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Core Conditions - Other > Minor Illnesses in Primary Care > Flashcards

Minor Illnesses in Primary Care Flashcards

1
Q

What is this?

What are the characteristic features of this condition?

A

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
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2
Q

What is the treatment for chickenpox?

A
  • 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
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3
Q

What virus causes chickenpox?

How is it transmitted?

A
  • 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
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4
Q

In which groups might treatment be given for chickenpox?

A
  • 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)
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5
Q

What can chickenpox represent as later on in life and why?

A
  • VZV will persist in ganglion cells following infection
  • reactivation of the virus may occur when the immune system is compromised, presenting as shingles
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6
Q

What is the most severe complication of chickenpox?

A
  • 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
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7
Q

During which times is chickenpox infective?

Where does it remain latent?

A
  • 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
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8
Q

How long is the incubation and prodrome phase for chickenpox?

What symptoms does this usually present with?

A
  • 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
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9
Q

How long is the symptomatic phase of chickenpox?

What is the typical presentation?

A
  • 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
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10
Q
A
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11
Q

When must aciclovir be administered for chickenpox treatment?

What are alternative antivirals?

A
  • it must be administered within 24 hours of the onset of the rash
  • valacyclovir or famciclovir can be used instead
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12
Q

What condition is this?

What are the main characteristics that make this apparent?

A

Shingles (Herpes Zoster)

  • the distribution of the lesions is both unilateral and dermatomal
  • there is painful blistering
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13
Q

Why does shingles occur?

Who is most at risk?

A
  • 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
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14
Q

What is the most common complication associated with shingles infection?

A

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)
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15
Q

What are the clinical features associated with shingles?

A
  • 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
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16
Q

What is herpes zoster ophthalmicus?

A
  • 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
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17
Q

What are the main clinical features of herpes zoster ophthalmicus?

A
  • 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
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18
Q

What is Hutchinson’s sign in herpes zoster ophthalmicus and what does it mean if it is positive?

A
  • 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
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19
Q

What are the potential complications of herpes zoster ophthalmicus?

A
  • if not treated properly, it can result in blindness
  • glaucoma
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20
Q

What is the alternative name for herpes zoster oticus?

What happens in this condition?

A

Ramsay Hunt Syndrome

  • this is reactivation of VZV in the geniculate ganglion
  • this affects the facial (CN VII) and vestibulocochlear (CN VIII) nerves
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21
Q

What are the clinical features of Ramsay Hunt syndrome?

A
  • 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
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22
Q

What is the treatment for shingles?

When must it be administered?

A
  • 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
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23
Q

What are the indications for antiviral therapy to treat shingles?

A
  • 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)
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24
Q

Who can receive a shingles vaccination?

How does this work?

A
  • 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
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25
Q

What is shown in this image?

A

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
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26
Q

How is molluscum contagiosum spread?

In which age group is the highest number of infections seen?

A
  • 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
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27
Q

What diagnosis should be considered if widespread molluscum contagiosum lesions are seen in adults?

A
  • immunosuppressed patients present with more lesions that are usually larger
  • if an adult presents with large, persistent, widespread lesions then AIDS should be suspected
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28
Q

Who is offered treatment for molluscum contagiosum?

What treatment is available?

A
  • 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
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29
Q

What is shown in this image?

What are the distinguishing features?

A

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
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30
Q

Who is most commonly affected by eczema?

How does the disease change over time?

A
  • 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
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31
Q

Why is family history important when diagnosing eczema (atopic dermatitis)?

A
  • 70% of patients have a family history of atopic disease
  • this includes eczema, asthma, allergic rhinitis and allergies
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32
Q

What are the main clinical features associated with eczema?

A
  • 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
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33
Q

What are the general measures that are recommended to patients with eczema?

A
  • avoid triggers
    • allergic trigger factors - pets, dust mites, pollen, certain foods
  • keep the skin moist
  • manage / eliminate stress
  • breastfeeding is recommended during infancy
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34
Q

What treatments are available for mild, moderate and severe eczema?

A

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
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35
Q

What is the main complication associated with eczema?

A
  • 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
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36
Q

What is the “glass test” and what does it demonstrate?

A
  • 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
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37
Q

What is involved in the acute management of meningococcal septicaemia?

A
  • 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
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38
Q

What is the definition of meningococcal septicaemia?

A
  • 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
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39
Q

What is shown in this image?

What causes this?

A

Herpes Labialis

  • also known as a cold sore
  • this is caused by herpes simplex virus, usually HSV-1
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40
Q

What are the clinical features of herpes labialis?

A
  • 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
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41
Q

What treatment is offered to patients with primary or recurrent herpes labialis?

A
  • 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
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42
Q

When might oral antiviral drugs be prescribed for herpes labialis?

What instructions are given to the patient about when to take this medication?

A
  • 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
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43
Q

What condition is shown in this picture?

In what age group is it usually seen in?

A

Impetigo

  • it is more common in children
  • it is characterised by honey-coloured, crusted lesions with surrounding erythema
  • it usually affects the face
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44
Q

What organisms typically cause impetigo?

Which type of impetigo do they cause?

A
  • 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
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45
Q

What is the difference between primary and secondary impetigo?

A
  • 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
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46
Q

What do the lesions look like in nonbullous and bullous impetigo?

A

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
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47
Q

What is Nikolsky sign and in which type of impetigo is it positive?

A
  • 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
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48
Q

What is the treatment for nonbullous and bullous impetigo?

A
  • 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
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49
Q

What type of primary lesions are present in acne vulgaris?

A

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
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50
Q

What is the treatment for mild acne (e.g. comedonal)?

A
  • topical benzoyl peroxide OR topical retinoids
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51
Q

What is the treatment for moderate severity acne (e.g. papular / pustular)?

A

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
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52
Q

What is the treatment for severe acne?

A

oral isotretinoin

  • therapy is particularly important in patients with inflammatory acne to prevent scarring
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53
Q

What are retinoids and how do they work?

What is the main contraindication and why?

A
  • 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
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54
Q

What is shown in this image?

A

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
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55
Q

What is the treatment for a furuncle?

A
  • 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
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56
Q

What are the 3 different ways to treat head lice in the UK?

A

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
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57
Q

What is shown in this image?

What are the arrows pointing to?

A

scabies

  • this presents with an intensely itchy rash
  • the arrows are pointing to the tracks made where the scabies mite lays it eggs
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58
Q

What are the clinical features of scabies?

Which parts of the body tend to be affected?

A
  • 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
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59
Q

What is the treatment for scabies?

A
  • 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
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60
Q

How is the scabies treatment applied and why must it be applied in this way?

A
  • 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
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61
Q

What is this condition?

Who tends to contract it?

A

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
62
Q

What are the clinical features of oral thrush?

A
  • 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
63
Q

What is the treatment for oral thrush?

A
  • first line treatment involves either topical nystatin or oral fluconazole
  • other azoles can be used if treatment fails e.g. itraconazole
64
Q

What is shown in this image?

What causes it?

A

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
65
Q

What is the treatment for aphthous ulcers?

A
  • they are self-limiting and there is no treatment
  • symptomatic treatment includesL
    • topical corticosteroids - dexamethasone
    • antimicrobials - tetracycline
    • anaesthetics - lidocaine
66
Q

What condition is shown in this image?

What causes it and what is it associated with?

A

rhinophyma

  • caused by inflammation and hypertrophy of sebum glands on the nose, which also produces remodelling of the nasal cartilage
  • associated with untreated rosacea
67
Q

What is rosacea?

What is the main difference between rosacea and acne?

A
  • 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
68
Q

Who tends to be more prone to rhinophyma?

A
  • 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
69
Q

What is the treatment for rosacea?

A
  • 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
70
Q

What is the treatment for rhinophyma?

A
  • 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
71
Q

When presenting with epistaxis, what advice is given to patients to stop the bleeding?

A
  • 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
72
Q

What is the difference between anterior and posterior epistaxis?

Who tends to be affected by each type?

A

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
73
Q

What is the most common site of bleeding in anterior epistaxis?

A

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
74
Q

Where is the most common site of bleeding in posterior epistaxis?

A

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
75
Q

What are the common causes of epistaxis?

In which patients can bleeding be more severe?

A
  • 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
76
Q

What is hereditary haemorrhagic telangiectasia and what are the main symptoms?

A
  • 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
77
Q

What are the immediate measures to control epistaxis?

A
  • 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)
78
Q
A
79
Q

What interventions are available if epistaxis continues after 10 - 15 minutes?

A
  • 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
80
Q

What happens if epistaxis persists despite nasal packing / cauterisation?

A
  • 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
81
Q

Why do people get a build-up of earwax?

What is the treatment for this and what should be avoided?

A
  • 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
82
Q

What is otitis externa and what is an alternative name for it?

A
  • 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
83
Q

What bacterial infections are usually responsible for otitis externa?

A
  • 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)
84
Q

What are the symptoms and signs of otitis externa?

A

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
85
Q

What are patients with diabetes / immunosuppression who contract otitis externa more at risk of?

How does this present differently?

A

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
86
Q

What are the complications of malignant otitis externa?

How is it treated?

A

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
87
Q

What is involved in the initial treatment of uncomplicated otitis externa?

A
  • 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
88
Q

What is the systemic treatment for otitis externa?

Who is this offered to?

A

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
89
Q

What is shown in this picture?

How can you tell?

A

conjunctivitis

  • there is redness of the entire conjunctiva with no apparent corneal or anterior chamber involvement
90
Q

What are the clinical features associated with conjunctivitis?

A
  • 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
91
Q

How is laterality, discharge and vision symptoms different in bacterial and viral conjunctivitis?

A

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
92
Q

What is the typical treatment for conjunctivitis?

A
  • 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
93
Q

What is shown in this image?

A

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
94
Q

What are typical causes of subconjunctival haemorrhage?

A
  • 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
95
Q

What is shown in this image and how should it be treated?

A

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
96
Q

What is shown in this image?

What causes it?

A

hordeolum (or stye)

  • this is an obstruction and infection of the tear gland or an eyelash follicle (Zeis or meibomian glands)
97
Q

What typically causes a hordeolum?

Who is more at risk?

A
  • it is mainly caused by Staphylococcus aureus
  • there is increased occurrence in individuals with acne vulgaris and diabetes mellitus
98
Q

What is the treatment for a stye?

A
  • 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
99
Q

What does it usually suggest if a patient has a ingrowing toenail with associated redness?

A
  • 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
100
Q

What typically causes paronychia?

What are the clinical features?

A
  • 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
101
Q

What is the treatment for paronychia?

A
  • elevation and warm soaks 3-4 times a day
  • antibiotics (e.g. amoxicillin-clavulanate) if infection is extensive
102
Q

How can a fungal nail infection be identified?

How is diagnosis confirmed?

A
  • 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
103
Q

What is the proper name for a fungal nail?

What is it typically caused by?

A
  • 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
104
Q

What is involved in the treatment of fungal nail infection?

A
  • 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
105
Q

What causes verrucas / plantar warts?

How can they be distinguished?

A
  • 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
106
Q

What is the treatment for verrucas / plantar warts?

A
  • 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
107
Q

What is shown in this image?

What causes it?

A

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)
108
Q

What is involved in the management of olecranon bursitis?

A
  • 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
109
Q
A
110
Q

What is the difference between “tennis elbow” and “golfer’s elbow”?

A
  • “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
111
Q

What is the definition of lateral epicondylitis (tennis elbow)?

What causes it?

A
  • 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*
112
Q

What is

A
113
Q

What is medial epicondylitis (golfers elbow) and what causes it?

A
  • 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*
114
Q

What are the management options for epicondylitis?

A
  • rest
  • oral or topical NSAIDs
  • physiotherapy
  • splints to immobilise the elbow or immobilise the wrist (to prevent flexion/extension)
  • steroid injections
115
Q

What is shown in this image?

A

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
116
Q

What are the clinical features of a ganglion cyst?

A
  • 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
117
Q

What is the treatment for a ganglion cyst?

A
  • 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
118
Q

What is carpal tunnel syndrome caused by?

What does it present with?

A
  • 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
119
Q

What are risk factors associated with carpal tunnel syndrome?

A
  • 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
120
Q

Where are symptoms located in mild to moderate carpal tunnel syndrome?

What are the typical symptoms and when are they worse?

A
  • 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
121
Q

What are the additional symptoms associated with moderate to severe carpal tunnel syndrome?

A
  • 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
122
Q

What is the treatment for carpal tunnel syndrome?

A

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
123
Q

What is the likely diagnosis in this patient?

What deformity is visible?

A

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
124
Q

What are the treatment options for knee osteoarthritis?

A
  • 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
125
Q

What is the typical “footballer’s injury” of the knee?

What are the 2 different types and how can you tell them apart?

A

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
126
Q

What is the most likely diagnosis in this presentation of a red, hot, swollen knee?

A

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
127
Q

What is the treatment for septic arthritis?

A
  • it requires urgent admission to hospital for IV antibiotics
  • the joint also needs to be washed out
128
Q
A
129
Q

How does infection occur in septic arthritis?

What are the risk factors for infection?

A
  • 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
130
Q

What is the most common cause of septic arthritis?

What other infections can cause it?

A
  • 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
131
Q

What is the classic triad of septic arthritis?

What joints are usually affected?

A
  • 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
132
Q

What antibiotics are used to treat septic arthritis caused by gram-positive and gram-negative cocci and gram-negative rods?

A

Gram-positive cocci:

  • penicillinase-resistant penicillins
    • oxacillin
    • nafcillin
    • cefazolin

Gram-negative cocci:

  • aminoglycosides
  • certriaxone

Gram-negative rods:

  • ceftazidime
133
Q

What antibiotics are used to treat septic arthritis caused by N. gonorrhoea or Chlamydia?

A
  • for gonorrhoea, IV ceftriaxone is used
  • for chlamydia, doxycycline is used
134
Q

What is Osgood-Schlatter disease?

A
  • 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
135
Q

Who tends to be affected by Osgood-Schlatter disease?

A
  • it tends to occur in younger people (aged 9 - 14) who are physically active
  • it is more common in boys
136
Q

What is the treatment for Osgood Schlatter disease?

A
  • treatment is conservative with rest, ice and NSAIDs
  • it generally resolves once full bone maturity is reached
137
Q

What is the difference between osteoporosis and osteopenia?

A

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
138
Q

Who is most at risk of osteoporosis and why?

What are additional risk factors?

A
  • 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
139
Q

What are the 2 different forms of primary osteoporosis?

A

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
140
Q

What drugs are indicated in drug-induced secondary osteoporosis?

A
  • 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)
141
Q

What are other causes of secondary osteoporosis?

A
  • multiple myeloma
  • excessive alcohol consumption
  • endocrine / metabolic disorders:
    • hypercortisolism (either from excess production or consumption of corticosteroids)
    • hypogonadism
    • hyperthyroidism
    • hyperparathyroidism
    • renal disease
142
Q

How does osteoporosis typically present?

A
  • 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
143
Q

What are vertebral compression fractures?

What can they lead to in the long term?

A
  • 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
144
Q
A
145
Q

How is osteoporosis diagnosed?

A

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
146
Q

What is the first line treatment for osteoporosis?

What are the side effects of this medication?

A
  • 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
147
Q

What is the main alternative treatment for osteoporosis?

A

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
148
Q

What is lymphedema?

A
  • 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
149
Q

What are the stages of lymphedema?

How does it typically present?

A
  • 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
150
Q
A

Core Conditions - Other (10 decks)

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