Minor Illnesses in Primary Care Flashcards
What is this?
What are the characteristic features of this condition?
chicken pox
- the distribution of the lesions is central rather than peripheral
- there are different ages of spots, starting with small papules and then progressing through to vesicles, and eventually scabs
What is the treatment for chickenpox?
- the treatment for chickenpox is symptomatic
- calamine lotion is a topical application that relieves pruritis
- in more severe cases, oral antihistamines (e.g. cetirizine) can be given
What virus causes chickenpox?
How is it transmitted?
- it is a primary infection caused by varicella-zoster virus (VZV)
- it is highly contagious
- transmission is mainly through airborne droplets
- it can also be transmitted via direct skin contact with vesicle fluid
In which groups might treatment be given for chickenpox?
- antiviral therapy is given with aciclovir
- this is given to high-risk groups, such as:
- adults and adolescents >/= 13 years of age
- immunosuppressed individuals
- individuals on long-term salicylate therapy (e.g. aspirin)
What can chickenpox represent as later on in life and why?
- VZV will persist in ganglion cells following infection
- reactivation of the virus may occur when the immune system is compromised, presenting as shingles
What is the most severe complication of chickenpox?
- congenital chickenpox (varicella) syndrome
- this occurs when chickenpox is contracted during the first 20 weeks of pregnancy
- it leads to malformations with potentially fatal consequences
During which times is chickenpox infective?
Where does it remain latent?
- it is infective 2 days before and up to 5 days after the onset of the rash
- or until all the pustules have formed crusts
- it can remain latent and reside inside the dorsal root ganglia or trigeminal ganglia
How long is the incubation and prodrome phase for chickenpox?
What symptoms does this usually present with?
- incubation period is 2 weeks (10 - 21 days)
- prodrome occurs 1-2 days prior to the onset of the rash
- presents with constitutional symptoms like fever and malaise
- this is more common with the primary infection in adults
- it is less typical in children - the rash is often the first sign of infection
How long is the symptomatic phase of chickenpox?
What is the typical presentation?
- tends to last for around 6 days
- widespread rash starting on the trunk, spreading to the face, scalp and extremities
- severe pruritis
- fever, headache and muscle or joint pain
When must aciclovir be administered for chickenpox treatment?
What are alternative antivirals?
- it must be administered within 24 hours of the onset of the rash
- valacyclovir or famciclovir can be used instead
What condition is this?
What are the main characteristics that make this apparent?
Shingles (Herpes Zoster)
- the distribution of the lesions is both unilateral and dermatomal
- there is painful blistering
Why does shingles occur?
Who is most at risk?
- following chickenpox primary infection, VZV remains dormant in the dorsal root ganglia
- VZV can be reactivated at any time in life, particularly when the patient is immunocompromised:
- decline in immune function with advancing age
- malignancy
- HIV infection
- immunosuppressive therapy
- malnutrition
- chronic stress
What is the most common complication associated with shingles infection?
post-herpetic neuralgia
- this is chronic neuropathic pain persisting for at least 3 months in the area previously affected by the rash
- there is a strong association with age (>50)
What are the clinical features associated with shingles?
- dermatomal rash, typically affecting 1-3 dermatomes on one side of the body
- “burning”, “tingling” or “stabbing/throbbing” pain often precedes the rash
- fever and headache
- parethesia (abnormal sensation caused by damage to peripheral nerves)
- itching
What is herpes zoster ophthalmicus?
- reactivation of VZV in the ophthlamic division of the trigeminal nerve
- it typically presents with a rash on the forehead with swelling of the eyelid
What are the main clinical features of herpes zoster ophthalmicus?
- fever, headache, general malaise
- pain and altered sensation of the forehead on one side
- rash affecting the forehead and upper eyelid appears a day to a week later
- discharge, redness and pain in the eye with potential photophobia
What is Hutchinson’s sign in herpes zoster ophthalmicus and what does it mean if it is positive?
- Hutchinson sign is positive when there is a vesicular rash on the nasal alae
- this indicates involvement of the nasociliary nerve
- there is possibility of severe intraocular infection
- uveitis, iritis, conjunctivitis, keratitis and optic neuritis
What are the potential complications of herpes zoster ophthalmicus?
- if not treated properly, it can result in blindness
- glaucoma
What is the alternative name for herpes zoster oticus?
What happens in this condition?
Ramsay Hunt Syndrome
- this is reactivation of VZV in the geniculate ganglion
- this affects the facial (CN VII) and vestibulocochlear (CN VIII) nerves
What are the clinical features of Ramsay Hunt syndrome?
- fever and vesicular rash in the auditory canal and pinna
-
vestibulocochlear nerve involvement leads to vertigo and sensorineural hearing loss
- hearing loss due to acquired or congenital lesions in the cochlear, CN VIII or central auditory pathways
- facial nerve involvement leads to facial paralysis on one side
What is the treatment for shingles?
When must it be administered?
- antiviral therapy with acyclovir, valacyclovir or famciclovir
- this speeds up resolution of lesions, reduces formation of new lesions and decreases pain
- it is most effective when administered within 72 hours of rash appearing, but can be administered up to a week after the rash appears
What are the indications for antiviral therapy to treat shingles?
- anyone aged > 50 years as they are at the greatest risk of post-herpetic neuralgia
- immunocompromised patients (treated with IV acyclovir)
- signs of disseminated zoster and/or neurological complications
- this is >20 extradermatomal vesicles, rash affecting 3 or more dermatomes and/or visceral organ involvement
- nontruncal involvement (e.g. herpes ophthalmicus)
Who can receive a shingles vaccination?
How does this work?
- offered by the NHS for 70-79 year olds
- it does not prevent shingles, but reduces the severity of the infection and post-herpetic neuralgia
What is shown in this image?
molluscum contagiosum
- this is a common localised skin infection that can affect the trunk, face and genitalia
- they are raised, pearly papules
- larger lesions have a central dimple
How is molluscum contagiosum spread?
In which age group is the highest number of infections seen?
- it is spread through direct skin contact and/or autoinoculation
- it is most common in children (peak incidence < 5 years) and early adolescence
- in adults, it is considered a sexually transmitted infection
What diagnosis should be considered if widespread molluscum contagiosum lesions are seen in adults?
- immunosuppressed patients present with more lesions that are usually larger
- if an adult presents with large, persistent, widespread lesions then AIDS should be suspected
Who is offered treatment for molluscum contagiosum?
What treatment is available?
- the lesions usually self-resolve within a few months and do not require treatment
- treatment is considered for:
- sexually transmitted molluscum contagiosum
- immunocompromised individuals
- immunocompetent children upon parental request
- the first line treatment is cryotherapy for adults
- this involves freezing the lesions with liquid nitrogen
What is shown in this image?
What are the distinguishing features?
eczema
- the rash is present on flexor surfaces
- the edges of the rash are not well-defined and it blends into the surrounding skin
- it is red, inflamed and has a dry/scaly layer
Who is most commonly affected by eczema?
How does the disease change over time?
- it typically manifests for the first time in early childhood (3 - 6 months of age)
- it often improves during adolescence, but can also become a chronic condition that extends into adulthood
Why is family history important when diagnosing eczema (atopic dermatitis)?
- 70% of patients have a family history of atopic disease
- this includes eczema, asthma, allergic rhinitis and allergies
What are the main clinical features associated with eczema?
- the main symptoms are intense pruritus and dry skin
- lesions usually become lichenified
- this involves thickening of the skin with accentuated skin markings
- lesions affect flexor surfaces / flexural creases
- e.g. antecubital fossa and popliteal fossa
What are the general measures that are recommended to patients with eczema?
-
avoid triggers
- allergic trigger factors - pets, dust mites, pollen, certain foods
- keep the skin moist
- manage / eliminate stress
- breastfeeding is recommended during infancy
What treatments are available for mild, moderate and severe eczema?
Mild eczema:
- treatment mainly involves emollients that prevent the skin from drying out
- mild potency topical steroids reduce inflammation
Moderate eczema:
-
topical calcineurin inhibitors, such as tacrolimus, can be used
- these are immunosuppressants
Severe eczema:
- phototherapy may be included
What is the main complication associated with eczema?
-
secondary infections
- staphylococcal skin infections
- eczema herpeticum
- tinea - especially Trichophytan rubrum
- this occurs when there is a break in the skin, due to it being too dry or the patient itching
What is the “glass test” and what does it demonstrate?
- this is used to identify a non-blanching rash
- this is a rash that does not go away when you press on it
- in children you are concerned about meningococcal septicaemia, especially if they have fever & vomiting
- this is an emergency and needs urgent transfer to hospital
What is involved in the acute management of meningococcal septicaemia?
- a single dose of parenteral benzylpenicillin must be administered at the earliest opportunity
- this should be given intravenously, or intramuscularly if a vein is not available
- withold benzylpenicillin if the person has a clear history of penicillin anaphylaxis
What is the definition of meningococcal septicaemia?
- this is a bloodstream infection caused by Neisseria meningitidis
- the bacteria enter the bloodstream and multiply, damaging the walls of blood vessels and causing bleeding into skin and organs
What is shown in this image?
What causes this?
Herpes Labialis
- also known as a cold sore
- this is caused by herpes simplex virus, usually HSV-1
What are the clinical features of herpes labialis?
- prodromal symptoms of pain, tingling and burning
- these occur around 24 hours prior to vesicles appearing
-
recurring, erythematous vesicles that turn into painful ulcerations
- these primarily affect the oral mucosa and lip borders
What treatment is offered to patients with primary or recurrent herpes labialis?
- offer paracetamol and/or ibuprofen to treat symptoms of pain and fever
- topical antiviral preparations are not routinely prescribed but are available over-the-counter
- these include aciclovir or penciclovir
- topical anaesthetic or analgesic preparations, mouthwash and lip barrier preparations are not routinely prescribed but are available over the counter
- oral antivirals are not prescribed for healthy people with herpes labialis
When might oral antiviral drugs be prescribed for herpes labialis?
What instructions are given to the patient about when to take this medication?
- in healthy people when the lesions are severe, frequent or persistent
- in immunocompromised individuals
- advise the patient to take the antiviral from the onset of prodromal symptoms before the vesicles appear, until the lesions have healed, for a minimum of 5 days
What condition is shown in this picture?
In what age group is it usually seen in?
Impetigo
- it is more common in children
- it is characterised by honey-coloured, crusted lesions with surrounding erythema
- it usually affects the face
What organisms typically cause impetigo?
Which type of impetigo do they cause?
- 80% cases are caused by Staphylococcus aureus
- this causes both bullous impetigo and nonbullous impetigo
- 10% cases are caused by Streptococcus pyogenes
- this causes nonbullous impetigo only
- 10% cases are a S. aureus and S. pyogenes coinfection
What is the difference between primary and secondary impetigo?
- primary impetigo is a bacterial infection of previously healthy skin
- this is usually by S. aureus which is part of the skin’s normal flora
- secondary impetigo involves a secondary infection of pre-existing skin lesions
- e.g. scabies, insect bites, abrasions, eczema
What do the lesions look like in nonbullous and bullous impetigo?
Nonbullous impetigo:
- papules, which turn into small vesicles surrounded by erythema and/or pustules
- vesicles/pustules rupture and the secretion dries to form honey-coloured crusts that heal without scarring
- may be pruritic
Bullous impetigo:
- vesicles that grow to form large, flaccid bullae which go on to rupture and form thin, brown crusts
What is Nikolsky sign and in which type of impetigo is it positive?
- the formation of a cutaenous blister upon stroking of the skin
- it is typically seen in bullous skin diseases
- it is positive in bullous impetigo
What is the treatment for nonbullous and bullous impetigo?
- for ALL types, wounds should be cleansed with antibacterial washes - e.g. chlorhexidine
Mild nonbullous impetigo:
- topical antibiotics such as mupirocin
Bullous impetigo (or severe nonbullous):
- first generation cephalosporins (e.g. cephalexin) or dicloxacillin
- macrolides may also be used as an alternative
What type of primary lesions are present in acne vulgaris?
Non-inflammatory: comedonal acne:
- closed comedones (“whiteheads”) which are closed small round lesions containing white material (sebum & shed keratin)
- open comedones (“blackheads”) which are dark with an open portion of sebaceous material
Inflammatory acne:
- papules and pustules are present, which arise from comedones
- nodular acne occurs when they are > 5mm in diameter
What is the treatment for mild acne (e.g. comedonal)?
- topical benzoyl peroxide OR topical retinoids
What is the treatment for moderate severity acne (e.g. papular / pustular)?
treatment involves combination therapy:
- topical benzoyl peroxide AND topical retinoids/antibiotics
- oral antibiotic (tetracycline-class) may be added
- combined oral contraceptives may be added in females
What is the treatment for severe acne?
oral isotretinoin
- therapy is particularly important in patients with inflammatory acne to prevent scarring
What are retinoids and how do they work?
What is the main contraindication and why?
- they normalise keratinization by inhibiting and modulating keratinocytes, leading to reduced sebum production
- they are contraindicated in pregnancy as they have strong teratogenic effects
- they should not be given to women of childbearing age without two methods of contraception
- e.g. oral contraceptive + barrier contraceptive / IUD
- women should take a monthly pregnancy test whilst taking retinoids
What is shown in this image?
Furuncle (folliculitis)
- folliculitis is localised inflammation of the hair follicle/ sebaceous glands that is limited to the epidermis
- a furuncle is deep folliculitis beyond the dermis with abscess formation in the subcutaenous tissue
What is the treatment for a furuncle?
- it is treated with antibiotics, depending on which organisms are involved
- incision and drainage is considered for deep lesions
- the furuncle should not be squeezed as this can cause a lot of inflammation in the area
What are the 3 different ways to treat head lice in the UK?
Physical insecticides:
- these kill the lice by coating their surfaces and suffocating them, so resistance is unlikely to develop
- this includes dimeticone 4% gel, lotion or spray
Chemical insecticides:
- these poison the lice by chemical means
- this is Malathion 0.5% aqueous liquid
Wet combing:
- this is “The Bug Buster” that is available on the NHS
What is shown in this image?
What are the arrows pointing to?
scabies
- this presents with an intensely itchy rash
- the arrows are pointing to the tracks made where the scabies mite lays it eggs
What are the clinical features of scabies?
Which parts of the body tend to be affected?
- intense pruritis that increases at night
- elongated, erythematous papules and burrows of 2-10mm length
- scattered vesicles filled with clear or cloudy fluid
- excoriations, pustules and secondary infection
- rash tends to start at the extremities, between the fingers in the skin folds, and spreads across the body
What is the treatment for scabies?
- topical application of a scabicidal agent
- the first line treatment is permethrin 5% lotion
- if this does not work or there are side effects, lindane 1% lotion can be used
- oral ivermectin is used in large outbreaks / severe forms of scabies
- oral antihistamines can be given for symptomatic treatment of pruritis
- all clothing and bedding should be regularly washed
How is the scabies treatment applied and why must it be applied in this way?
- Malathion liquid and permethrin cream both require 2 applications that are 7 days apart
- the skin remains itchy for a week after treatment when the scabies has been killed
- this is becuase it is the scabies mite faeces that causes the itching
What is this condition?
Who tends to contract it?
oral thrush
- redness of the tongue underneath white slough
- lesions are found on the inside of the cheeks and on the palate
- it occurs in elderly and/or debilitated individuals
- it commonly occurs with steroid treatment - inhaler or tablets
What are the clinical features of oral thrush?
- white plaques in the oral cavity that can be scraped off to reveal red, inflamed or bleeding areas
- cottony feeling in the mouth
- loss of taste and there may be pain while eating
- fissuring at mouth corners
- usually seen in immunocompromised patients e.g. HIV or diabetics
What is the treatment for oral thrush?
- first line treatment involves either topical nystatin or oral fluconazole
- other azoles can be used if treatment fails e.g. itraconazole
What is shown in this image?
What causes it?
aphthous ulcer
- cause is unknown but tends to occur in young people and is linked to stress and poor diet
- associated with deficiencies of certain vitamins
- these are painful mucosal ulcers which recur commonly
What is the treatment for aphthous ulcers?
- they are self-limiting and there is no treatment
- symptomatic treatment includesL
- topical corticosteroids - dexamethasone
- antimicrobials - tetracycline
- anaesthetics - lidocaine
What condition is shown in this image?
What causes it and what is it associated with?
rhinophyma
- caused by inflammation and hypertrophy of sebum glands on the nose, which also produces remodelling of the nasal cartilage
- associated with untreated rosacea
What is rosacea?
What is the main difference between rosacea and acne?
- it is a chronic inflammatory skin disease of unknown aetiology
- it presents with central facial erythema, telangiectasias and papules / pustules
- telangiectasias are visible dilations of small superficial blood vessels
- in contrast with acne, comedones are not present
- comedones (whiteheads / blackheads) form when sebaceous glands are blocked
Who tends to be more prone to rhinophyma?
- it occurs more often in those exposed to UV light
- e.g. homeless or working permanently outside
- it is associated with excess alcohol intake
- rhinophyma is primarily seen in males and the elderly
What is the treatment for rosacea?
- topical brimonidine and topical oxymetazoline are used to treat the erythema
- metronidazole, azelaic acid and ivermectin are used to treat papules and pustules
- in more severe disease, oral tetracyclines (e.g. doxycycline) or isotretinoin may be used
What is the treatment for rhinophyma?
- need to treat the underlying rosacea (often with isotretinoin)
-
laser therapy is used to shave off the hypertrophied glands and inflamed skin
- rhinophyma occurs due to thickened skin and overactive sebaceous glands due to tissue overgrowth
When presenting with epistaxis, what advice is given to patients to stop the bleeding?
-
apply pressure to the soft, anterior part of the nose and not the hard, bony nasal bridge
- this is because most anterior nose bleeds originate from Little’s area on the nasal septum
- sit forwards with your mouth open to prevent swallowing of blood
What is the difference between anterior and posterior epistaxis?
Who tends to be affected by each type?
Anterior epistaxis:
- this involves bleeding from the nostrils
- it tends to occur in children < 10 years of age
Posterior epistaxis:
- this involves bleeding through the posterior nasal apertures
- this is usually bleeding down the throat with no external signs of bleeding
- haemoptysis, haemataemesis and/or melena may occur due to swallowing large amounts of blood
- occurs in older individuals > 50 years of age
- associated with hypertension and atherosclerosis
- it can be a sign of life-threatening haemorrhage
What is the most common site of bleeding in anterior epistaxis?
Kiesselbach plexus
- this is an anastomosis of 4 arteries:
- anterior ethmoidal artery
- sphenopalatine artery
- greater palatine artery
- superior labial artery
- they are located at Little’s area on the anteroinferior portion of the nasal septum
- remember the arteries with LEGS:
- L - labial (superior)
- E - ethmoidal (anterior)
- G - greater palatine
- S - sphenopalatine
Where is the most common site of bleeding in posterior epistaxis?
Woodruff plexus
- this is a collection of arteries in the posteroinferior region of the lateral nasal cavity
- formed by anastomoses of the:
- sphenopalatine artery (branch of the maxillary artery)
- pharyngeal artery
What are the common causes of epistaxis?
In which patients can bleeding be more severe?
- nose picking
- children’s nails should be cut short to prevent this
- foreign body in the nasal cavity
- dry nose
- usually bleeding stops on its own, but severe epistaxis may occur in:
- hypertension
- bleeding disorders
- after severe traumatic injury
- hereditary haemorrhagic telangiectasia
What is hereditary haemorrhagic telangiectasia and what are the main symptoms?
- autosomal dominant genetic condition
- causes abnormal vascular development in the mucous membranes, skin, GI tract, genitourinary tract, liver, lungs and/or brain
- it commonly presents with recurrent epistaxis
- it can also cause chronic bleeding from the GI tract
- this requires transfusions and iron supplementation
What are the immediate measures to control epistaxis?
- keep the patient calm
- elevate the patient’s upper body and bend their head forward
- apply cold packs and sustained, direct pressure by pinching the nose at the nostrils for 10 mins to occlude the bleeding vessel
- apply topical vasoconstrictors (e.g. oxymetazoline, phenylephrine)
What interventions are available if epistaxis continues after 10 - 15 minutes?
- cauterization of the bleeding vessel using silver nitrate or electrocautery
-
nasal packing using gauze impregnated with petroleum jelly and antibiotics
- antibiotics are for Staphylococcus aureus coverage
What happens if epistaxis persists despite nasal packing / cauterisation?
- arterial embolisation or endoscopic ligation of the bleeding vessel
- the anterior ethmoidal artery is ligated in anterior epistaxis
- the sphenopalatine artery is ligated in posterior epistaxis
Why do people get a build-up of earwax?
What is the treatment for this and what should be avoided?
- caused by irritation to the ear canal from items such as dust or “in-ear” headphones
- olive oil drops can be used to soften the wax
-
cotton buds should not be used as they impact the wax and damage the lining of the ear canal
- they push the wax further into the ear canal
- irritation also causes the production of more ear wax
What is otitis externa and what is an alternative name for it?
- inflammation of the external auditory canal, usually due to a local bacterial infection
- it is also called “swimmer’s ear”
- risk factors include injury to the skin of the external auditory canal and/or exposure to water
What bacterial infections are usually responsible for otitis externa?
- 40% of cases are caused by Pseudomonas aeruginosa, commonly from swimming activities
- this grows in water and humid climates
- Staphylococcus aureus
- Proteus mirabilis
- Escherichia coli
- (also has viral and fungal causes)
What are the symptoms and signs of otitis externa?
Symptoms:
- severe ear pain, particularly at night
- otorrhoea (discharge from the ear)
- intense itching in the external auditory canal
Clinical signs:
- the tragus is tender to touch
- pulling up and back on the auricle causes pain
-
conductive hearing loss
- hearing loss due to impaired/interrupted conduction of sound through the outer ear, tympanic membrane or inner ear
What are patients with diabetes / immunosuppression who contract otitis externa more at risk of?
How does this present differently?
malignant (necrotising) otitis externa
- this is necrotising inflammation of the external auditory canal caused by Pseudomonas aeruginosa (95%)
- presents as otitis externa, but with red and swollen periauricular soft tissue
- most common in elderly patients with diabetes
What are the complications of malignant otitis externa?
How is it treated?
Complications:
- facial nerve palsy
- osteomyelitis of the skull base
- leads to extradural abscess, venous sinus thrombosis & paralysis of other cranial nerves
Treatment:
-
IV antibiotic therapy with ciprofloxacin
- patients can be switched to oral antibiotics once clinical symptoms resolve
What is involved in the initial treatment of uncomplicated otitis externa?
- antibiotic ear drops - ofloxacin, ciprofloxacin or gentamicin
- topical corticosteroids (e.g. hydrocortisone, prednisolone) to control itching / inflammtion
-
aural toilet to clean and dry the external auditory canal and remove discharge, wax and debris
- this involves a mixture of isopropyl alcohol and acetic acid
- patients are advised to keep the EAC clean and DRY
What is the systemic treatment for otitis externa?
Who is this offered to?
oral ciprofloxacin (in addition to topical treatment)
- immunosuppression
- diabetes mellitus
- severe otitis externa with cellulitis of the face and neck
- when topical administration of antibiotics is not possible
- e.g. severe oedema of the external auditory canal
What is shown in this picture?
How can you tell?
conjunctivitis
- there is redness of the entire conjunctiva with no apparent corneal or anterior chamber involvement
What are the clinical features associated with conjunctivitis?
-
conjunctival injection
- conjunctival hyperemia (increased blood flow) with dilatation of blood vessels
- leads to ocular hyperemia and reddening - “pinkeye”
- discharge and crust formation
- chemosis - oedema of the eyelids and/or conjunctiva
- burning or foreign-body sensation
- photophobia (if cornea is involved)
- itching
How is laterality, discharge and vision symptoms different in bacterial and viral conjunctivitis?
Bacterial:
- usually unilateral
- produces thick purulent discharge (yellow, white or green)
- reduced vision and risk of blindness if the cornea is involved
Viral:
- typically bilateral as it starts in one eye and spreads to the other within a few days
- clear watery discharge (with mucoid component)
- vision is usually normal
What is the typical treatment for conjunctivitis?
- treatment depends on the cause
- in adults it is not usually treated as it is self-limiting
- in children it can be quite disruptive, so antibacterial drops (chloramphenicol) can improve symptoms by a few days
What is shown in this image?
subconjunctival haemorrhage
- this is a bleed beneath the conjunctiva, which is bounded by its attachment to the edge of the cornea
- looks very dramatic but is usually asymptomatic and completely harmless
What are typical causes of subconjunctival haemorrhage?
- usually caused by spontaneous capillary leak from conjunctival or episcleral capillaries
- or can be caused by straining
- e.g. chronic constipation, childbirth, coughing
- it is more common with concurrent anticoagulant or anti-platelet therapy
What is shown in this image and how should it be treated?
foreign body
- this is a medical emergency that should be referred to eye casulaty due to risk of penetration
- there can be ulceration / infection around the foreign body that can damage the cornea
What is shown in this image?
What causes it?
hordeolum (or stye)
- this is an obstruction and infection of the tear gland or an eyelash follicle (Zeis or meibomian glands)
What typically causes a hordeolum?
Who is more at risk?
- it is mainly caused by Staphylococcus aureus
- there is increased occurrence in individuals with acne vulgaris and diabetes mellitus
What is the treatment for a stye?
- usually self-limiting and resolve spontaneously after 1-2 weeks
- warm compress and massage
- eyelid margin hygiene helps to remove debris and unclog blocked glands
-
topical antibiotic treatment with gentamicin, amoxicillin or erythromycin
- it is NOT treated with eyedrops as it is a skin problem, not an eye problem
What does it usually suggest if a patient has a ingrowing toenail with associated redness?
- this suggests ingrowing toenail with paronychia
- this is soft tissue infection around a nail
- bacteria has entered after the skin has been broken, causing infection and inflammation
What typically causes paronychia?
What are the clinical features?
- it is caused by trauma (e.g. nail biting, manicuring) or cracks in the barrier between the nail and the nail fold
- this leads to bacterial infection with Staphylococcus aureus
- there are classic signs of inflammation
- in some cases there may be pus in one of the lateral folds of the nail
What is the treatment for paronychia?
- elevation and warm soaks 3-4 times a day
- antibiotics (e.g. amoxicillin-clavulanate) if infection is extensive
How can a fungal nail infection be identified?
How is diagnosis confirmed?
- the nail appears white, thickened and crumbly
- there is onycholysis (areas of white where nail has been lifted off the nailbed)
- diagnosis is confirmed by sending nail clippings for mycology
What is the proper name for a fungal nail?
What is it typically caused by?
- if it is caused by dermatophytes, most commonly T. rubrum, it is referred to as tinea unguium
- if it is caused by yeasts and molds, it is referred to as onychomycosis
What is involved in the treatment of fungal nail infection?
- treated with topical antifungals such as terbinafine
- it requires a long course of treatment as you want to stop the spread of infection whilst the toenail grows out
- systemic antifungals are indicated in immunocompromised patients, if there is extensive spread or if topical treatment fails
What causes verrucas / plantar warts?
How can they be distinguished?
- caused by human papilloma virus (HPV)
- they are equivalent to warts found on hands, but as they occur on the soles of the feet they get squashed into the foot
- they have characteristic haemorrhages on the surface, which distinguish them from simple callouses
What is the treatment for verrucas / plantar warts?
- they are usually self-limiting
- if required, the treatment is weak topical salicyclic acid
- usually treatment is given if the wart is in a position that causes pain or irritation when walking
What is shown in this image?
What causes it?
olecranon bursitis
- this is a non-tender swelling over the elbow that is fluctuant and fluid-filled
- it is caused by continuous pressure on the elbow (i.e. resting on a table) or by acute trauma (i.e. a blow to the elbow)
What is involved in the management of olecranon bursitis?
- need to exclude infection by checking whether patient has any systemic symptoms
- antibiotics are given if septic bursitis is present
- NSAIDs are given to reduce the inflammation
-
aspiration can be considered, but pressure-bandages are required or it will fill up again afterwards
- this is performed when bursitis is recurrent and doesn’t respond to conservative management
What is the difference between “tennis elbow” and “golfer’s elbow”?
- “tennis elbow” refers to lateral epicondylitis
- “golfer’s elbow” refers to medial epicondylitis
- epicondylitis refers to pain and tenderness over the medial or lateral aspect of the elbow due to tear in tendon
What is the definition of lateral epicondylitis (tennis elbow)?
What causes it?
- it is an overuse injury of the hand, especially finger extensor tendons which originate in the lateral humeral epicondyle
- it is most commonly due to repeated or excessive pronation/supination and extension of the wrist
- Remember - an EXTended game of TENNIS will ruin the Lawn*
- repeated EXTension of the elbow causes Lateral epicondylitis*
What is
What is medial epicondylitis (golfers elbow) and what causes it?
- an overuse injury of the hand, especially finger flexor tendons which originate in the medial humoral epicondyle
- most commonly due to repeated wrist flexion and forearm pronation
- Remember - a FLexible game of GOLF allows Mulligans*
- repeated FLexion of the elbow causes Medial epicondylitis*
What are the management options for epicondylitis?
- rest
- oral or topical NSAIDs
- physiotherapy
- splints to immobilise the elbow or immobilise the wrist (to prevent flexion/extension)
- steroid injections
What is shown in this image?
ganglion cyst
- this is a benign mucin-filled cyst that develops along tendons or joints and has no true epithelial lining
- it is associated with either a mobile joint (e.g. wrist or ankle), or with a tendon sheath
- it is not painful and usually occurs over the wrist
What are the clinical features of a ganglion cyst?
- it is usually asymptomatic but can cause joint pain
- it is a fluctuant, transilluminant swelling
- it can lead to nerve compression, which may cause numbness, weakness or tingling
What is the treatment for a ganglion cyst?
- if it asymptomatic then it is usually just observed
- if it is symptomatic, then aspiration or surgical resection can be carried out
- they are difficult to aspirate as synovial fluid is viscous and they often recur
- only resected if large or cause problems
What is carpal tunnel syndrome caused by?
What does it present with?
- it is caused by chronic or acute compression of the median nerve by the transverse carpal ligament
- it is characterised by both sensory disturbances and motor symptoms in the area innervated by the median nerve distal to the carpal tunnel
- sensory disturbances include pain, tingling and numbness
- motor symptoms include weakness and clumsiness of the thumb
What are risk factors associated with carpal tunnel syndrome?
- manual work
- rheumatoid arthritis
- pregnancy and puerperium (6-8 weeks postpartum)
- hormone-mediated weight gain and wrist oedema can compress carpal tunnel
- obesity
- osteoarthritis
- systemic amyloidosis
- due to deposition of amyloid fibrils in the transverse carpal ligament
- renal failure
- due to dialysis-associated deposition of amyloid
- hypothyroidism
- acromegaly
Where are symptoms located in mild to moderate carpal tunnel syndrome?
What are the typical symptoms and when are they worse?
- symptoms develop in areas innervated by the median nerve
- palmar surface of the thumb, index and middle fingers
- radial half of the ring finger
- symptoms include:
- paresthesia - burning sensation, tingling
- loss of sensation / numbness
- pain
- symptoms are worse at night
What are the additional symptoms associated with moderate to severe carpal tunnel syndrome?
- there are additional motor symptoms
- weakened pinch and grip which leads to patients dropping objects
- severe, sustained median nerve compression can lead to thenar atrophy and impaired thumb opposition
What is the treatment for carpal tunnel syndrome?
Mild to moderate symptoms - conservative treatment:
- immobilisation of the wrist with a splint worn at night
- steroid injection with triamcinolone
- short-term oral glucocorticoid therapy
Moderate to severe symptoms:
- open or endoscopic release of the transverse carpal ligament
What is the likely diagnosis in this patient?
What deformity is visible?
knee osteoarthritis
- there is swelling of the right knee
- the varus deformity is present, which is caused by degeneration of the medial meniscus and consequent loss of joint space in the medial compartment
- patient will complain of progressive pain and swelling with pain on weight bearing radiating to the hip
What are the treatment options for knee osteoarthritis?
- keep active with weight-bearing and non-weight bearing exercises
- physiotherapy helps to strengthen the muscles around the knee to give more support
- analgesics to manage the pain
- steroid injections (only effective if there is an inflammatory component)
- surgery - usually occurs in elderly patients with comorbidities so this can be difficult
What is the typical “footballer’s injury” of the knee?
What are the 2 different types and how can you tell them apart?
torn medial meniscus or torn anterior cruciate ligament
- the history of injury determines the most likely diagnosis
- if it is a TWISTING injury, think torn medial meniscus
- ACL tear is more common in a forward movement on a planted leg (i.e. sudden deceleration)
- both result in a sudden onset disabling pain
What is the most likely diagnosis in this presentation of a red, hot, swollen knee?
septic arthritis
- this is a bacterial infection of the joint space
- the patient will be systemically unwell
- it can be confused for pre-patellar bursitis, but in this case, the patient would NOT be systemically unwell
What is the treatment for septic arthritis?
- it requires urgent admission to hospital for IV antibiotics
- the joint also needs to be washed out
How does infection occur in septic arthritis?
What are the risk factors for infection?
- infection occurs through haematogenous spread or by direct contamination (e.g. trauma)
- risk factors include:
- immunosuppression
- prosthetic implants
- underlying joint disease, particularly rheumatoid arthritis
- diabetes
- age > 80 years
- IV drug use
What is the most common cause of septic arthritis?
What other infections can cause it?
- Staphylococcus aureus is most common in adults and children > 2 years
- Streptococci
- N. gonorrhoea is most common in sexually-active young adults
- S. epidermidis
- Gram-negative rods such as E. coli and P. aeruginosa
- particularly in the elderly, immunosuppressed and IVDU
What is the classic triad of septic arthritis?
What joints are usually affected?
- classic triad of fever, joint pain and restricted range of motion
- arthritis is usually monoarticular
- it most commonly affects the knees, followed by the hip, wrists, shoulders and ankles
- joints are swollen, red and painful
What antibiotics are used to treat septic arthritis caused by gram-positive and gram-negative cocci and gram-negative rods?
Gram-positive cocci:
- penicillinase-resistant penicillins
- oxacillin
- nafcillin
- cefazolin
Gram-negative cocci:
- aminoglycosides
- certriaxone
Gram-negative rods:
- ceftazidime
What antibiotics are used to treat septic arthritis caused by N. gonorrhoea or Chlamydia?
- for gonorrhoea, IV ceftriaxone is used
- for chlamydia, doxycycline is used
What is Osgood-Schlatter disease?
- this is a tibial osteochondritis that arises from overuse of the quadriceps muscle during periods of growth
- this causes a traction apophysitis at the tibial insertion of the quadriceps tendon
- inflammation at the site where the tendon inserts on the bone
- it usually presents with a tender swelling below the knee
Who tends to be affected by Osgood-Schlatter disease?
- it tends to occur in younger people (aged 9 - 14) who are physically active
- it is more common in boys
What is the treatment for Osgood Schlatter disease?
- treatment is conservative with rest, ice and NSAIDs
- it generally resolves once full bone maturity is reached
What is the difference between osteoporosis and osteopenia?
osteoporosis:
- there is loss of trabecular and cortical bone mass
- the loss of bone mineral density leads to decreased bone strength and increased susceptibility to fractures
osteopenia:
- decreased bone strength, but less severe than osteoporosis
Who is most at risk of osteoporosis and why?
What are additional risk factors?
- typically affects postmenopausal women and the elderly
- an abrupt decline in oestrogen and age-related processes play a role
- other risk factors include smoking, alcohol consumption and inactivity
What are the 2 different forms of primary osteoporosis?
Type I - postmenopausal osteoporosis:
- oestrogen stimulates osteoblasts and inhibits osteoclasts
- osteoblasts promote development of new bone
- osteoclasts break down bone matrix
- decreased oestrogen levels following menopause leads to increased bone resorption
Type II - senile osteoporosis:
- gradual loss of bone mass as patients age (especially > 70 years)
- osteoblast activity declines leading to less osteoid production
What drugs are indicated in drug-induced secondary osteoporosis?
- most commonly due to long-term systemic therapy with corticosteroids (e.g. autoimmune disease)
- anticonvulsants such as phenytoin
- thyroxine used to treat hypothyroidism
- anticoagulants such as heparin
- proton pump inhibitors
- aromatase inhibitors (anti-oestrogen drugs)
- immunosuppressants (e.g. tacrolimus)
What are other causes of secondary osteoporosis?
- multiple myeloma
- excessive alcohol consumption
- endocrine / metabolic disorders:
- hypercortisolism (either from excess production or consumption of corticosteroids)
- hypogonadism
- hyperthyroidism
- hyperparathyroidism
- renal disease
How does osteoporosis typically present?
- it is mostly asymptomatic
- tends to present with fragility fractures
- these are pathological fractures that are caused by everyday activities or minor trauma
- e.g. bending over, sneezing, falling from standing height
- often vertebral fractures but also commonly affect the femoral neck, distal radius and other long bones
What are vertebral compression fractures?
What can they lead to in the long term?
- often asymptomatic but can cause acute back pain
- multiple fractures can lead to decreased height and thoracic kyphosis
- this describes dorsal convexity of the spine
How is osteoporosis diagnosed?
DEXA scan
- this calculates bone mineral density
- the T-score is the difference in standard deviations between the patient’s BMD and the BMD of a young adult female reference mean
- osteoporosis is diagnosed if T-score = -2.5 SD and/or a fragility fracture is present
What is the first line treatment for osteoporosis?
What are the side effects of this medication?
- bisphosphonates, such as alendronate, risedronate
- they inhibit osteoclasts, preventing bone resorption
- the side effects include:
- hypocalcaemia
- oesophagitis (maintain upright position after taking for 30 mins to avoid this)
- osteonecrosis of the jaw
- they tend not to be used in patients with GI upset as they can irritate the gut lining
What is the main alternative treatment for osteoporosis?
DENOSUMAB
- this is a once yearly injection of a monoclonal antibody against RANKL
- it leads to decreased osteoclast activity
- used in patients with impaired renal fucntion or if bisphosphonate therapy failed
What is lymphedema?
- oedema associated with lymphatic obstruction and reduced fluid clearance due to compromised lymphatic vessels or lymph nodes
- this results in viscous lipid-rich, protein-rich fluid in the interstitial space
What are the stages of lymphedema?
How does it typically present?
- latent stage - reduced capacity of lymphatic vessels but no swelling
- reversible swelling - some pitting oedema present
- gradual fibrosis - the skin gradually hardens, non-pitting stage
- irreversible elephantiasis - an enlarged hardened limb with fibrotic skin
