, red scaly patches
aeitiology unkown ?HHV
asymptomatic (fever, headache, temp)
Herald patch first (oval/round), 2-5cm in diameter, pink/red, ~ chest/upper back
5/20 days after wifespread rash back, chest, abd (christmas tree distrubution), 1/3cm
rash fades in 2-12 wks
If does not clear in three months or intense itching refer to derm
Can use antihistamine tablets, if severe steroid cream, methol cream cooling
- What is Personal Independence Payment (PIP)?
- How much could I get?
- Personal Independence Payment (PIP) is a benefit for people who may need help with daily activities or getting around because of a long-term illness or disability.
PIP has two parts - a daily living component and a mobility component.
PIP has replaced Disability Living Allowance for anyone making a new claim.
- image (preparing food and drink, dressing and undressing, or moving around)
Pneumonia
How do you treat CAP
CURB-65 Score 0-1 (mild) community-acquired pneumonia
- Amoxicillin oral 500mg tds for 5 days
- If penicillin allergic: Doxycycline oral 200mg od for 5 days.
CURB-65 Score 2 (moderate) community-acquired pneumonia
- Amoxicillin oral 1g tds for 5 days and Doxycycline oral 200mg od for 5 days
- If penicillin allergic: give only Doxycycline oral 200mg od for 5 days.
CURB-65 Score ≥ 3 (Severe) community-acquired pneumonia
- Send off legionella urine antigen test. Consider critical care referral.
- Co-Amoxiclav IV 1.2g tds and Doxycycline oral 200mg od for 5 days
- If non-anaphylactic penicillin allergy:
- Meropenem IV 1g tds and Doxycycline oral 200mg od and for 5 days (reduce dose if renal impairment).
HAP management
Mild/moderate hospital-acquired pneumonia and not known to be MRSA carrier
- Co-amoxiclav oral 625mg tds for 5 days
- If NBM: Co-amoxiclav IV 1.2g tds
- If penicillin allergy: Doxycycline oral 200mg od for 5 days (Reduce dose if renal impairment)
- If NBM and non-anaphylactic penicillin allergy: Meropenem IV 1g tds.
- Contact microbiology for advice if anaphylactic penicillin allergy
Severe hospital-acquired pneumonia
- Co-amoxiclav IV 1.2g tds for 5 days (reduce dose if renal impairment)
- If non-anaphylactic penicillin allergy :
- Meropenem IV 1g tds for 5 days (reduce dose if renal impairment). Contact microbiology for advice if anaphylactic penicillin allergy
Aspiration pneumonia:
Mild/moderate aspiration pneumonia
- Co-amoxiclav oral 625mg tds for 5 days
- If NBM: Co-amoxiclav IV 1.2g tds. Convert back to above oral regimen as soon
- as possible to complete the 5 day course.
- If penicillin allergy: Ciprofloxacin oral 500mg bd and Metronidazole oral 400mg bd for 5 days.
- If atypical pathogen suspected add in Doxycycline oral 200mg od or if NBM
- Clarithromycin IV 500mg bd.
Severe aspiration pneumonia:
- Co-amoxiclav IV 1.2g tds.
- If non-anaphylactic penicillin allergy:
- Meropenem IV 1g tds for 5 days (reduce dose if renal impairment). Contact microbiology for advice if anaphylactic penicillin allergy
Pharyngitis / Sore throat / Tonsillitis management
How should I treat my cold/cough/sore throat?
How long do colds last up to?
Cough?
+ fluid
+ rest
+ para/ibu dissolved alternate every 4hrs gargle and then swallow
~2wks
Coughs for up to 3-4 week
Cough symtoms in children and how to manage?
- In children, a temperature > 37.5°C is considered a fever -> paracetamol & ibuprofen
- Disturbed sleep: mucus from the nose and throat runs downwards and your child coughs more to clear it
> 1yo, a spoon of honey (perhaps in a warm drink) half an hour before bed may help them to wake less often.
>2yo, vapour rubs (containing camphor, menthol and/or eucalyptus) may help children
- Drinking and eating less (can go a few days without eating much)
- Prevent dehydration
Otitis media and otitis externa management
Acute sinusitis management
chronic sinusitis
Management of acute bronchitis & acute exacerbation of COPD
Flowchart for women (under 65 years) with suspected UTI
>65yo UTI
Management:
- UTI for BOTH women and men OF ALL AGE
- UTI in pregnancy
- UTI in Children
Management:
- UTI in Children Child ≥ 3 months
Child ≥ 3 months but < 3 years with suspected UTI : Use dipstick testing
If both leucocyte esterase and nitrite are negative: do not start antibiotic treatment; do not send a urine sample for microscopy and culture unless at least 1 of the criteria under“Indication for culture” apply.
If leucocyte esterase or nitrite, or both are positive: start antibiotic treatment; send a urine sample for culture
Acute pyelonephritis in adults
Recurrent UTI in non-pregnant women ≥ 3UTIs/year (Check if true recurrence or inappropriate treatment)
Acute proctitis management
How do you eradicate H.pylori
How to manage C.diff in the community on Day 1
How to manage C.diff in the community on day 2-3, 4-9, 10
Describe the Bristol stool chart
How do you manage acute diverticulitis
in diverticulitis do not do flexi sig risk of perforation
How do you come to a diagnosis with a patient presenting with vaginal discharge
How do you manage Vaginal candidiasis, Bacterial vaginosis, Trichomoniasis
How do you manage Chlamydia trachomatis & Endometritis
(5000 UNITS of dalteparin prohphylactically)
PID
heparin will prevent new clots forming
alteplase will break down the clot
post natal perineal wound infections management
- Antibacterial resistance of Propionibacterium acnes is increasing; there is cross-resistance between erythromycin and clindamycin. To avoid development of resistance:
- Although minocycline is as effective as other tetracyclines for acne, it is associated with a greater risk of ?
- Co-cyprindiol
- How do oral retinoids work
Used for?
Benzoyl peroxide -> kills bacteria (s/e: skin irritation, dryness, or peeling)
Topical retinoids are creams, lotions and gels (more thick to less thick (more watery)) containing medicine derived from Vitamin A
Mild to moderate acne:
- benzoyl peroxide (start low conc, should see effects within 2months)
- topical retinoid ( tretinoin, its isomer isotretinoin, and adapalene (a retinoid-like drug))
- topical erythromycin or clindamycin -> if not working oral Abx
- Azeliac acid (antimicrobial and anticomedonal property, less likely to cause s/e then BPO)
Moderate to severe acne:
- co-cyprindiol ( cyproterone acetate with ethinylestradiol); it is for women only
- Oral abx: oxytetracycline or tetracycline, -> no improvement after the first 3 months another oral antibacterial should be used. Maximum improvement usually occurs after 4 to 6 months but in more severe cases treatment may need to be continued for 2 years or longer.
Doxycycline and lymecycline are alternatives to tetracycline
Severe acne
- isotretinoin
2.
- when possible use non-antibiotic antimicrobials (such as benzoyl peroxide or azelaic acid);
- avoid concomitant treatment with different oral and topical antibacterials;
- if a particular antibacterial is effective, use it for repeat courses if needed (short intervening courses of benzoyl peroxide or azelaic acid may eliminate any resistant propionibacteria);
- do not continue treatment for longer than necessary (however, treatment with a topical preparation should be continued for at least 6 months).
- lupus erythematosus-like syndrome. Minocycline sometimes causes irreversible pigmentation; it is given in a once or twice daily dose.
- (cyproterone acetate with ethinylestradiol) contains an anti-androgen. It is licensed for use in women with moderate to severe acne that has not responded to topical therapy or oral antibacterials, and for moderately severe hirsutism. Although it is an effective hormonal contraceptive, it should not be used solely for contraception.
Improvement probably occurs because of decreased sebum secretion which is under androgen control. Some women with moderately severe hirsutism may also benefit because hair growth is also androgen-dependent.
5.
- Isotretinoin reduces sebum secretion.
- nodulo-cystic and conglobate acne,
severe acne,
scarring,
acne which has not responded to an adequate course of a systemic antibacterial,
acne which is associated with psychological problems
women who develop acne in the 3rd or 4th decades of life, since late onset acne is frequently unresponsive to antibacterials.
- Mild acne can be treated with topical preparations alone. Benzoyl peroxide is more useful for inflammatory lesions and topical retinoids e.g. ? where comedones predominate. The two can be used in combination if necessary, ? Patients should be encouraged to apply the preparations to the whole affected area, not just to individual lesions. They should be warned that irritation is likely at the start of treatment; frequency of application may need to be reduced if excessive irritation occurs. Improvement is unlikely during the first 6-8 weeks of treatment, but should be reviewed after? Patients should be warned that Benzoyl peroxide preparations may stain clothing and bed linen.
- Topical antibiotics such as clindamycin or erythromycin also reduce inflammation, but antibiotic resistance is becoming a problem. Combining an antibiotic with benzoyl peroxide (to which resistance does not occur) may help to reduce this, as in the combination product ?
- ? (adapalene in combination with benzoyl peroxide) may be used as an alternative to Duac. It has the advantage of a once daily application and no issues with antibiotic resistance development.
- Patients with moderate-severe acne or those known to scar easily should also receive systemic antibiotics. Use adequate doses for at least ?; lower doses may be less effective and relapse tends to occur more frequently.
- Antibiotic resistance is an increasing problem with systemic treatment. It may be minimised by using topical treatments where possible, not continuing treatment longer than necessary, using topical benzoyl peroxide in between antibiotic courses and avoiding oral and topical treatment with different antibiotics at the same time.
- Patients who do not respond to antibiotics should be referred to a dermatologist for further advice. Severe nodulocystic acne and that resistant to standard treatment may be treated with the retinoid ?, for which hospital referral is required.
- Female patients may respond to hormonal contraception, eg?
tretinoin
one at night and one in the morning
3 months
Duac
Epiduo
six months
isotretinoin
Dianette
Impetigo
Primary Care Cellulitis Pathway
- What do we mean by class 1 antibiotics?
- Management?
- Class 1 patients neither have features of systemic infection nor any of the comorbidities
2.
- What is Class 2 cellulitis
- Class 2 patients EITHER are
* systemically affected (i.e. have a temperature > 37.9°C or are vomiting)
OR
- have one or more comorbidities; i.e.
- Peripheral vascular disease
- Treated diabetes or blood glucose > 11mmol/L
- Chronic venous insufficiency
- Morbid obesity (i.e. BMI ≥40)
- Liver cirrhosis
2.
- How do you manage class 3 and 4 cellulits
- What is class 3 & 4 cellulitis
ALT-70 Score for Cellulitis
Class 3 patients EITHER are clinically unstable, e.g. have
- Acutely altered mental status
- Heart rate > 99/min
- Respiratory rate > 20/min
- Systolic BP < 100mmHg
OR
have unstable comorbidities; i.e.
Uncontrolled diabetes
Varicoseulcer
Peripheral vascular disease with critical ischaemia or arterial ulcer
Class 4 patients have a systolic BP of < 90mmHg or other features of severe sepsis or life- threatening infection, such as necrotizing fasciitis (NB: Such patients may need surgery)
Rx
- What is tinea pedis?
- Signs and symptoms of athletes foot?
RF
complications
prevention
Rx: Miconazole, terbinafine
- Dermatophyte infection of the soles of the feet and the interdigital spaces
- Tinea pedis is most commonly caused by Trichophyton rubrum
- very sweaty while confined within tightfitting shoes
- ringworm
- scaly rash that usually causes itching, stinging and burning.
contagious and can be spread via contaminated floors, towels or clothing.
RF:
- Are a man
- Frequently wear damp socks or tightfitting shoes
- Share mats, rugs, bed linens, clothes or shoes with someone who has a fungal infection
- Walk barefoot in public areas where the infection can spread, such as locker rooms, saunas, swimming pools, communal baths and showers
Complications
- Your hand. People who scratch or pick at the infected parts of their feet may develop a similar infection in one of their hands.
- Your nails. The fungi associated with athlete’s foot can also infect your toenails, a location that tends to be more resistant to treatment.
- Your groin. Jock itch is often caused by the same fungus that results in athlete’s foot. It’s common for the infection to spread from the feet to the groin as the fungus can travel on your hands or on a towel.
Prevention
- Keep your feet dry, especially between your toes. Go barefoot to let your feet air out as much as possible when you’re home. Dry between your toes after a bath or shower.
- Change socks regularly. If your feet get very sweaty, change your socks twice a day.
- Wear light, well-ventilated shoes. Avoid shoes made of synthetic material, such as vinyl or rubber.
- Alternate pairs of shoes. Don’t wear the same pair every day so that you give your shoes time to dry after each use.
- Protect your feet in public places. Wear waterproof sandals or shoes around public pools, showers and lockers rooms.
- Treat your feet. Use powder, preferably antifungal, on your feet daily.
- Don’t share shoes. Sharing risks spreading a fungal infection.
How do you manage Diabetic foot infection
How do you manage mastitis
How do you manage bites, scabies and boils?
tetanus bacteria, msucle spasms stiffness lockjaw
How do you manage conjunctivitis
How do you manage Varicella zoster / chicken pox & Herpes zoster / shingles?
- What is it?
- How do you manage paronychia?
- bacterial or fungal infection of the hand or foot where the nail and skin meet at the side or the base of a finger or toenail. The infection can start suddenly (acute paronychia) or gradually (chronic paronychia)
2.
- Moist heat (warm soaks) three to four times a day to alleviate pain, localize the infection, and hasten draining of the pus (‘bring to a head’)
- Incision and drainage are recommended if a fluctuant pus collection or abscess has developed
- Consider: topical antibiotics, such as fucidic acid cream, for minor, localised infection.
- Consider prescribing a 7-day course of oral antibiotics if incision and drainage:
- Is not required.
- Was performed, but the person has signs of cellulitis or fever, or has other comorbidities (such as diabetes or immunosuppression).
- Flucloxacillin or clarithromycin are recommended first line (erythromycin in breastfeeding women)
- Give the person self-care advice:Advise all people to:
Take paracetamol or a nonsteroidal anti-inflammatory drug (NSAID) as required for pain relief.
Keep the affected areas clean and dry.
Avoid further trauma or manipulation of the nail.
Trim hang nails to a semi-lunar smooth edge and avoid biting nails or lateral nail folds.
If the person works with their hands in a moist environment (such as dish washers), advise that:
Frequent exposure to water (particularly with detergent) increases their risk of getting a paronychia.
Treatment is unlikely to be successful if exposure to the wet or moist environment continues.
Consider taking a swab of the contents of a paronychia if:
- The paronychia is enlarging.
- There is inflammation of surrounding tissue.
- The paronychia is recurrent.
- The paronychia has not responded to treatment within 2 to 3 days.
- The person is systemically unwell.
- The person has a history of contact with meticillin-resistant Staphylococcus aureus (MRSA).
- There is doubt about the diagnosis.
- The person is immunosuppressed.
- The person has diabetes.
- They should wear gloves (preferably cotton lined) to protect fingers.
- If the person is immunocompromised, advise that they should remain vigilant against any minor trauma to the finger tips and nails.
Management of acne vulgaris in primary care?
Combined oral contraceptives (if not contraindicated) in combination with topical agents can be considered as an alternative to systemic antibiotics in women.
Oral progesterone only contraceptives or progestin implants with androgenic activity may exacerbate acne, second and third generation combined oral contraceptives are generally preferred.
Co-cyprindiol (Dianette®) or other ethinylestradiol/cyproterone acetate containing products may be considered in moderate to severe acne where other treatments have failed but require careful discussion of the risks and benefits with the patient.
How do we manage HF in primary care?
ACE inhibitors
- Why do we use?
- Drugs and Monitoring
- Advice to patients
- Reduces mortality/events and improves symptoms
- Baseline U&Es
- Use formulary choice drugs (1st Choice Lisinopril, 2ndChoice Ramipril)
- Begin with lowest suitable starting dose and titrate dose upwards slowly
- Increase dose at minimum 2 week intervals alongside regular BP checks (seated and standing)
- Re-check BP and U&Es 1-2 weeks after initiation and after each dose increase
- Aim to get to maximum tolerated dose for each patient
- Once on maximum dose continue monitoring U&Es every 3-6 months
- Cough rarely requires discontinuation. If troublesome consider switching to ARB (Second line to ACE-I in heart failure– reduces hospitalisation but not mortality)
- ↑ creatinine by 30% from baseline or ↓ eGFR by 25% is acceptable for continuingACEi
- Potassium ≤ 5.5 mmol/l is acceptable. Half ACEi dose if potassium> 5.5mmol/l.
- Stop ACEi if potassium>6 mmol/l
- Advise patients to avoid OTC NSAIDs and salt substitutes high in potassium
Warn patient about possibility of postural hypotension
what is ramsey hunt syndrome
facial neuropathy associated with erythematous vesicular rash of the skin of the ear canal, auricle (also termed herpes zoster oticus), and/or mucous membrane of the oropharynx
