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
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
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
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)
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
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
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
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
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
10
Q
A
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
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
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
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)
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
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
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
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
19
Q
What are the potential complications of herpes zoster ophthalmicus?
A
- if not treated properly, it can result in blindness
- glaucoma
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
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
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
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)
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
25
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_**
26
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**
27
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
28
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**
29
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**
30
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
31
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**
32
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
33
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
34
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
35
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
36
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
37
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
38
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**
39
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_**
40
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
41
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
42
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**
43
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**
44
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_**
45
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
46
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_**
47
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_**
48
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
49
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**
50
What is the treatment for mild acne (e.g. comedonal)?
* topical **_benzoyl peroxide_** OR topical **_retinoids_**
51
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
52
What is the treatment for severe acne?
**_oral isotretinoin_**
* therapy is particularly important in patients with inflammatory acne to prevent scarring
53
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
54
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
55
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
56
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
57
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
58
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**
59
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
60
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
61
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
62
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
63
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**
64
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
65
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_**
66
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_**
67
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
68
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**
69
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
70
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
71
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
72
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_**
73
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
74
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**
75
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
76
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
77
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**)
78
79
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
80
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**
81
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
82
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_**
83
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)
84
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
85
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_**
86
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
87
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_**
88
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
89
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**
90
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
91
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
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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
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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**
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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_**
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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**
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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**)
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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**
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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
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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
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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
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What is the treatment for paronychia?
* elevation and warm soaks 3-4 times a day
* antibiotics (e.g. **_amoxicillin-clavulanate_**) if infection is extensive
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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
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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_**
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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**
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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
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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
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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)
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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
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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
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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*
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What is
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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*
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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
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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_**
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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**
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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
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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
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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
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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_**
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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_**
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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
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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_**
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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
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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**
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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
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What is the treatment for septic arthritis?
* it requires urgent admission to hospital for IV antibiotics
* the joint also needs to be washed out
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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
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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
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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**
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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
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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
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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**
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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
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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
137
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 d**ecreased bone strength** and increased susceptibility to **fractures**
***_osteopenia:_***
* decreased bone strength, but less severe than osteoporosis
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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_**
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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