ID Ix Mx

Question 1

Behçet’s disease

Answer 1

Ix:
1) oral ulcers
2) genital ulcers
3) anterior uveitis

thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum

Ix = Clinical findings

positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with small pustule forming)

Question 2

Candidiasis

Answer 2

1) ‘cottage cheese’, non-offensive discharge
2) vulvitis: superficial dyspareunia, dysuria
itch
3) vulval erythema, fissuring, satellite lesions may be seen

Ix = a high vaginal swab is NOT routinely indicated if the clinical features are consistent with candidiasis

Mx:
1st = Oral fluconazole 150 mg as a single dose
2nd = clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated

vulval sx = add topical imidazole

Pregnant = only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated!

Recurrent (4+/yr) =

1. Check compliance + diagnosis
2. Consider a blood glucose test to exclude diabetes
3. Exclude lichen sclerosus

Induction-maintenance regime = (Induction: oral fluconazole every 3 days for 3 doses) + (Maintenance: oral fluconazole weekly for 6 months)

Question 3

Cellulitis

Erysipelas = limited version of cellulitis also caused by s.pyogenes

Answer 3

Most common cause = Streptococcus pyogenes
Less commonly Staphylcoccus aureus

Features
commonly occurs on the shins
usually unilateral - bilateral cellulitis is rare and suggests an alterative diagnosis
erythema
generally reasonably well-defined margins but some cases may present with diffuse erythema
blisters and bullae may be seen with more severe disease
swelling
systemic upset
fever
malaise
nausea

Ix = Clinical!

Mx:

Management is guided by the Eron classification.

1 = no systemic sx
2 = no systemic sx but a co-morbidity will interfere
3 = systemic upset or unstable co-morbidities
4 = sepsis/nec fasc

Eron Class I: mild/mod 1st = oral fluclox

oral clarithromycin, erythromycin (in pregnancy) or doxycycline is recommended in patients allergic to penicillin

Eron Class II
NICE recommend: ‘Admission may not be necessary if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the person - check local guidelines.’

Eron Class III-IV = Admit!!
NICE recommend: oral/IV co-amoxiclav, oral/IV clindamycin, IV cefuroxime or IV ceftriaxone

Question 4

Allergic conjunctivitis = May occur alone but is often seen in the context of hay fever

Answer 4

Features
Bilateral symptoms conjunctival erythema, conjunctival swelling (chemosis)
Itch is prominent
the eyelids may also be swollen
May be a history of atopy
May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens)

Mx:
1st = topical or systemic antihistamines
2nd = topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil

Question 5

Infective Conjunctivitis (mx for normal pregnant and contact users)

Answer 5

Bacterial conjunctivitis = Purulent discharge
Eyes may be ‘stuck together’ in the morning)

Viral conjunctivitis = Serous discharge
Recent URTI
Preauricular lymph nodes

Mx: Normally a self-limiting condition that usually settles without treatment within 1-2 weeks

Topical antibiotic therapy is commonly offered to patients, e.g. Chloramphenicol. Chloramphenicol drops are given 2-3 hourly initially whereas chloramphenicol ointment is given qds initially

Pregnant women = Topical fusidic acid

Contact lens users = Topical fluoresceins should be used to identify any corneal staining, Treatment as above (fluorescent contact lenses)

contact lens should not be worn during an episode of conjunctivitis

advice should be given not to share towels
school exclusion is not necessary

Question 6

Cytomegalovirus (CMV)

Answer 6

Congenital CMV infection = growth retardation, pinpoint petechial ‘blueberry muffin’ skin lesions, microcephaly, sensorineural deafness, encephalitiis (seizures) and hepatosplenomegaly

CMV mononucleosis = Infectious mononucelosis-like illness. May develop in immunocompetent individuals

CMV retinitis = Common in HIV patients with a low CD4 count (< 50)

presents with visual impairment e.g. ‘blurred vision’. Fundoscopy shows retinal haemorrhages and necrosis, often called ‘pizza’ retina

Mx = IV ganciclovir

Question 7

Epididymitis and orchitis

Answer 7

Features
unilateral testicular pain and swelling
urethral discharge may be present, but urethritis is often asymptomatic
factors suggesting testicular torsion include patients < 20 years, severe pain and an acute onset

The most important differential diagnosis is testicular torsion. This needs to be excluded urgently to prevent ischaemia of the testicle.

Ix: Typically guided by the age of the patient

Younger adults = assess for STI
Older adults with a low-risk sexual history = MSU for M&C

Mx:
STI is most likely -> urgent referral to a local STI clinic

Organism unknown = IM ceftriaxone 500mg + doxycycline 100mg by mouth twice daily for 10-14 days

if enteric organisms are the most likely cause CKS
send an MSU as above

Treating empirically with an oral quinolone for 2 weeks (e.g. ofloxacin)

Further investigations following treatment may be recommended to exclude any underlying structural abnormalities

Question 8

Epiglottitis

Answer 8

Features
rapid onset
high temperature, generally unwell
stridor
drooling of saliva
‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position

Diagnosis is made by direct visualisation (only by senior/airway trained staff, see below). However, x-rays may be done, particularly if there is concern about a foreign body:
a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
in contrast, a posterior-anterior view in croup will show subglottic narrowing, commonly called the ‘steeple sign’

Management
immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
if suspected do NOT examine the throat due to the risk of acute airway obstruction
the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary
oxygen
intravenous antibiotics

Question 9

Herpes simplex virus

Answer 9

Features
primary infection: may present with a severe gingivostomatitis
cold sores
painful genital ulceration

Mx:
gingivostomatitis = oral aciclovir, chlorhexidine mouthwash

cold sores = topical aciclovir although the evidence base for this is modest

genital herpes = oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir

Pregnant = urgent specialist review

Question 10

Human immunodeficiency virus (HIV)

Pt does not have disclose HIV status in referral for abortions

Answer 10

Ix: antibodies and p24 antigen

asymptomatic pt = After an initial negative result, offer a repeat test at 12 weeks

Mx:

Antiretroviral therapy (ART) = 2 NRTI) + PI/NNRTI

Start ART as soon as HIV diagnosis is made!

Entry inhibitors
maraviroc (binds to CCR5, preventing an interaction with gp41), enfuvirtide (binds to gp41, also known as a ‘fusion inhibitor’)
prevent HIV-1 from entering and infecting immune cells

Nucleoside analogue reverse transcriptase inhibitors (NRTI)
examples: zidovudine (AZT), abacavir, emtricitabine, didanosine, lamivudine, stavudine, zalcitabine, tenofovir
general NRTI side-effects: peripheral neuropathy
tenofovir: used in BHIVAs two recommended regime NRTI. Adverse effects include renal impairment and ostesoporosis
zidovudine: anaemia, myopathy, black nails
didanosine: pancreatitis

Non-nucleoside reverse transcriptase inhibitors (NNRTI)
examples: nevirapine, efavirenz
side-effects: P450 enzyme interaction (nevirapine induces), rashes

Protease inhibitors (PI)
examples: indinavir, nelfinavir, ritonavir, saquinavir
side-effects: diabetes, hyperlipidaemia, buffalo hump, central obesity, P450 enzyme inhibition
indinavir: renal stones, asymptomatic hyperbilirubinaemia
ritonavir: a potent inhibitor of the P450 system

Integrase inhibitors
block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell
examples: raltegravir, elvitegravir, dolutegravir

Question 11

Infectious mononucleosis (EBV)

Answer 11

Triad = sore throat, pyrexia and lymphadenopathy

Ix = FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.

Mx = supportive (Sx typically resolve after 2-4 weeks)

rest during the early stages, drink plenty of fluid
avoid alcohol
simple analgesia for any aches or pains

consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture

Other features include:
malaise, anorexia, headache
palatal petechiae
splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
hepatitis, transient rise in ALT
lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes
haemolytic anaemia secondary to cold agglutins (IgM)

A maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis

Question 12

Malaria

Question 13

Mastitis/breast abscesses

Answer 13

Features
painful, tender, red hot breast
fever, and general malaise may be present

Mx:
1st = Continue breastfeeding.
simple measures
analgesia
warm compresses

Antibiotics if;
- Systemically unwell
- Nipple fissure is present,
- If sx do not improve after 12-24 hours of effective milk removal
- or if culture indicates infection

1st = oral flucloxacillin for 10-14 day

Reflects the fact that the most common organism causing infective mastitis is Staphylococcus aureus

Breastfeeding or expressing should continue during antibiotic treatment.

If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.

Question 14

Necrotising fasciitis

Features
acute onset
pain, swelling, erythema at the affected site
often presents as rapidly worsening cellulitis with pain out of keeping with physical features
extremely tender over infected tissue with hypoaesthesia to light touch
skin necrosis and crepitus/gas gangrene(c.perfrinogens) are late signs
fever and tachycardia may be absent or occur late in the presentation

Answer 14

Necrotising fasciitis is a medical emergency that is difficult to recognise in the early stages.

It can be classified according to the causative organism:

Type 1 = Mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type

Type 2 = Streptococcus pyogenes

Risk factors
skin factors: recent trauma, burns or soft tissue infections
diabetes mellitus is the most common preexisting medical condition (particularly if on SGLT-2 inhibitors)
IV drug use
immunosuppression

The most commonly affected site is the perineum (Fournier’s gangrene)

Mx = Urgent surgical referral debridement + IV ab’s

Question 15

Orbital cellulitis

Presentation
Redness and swelling around the eye
Severe ocular pain
Visual disturbance
Proptosis
Ophthalmoplegia/pain with eye movements
Eyelid oedema and ptosis
Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)

Answer 15

Differentiating orbital from preseptal cellulitis;

reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis

Ix = FBC + opthal assessment + CT + Blood cultures

Mx = Admit + IV antibiotics

Full blood count – WBC elevated, raised inflammatory markers.
Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema.
CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis.
Blood culture and microbiological swab to determine the organism.
Most common bacterial causes = Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.

Question 16

Otitis externa

Answer 16

Features
ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal

Mx:
1st = topical antibiotic or a (topical antibiotic+steroid)
2nd = fluclox if infection is spreading/perforated tympanic membrane
3rd = Refer to ENT!
4th = antifungal/alt diagnosis

Malignant otitis externa is more common in elderly diabetics.

In this condition, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. Intravenous antibiotics may be required.

Question 17

Otitis media

Features
otalgia
some children may tug or rub their ear
fever occurs in around 50% of cases
hearing loss
recent viral URTI symptoms are common (e.g. coryza)
ear discharge may occur if the tympanic membrane perforates

Answer 17

Possible otoscopy findings:
bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope

Ix:
Acute onset of symptoms
otalgia or ear tugging
presence of a middle ear effusion
bulging of the tympanic membrane, or
otorrhoea
decreased mobility on pneumatic otoscopy
inflammation of the tympanic membrane (i.e. erythema)

Mx = Self-limiting condition that does not require an antibiotic prescription

There are however some exceptions requiring urgent antibiotics;

• Symptoms lasting more than 4 days or not improving
• Systemically unwell but not requiring admission
• Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
• <2yo with bilateral otitis media
• Otitis media with perforation and/or discharge in the canal

1st = 5-7days of amoxicilin (erythro/clarithro if pen-allergic)

Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days.

Question 18

Pneumonia

Most common cause?

Answer 18

Most common cause = step pneumoniae

Ix = Chest x-ray + CURB-65

Intermediate or high-risk pt’s = blood and sputum cultures, pneumococcal and legionella urinary antigen tests

CRP monitoring is recommend for admitted patients to help determine response to treatment

Mx (low-severity CAP):
1st = amoxicillin 5 days
if penicillin allergic then use a macrolide or tetracycline

Mx of moderate and high-severity CAP:
1st = 7-10days Dual antibiotic therapy (amoxicillin and a macrolide)

High severity = beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or pip+taz and a macrolide (ie. azith/clarith/eryth-romycin)

CURB-65;

0/1 = home
2 = admit to genral ward
3 = HDU/ICU!

Question 19

Rhinosinusitis (acute and chronic)

Predisposing factors include:
atopy: hay fever, asthma
nasal obstruction e.g. Septal deviation or nasal polyps
recent local infection e.g. Rhinitis or dental extraction
swimming/diving
smoking

Answer 19

Features

facial pain: typically frontal pressure pain which is worse on bending forward
nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
nasal obstruction: e.g. ‘mouth breathing’
post-nasal drip: may produce chronic cough

Mx of recurrent or chronic sinusitis;
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution

Question 20

Syphilis

Primary features
1. chancre - painless ulcer at the site of sexual contact

2. local non-tender lymphadenopathy
3. often not seen in women (the lesion may be on the cervix)

Secondary features - occurs 6-10 weeks after primary infection

1. systemic symptoms: fevers, lymphadenopathy
   rash on trunk, palms and soles
2. buccal ‘snail track’ ulcers (30%)
3. condylomata lata (painless, warty lesions on the genitalia )

Answer 20

Ix = Clinical features + serology + biopsy

Treponema pallidum is a very sensitive organism and cannot be grown on artificial media. The diagnosis is therefore usually based on clinical features, serology and microscopic examination of infected tissue.

Mx:
1st = IM benpen
alternatives: doxycycline

+RPR/VDRL titre monitoring

Nontreponemal (rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) titres should be monitored after treatment to assess the response
a fourfold decline in titres (e.g. 1:16 → 1:4 or 1:32 → 1:8)is often considered an adequate response to treatment

The Jarisch-Herxheimer reaction is sometimes seen following treatment

JH-reaction = Fever, rash, tachycardia after the first dose of antibiotic
in contrast to anaphylaxis, there is no wheeze or hypotension
it is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment
no treatment is needed other than antipyretics if required

Serological tests can be divided into:

Non-treponemal tests
not specific for syphilis, therefore may result in false positives (see below)
based upon the reactivity of serum from infected patients to a cardiolipin-cholesterol-lecithin antigen
assesses the quantity of antibodies being produced
becomes negative after treatment
examples include: rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL)

Treponemal-specific tests
generally more complex and expensive but specific for syphilis
qualitative only and are reported as ‘reactive’ or ‘non-reactive’
examples include: TP-EIA (T. pallidum enzyme immunoassay), TPHA (T. pallidum HaemAgglutination test)
the TP-EIA test has become increasingly popular in recent years

Question 21

Threadworm infection

Answer 21

Ix = applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs.

However, most patients are treated empirically and this approach is supported in the CKS guidelines.

Mx = anthelmintic + hygiene measures for all members of the household

Children > 6 months = mebendazole

Question 22

Tonsillitis

Answer 22

Ix: Characterised by pharyngitis, fever, malaise and lymphadenopathy

Most common cause = S. pyogenes

The tonsils are typically oedematous and yellow or white pustules may be present

Infectious mononucleosis may mimic the condition

Mx:

Bacterial = Penicillin type antibiotics

Criteria for tonsillectomy (must be met in full);

1. Sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
2. 5+ episodes of sore throat per year
3. Sx have been occurring for at least a year
4. The episodes of sore throat are disabling and prevent normal functioning

Other established indications for a tonsillectomy include;

Recurrent febrile convulsions secondary to episodes of tonsillitis
obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
peritonsillar abscess (quinsy) if unresponsive to standard treatment

Complications of tonsillitis include:
otitis media
Local abcess -> Quinsy - peritonsillar abscess
Rheumatic fever and glomerulonephritis very rarely

Complications of tonsillectomy
primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain

Question 23

Tuberculosis

Answer 23

Ix = Chest x-ray
Upper lobe cavitation + bilateral hilar lymphadenopathy

GS = Sputum culture for microscopy! to assess drug-sensitivities

NAAT = rapid

Sputum smear (ZN-stain) = 3 smear specimens are needed

Sensitivity = Culture! >Smear>NAAT

Mx:

Active TB;

Initial phase - first 2 months (RIPE)
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

Continuation phase - next 4 months
Rifampicin
Isoniazid

Latent tuberculosis;

3 months of (isoniazid & pyridoxine) + rifampicin

OR 6 months of (isoniazid & pyridoxine)

pyridoxine(vitB6) is because isoniazide depletes B6

Meningeal tuberculosis = 12+ months RIPE + steroids

Directly observed therapy with a dosing regimen of x3 per week is indicated in certain groups, including:

• Homeless people w active TB
• Pt’s who are likely to have poor concordance
• All prisoners with active or latent TB

Sputum culture is more sensitive than a sputum smear and NAAT
can assess drug sensitivities
can take 1-3 weeks (if using liquid media, longer if solid media)

Sputum smear
rapid and inexpensive test
stained for the presence of acid-fast bacilli (Ziehl-Neelsen stain)
all mycobacteria will stain positive (i.e. nontuberculous mycobacteria)
the sensitivity is between 50-80%
this is decreased in individuals with HIV to around 20-30%

Nucleic acid amplification tests (NAAT)
allows rapid diagnosis (within 24-48 hours)
more sensitive than smear but less sensitive than culture

Question 24

Urticaria (acute, chronic) = a local or generalised superficial swelling of the skin. The most common cause of urticaria is allergy although non-allergic causes are seen.

Answer 24

Features
pale, pink raised skin. Variously described as ‘hives’, ‘wheals’, ‘nettle rash’
pruritic

Mx: 1st = non-sedating antihistamines (certirizine)

severe/resistant = prednisolone

Question 25

Varicella zoster

Answer 25

Clinical features (tend to be more severe in older children/adults)

fever initially
itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
systemic upset is usually mild

Mx = supportive
keep cool, trim nails
calamine lotion

School exclusion: Most infectious period is 1–2 days before the rash appears, but infectivity continues until all the lesions are dry and have crusted over (usually about 5 days after the onset of the rash)

immunocompromised pt/newborns w peripartum exposure = varicella zoster immunoglobulin (VZIG).

If chickenpox develops = IV acicyclovir

Ramsay Hunt syndrome (herpes zoster oticus) = The reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.

Features
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus

Mx = oral aciclovir + corticosteroids

Question 26

Vasculitides

Question 27

Vestibular neuritis and Labyrinthitis

Answer 27

Epidemiology
The average age of presentation is 40-70 years

Patients typically present with an acute onset of:

vertigo: NOT triggered by movement but exacerbated by movement
nausea and vomiting
hearing loss: may be unilateral or bilateral, with varying severity
tinnitus
preceding or concurrent symptoms of URTI

Signs of labyrinthitis:

spontaneous unidirectional horizontal nystagmus towards the unaffected side
sensorineural hearing loss: shown by Rinne’s test and Weber test
abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
gait disturbance: the patient may fall towards the affected side

Ix = Largely based on history and examination.

Mx = Episodes are usually self-limiting

Reduce dizziness = prochlorperazine or antihistamines

Question 28

Cryptosporidium pravum?

Immunocompromised, infected jejunum, diarrhoea

Answer 28

Ix: ZN stain shows protozoa, Kinyoun Acid-fast stain

+ eggs in stool

Mx: paromomycin

Question 29

What to do with a needle stick injury?

Answer 29

Encourage bleeding from the wound!

Question 30

Why is c.diff difficult to destroy?

Answer 30

Spore formation!

Question 31

Oesophageal candidiasis who gets it? sx + mx?

Answer 31

Who: HIV pts
sx: dysphagia and odynophagia
Mx: 1st = Fluconazole + itraconazole

Question 32

Toxic epidermal necrolysis (TEN) is a potentially life-threatening skin disorder that is most commonly seen secondary to a drug reaction

In this condition, the skin develops a scalded appearance over an extensive area. Some authors consider TEN to be the severe end of a spectrum of skin disorders which includes erythema multiforme and Stevens-Johnson syndrome,

Answer 32

Features
systemically unwell e.g. pyrexia, tachycardic
positive Nikolsky’s sign: the epidermis separates with mild lateral pressure

Drugs known to induce TEN
phenytoin
sulphonamides
allopurinol
penicillins
carbamazepine
NSAIDs

Mx:

stop precipitating factor
supportive care
often in an intensive care unit
volume loss and electrolyte derangement are potential complications
intravenous immunoglobulin has been shown to be effective and is now commonly used first-line
other treatment options include: immunosuppressive agents (ciclosporin and cyclophosphamide), plasmapheresis

Question 33

Enteric Fever

Question 34

Difference between primary/post primary TB?

Answer 34

primary = initial infection (asymptomatic)
post-primary = after latent period TB attacks and pt has sx

Question 35

How to identify mycoplasma pneumoniae?

Answer 35

Mycoplasma pneumonia usually occur every 3–4 years and may present with
generalized features such as headache, arthralgia and myalgia.

A chest x-ray may show patchy consolidation through the lung fields. In addition, the clinical features of disease often do not usually correlate
with the x-ray findings.

Question 36

causes of upper/lower lobe fibrosis?

Answer 36

Upper. =TAPE

TB
Aspergilliosis
Pneumoconiosis (silica/coal)
Extrinsic allergic alveolitis

Lower. = STAIR

Sarcoid
Toxins (Bleomycin, Amiodarone, Nitrofurantoin, Sulfasalazine, Methotrexte)
Asbestosis
Idiopathic pulmonary fibrosis
Rheumatology (SLE, RhAr, sjogrens, crest)

Question 37

single painless genital ulcer?
soft genital ulcer?
vesicular genital rash?
lots of discharge?

Answer 37

syphilis
chancroid
herpes
gonorrhoea

Question 38

differentiators for hep a vs b vs c

Answer 38

a = most common, faeco-oral transmission (contaminated water), fever, malaise, anorexia and nausea. mx. = conservative

B = transmitted IV, sexually and vertically from mother to child. Clinical features may be similar to those seen in hepatitis A. In addition, extrahepatic
features, such as rashes, arthralgia and glomerulonephritis, are more
common!

C = transmitted by
the intravenous route and is sexually transmitted. Acute infection is usually asymptomatic or mild, making this answer incorrect for this
question. The majority of patients develop a chronic infection which
predisposes to developing liver cirrhosis. mx = Pegylated interferon
alpha plus ribavirin

Question 39

differentiator for schistosomiasis vs leishmania vs

Answer 39

Schistosomiasis (B) is caused by water-borne flukes. Snail vectors release
cercariae into the water where they can penetrate the skin or mucous
membranes of humans. An itchy papular rash (known as a swimmer’s itch) may develop at the site of penetration.

Once they have penetrated through
the skin or the mucous membranes, the schistosomoules migrate to the
liver.

Approximately 3 weeks after infection, the host may develop fever,
rash, myalgia, diarrhoea and there may be hepatosplenomegaly on
examination (this reaction is termed Katayama fever). The flukes mature in
the liver and then migrate to their final destination (either the mesenteric
veins or the vesicular plexus). In their final positions, the flukes may result
in a chronic infection with varying clinical features and eosinophilia!

Leishmaniasis is a parasitic infection transmitted via sand flies. While
cutaneous leishmaniasis may present with skin signs and symptoms, it does not have an itchy papular rash. Fevers and palpable liver edge may be the initial features of visceral leishmaniasis, but onset tends be slower than schistosomiasis and take a longer time to be manifested from the initial infection.

African trypanosomiasis is sleeping sickness.

Question 40

MRSA mx?

Who should be screened for MRSA?
How should a patient be screened for MRSA?
how to supress transmission? (nose + skin)
mx?

Answer 40

Who?
All patients awaiting elective admissions (exceptions include day patients having terminations of pregnancy and ophthalmic surgery. Patients admitted to mental health trusts are also excluded)
and all emergency admissions !

How?
Nasal swab and skin lesions or wounds
the swab should be wiped around the inside rim of a patient’s nose for 5 seconds
the microbiology form must be labelled ‘MRSA screen’

Suppression of MRSA from a carrier once identified

nose: mupirocin 2% in white soft paraffin, tds for 5 days

skin: chlorhexidine gluconate, od for 5 days. Apply all over but particularly to the axilla, groin and perineum

mx = vanc

Question 41

Causes of meningitis by age group?

Answer 41

0 - 3 months = Group B Streptococcus (most common cause in neonates)

6 years - 60 years
Neisseria meningitidis*
Streptococcus pneumoniae

> 60 years
Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes

Immunosuppressed = Listeria monocytogenes

*The presence of
a non-blanching, petechial rash indicates that the meningitis is caused by Neisseria meningitidis

Question 42

What ab can you not mix with ethanol? what are the sx?

Answer 42

Metronidazole! or Cefoperazone (a cephalosporin)

flushing, headache, vomiting and palpitations, tachy

Question 43

Tetanus

Patient has had a full course of tetanus vaccines, with the last dose < 10 years ago?

Patient has had a full course of tetanus vaccines, with the last dose > 10 years ago
if tetanus prone wound? high-risk wounds?

If vaccination history is incomplete or unknown?

Answer 43

Patient has had a full course of tetanus vaccines, with the last dose < 10 years ago
no vaccine nor tetanus immunoglobulin is required, regardless of the wound severity

Patient has had a full course of tetanus vaccines, with the last dose > 10 years ago
if tetanus prone wound: reinforcing dose of vaccine

high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue):
reinforcing dose of vaccine + tetanus immunoglobulin

If vaccination history is incomplete or unknown;

reinforcing dose of vaccine, regardless of the wound severity
for tetanus prone and high-risk wounds: reinforcing dose of vaccine + tetanus immunoglobulin

Question 44

Animal bite mx?

Answer 44

co-amox

penallergic = doxycycline + metronidazole

Question 45

Cau

Question 46

Chlamydia vs gonorrhoea vs bac vag?

Answer 46

Both have dysuria and discharge?

Chlam;

mx: 1st = doxy

For close contacts - Treatment is given on the basis of exposure to infection rather than proven infection. So partners get doxy before testing positive

Gon;

mx:
1st = IM ceftriaxone
2nd = oral cefixime + oral azithromycin

Bac vag (fishy garden vaginalis)

asymptomatic = nothing
symptomatic = oral metro (even if pregnant) or topical clinda

Question 47

Giardiasis

Answer 47

12 day incubation period and prolonged, non-bloody diarrhoea point towards giardiasis

Ix:

stool microscopy for trophozoite and cysts: sensitivity of around 65%
stool antigen detection assay: greater sensitivity and faster turn-around time than conventional stool microscopy methods
PCR assays are also being developed

Treatment is with metronidazole.