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Year 3 > Miscellaneous conditions > Flashcards

Miscellaneous conditions Flashcards

1
Q

Acute Respiratory Distress Syndrome

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigation
A
  1. Syndrome of acute and persistent lung inflammation with increased vascular permeability; characterised by: acute onset, bilat infiltrates consistent with pulm oedema; hypoxaemia; no clinical evidence of increased left arterial pressure (pulm cap wedge pressure), ARDS severe end of acute lung injury
  2. Severe insults to lung and other organs leads to the release of inflammatory mediators; leads to increased cap permeability, pulm oedema, impaired gas exchange and reduced lung compliance
    1. Causes: sepsis, aspiration, pneumonia, pancreatitis, trauma/burns, transfusion, transplantation (bone marrow and lung), drug OD/reaction
    2. 3 path stages of ARDS: exudative, proliferative, fibrotic
  3. Annual UK incidence 1/6000
  4. Rapid deterioration of resp funciton, dyspneoa, resp distress, cough, syx of cause
  5. Cyanosis, tachypnoea, tachycardia, widespread inspiratory crepitations, hypoxia refractory to O2 tx, sx usually bilat but can be asymmetrical in early stages
  6. CXR: bilat alveolar infiltrates and interstitial shadowing
    1. Bloods: figure out cause, FBC, U+Es, LFT, ESR/CRP, amylase, ABG, blood culture, sputum culture, plasma BNP <100 pg/mL distinguish ARDS from HF
    2. Echo: severe dysfunction of aortic/mitral valve, low left ventricular ejection fractions = haemodynamic oedema rather than ARDS
    3. Pulm artery catheterisation: check pulm cap wedge pressure
    4. Bronchoscopy: if cause not from hx
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2
Q

Alcohol withdrawal

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx and Sx
  5. Investigation
  6. Management
  7. Complications
  8. Prognosis
A
  1. Syx that may occur when a person has been drinking too much alcoohol on a regular basis and suddenly stops drinking
  2. Chronic alcohol consumption suppresses the activity of glutamate so body compensates increasing sensitivity to glutamate; so when alcohol consumption stops you get increased glutamate activity leading to excitatory syx
  3. Untx 6% of alcohol dependent pts, develop clinically relevant syx of withdrawal , up to 10% of them will develop delirium tremens
  4. Hx of high alcohol intake;
    1. mild syx: insomnia, and fatigue, tremor, mild anxiety/feeling nervous, mild restlesness/agitation, N/V, headache, sweating, palpitations, anorexia, depression, craving alcohol
    2. More severe syx: hallucinations, withdrawal seizures (generalised tonic-clonic), delirium tremens (acute confusional state often seen as withdrawal syndrome in chronic alcoholics and caused by sudden cessation of drinking alcohol, precipitated by head injury or acute infection causing abstinence from alcohol
    3. Features of delirium tremens: anxiety, tremor, sweating, vivid and terrifying visual/sensory hallucinations, can be FATAL
  5. No investigations
  6. Chlordiazepoxide - reduces syx of alcohol withdrawal
    1. Barbiturates may be used if refractory to BZD
    2. Thiamine prevents progression to wernicke-korsakoff syndrome
  7. Pts can have seizures and die if left untx
  8. Delirium tremens has mortality of 35% if untx, mortality <2% with early detection and tx
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3
Q

Anaphylaxis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
  7. Management
  8. Complications
  9. Prognosis
A
  1. Acute life-threatening multisystem syndrome caused by sudden release of mast cell and basophil-derived mediators into the circulation
  2. Immunogenic: IgE-mediated or immune complex/complement mediated
    1. Non-immunogenic: mast cell or basophil degranulation without the involvement of antibodies (vancomycin, codeine, ACEi)
    2. Pathophysiology: inflammatory mediators such as histamine are released leading to bronchospasm, increased cap perm and reduce vascular tone -> OEDEMA
    3. Common allergens: drugs, latex, penicillin, shellfish (anaphylaxis can be caused by the repeat admin of blood products in a patient with selective IgA deficiency - due to the formation of anti-IgA Abs)
  3. Common
  4. Wheeze, shortness of breath and a sense of choking, swelling of lips and face, pruritus, rash (note = hx of other hypersensitivity reactions - asthma, allergic rhinitis)
  5. Tachypnoea, wheeze, cyanosis, swollen upper airways and eyes, rhinitis, conjunctival infection, urticarial rash, hypotension, tachycardia
  6. Clinical dx; serum tryptase, histamine levels or urinary metabolites of histamine may help support the clinical dx
    1. Following an attack: allergen skin testing IDs allegen; IgE immunoassays, finding food specific IgE in serum
  7. ABCDE; high flow oxygen, IM adrenaline, chlorpheniramine (antihistamine), hydrocortisone, if continued resp deterioration, may require bronchodilator therapy, monitor pulse oximetry, ECG, BP
  8. SHOCK, organ damage can result from shock
  9. Good with prompt treatment
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4
Q

Aspirin overdose

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Excessive ingestion of aspirin causing toxicity
  2. Result of deliberate self harm, suicidal intent or by accident; 10-20g casue mod-severe toxicity in adults
    1. Pathophysiology of aspirin OD: increases resp rate and depth, stimulating resp centre; hyperventilation (resp alk) compensated by increasing urinary HCO3 and excretion; dehydration and hypokalaemia; loss of HCO3, uncoupling of mitochondrial oxidative phosphorylation and the build up of lactic acid can lead to met acidosis
    2. SEVERE cases: CNS depression and resp failure can occur
  3. One of most common drug ODs
  4. Figure out: how much aspirin taken, when, any other drugs, any alcohol?
    1. Pts initially asyx
    2. Early syx: flushed, fever, sweating, hyperventilation, dizziness, tinnitus, deafness
    3. Later syx: lethargy, confusion, convulsions, drowsiness, resp depression, coma
  5. Fever, tachycardia, hyperventilation, epigastric tenderness
  6. Bloods: salicylate levels, FBC, U+Es check for hypoK, LFTs high AST/ALT, clotting screen - high PT, other drug levels (paracetamol), ABG - mixed met acidosis and resp alk
    1. ECG:Sx of hypoK - flattened/inverted T waves, U waves, prolonged PR interval, ST depression
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5
Q

Burns injury

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. When tissue damage occurs by thermal, electrical or chemical injury
  2. Contact with hot objects, electricity, UV light, irradiation, chemicals; high risk patients: young children, elderly
  3. UK has > 12,000 admission per year
  4. Note the circumstances of the burn, important to find out the time, temperature and length of contact with the agent, consider risk of smoke inhalation and carbon monoxide and carbon monoxide poisoning
  5. Check inhalational injury or airway compromise: stridor, dyspnoea, hoarse voice, soot in nose, singed nose hairs, carbonaceous sputum; check site/depth/distribution of burn;
    1. Partial thickness burn, subdivided into:
      1. Superficial: red, oedematous skin and painful (heals within 7d with peeling of dead skin)
      2. Deep: blistering and mottling and PAINFUL - heals over 3wks usually without scarring
    2. Full thickness burn: destruction of the epidermis and dermis; charred leathery eschars, firm and painless with loss of sensation; healing occurs by scarring or contractures and requires skin grafting
    3. Size of burn: described as a percentage of body surface area
  6. Bloods: O2 sat, ABG, carboxyHb (inhalation injury), FBC, U+E, Group and save
    1. Serum CK, urine myoglobin (check muscle damage), ECG
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6
Q

Extradural haemorrhage

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Bleeding and accumulaton of blood in extradural space
  2. Trauma due to fracture of temporal or parietal bones leading to rupture of the middle meningeal artery
    1. RF: bleeding tendency: haemophilia, anticoag therapy
  3. UK incidence: 20/10,000; 10% severe head injuries; seen in young adults
  4. Head injury with temporary loss of consciousness, followed by lucid interval and progressiv deterioration in conscious level
  5. Scalp tx of fracture; headache, deteriorating GCS, sx of raised ICP (dilated, unresponsive pupil on side of injury); cushing’s reflex = HTN, bradycardia, irreg breathing
  6. Urgent CT scan: check for haematoma, look for features of raised ICP - midline shift
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7
Q

Multi-organ dysfunction syndrome

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx and Sx
  5. Investigations
A
  1. Clinical syndrome characterised by the development of progressive and potentially reversible physiological dysfunction of 2 or more organs or organ systems, that’s induced by a variety of insults, including sepsis
  2. From: infection, injury, hypoperfusion, hypermetabolism; 1ry cause can trigger a systemic inflammatory response (sepsis or SIRS); MODS is the final stage in a continuum beginning with SIRS + infection -> sepsis -> severe sepsis -> MODS
  3. Not very common
  4. MOD score: stage 1 = increased vol requirements, mild resp alk, oliguria, hyperglycaemia, increased insulin requirements
    1. 2: tachypnoea, hypocapnia, hypoxaemia, moderate liver dysfunction and haematologic abnormalities
    2. 3: shock, azotaemia (high N in blood), acid-base disturbance, significant coag abnormalities
    3. 4: vasopressor dependent, oliguria/anuria, development of ischaemic colitis and lactic acidosis
  5. Monitor vital sx, ABG necessary to look at hypoxaemia, lactic acidosis
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8
Q

Opiate overdose

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Taking more opiates than you should
  2. Opiates have widespread effects across the body and side-effects can range from constipation to resp depression and death
    1. Drugs: codeine, diamorphine, dihydrocodeine, fentanyl, loperamide, methadone, morphine
    2. RF: mental health conditions, alcoholics, morphine toxicity at lower dose due to hepatic/renal impairment, hypotension, hypothyroidism, asthma (decreased resp reserve)
  3. Elderly more at risk because more likely to be on opiates, heroin and morphine responsible for most drug related deaths
  4. Constipation, N/V, loss of appetite, sedation, craving next dose, drowsiness if acute OD
  5. Resp depression, hypotension and tachycardia, pinpoint pupils
  6. Toxicology screen, paracetamol blood level, small test dose of naloxone if in doubt, ABG, FBC
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9
Q

Paracetamol OD

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Excessive ingestion of paracetamol causing toxicity
  2. MAX recommended dose: 1g, or 2g in 24hrs; intake >12g causes hepatic necrosis
    1. RF: chronic alcohol abusers, pts on enzyme inducing drugs, malnourished, anorexia nervosa, HIV, paracetamol OD commonly associated with large amounts of alcohol
  3. Most common intentional drug OD in the UK, causes 100 deaths/yr in UK
  4. Ascertain timing and quantity of OD and RF
    1. 0-24hrs: asyx, mild N/V, lethargy, malaise
    2. 24-72hrs: RUQ pain, vomiting
    3. 72+hrs: increased confusion, jaundice
  5. 0-24 no sx; 24-72: liver enlargement and tenderness; 72+: jaundice, coagulopathy, hypoglycaemia, renal angle tenderness
  6. Measure paracetamol levels - peak after 4hrs of ingestion
    1. FBC, U+Es, glucose, LFTs, clotting screen, lactate, ABG
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10
Q

Benign Breast Disease

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
  7. Management
  8. Complications
  9. Prognosis
A
  1. Breast tissue changes ranging from normal to abnormal in development, cyclical chnge or involution phases including:
    1. Fibrocystic change
    2. Breast cysts
    3. Fibroadenomas:from hypertrophy of breast lobule
    4. Sclerosing adenosis: aberration of normal involution
    5. Intraductal papillomas: small benign tumour that forms in milk duct
    6. Duct ectasia: when central ducts become dilated with ductal secretions, which may leak into periductal tissues and cause an inflammatory reaction (periductal mastitis)
    7. Periductal mastitis
    8. Fat necrosis
  2. Related to changes in hormone levels; fat encrosis occurs 2ry to trauma; RF: less common in pts on COCP, smoking is RF for periductal mastitis
  3. Very common, diffuse fibrocystic changes very common (60% of women), fibroadenomas are more common in 15-35yrs
  4. Hx of breast discomfort or pain, swelling or lump, nipple discharge (if bloody then malignancy), assess risk factors for breast cancer ask pt about: FHx, exposure to oestrogen (age of menarche, menopause, number of kids, breastfeeding, use of OCP/HRT)
  5. Focal or diffuse nodularity of breast;
    1. fibroadenoma: smooth, well circumscribed and mobile lumbs (known as breast mouse)
    2. Duct ectasia: condition in which central ducts become dilated with ductal secretion due to a blockage of the lactiferous ducts - causes yellow/green discharge
    3. Features of malignancy will be absent in benign breast disease: dimpling, peau d’orange, enlarged axillary LN
  6. Triple assessment: clinical examination
    1. Imaging: mammography (2-view), US in younger pts
    2. Cytology/histology: fine needle aspiration - sent for cytological analysis; excision biopsy - sent for hitological analysis
  7. Conservative: symptomatic tx (analgesia for mastalgia), fibroadenoma may be treated conservatively
    1. Surgery: removal or excision biopsy of a breast lump, wide local incision if any suspicion of the lump not being benign;
      1. microdochectomy (surgical removal of a lactiferous duct - for Intraductal papilloma)
      2. Hadfield’s procedure (surgical removal of all lactiferous ducts under the nipple - used for duct ectasia
  8. Pain; recurrence
  9. Good; recurrence is common
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11
Q

Breast abscess

  1. Definition
  2. Atiology/RF
  3. Epidemiology
  4. Presenting syx
  5. Presenting sx
  6. Investigation
  7. Management
  8. Complications
  9. Prognosis
A
  1. Abscess formation in breast tissues; lactational VS non-lactational
  2. Infection - based on where abscess is:
    1. Lactational: Staph aureus
    2. Non-lactational: Staph aureus and anaerobes
    3. RF: lactation, smoking, mammary duct ectasia, periductal mastitis, wound infections
  3. Lactational breast abscess are common and tend to occur soon after starting breast feeding or weaning; non-lactational breast abscess are more common in 30-60yr smoking
  4. Breast discomfort, painful swelling, generally unwell and feverish; non-lactational - tend to present with a hx of previous infections with less pronounced systemic upset
  5. Local: swollen, warm and tender area of the breast, overlying skin may be inflamed, nipple may be cracked
    1. Non-lactational: scars/tissue distortion from previous episodes; sx of duct ectasia (nipple retraction)
    2. Systemic: pyrexia, tachycardia
  6. USS, MC+S of pus samples
  7. Medical: ABx - lactational: fluclxacillin; non-lactational: flucloxacillin + metronidazole
    1. Surgical: lactational: incision and drainage; non-lactational: open drainage should be avoide, involved duct system should be excised once the infection has settled
  8. Mammary fistula; overlying skin may undergo necrosis
  9. Untx - breast abscess may discharge onto the skin surface; non-lactational breast abscesses tend to recur
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12
Q

Basal Cell Carcinoma

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx
  5. Presenting sx
  6. Investigation
A
  1. Commonest form of skin malignancy - rodent ulcer
  2. Main RF: prolonged sun exposure or UV radiation; seen in Gorlin’s syndrome; other RF: photosensistising pitch, tar arsenic
  3. Common in those with fair skin; common in areas of high sunlight exposure, common in elderly, rare before the age of 40yrs; lifetime risk in caucasians 1 in 3
  4. Chronic slowly progressive skin lesion -> found on face, scalp, ears, trunk
  5. Nodulo-ulcerative (most common) - small glistening translcent skin over coloured papule; slowly enlarges; central ulcer with raised pearly edges; fine telangiectasia over the tumour surface; cystic change in larger lesions
    1. Morphoeic: Expanding yellow/white waxy plaque with an ill-defined edge, more aggressive than nodulo-ulcerative
    2. Superficial: most often on trunk, multiple pink/brown scaly plaques with a fine edge expanding slowly
    3. Pigmented: specks of brown or black pigment may be present in any BCC
  6. Biopsy rarely necessary; dx is mainly clincal suspicion
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13
Q

Contact dermatitis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx and sx
  5. Investigation
A
  1. An inflammatory skin reaction in response to an external stimulus, acting either as an allergen or an irritant
  2. 2 main types coexist:
    1. Allergic: delayed type IV hypersensitivityreaction, which occurs after sensitisation and subsequent re-exposure to the allergen
    2. Irritant: an inflammatory response that occurs after damage to the skin, usually by chemicals
    3. Common allergens: cosmetics, metals, topical medications, textiles
    4. Common irritants: detergents and soaps, solvents, powders
  3. 4-7% all dermatology consultations; hands are most commonly affected
  4. Hands are most frequently affected;
    1. contact dermatitis from clothing can occur in the axillae, groins and feet;
    2. redness of skin;
    3. vesicles and papules in affected area;
    4. crusting and scaling of skin;
    5. itching of affected area;
    6. fissues;
    7. hyperpigmentation;
    8. pain or burning sensation;
    9. make sure you do a thorough occupational hx
  5. No investigations necessary most of the time; some may need patch testing
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14
Q

Eczema

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx
  5. Presenting sx
  6. Investigation
A
  1. Pruritic papulovesicular skin reaction to endogenous and exogenous agents
  2. Lots of types because there are many different triggers
    1. Exogenous: irritants (nappy rash), contact (delayed type 4 hypersensitivity reactions) atopic
    2. Endogenous: atopic, seborrhoeic, pompholyx (type of eczema that affects the hands and feet), varicose, lichen simplex
    3. varicose - due to increased venous pressure in lower limbs
  3. Contact - prevalence 4%; atopic: onset in 1st yr of life, childhood incidence 10-20%
  4. Itchin, heat, tenderness, redness, weeping, crusting; asking about occupational exposure to irritants; FHx of atopy
  5. Acute: poorly demarcated erythematous oedematous dry scaling patches, papules, vesicles, with exudation and crusting, excoriation marks
    1. Chronic: thickened epidermis, skin lichenification, fissues, change in pigmentation
    2. Based on type of eczema:
      1. Atopic: mainly affects face and flexures
      2. Seborrhoeic: yellow greasy scaales on erythematous plaques - found on eyebrows, scalp, presternal area
      3. Pompholyx: vesiculobullous eruption on palm and soles
      4. Varicose: associated with marked varicose veins
      5. Nummular: coin shaped, on legs and trunk
      6. Asteatotic: dry, crazy pairing pattern
  6. Contact eczema: skin patch testing - disc containing allergens is diluted and applied on skin for 48hrs - if red raised lesion = positive
    1. Atopic eczema: lab testing - IgE levels
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15
Q

Erythema Multiforme

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx
  5. Presenting sx
  6. Investigation
A
  1. Acute hypersensitivity reaction of skin and mucous membranes; stevens-Johnson syndrome is a severe form with bullous lesions and necrotic ulcers
  2. Degeneration of basal epidermal cells; development of vesicles between cells in the basement membrane; lymphocytic infiltrate around the blood vessels and at dermo-epidermal junction; precipitating factor is only identified 50% of the time
    1. Precipitating factors: drugs (sulphonamides, penicillin, phenytoin), infection (HSV, EBV, adenovirus, chlamydia, histoplasmosis), inflammatory (RhA, SLE, sarcoidosis, UC), malignancy (lymphomas, leukaemia, myeloma), radiotherapy
  3. Any age group, mainly in children and young adults; twice as common in males
  4. Non-specific prodromal syx of URTI, sudden appearance of itching/burning/painful skin lesions; may fade leaving pigmentation
  5. Classic target lesions with a rim of erythema surrounding a paler area; vesicles/bullae; urticarial plaques; lesions often symmetricall and distributed over arms and legs including palms, soles and extensor surfaces
    1. Stevens-Johnson syndrome: affectig > 2 mucous membranes (lips, conjuctiva, cornea, mouth genitalia); systemic syx (sore throat, cough, fever, headache, myalgia, arthralgia, D/V); shock (hypotension and tachycardia)
  6. Usually unnecessary - erythema multiforme - clinical dx; Bloods: high WC, eosinophils, ESR/CRP
    1. Imaging: exclude sarcoidosis and atypical pneumonia
    2. Skin biopsy: histology and direct immunoflourescence if in doubt
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16
Q

Erythema nodosum

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx
  5. Presenting sx
  6. Investigation
A
  1. Panniculitis (itis of subcut fat tissue), presenting as red/violet subcut nodules
  2. Delayed hypersensitivity reaction to antigens associated with various infectious agents, drugs and diseases
    1. Infection: bacterial (strep), viral (EBV), fungal (histoplasmosis)
    2. Systemic disease: sarcoidosis, IBD, Behcet’s disease
    3. Malignancy: Leukaemia, Hodgkin’s disease
    4. Drugs: sulphonamides, penicillin, OCP
    5. Pregnancy
    6. 25% have no identifiable cause
  3. Usually affect yooung adults; 3x more common in females
  4. Tender red/violet nodules bilat on both shins; occasional thigh/forearms; fatigue, fever, anorexia, wt loss, arthralgia, syx of underlying cause
  5. Crops of red/violet dome-shaped nodules, usually present on both shins; occasionally on thighs/forearms; nodules tender to palpation; low grade pyrexia; joints may be tender and painful on movement; sx of underlying cause
  6. Determine cause; bloods: anti-streptolysin O titres, FBC/CRP/ESR, U+Es, serum ACE (^ in sarcoidosis)
    1. Throat swab and cultures
    2. Mantoux/head skin testing for TB
    3. CXR for bilat hilar lymphadenopathy/TB/sarcidosis/fungal infections sx
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17
Q

Lipoma

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx and sx
  5. Investigation
A
  1. Slow-growing, benign adipose tumours that are most often found in subcut tissues
  2. Benign tumours of adipocytes,
    1. conditions associated with lipomas: familial multiple lipomatosis, Gardner’s syndrome, Dercum’s disease, Madelung’s disease
    2. Liposarcoma - rare malignant tumour of adipose tissue
  3. Seen at any age but more common between 40-60, relatively common
  4. Most asyx, compression of nerve causes pain, soft/firm nodule, smooth normal surface, skin coloured, most <5cm in diameter, mobile, soft/doughy feel
  5. Clinical dx, US/MRI/CT used if doubt about dx
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18
Q

Melanoma

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx
  5. Presenting sx
  6. Investigation
A
  1. Malignancy arising from neoplastic transformation of melanocytes, pigment forming cells - leading cause of death from skin disease
  2. DNA damage by UV radiation leads to neoplastic transformation - 50% arise in exisiting naevi, 50% in previously normal skin
    1. 4 histopath types:
      1. Superficial spreading 70%: arises in pre-exisiting naevus, expands in radial fashion before vertical growth phase
      2. nodular (15%): arises de novo, aggressive, No radial growth phase
      3. Lentigo maligna (10%): more common in elderly with sun damage, large flat lesions, progresses slowly and usually on face
      4. Acral lentiginous (5%): arises on palms, soles and subungual areas; most common in NON white popn
  3. Steadily increasing incidence; white races have 20x increaed risk c.f. non white
  4. Change in size, shape, colour of pigmented skin lesion; redness, blleding, crusting, ulceration
  5. ABCDE (benign vs malignant):
    1. Asymmetry: symmetrical/asymmetrical
    2. Border irregularity: Even/uneven
    3. Colour variation: One colour/2 or more
    4. Diameter: <6mm/>6mm
    5. Elevation/Evolution: Ordinary mole/chnaging in size/shape/colour or other trait
  6. Excisional biopsy: histological dx and determination of Clark’s levels and breslow’s thickness
    1. Lymphoscintigraphy - radioactive compound is injected into the lesion and images are taken over 30 min to trace the lymphatic drainage and ID sentinel nodes
    2. Sentinel Lymph node biopsy - for metastatic involvement
    3. Staging using USS, CT/MRI, CXR
    4. Bloods: LFTs (liver common site of mets)
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19
Q

Molluscum contagiosum

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx
  5. Presenting sx
  6. Investigation
A
  1. Common skin infection caused by pox virusthat affects children and adults; transmission usually by direct skin contact
  2. Viral skin infection caused by molluscum contagiosum virus; type of pox virus
    1. RF: mainly in children, immunocompromised and atopic eczema
  3. Common, 90% of pt are <15yrs; lot of people will not seek medical attention for it
  4. Incubation period: 2-8wks; usually asyx; may be tenderness, pruritus and eczema around lesion which last for around 8m
  5. Firm, smooth, umbilicated papules - 2-5mm in diameter; children tends to occur in trunk and extremities; adults tend to occur on lower abdo, genital area and inner thighs, suggesting sexual contact
  6. Clinical dx, dermatoscopy useful if in doubt
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20
Q

Pressure sores

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx and sx
  5. Investigation
A
  1. Damage to the skin, usually over bony prominence as a result of pressure
  2. Constant pressure limits blood flow to the skin, leading to tissue damage; occurs as a result of pressure, friction and shear
    1. RF: immobility, alzheimer’s disease, diabetes
  3. very common in hospitals; more commonly in elderly
  4. Most commonly in sacrum and heel; pressure sores staged from 1-4; very tender, may be infected leading to fevers, erythema and foul smell
  5. No investigations necessary; clinical dx, waterlow score is used to predict risk of pressure sores in pts
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21
Q

Psoriasis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx
  5. Presenting sx
  6. Investigation
A
  1. Chronic inflammatory skin disease which has characteristic lesions and may be complicated by arthritis
  2. Unknown; genetic, env factors and drugs are implicated
    1. RF: guttate psoriasis (streptococcal sore throat), palmoplantar (smoking, middle aged women, AI thyroid disease), generalised pustular (hypoparathyroidism)
  3. Affects 1-2% of popn; peak age of onset: 20yrs
  4. Itching and occasionally tender skin; pinpoint bleeding with removing scales (auspitz phenomenon); skin lesions may develop at sites of trauma/scars (koebner phenomenon)
  5. Discoid/nummular: symmetrical, well demarcated erythematous plaques with silvery scales over EXTENSOR surfaces (knee, elbows, scalp, sacrum)
    1. Flexural psoriasis: less scaly plaques in axilla, groins, perianal and genital skin
    2. Guttate psoriasis: small drop-like lesions over trunk and limbs
    3. Palmoplantar psoriasis: erythematous plaques and soles
    4. Generalised pustular psoriasis: pustules distributed over limbs and torso
    5. Nail signs: pitting, oncholysis, subungual hyperkeratosis
    6. Joint sx: 5 presentations of psoriatic arthritis: asymmetrical oligoarthritis, symmetrical polyarthritis, DIP joint predominance, arthritis mutilans, psoriatic spondylitis
  6. Most pts don’t need investigations; guttate - anti-streptolysin-O titre, throat swab
    1. Flexural psoriasis: skin swabs to exclude candidiasis
    2. Nail clipping analysis for onychomycosis (fungal infection)
    3. Joint involvement and analysed by checking for RhF and radiographs
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22
Q

Sebaceous cysts

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
  7. Management
  8. Complications
  9. Prognosis
A
  1. Epithelium lined, keratinous, debris-filled cyst arising from blocked hair follicle - a.k.a. epidermal cyst
  2. Occlusion of pilosebaceous gland; caused by traumatic insertion of epidermal elements into the dermis; embryonic remnants
    1. RF: Gardner’s syndrome = aut dominant condition characterised by presence of multiple polyps in the colon and in extra colonic sites
  3. Very common at any age
  4. Non-tender, slow growing skin swelling; often multiple; common on hair bearing regions of body (face, scalp, trunk, scrotum) -> red, hot, tender with superimposed infection/inflammation
  5. Smooth tethered lump, overlying skin punctum; may discharge granular creamy material that smells bad
  6. None needed; skin biopsy/FNA for other differentials
  7. Conservative - leave alone if no distress caused; surgical - excision of cyst under LA; medical: abx if infection
  8. Infection, abscess formation, recurrence, may ulcerate
  9. Excellent, most don’t need tx
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23
Q

Squamous cell carcinoma

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Malignancy of epidermal keratinocytes of the skin; Marjolin’s ulcer is squamous cell carcinoma arising from chronically inflamed skin
  2. Main RF = UV - sun exposure leads to actinic keratosis; other RF: radiation, carcinogens, chronic skin disease, HPV, long-term immunosuppression; defects in DNA repair (xeroderma pigmentosum)
  3. 2nd most common cutaneous malignancy; mainly in middle aged/elcerly people; light skinned at higher risk; 2-3x more common in males
  4. Skin lesion, ulcerated, recurrent bleeding, non-healing
  5. Variable appearance - ulcerated, hyperkeratotic, crusted, scaly, non-healing; often sun exposed areas
    1. Palpate for local lymphadenopathy
  6. Skin biopsy - confirm malignancy and type
    1. FNA/LN biopsy: if mets suspected
    2. Staging - CT, MRI, PET
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24
Q

Urticaria

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx and Sx
  5. Investigation
A
  1. Itchy, red, blotchy rash resulting from swelling of superficial parts of the skin; angiooedema occurs when the deeps tissues/lower dermis and subcut tisues are involved and become swollen - HIVES
  2. Caused by activation of mast cells in skin - releasing histamines -> cap leakage -> swelling of skin and vasodilation = erythematous appearance
    1. Triggers:
      1. Acute: Allergies, viral infections, skin contact with chemicals and physical stimuli
      2. Chornic: chronic spontaneous urticaria (meds, stress, infections), autoimmune
  3. 15% of popn experience it at some point of life; acute more common than chronic
  4. Central, itchy white papule or plaque surrounded by erythematous flare; lesions vary in size and shape; associated with swelling of soft tissue of eyelids/lips/tongue (angioedema) - individual lesions usually transient
    1. Time scale: acute= syx develop quickly but normally resolve within 48hrs; chronic = rash persists for >6wks
  5. Usually clinical - tests may be required for chronic urticaria - FBC, ESR/CRP, patch testing, IgE test
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25
Q

Benign Paroxysmal Postional Vertigo

  1. Definition
  2. Aetiology/RF
  3. Presenting Syx
  4. Presenting Sx
  5. Investigations
A
  1. Vertigo lasting seconds to minutes on changing head position - lying down or turning the head suddenly
  2. Displacement of otoliths (from degen, trauma or post-viral) into semi circular canals
  3. Dizziness, Vertigo, loss of balance/unsteadiness, N/V
  4. No sx
  5. Hallpike tests
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26
Q

Meniere’s disease

  1. Definition
  2. Aetiology/RF
  3. Presenting Syx and Sx
  4. Investigations
A
  1. Recurrent episodes of tinnitus, paroxysmal vertigo and unilateral fluctuating hearing loss
  2. Disturbed homeostasis of endolymph (fluid in inner ear)
  3. Vertigo, loss of hearing in affected ear, tinnitus, loss of balance, headaches, N/V
  4. No specific test that confirms dx; some other investigations - MRI used to exclude other causes
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27
Q

Thyroglossal cyst

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Epithelium lined cyst found along course of descent of thyroid gland
  2. Thyroid duct is embryonic remnant of path of descent of thyroid gland from mouth; duct normally disappears in 6th week, but if some tissue remains, it could develop into cyst
    1. RF: rare familial variants
  3. Children and adolescents; mean age of presentation = 5yrs; 3x more common than branchial cysts
  4. Swelling/lump noticed in midline of the ant neck; usually asyx; tenderness/rapid enlargement due to infection
  5. Midline, smooth, rounded swelling; typically found between thyroid notch and hyoid bone; moves upwards with swallowing - transilluminated; DDx - LN, dermoid cyst, ectopic erythroid tissue
  6. None necessary if euthyroid; if cyst suprahyoid - TFTs performed to exclude lingual thyroid, as otherwise pts becomes hypothyroid
    1. US/MRI helps differentiate from other structures
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28
Q

Tonsillitis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Inflammation due to infection of tonsils
  2. Usually viral (common cold or influenza); bacterial - group A strep)
    1. RF: immune deficiency, FHx of tonsillitis or atopy
  3. Very common; usually in children and young adults
  4. Pain in throat, painful swallowing, may have referral to ears, abdo pain (small children), headache, loss/change voice
  5. Red throat, swollen tonsils (white flecks of pus), high temp (sometimes), swollen LN,
    1. classic strep tonsilitis = acute onset, headache, abdo pain, dysphagia
    2. Exam: intense erythema of tonsils and pharynx; yellow exudate; tender enlarged anterior cervical glands
  6. Throat swabs and rapid antigen tests can be performed but NOT recommended; swabs may not be able to distinguish between infection and colonisation
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29
Q

Abscess

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx and Sx
  5. Investigations
  6. Management
  7. Complications
  8. Prognosis
A
  1. Painful collection of pus usually caused by bacterial infection
  2. Can develop anywhere in the body; 2 main types: skin and internal; bacterial infection leads to activation of immune response and recruitment of neutrophils to the site of infection; as white cells attack the bacteria, surrounding tissue is damaged creating a cavity which fills with pus to form an abscess
    1. Pus = mixture of dead tissue + white cells + bacteria
  3. Skin abscess relatively common; IV drug use = major RF for skin abscesses; internal less common
  4. Swollen, pus filled lump under surface of skin with associated fever and chills; internal not visualised by characterised by: pain in affected area/referred pain, swinging fevers, malaise
  5. US in visualising
  6. Some small skin abscesses may disappear by themselves;
    1. Incision and drainage: first check whether foreign object is causing the abscess; abscess cut open and drained
    2. ABx: alongside incision and drainage
  7. Recurrence
  8. Good with tx
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30
Q

Candidiasis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx and Sx
  5. Investigation
A
  1. Infection caused by candida
  2. 15 diff species - candida albicans most common in humans
    1. Main types: oral/oesophageal candidiasis, Candidal vulvovaginitis/skin infections and invasive candidal infections
    2. RF: broad spectrum ABx, immunocomprise (HIV, corticosteroids), central venous lines, cushing’s disease, DM, GIT surgery
  3. 60% of the healthy adult popn are carriers; >80% of HIV pts occurs; candida is one of the most common causes of invasive fungal infections in the western world
  4. Oral candidiasis: oral thrush (pseudomembranous oral candidiasis) - curd like white patches in mouth, removed easily revealing red base - common in neonates; main features: redness of tongue and mouth, white plaques
    1. Oesophageal: dysphagia, pain on swallowing food/fluids, AIDS defining illness
    2. Candidal skin infections: soreness and itching, skin appearance can be variable, red/moist skin area with ragged/peeling edge and possibly papules and pustules
  5. Oral candidiasis - swabs and cultures not particularly useful as in many people’s mouths
    1. Swabs relevant for drug resistance check; therapeutic trials of anti-fungal can help with dx
    2. Oesophageal candidiasis definitive dx by endoscopy
    3. Invasive candidiasis: blood cultures required if candidaemia is possible
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31
Q

Cellulitis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
  7. Management
  8. Complications
  9. Prognosis
A
  1. Acute non-purulent spreading infection of subcut tissue causing overlying skin inflammation
  2. Often results from penetrating injury, local lesions, fissuring
    1. Most common organisms: strep pyogenes, staph aureus -> beware of MRSA
    2. Cellulitis of the orbit usually caused by H. influenzae
    3. RF: skin break, poor hygeine, poor vascularisation of tissue (due to DM)
  3. Very common
  4. Hx of cut, scratch or injury;
    1. periorbital cellulitis: painful swollen red skin around the eye;
    2. orbital cellulitis: painful or limited eye movements, visual impairment
  5. Lesion: erythema, oedema, warm tender indistinct margins, pyrexia (suggest systemic spread), exclude abscess and aspirate pus if suspected
    1. Periorbital: swollen eye lids, conjunctival infection
    2. Orbital cellulitis: proptosis, impaired visual acuity and eye movements; test RAPD, visual acuity and colour vision
  6. Bloods: WCC, blood culture
    1. Discharge: sample and send for MC&S
    2. Aspiration - if pus suspected
    3. CT/MRI - orbital cellulitis is suspected (helps assess posterior spread of infection
  7. Medical: oral penicillins or tetracyclines effective; if hospital acquired -> treat empirically based on local guidelines and change depending on the sensitivity of cultured organisms
    1. Surgical: orbital decompression may be needed in orbital cellulitis (emergency)
    2. Abscess: aspirate, incision and drainage, excised completely
  8. Sloughing of overlying skin; orbital cellulitis - cause perm loss of vision, spread to the brain, abscess formation, meningitis, cavernous sinus thrombosis
  9. Good prognosis
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32
Q

Herpes simplex

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Disease resulting from HSV1 or HSV2 infection
  2. Transmitted via close contact (kissing/sexual intercourse), with an individual that is shedding the virus
    1. Pathophysiology: after 1ry infection, virus becomes dormant (within nerve ganglia), reactivation occur in response to physical and emotional stresses or immunosuppresion; virus causes cytolysis of infected epithelial cells leading to vesicle formation
  3. 90% of adults are seropositive for HSV1 by 30yr; 35% of adlts >60 yrs are HSV2 seropositive; more than 1/3 of the world popn have recurrent HSV infection
  4. HSV1- 1ry infection often asyx; possiible syx = pharyngitis, gingivostomatitis (eating may be painful), herpetic whitlow (abscess at end of finger caused by infection with HSV
    1. reactivation of HSV1: prodrome of perioral tingling and burning, vesicles appear - they will ulcerate and crust over, complete healing within 8-10d
    2. syx of HSV2: painful blisters and rash in the genital, perigenital and anal area; dysuria, fever and malaise
    3. syx of HSV encephalitis: usually caused by HSV1 so causes HSV1 type syx
    4. Syx of HSV keratoconjunctivitis: watering eyes, photophobia
  5. HSV1 primary infection: tender cervical lymphadenopathy, erythematous/oedematous pharynx, oral ulcers filled with yellow slough (gingivostomatitis), herpetic whitlow
    1. Herpes labialis (reactivation affecting the mouth) perioral vesicles/ulcers/crusting
    2. HSV2: maculopapular rash, vesicles, ulcers, all of these are found on the external genitalia, anal margin, upper thighs; others: inguinal lymphadenopathy, pyrexia
    3. HSV2 encephalitis: sx of encephalitis
    4. HSV keratoconjunctivitis: dendritic ulcer on the iris
  6. Dx usually clinical, vesicle fluid can be sampled and sent for electron microscopy, PCR
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33
Q

HIV

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx and Sx
  5. Investigations
A
  1. Infection with human immunovirus
  2. Transmitted by: sexual intercourse (heterosexual most common mode of transmission, homosexuals at greater risk in the west); blood/other body fluids: mother to child (intrauterine, childbirth, breastfeeding), needles, blood transfusions, organ transplantation
    1. Path:HIV enters CD4+ lymphocytes by binding to their g120 receptors; reverse transcriptase allows the incorporation of HIV genetic material into the host genoma; leads to dissemination of HIV, cell death and eventual T-cell depletion
  3. Increasing incidence in africa and asia
  4. 3 phases of HIV:
    1. seroconversion: self limiting, fever, night sweats, generalised lymphadenopathy, sore throat, others: oral ulcers, rash, myalgia, headache, encephalitis, diarrhoea
    2. Early/asyx: apparently well, some may have persistent lymphadenopathy, progressive minor syx (rash, oral thrush, wt loss)
    3. AIDS: syndrome of 2ry diseases resulting from immunodeficiency
    4. Direct effects of HV infection:
      1. Neuro - polyneuropathy, dementia
      2. Lung: lymphocytic interstitial pneumonitis
      3. Heart: cardiomyopathy, myocarditis
      4. Haem: anaemia, thrombocytopaenia
      5. GI: anorexia, wasting
      6. Eyes: cotton wool spots
    5. 2ry effects from immunodeficiency:
      1. Bacterial infection: TB, pneumococcal infections, skin infections
      2. Viral: CMV, HSV, VZV, HPV, EBV
      3. Fungal: pneumocystic jirovecii pneumonia, cryptococcus, candidiasis, invasive aspergillosis
      4. Protozoal: toxoplasmosis, cryptosporidia
      5. Tumours: Kaposi sarcoma, SCC, NHL, hodgkin’s lymphoma
  5. HIV testing: HIV ab, PCR for viral RNA, CD4 count, viral load
    1. Others: pneumocystic pneumonia (CXR), cryptococcal meningitis (brain CT/MRI or LP), CMV colitis (colonoscopy and biopsy), toxoplasmosis (brain CT or MRI), cryptosporidia (stool microscopy)
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34
Q

Infectious mononucleosis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
  7. Management
  8. Complications
  9. Prognosis
A
  1. Clinical syndrome caused by primary EBV infection - glandular fever
  2. EBV is a gamma-herpes virus (dsDNA), found in pharyngeal secreions of infected individuals and is transmitted by close contact - kissing
    1. EBV infection of epithelial cells of oropharynx leads to b cell infection which then disseminate EBV across the body -> humoral and cellular immune response
    2. Atypical lymphocytes in peripheral blood are a classic feature of infectious mono
    3. EBV remains latent in lymphocytes - reactivation following stress/immunosuppression may occur
  3. Common; 2 peaks: 1-6yrs and 14-20yrs
  4. Incubation is 4-8wks; abrupt onset of syx: sore throat, fever, fatigue, headache, malaise, anorexia, sweating and abdo pain
  5. Pyrexia; oedema and erythema of the pharynx; white/creamy exudate on the tonsils; palatal petechiae; cervical/generalised lymphadenopathy; spleno/hepatomegaly, jaundice (5-10%); widespread maculopapular rash in pts who received ampicillin
  6. Bloods: FBC leucocytosis, LFTs: high ALT/AST
    1. Blood fild: lymphocytosis with atypical lymphocytes
    2. Heterophil Ab test (monospot test/aul bunnell test) - based on EBV ag being similar to Ag on RBC of animals but NOT humans; mixing blood of EBV+ human with animal blood, makes animal RBC aggregate and precipitate out of solution -> may give false negatives in early stages of infection before Ab generated
    3. Throat swab: exclude strep tonsilitis
    4. IgM/IgG to EBV viral capsid Ag
    5. IgG against EB nuclear Ag
  7. Bed rest; paracetamol and NSAIDs for fever and malaise
    1. Corticosteroids in severe cases
    2. DONT give amoxicillin/ampicillin if suspected as develop maculopapular rash
    3. Advice: avoid contact sports for 2wks (rupture spleen)
  8. Lethargy for several months
    1. Resp: airway obstruction from oedematous pharynx, 2ry bacterial throat infection, pneumonitis
    2. Haem: haemolytic/aplastic anaemia, thrombocytopaenia
    3. GI/Renal: splenic rupture, fulminant hepatitis, pancreatitis, mesenteric adenitis, renal failure
    4. CNS: Guillain-Barre, encephlitis, viral meningitis
    5. EBV associated malignancy: Burkitt’s lymphoma, nasopharyngeal cancer, hodgkin’s lymphoma
  9. Most make uncomplicated recovery in 3wks; immunodef and death is VERY RARE
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35
Q

Malaria

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. infection with protozoan plasmodium; 5 types:
    1. Plasmodium falciparum (most serious)
    2. P. vivax
    3. P. ovale
    4. P. malariae
    5. P. knowlesi
  2. Transmitted by bite of female anopheles mosqiuito and rotozoa grow in RBC
    1. Life cycle: injection of sporozoites into blood stream by mosquito, invasion and replication in hepatocytes; parasites reinvade blood and enter RBC, replicate and develop ring forms; RBc rupture and release merozoites which reinfect other RBC; Gametocytes taken up when another mosquito feeds, develop into sporozoites in gut of mosquito; then move into salivary gland of mosquito to be transmitted
    2. Innate immunity: sickle cell trait, G6PD deficiency, pyruvate kinase def, thalassaemia
  3. Endemic in tropic, 250 million people worldwide
  4. Feverish traveller with incubation up to 1yr;
    1. cyclical syx: high fever, flu-like syx, severe sweating, shivering cold/rigors
    2. Cerebral syx: headache, disorientation, coma
  5. Pyrexia, anaemia (haemolytic), hepatosplenomegaly
  6. Thin/thick blood films: thick for quantifying and thin for ID type of malaria
    1. Bloods:FBC (haemolytic), U+E. LFTs, ABG
    2. Urinalysis to check for blood/protein
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36
Q

Varicella Zoster

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigation
  7. Management
  8. Complications
  9. Prognosis
A
  1. 1ry infection is called varicella (chicken pox); reactivation of dormant virus causes zoster (shingles) -> varicella zoster also known as herpes zoster
  2. VZV is herpes ds-DNA; highly contagious; transission by aerosol inhalation or direct contact with vesicular secretions
  3. Chicken pox peak incidence is 4-10yrs; shingles peak: >50yrs; 90% of adults are VZV IgG+ve
  4. Chicken pox: prodromal malaise, mild pyrexia, sudden appearance of intensely itchy spreading rash mainly affecting face and trunk; vesicles weep and crust over; new vesicles have all crusted over (7-10d)
    1. Shingles: may occur after a period of stress; tingling/hyperaesthesia in dermatomal distriution (virus remains dormant in dorsal root ganglia and reactivation makes virus travel down sensory axon); painful skin lesions; recovery 10-14d
  5. Chickenpox: maculopapular rash, areas of weeping and crusting, skin excoriation (scratching), mild pyrexia
    1. Shingles: vesicular maculopapular rash, dermatomal distribution, skin excoriation
  6. Usually clinical dx; vesicle fluid may be sent for electron microscopy viral PCR (RARE); chicken pox in adult with PMH of varicella infection = HIV test
  7. Chickenpox: children - tx syx; adult: consider acyclovir
    1. Shingles: aciclovir, valaciclovir, famciclovir
    2. Prevention: VZIg - in immunosuppressed/pregnant
  8. Chickenpox: 2ry infection, scarring, pneumonia, encephalitis, congenital varicella syndrome
    1. Shingles: postherpetic neuralgia, zosterophthalmicus (rash in ophthalmic division of V nerve), ramsay-hunt syndrome, sacral zoster, motor zoster
  9. Depends on complications; worse in pregnancy, ederly and immunosuppressed
  10. Ramsay Hunt Syndrome: reactivation of VZV in geniculate ganglion causing zoster of the ear and facial nerve palsy - vesicles may be seen behind pinna of ear or in ear canal
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37
Q

Alcohol dependence

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Characterised by 3+ of:
    1. Withdrawal on cessation of alcohol
    2. Tolerance
    3. Compulsion to drink, difficulty controlling termination or levels of use
    4. Persistent desire to cut down/control use
    5. Time spent obtaining/using/recovering from alcohol
    6. Neglect of other interests
    7. Continued use despite physical and psych problems
    8. Recommended weekly amount <14u/week
  2. Genetic/env factors; pts with depressive/anxiety states are at increased risk
    1. Withdrawal path: alcohol enhances GABA activity, inhibiting glutamate neurotransmission
      1. Chronic alcohol exposure leads to compensatory reduction in GABA receptor function and upreg of glutamate receptors
      2. Abrupt alcohol cessation leads to overactivation of those glutamate receptors
  3. US prevalence 2-9%
  4. Hx of heavy drinking;
    1. CAGE: felt you should cut down on drinking; annoyed by people telling you to stop drinking?; guilty about how much you drink; do you feel like you need a drink to wake up? (eye opener)
    2. other comorbidities/RF - smoking/depression
    3. Features of acute intox: amnesia, ataxia, dysarthria, disorientation, palpitations, flushing, coma
    4. Syx of withdrawal: Nausea, sweating, tremor, restlessness, agitation, visual hallucinations, confusion, seizures
  5. Sx of chronic misuse: ddupuytren’s contracture, palmar erythema, bruising, spider naevi, telangiectasia, facial mooning, bilat parotid enlargement, gynaecomastia, smell of alcohol
    1. Sx of complications: alcoholic hepatitis, liver failure
  6. Bloods: macrocytic anaemia, high GGT, AST/ALT, others: high uric acid, triglycerides, markers of organ damage
    1. Acute overdose: blood alcohol, glucose, ABG, U+Es, tox screen - drug OD
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38
Q

Anxiety disorder

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx and Sx
  5. Investigations
A
  1. Group of mental disorders characterised by feelings of anxiety or fear
  2. Syndrome of ongoing anxiety and worry about many events or thoughts that the pt generally recognises as excessive and inappropriate; RF: 35-54, divorced/separated, living alone/single parent
  3. Lifetime prevalence of about 5%; more common in women
  4. Dx criteria: excessive anxiety/worry occurring more days than not for 6m, pt finds it difficult to control worry, anxiety and worry associated with 3+ of:
    1. restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
    2. Autonomic arousal syx: palpitations, sweating, trembling, dry mouth
    3. Chest/Abdo syx: difficulty breathing, feeling of choking, chest pain/discomfort, nausea/abdo pain
    4. Syx involving mental state: dizziness/light-headedness, feeling of losing control, fear of dying
    5. General syx: hot flushes/cold chills, numbness/tingling sensation, mmuscle tensions/aches and pains, restlessness, globus
  5. Clinical dx
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39
Q

Depressive disorders

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting syx and sx
  5. Investigations
A
  1. Mood disorder that causes persistent feeling of sadness and loss of interest
  2. NICE recommends use of DSM-IV classification to dx depression;
    1. major dep requires
      1. at least 1 of core syx: persistent sadness/low mood nearly every day, loss of interests or pleasures in most activities
      2. Along with some of: fatigue/loss of energy, worthlessness, excessive/inappropriate guilt; suicidal thoughts, diminished ability to think/conc, psychomotor agitation and retardation, insomnia, changes in appetite/wt loss
    2. Syx persist for >2wks
    3. RF: female, hx of depression, significant physical illness causing disability/pain, other mental health problems, part of refugee community
  3. 5% adults will have depressive episode every year; 1/4 women develop depression severe enough to require tx at some point in their lives
  4. Look at aetiology; somatisation (physical syx due to psych illness) is very important; elderly people may present with depressive pseudodementia
    1. Assessment tool: pt health questionnaire, hospital anxiety and depression scale and beks depression inventory
  5. Consider organic causes - hypothyroidism, hypercalcaemia, addisons disease, cushing’s disease
    1. Inv for other causes: blood glucose, U+Es, TFT, Cal, FBC, MRI/CT
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40
Q

Cataracts

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Opacification of the lens of the eye
  2. Most are idiopathic (age-related);
    1. 2ry causes:
      1. Local: previous eye trauma, uveitis
      2. Systemic: diabetes, metabolic (wilson’s disease), skin disease (scleroderma), drug (steroids)
      3. Congenital: congenital rubella syndrome
  3. Major cause of treatable blindness worldwide
  4. Gradual onset painless loss of vision; glare from bright light, vision may worsen in bright light, some may experience monocular diplopia with haloes around lights; some may begin to be able to read without glasses (sclerotic cataract may increase the lens’ converging power)
  5. Loss of red reflex, hazy lens appearance, reduced visual activity
  6. Usually unnecessary
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41
Q

Conjunctivitis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Inflammation of the conjunctiva; associated inflammation of the cornea -> keratoconjunctivitis; associated eye lid involvement -> blepharoconjunctivitis
  2. Infectious: viral, bacterial; non-infectious: allergic, mechanical/irritative/toxic, immune-mediated, neoplastic
    1. RF: contact lens use
  3. Worldwide distribution; affects any age group; no gender, ethnic or social preponderance
  4. Red eye (usually generalised and bilat); irritation, discomfort and grittiness; discharge (may be watery, mucoid, sticky or purulent depending on cause); photophobia (suggest corneal involvement); visual acuity usually unaltered
  5. Conjunctival injection; dilated conjunctival vessels, conjunctival chemosis (swell of conjunctiva), conjunctival follicles (round collections of lymphocytes appearing as small dome shaped nodules), conjunctival papillae (associated with allergic immune response)
  6. Dx usually made following hx and examination; further investigations performed by specialists
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42
Q

Glaucoma

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigation
A
  1. Optic neuropathy with typical field defect usually associated with ocular hypertension (intra-ocular pressure > 21mmHg)
  2. Primary causes: acute closed-angle, chronic closed angle, 1ry open angle
    1. 2ry: trauma, uveitis, steroids rubeosis iridis (formation of new blood vessels on the surface of the iris)
    2. Congenital: Buphthalmos - enlargement of the eye balls
    3. Pathophysiology: ocular HTN leads to compression and stretching of the retinal nerve fibres -> scotomas and visual field defects; ocular HTN due to reduced outflow of aqueous humour caused by:
      1. AOAG: Obstruction to outflow (caused by narrowing of the iridocorneal angle and hence, narrowing of the canal of schlemm leading to rapid and severe rise in IOP)
      2. POAG: Resistance to outflow through trabecular meshwork -> blockage of trabecular meshwork by blood or inflammatory cells
  3. Prevalence: 1% in over 40yrs, 10% in over 80yrs; 3rd most common cause of blindness worldwide
  4. ACAG: painful red eye, vomiting, impaired vision, haloes seen around lights
    1. POAG: usually asyx, peripheral visual field loss
    2. Congenital: buphthalmos, watering, cloudy cornea
  5. ACAG: red eye, hazy cornea, loss of red reflex, fixed/dilated pupil, eye tender and hard on palpation, cupper optic disc, visual field defect, moderated raised IOP
    1. POAG: optic disc may be cupped, usually no sx
  6. Goldmann applanation tonometry: standard method of measuring IOP, normal = 15mmHg
    1. Pachymetry: using US or optical scanning to measure central corneal thickness; CCT < 590mm = higher risk of glaucoma
    2. Fundoscopy: detects pathologically cupped optic disc
    3. Gonioscopy: assess iridocorneal angle
    4. Perimetry (visual field testing)
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43
Q

Uveitis

  1. Definition
  2. Aetiology/RF
  3. Epidemiology
  4. Presenting Syx
  5. Presenting Sx
  6. Investigations
A
  1. Inflammation of the iris and ciliary body
  2. May be caused by infection (HSV); can occur as a manifestaton of systemic inflammatory conditions (reactive arthritis, ankspond, IBD, sarcoidosis, Behcet’s disease)
    1. Sympathetic ophthalmia: inflammation of the contralateral eye wks/months after penetrating injury; due to recognition of eye Ag in contralat eye by T cells that were activated by initial penetrating injury to the opposite eye
  3. Uveitis associated with spondyloarthritis is twice as common in males as females
  4. Pain due to inflammation, during accommodation; photophobia, red eyes, blurred vision, lacrimation, rarely associated with tubulointerstitial nephritis (causing flank pain/hameaturia/proteinuria)
  5. Reduced visual acuity; ciliary flush; hypopyon (exudate and inflammatory cells in inferior angle of ant chamber); small irreg pupil due to adhesions of iris to lens
    1. Slit lamp - keratitic precipitates - leucocyte deposits on corneal endothelium
    2. Fundoscopy: exclude reinal detachment
    3. Sx of complications: increased IOP, cataract
    4. Sx of underlying aetiology
  6. Investigations for associated systemic conditions (spondyloarthritides - sacroiliac joint XR, HLA typing)
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44
Q

Definition

Acute Respiratory distress syndrome

A
  1. Syndrome of acute and persistent lung inflammation with increased vascular permeability;
  2. characterised by: acute onset, bilat infiltrates consistent with pulm oedema; hypoxaemia;
    1. no clinical evidence of increased left arterial pressure (pulm cap wedge pressure), ARDS severe end of acute lung injury
  3. Severe insults to lung and other organs leads to the release of inflammatory mediators;
  4. leads to increased cap permeability, pulm oedema, impaired gas exchange and reduced lung compliance
  5. Causes: sepsis, aspiration, pneumonia, pancreatitis, trauma/burns, transfusion, transplantation (bone marrow and lung), drug OD/reaction
  6. 3 path stages of ARDS: exudative, proliferative, fibrotic
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45
Q

S+S

ARDS

A
  1. Rapid deterioration of resp function, dyspnoea, resp distress, cough, syx of cause
  2. Cyanosis, tachypnoea, tachycardia, widespread inspiratory crepitations, hypoxia refractory to O2 tx, sx usually bilat but can be asymmetrical in early stages
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46
Q

Investigations

ARDS

A
  1. CXR: bilat alveolar infiltrates and interstitial shadowing
  2. Bloods: figure out cause, FBC, U+Es, LFT, ESR/CRP, amylase, ABG, blood culture, sputum culture, plasma BNP <100 pg/mL distinguish ARDS from HF
  3. Echo: severe dysfunction of aortic/mitral valve, low left ventricular ejection fractions = haemodynamic oedema rather than ARDS
  4. Pulm artery catheterisation: check pulm cap wedge pressure
  5. Bronchoscopy: if cause not from hx
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47
Q

Definition

Alcohol withdrawal

A
  1. Syx that may occur when a person has been drinking too much alcoohol on a regular basis and suddenly stops drinking
  2. Chronic alcohol consumption suppresses the activity of glutamate so body compensates increasing sensitivity to glutamate;
  3. so when alcohol consumption stops you get increased glutamate activity leading to excitatory syx
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48
Q

S+S

Alcohol withdrawal

A
  1. Hx of high alcohol intake;
  2. mild syx: insomnia, and fatigue, tremor, mild anxiety/feeling nervous, mild restlesness/agitation, N/V, headache, sweating, palpitations, anorexia, depression, craving alcohol
  3. More severe syx: hallucinations, withdrawal seizures (generalised tonic-clonic), delirium tremens (acute confusional state often seen as withdrawal syndrome in chronic alcoholics and caused by sudden cessation of drinking alcohol, precipitated by head injury or acute infection causing abstinence from alcohol
  4. Features of delirium tremens: anxiety, tremor, sweating, vivid and terrifying visual/sensory hallucinations, can be FATAL
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49
Q

Management

Alcohol withdrawal

A
  1. Chlordiazepoxide - reduces syx of alcohol withdrawal
  2. Barbiturates may be used if refractory to BZD
  3. Thiamine prevents progression to wernicke-korsakoff syndrome
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50
Q

Definition

Anaphylaxis

A
  1. Acute life-threatening multisystem syndrome caused by sudden release of mast cell and basophil-derived mediators into the circulation
  2. Immunogenic: IgE-mediated or immune complex/complement mediated
  3. Non-immunogenic: mast cell or basophil degranulation without the involvement of antibodies (vancomycin, codeine, ACEi)
  4. Pathophysiology: inflammatory mediators such as histamine are released leading to bronchospasm, increased cap perm and reduce vascular tone -> OEDEMA
  5. Common allergens: drugs, latex, penicillin, shellfish (anaphylaxis can be caused by the repeat admin of blood products in a patient with selective IgA deficiency - due to the formation of anti-IgA Abs)
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51
Q

S+S

Anaphylaxis

A
  1. Wheeze, shortness of breath and a sense of choking,
  2. swelling of lips and face,
  3. pruritus,
  4. rash (note = hx of other hypersensitivity reactions - asthma, allergic rhinitis)
  5. Tachypnoea, wheeze,
  6. cyanosis, swollen upper airways and eyes,
  7. rhinitis, conjunctival infection,
  8. urticarial rash, hypotension,
  9. tachycardia
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52
Q

Investigations

Anaphylaxis

A
  1. Clinical dx; serum tryptase, histamine levels or urinary metabolites of histamine may help support the clinical dx
  2. Following an attack: allergen skin testing IDs allergen;
  3. IgE immunoassays, finding food specific IgE in serum
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53
Q

Management

Anaphylaxis

A
  1. ABCDE;
  2. high flow oxygen,
  3. IM adrenaline,
  4. chlorpheniramine (antihistamine),
  5. hydrocortisone,
  6. if continued resp deterioration,
  7. may require bronchodilator therapy,
  8. monitor pulse oximetry,
  9. ECG,
  10. BP
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54
Q

Definition

Aspirin OD

A
  1. Excessive ingestion of aspirin causing toxicity
  2. Result of deliberate self harm, suicidal intent or by accident;
  3. 10-20g casue mod-severe toxicity in adults
  4. Pathophysiology of aspirin OD: increases resp rate and depth, stimulating resp centre;
  5. hyperventilation (resp alk) compensated by increasing urinary HCO3 and excretion;
  6. dehydration and hypokalaemia;
  7. loss of HCO3, uncoupling of mitochondrial oxidative phosphorylation and the build up of lactic acid can lead to met acidosis
  8. SEVERE cases: CNS depression and resp failure can occur
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55
Q

S+S

Aspirin OD

A
  1. Figure out: how much aspirin taken, when, any other drugs, any alcohol?
  2. Pts initially asyx
  3. Early syx: flushed, fever, sweating, hyperventilation, dizziness, tinnitus, deafness
  4. Later syx: lethargy, confusion, convulsions, drowsiness, resp depression, coma
  5. Fever, tachycardia, hyperventilation, epigastric tenderness
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56
Q

Investigations

Aspirin OD

A
  1. Bloods: salicylate levels, FBC,
  2. U+Es check for hypoK,
  3. LFTs high AST/ALT,
  4. clotting screen - high PT,
  5. other drug levels (paracetamol),
  6. ABG - mixed met acidosis and resp alk
  7. ECG: Sx of hypoK - flattened/inverted T waves, U waves, prolonged PR interval, ST depression
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57
Q

Definition

Burns injury

A
  1. When tissue damage occurs by thermal, electrical or chemical injury
  2. Contact with hot objects, electricity, UV light, irradiation, chemicals;
  3. high risk patients: young children, elderly
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58
Q

S+S

Burns injury

A
  1. Note the circumstances of the burn, important to find out the time, temperature and length of contact with the agent, consider risk of smoke inhalation and carbon monoxide and carbon monoxide poisoning
  2. Check inhalational injury or airway compromise: stridor, dyspnoea, hoarse voice, soot in nose, singed nose hairs, carbonaceous sputum;
  3. check site/depth/distribution of burn;
  4. Partial thickness burn, subdivided into:
    1. Superficial: red, oedematous skin and painful (heals within 7d with peeling of dead skin)
    2. Deep: blistering and mottling and PAINFUL - heals over 3wks usually without scarring
  5. Full thickness burn: destruction of the epidermis and dermis; charred leathery eschars, firm and painless with loss of sensation; healing occurs by scarring or contractures and requires skin grafting
  6. Size of burn: described as a percentage of body surface area
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59
Q

Investigations

Burns injury

A
  1. Bloods: O2 sat, ABG, carboxyHb (inhalation injury), FBC, U+E, Group and save
  2. Serum CK, urine myoglobin (check muscle damage), ECG
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60
Q

Definition

Extradural haemorrhage

A
  1. Bleeding and accumulaton of blood in extradural space
  2. Trauma due to fracture of temporal or parietal bones leading to rupture of the middle meningeal artery
  3. RF: bleeding tendency: haemophilia, anticoag therapy
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61
Q

S+S

Extradural haemorrhage

A
  1. Head injury with temporary loss of consciousness, followed by lucid interval and progressive deterioration in conscious level
  2. Scalp tx of fracture;
  3. headache, deteriorating GCS, sx of raised ICP (dilated, unresponsive pupil on side of injury);
  4. cushing’s reflex = HTN, bradycardia, irreg breathing
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62
Q

Investigations

Extradural haemorrhage

A
  1. Urgent CT scan: check for haematoma, look for features of raised ICP - midline shift
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63
Q

Definition

Multi-organ dysfunction syndrome

A
  1. Clinical syndrome characterised by the development of progressive and potentially reversible physiological dysfunction of 2 or more organs or organ systems, that’s induced by a variety of insults, including sepsis
  2. From: infection, injury, hypoperfusion, hypermetabolism;
  3. 1ry cause can trigger a systemic inflammatory response (sepsis or SIRS); MODS is the final stage in a continuum beginning with SIRS + infection -> sepsis -> severe sepsis -> MODS
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64
Q

S+s

Multi-organ dysfunction syndrome

A
  1. MOD score:
  2. stage 1 = increased vol requirements, mild resp alk, oliguria, hyperglycaemia, increased insulin requirements
  3. 2: tachypnoea, hypocapnia, hypoxaemia, moderate liver dysfunction and haematologic abnormalities
  4. 3: shock, azotaemia (high N in blood), acid-base disturbance, significant coag abnormalities
  5. 4: vasopressor dependent, oliguria/anuria, development of ischaemic colitis and lactic acidosis
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65
Q

Investigations

Multiorgan dysfunction syndrome

A
  1. Monitor vital sx, ABG necessary to look at hypoxaemia, lactic acidosis
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66
Q

Definition

Opiate OD

A
  1. Taking more opiates than you should
  2. Opiates have widespread effects across the body and side-effects can range from constipation to resp depression and death
  3. Drugs: codeine, diamorphine, dihydrocodeine, fentanyl, loperamide, methadone, morphine
  4. RF: mental health conditions, alcoholics, morphine toxicity at lower dose due to hepatic/renal impairment, hypotension, hypothyroidism, asthma (decreased resp reserve)
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67
Q

S+S

Opiate OD

A
  1. Constipation, N/V, loss of appetite, sedation, craving next dose, drowsiness if acute OD
  2. Resp depression, hypotension and tachycardia, pinpoint pupils
68
Q

Investigations

Opiates OD

A
  1. Toxicology screen,
  2. paracetamol blood level,
  3. small test dose of naloxone if in doubt,
  4. ABG, FBC
69
Q

Definition Paracetamol OD

A
  1. Excessive ingestion of paracetamol causing toxicity
  2. MAX recommended dose: 1g, or 2g in 24hrs;
  3. intake >12g causes hepatic necrosis
  4. RF: chronic alcohol abusers, pts on enzyme inducing drugs, malnourished, anorexia nervosa, HIV, paracetamol OD commonly associated with large amounts of alcohol
70
Q

S+S

Paracetamol OD

A
  1. Ascertain timing and quantity of OD and RF
  2. 0-24hrs: asyx, mild N/V, lethargy, malaise
  3. 24-72hrs: RUQ pain, vomiting
  4. 72+hrs: increased confusion, jaundice
  5. 0-24 no sx;
  6. 24-72: liver enlargement and tenderness;
  7. 72+: jaundice, coagulopathy, hypoglycaemia, renal angle tenderness
71
Q

Investigations

Paracetamol OD

A
  1. Measure paracetamol levels - peak after 4hrs of ingestion
  2. FBC, U+Es, glucose, LFTs, clotting screen, lactate, ABG
72
Q

Definition

Benign Breast Disease

A
  1. Breast tissue changes ranging from normal to abnormal in development, cyclical chnge or involution phases including:
  2. Fibrocystic change
  3. Breast cysts
  4. Fibroadenomas:from hypertrophy of breast lobule
  5. Sclerosing adenosis: aberration of normal involution
  6. Intraductal papillomas: small benign tumour that forms in milk duct
  7. Duct ectasia: when central ducts become dilated with ductal secretions, which may leak into periductal tissues and cause an inflammatory reaction (periductal mastitis)
  8. Periductal mastitis
  9. Fat necrosis
  10. Related to changes in hormone levels; fat encrosis occurs 2ry to trauma; RF: less common in pts on COCP, smoking is RF for periductal mastitis
73
Q

S+S

Benign breast disease

A
  1. Hx of breast discomfort or pain, swelling or lump, nipple discharge (if bloody then malignancy), assess risk factors for breast cancer ask pt about: FHx, exposure to oestrogen (age of menarche, menopause, number of kids, breastfeeding, use of OCP/HRT)
  2. Focal or diffuse nodularity of breast;
  3. fibroadenoma: smooth, well circumscribed and mobile lumbs (known as breast mouse)
  4. Duct ectasia: condition in which central ducts become dilated with ductal secretion due to a blockage of the lactiferous ducts - causes yellow/green discharge
  5. Features of malignancy will be absent in benign breast disease: dimpling, peau d’orange, enlarged axillary LN
74
Q

Investigations

Benign breast disease

A
  1. Triple assessment: clinical examination
  2. Imaging: mammography (2-view), US in younger pts
  3. Cytology/histology: fine needle aspiration - sent for cytological analysis; excision biopsy - sent for hitological analysis
75
Q

Managment

Benign breast disease

A
  1. Conservative: symptomatic tx (analgesia for mastalgia), fibroadenoma may be treated conservatively
  2. Surgery: removal or excision biopsy of a breast lump, wide local incision if any suspicion of the lump not being benign;
  3. microdochectomy (surgical removal of a lactiferous duct - for Intraductal papilloma)
  4. Hadfield’s procedure (surgical removal of all lactiferous ducts under the nipple - used for duct ectasia
76
Q

Definition

Breast Abscess

A
  1. Abscess formation in breast tissues; lactational VS non-lactational
  2. Infection - based on where abscess is:
  3. Lactational: Staph aureus
  4. Non-lactational: Staph aureus and anaerobes
  5. RF: lactation, smoking, mammary duct ectasia, periductal mastitis, wound infections
77
Q

S+S

Breast abscess

A
  1. Breast discomfort, painful swelling, generally unwell and feverish;
  2. non-lactational - tend to present with a hx of previous infections with less pronounced systemic upset
  3. Local: swollen, warm and tender area of the breast, overlying skin may be inflamed, nipple may be cracked
  4. Non-lactational: scars/tissue distortion from previous episodes;
  5. sx of duct ectasia (nipple retraction)
  6. Systemic: pyrexia, tachycardia
78
Q

Investigations

Breast abscess

A

USS, MC+S of pus samples

79
Q

Management

Breast abscess

A
  1. Medical: ABx - lactational: flucloxacillin;
  2. non-lactational: flucloxacillin + metronidazole
  3. Surgical: lactational: incision and drainage;
  4. non-lactational: open drainage should be avoided, involved duct system should be excised once the infection has settled
80
Q

Definition

Basal cell carcinoma

A
  1. Commonest form of skin malignancy - rodent ulcer
  2. Main RF: prolonged sun exposure or UV radiation;
  3. seen in Gorlin’s syndrome;
  4. other RF: photosensistising pitch, tar arsenic
81
Q

S+S

Basal cell carcinoma

A
  1. Chronic slowly progressive skin lesion -> found on face, scalp, ears, trunk
  2. Nodulo-ulcerative (most common) - small glistening translcent skin over coloured papule;
  3. slowly enlarges;
  4. central ulcer with raised pearly edges;
  5. fine telangiectasia over the tumour surface;
  6. cystic change in larger lesions
  7. Morphoeic: Expanding yellow/white waxy plaque with an ill-defined edge, more aggressive than nodulo-ulcerative
  8. Superficial: most often on trunk, multiple pink/brown scaly plaques with a fine edge expanding slowly
  9. Pigmented: specks of brown or black pigment may be present in any BCC
82
Q

Definition

Contact dermatitis

A
  1. An inflammatory skin reaction in response to an external stimulus, acting either as an allergen or an irritant
  2. 2 main types coexist:
  3. Allergic: delayed type IV hypersensitivityreaction, which occurs after sensitisation and subsequent re-exposure to the allergen
  4. Irritant: an inflammatory response that occurs after damage to the skin, usually by chemicals
  5. Common allergens: cosmetics, metals, topical medications, textiles
  6. Common irritants: detergents and soaps, solvents, powders
83
Q

S+S

Contact dermatitis

A
  1. Hands are most frequently affected;
  2. contact dermatitis from clothing can occur in the axillae, groins and feet;
  3. redness of skin;
  4. vesicles and papules in affected area;
  5. crusting and scaling of skin;
  6. itching of affected area;
  7. fissues;
  8. hyperpigmentation;
  9. pain or burning sensation;
  10. make sure you do a thorough occupational hx
84
Q

Definition

Eczema

A
  1. Pruritic papulovesicular skin reaction to endogenous and exogenous agents
  2. Lots of types because there are many different triggers
  3. Exogenous: irritants (nappy rash), contact (delayed type 4 hypersensitivity reactions) atopic
  4. Endogenous: atopic, seborrhoeic, pompholyx (type of eczema that affects the hands and feet), varicose, lichen simplex
  5. varicose - due to increased venous pressure in lower limbs
85
Q

S+S

Eczema

A
  1. Itchin, heat, tenderness, redness, weeping, crusting;
  2. asking about occupational exposure to irritants;
  3. FHx of atopy
  4. Acute: poorly demarcated erythematous oedematous dry scaling patches, papules, vesicles, with exudation and crusting, excoriation marks
  5. Chronic: thickened epidermis, skin lichenification, fissues, change in pigmentation
  6. Based on type of eczema:
    1. Atopic: mainly affects face and flexures
    2. Seborrhoeic: yellow greasy scaales on erythematous plaques - found on eyebrows, scalp, presternal area
    3. Pompholyx: vesiculobullous eruption on palm and soles
    4. Varicose: associated with marked varicose veins
    5. Nummular: coin shaped, on legs and trunk
    6. Asteatotic: dry, crazy pairing pattern
86
Q

Investigations

Eczema

A
  1. Contact eczema: skin patch testing - disc containing allergens is diluted and applied on skin for 48hrs - if red raised lesion = positive
  2. Atopic eczema: lab testing - IgE level
87
Q

Definition

Erythema multiforme

A
  1. Acute hypersensitivity reaction of skin and mucous membranes;
  2. stevens-Johnson syndrome is a severe form with bullous lesions and necrotic ulcers
  3. Degeneration of basal epidermal cells;
  4. development of vesicles between cells in the basement membrane;
  5. lymphocytic infiltrate around the blood vessels and at dermo-epidermal junction;
  6. precipitating factor is only identified 50% of the time
  7. Precipitating factors: drugs (sulphonamides, penicillin, phenytoin), infection (HSV, EBV, adenovirus, chlamydia, histoplasmosis), inflammatory (RhA, SLE, sarcoidosis, UC), malignancy (lymphomas, leukaemia, myeloma), radiotherapy
88
Q

Investigations

Erythema multiforme

A
  1. Usually unnecessary - erythema multiforme - clinical dx; Bloods: high WC, eosinophils, ESR/CRP
  2. Imaging: exclude sarcoidosis and atypical pneumonia
  3. Skin biopsy: histology and direct immunoflourescence if in doubt
89
Q

Definition

Erythema nodosum

A
  1. Panniculitis (itis of subcut fat tissue), presenting as red/violet subcut nodules
  2. Delayed hypersensitivity reaction to antigens associated with various infectious agents, drugs and diseases
  3. Infection: bacterial (strep), viral (EBV), fungal (histoplasmosis)
  4. Systemic disease: sarcoidosis, IBD, Behcet’s disease
  5. Malignancy: Leukaemia, Hodgkin’s disease
  6. Drugs: sulphonamides, penicillin, OCP
  7. Pregnancy
  8. 25% have no identifiable cause
90
Q

S+S

Erythema nodosum

A
  1. Tender red/violet nodules bilat on both shins; occasional thigh/forearms;
  2. fatigue, fever, anorexia, wt loss, arthralgia, syx of underlying cause
  3. Crops of red/violet dome-shaped nodules, usually present on both shins;
  4. occasionally on thighs/forearms;
  5. nodules tender to palpation;
  6. low grade pyrexia;
  7. joints may be tender and painful on movement;
  8. sx of underlying cause
91
Q

Investigations

Erythema nodosum

A
  1. Determine cause;
  2. bloods: anti-streptolysin O titres, FBC/CRP/ESR, U+Es, serum ACE (^ in sarcoidosis)
  3. Throat swab and cultures
  4. Mantoux/head skin testing for TB
  5. CXR for bilat hilar lymphadenopathy/TB/sarcidosis/fungal infections sx
92
Q

Definition

Lipoma

A
  1. Slow-growing, benign adipose tumours that are most often found in subcut tissues
  2. Benign tumours of adipocytes,
  3. conditions associated with lipomas: familial multiple lipomatosis, Gardner’s syndrome, Dercum’s disease, Madelung’s disease
  4. Liposarcoma - rare malignant tumour of adipose tissue
93
Q

S+S

Lipoma

A
  1. Most asyx,
  2. compression of nerve causes pain,
  3. soft/firm nodule,
  4. smooth normal surface,
  5. skin coloured,
  6. most <5cm in diameter,
  7. mobile,
  8. soft/doughy feel
94
Q

Definition

Melanoma

A
  1. Malignancy arising from neoplastic transformation of melanocytes, pigment forming cells - leading cause of death from skin disease
  2. DNA damage by UV radiation leads to neoplastic transformation - 50% arise in exisiting naevi, 50% in previously normal skin
  3. 4 histopath types:
    1. Superficial spreading 70%: arises in pre-exisiting naevus, expands in radial fashion before vertical growth phase
    2. nodular (15%): arises de novo, aggressive, No radial growth phase
    3. Lentigo maligna (10%): more common in elderly with sun damage, large flat lesions, progresses slowly and usually on face
    4. Acral lentiginous (5%): arises on palms, soles and subungual areas; most common in NON white popn
95
Q

S+S

Erythema multiforme

A
  1. Non-specific prodromal syx of URTI, sudden appearance of itching/burning/painful skin lesions;
  2. may fade leaving pigmentation
  3. Classic target lesions with a rim of erythema surrounding a paler area;
  4. vesicles/bullae;
  5. urticarial plaques;
  6. lesions often symmetricall and distributed over arms and legs including palms, soles and extensor surfaces
  7. Stevens-Johnson syndrome: affecting > 2 mucous membranes (lips, conjuctiva, cornea, mouth genitalia);
  8. systemic syx (sore throat, cough, fever, headache, myalgia, arthralgia, D/V);
  9. shock (hypotension and tachycardia)
96
Q

S+S

Melanoma

A
  1. Change in size, shape, colour of pigmented skin lesion;
  2. redness, blleding, crusting, ulceration
  3. ABCDE (benign vs malignant):
    1. Asymmetry: symmetrical/asymmetrical
    2. Border irregularity: Even/uneven
    3. Colour variation: One colour/2 or more
    4. Diameter: <6mm/>6mm
    5. Elevation/Evolution: Ordinary mole/chnaging in size/shape/colour or other trait
97
Q

Investigations

Melanoma

A
  1. Excisional biopsy: histological dx and determination of Clark’s levels and breslow’s thickness
  2. Lymphoscintigraphy - radioactive compound is injected into the lesion and images are taken over 30 min to trace the lymphatic drainage and ID sentinel nodes
  3. Sentinel Lymph node biopsy - for metastatic involvement
  4. Staging using USS, CT/MRI, CXR
  5. Bloods: LFTs (liver common site of mets)
98
Q

Definition

Molluscum contagiosum

A
  1. Common skin infection caused by pox virusthat affects children and adults; transmission usually by direct skin contact
  2. Viral skin infection caused by molluscum contagiosum virus;
  3. type of pox virus
  4. RF: mainly in children, immunocompromised and atopic eczema
99
Q

S+S

Molluscum contagiosum

A
  1. Incubation period: 2-8wks;
  2. usually asyx;
  3. may be tenderness, pruritus and eczema around lesion which last for around 8m
  4. Firm, smooth, umbilicated papules - 2-5mm in diameter;
  5. children tends to occur in trunk and extremities;
  6. adults tend to occur on lower abdo, genital area and inner thighs, suggesting sexual contact
100
Q

Definition

Pressure sores

A
  1. Damage to the skin, usually over bony prominence as a result of pressure
  2. Constant pressure limits blood flow to the skin, leading to tissue damage;
  3. occurs as a result of pressure, friction and shear
  4. RF: immobility, alzheimer’s disease, diabetes
101
Q

S+S

Pressure sores

A
  1. Most commonly in sacrum and heel;
  2. pressure sores staged from 1-4;
  3. very tender, may be infected leading to fevers, erythema and foul smell
102
Q

Definition

Psoriasis

A
  1. Chronic inflammatory skin disease which has characteristic lesions and may be complicated by arthritis
  2. Unknown; genetic, env factors and drugs are implicated
  3. RF: guttate psoriasis (streptococcal sore throat), palmoplantar (smoking, middle aged women, AI thyroid disease), generalised pustular (hypoparathyroidism)
103
Q

S+S

Psoriasis

A
  1. Itching and occasionally tender skin;
  2. pinpoint bleeding with removing scales (auspitz phenomenon);
  3. skin lesions may develop at sites of trauma/scars (koebner phenomenon)
  4. Discoid/nummular: symmetrical, well demarcated erythematous plaques with silvery scales over EXTENSOR surfaces (knee, elbows, scalp, sacrum)
  5. Flexural psoriasis: less scaly plaques in axilla, groins, perianal and genital skin
  6. Guttate psoriasis: small drop-like lesions over trunk and limbs
  7. Palmoplantar psoriasis: erythematous plaques and soles
  8. Generalised pustular psoriasis: pustules distributed over limbs and torso
  9. Nail signs: pitting, oncholysis, subungual hyperkeratosis
  10. Joint sx: 5 presentations of psoriatic arthritis: asymmetrical oligoarthritis, symmetrical polyarthritis, DIP joint predominance, arthritis mutilans, psoriatic spondylitis
104
Q

Investigations

Psoriasis

A
  1. Most pts don’t need investigations;
  2. guttate - anti-streptolysin-O titre, throat swab
  3. Flexural psoriasis: skin swabs to exclude candidiasis
  4. Nail clipping analysis for onychomycosis (fungal infection)
  5. Joint involvement and analysed by checking for RhF and radiographs
105
Q

Definition

Sebaceous cysts

A
  1. Epithelium lined, keratinous, debris-filled cyst arising from blocked hair follicle - a.k.a. epidermal cyst
  2. Occlusion of pilosebaceous gland;
  3. caused by traumatic insertion of epidermal elements into the dermis;
  4. embryonic remnants
  5. RF: Gardner’s syndrome = aut dominant condition characterised by presence of multiple polyps in the colon and in extra colonic sites
106
Q

S+S

Sebaceous cysts

A
  1. Non-tender, slow growing skin swelling;
  2. often multiple;
  3. common on hair bearing regions of body (face, scalp, trunk, scrotum) -> red, hot, tender with superimposed infection/inflammation
  4. Smooth tethered lump, overlying skin punctum;
  5. may discharge granular creamy material that smells bad
107
Q

Definition

Squamous cell carcinoma

A
  1. Malignancy of epidermal keratinocytes of the skin;
  2. Marjolin’s ulcer is squamous cell carcinoma arising from chronically inflamed skin
  3. Main RF = UV - sun exposure leads to actinic keratosis;
  4. other RF: radiation, carcinogens, chronic skin disease, HPV, long-term immunosuppression;
  5. defects in DNA repair (xeroderma pigmentosum)
108
Q

S+S

Squamous cell carcinoma

A
  1. Skin lesion, ulcerated, recurrent bleeding, non-healing
  2. Variable appearance - ulcerated, hyperkeratotic, crusted, scaly, non-healing; often sun exposed areas
  3. Palpate for local lymphadenopathy
109
Q

Investigations

Squamous cell carcinoma

A
  1. Skin biopsy - confirm malignancy and type
  2. FNA/LN biopsy: if mets suspected
  3. Staging - CT, MRI, PET
110
Q

Definition

Urticaria

A
  1. Itchy, red, blotchy rash resulting from swelling of superficial parts of the skin; angiooedema occurs when the deeps tissues/lower dermis and subcut tisues are involved and become swollen - HIVES
  2. Caused by activation of mast cells in skin - releasing histamines -> cap leakage -> swelling of skin and vasodilation = erythematous appearance
  3. Triggers:
    1. Acute: Allergies, viral infections, skin contact with chemicals and physical stimuli
    2. Chornic: chronic spontaneous urticaria (meds, stress, infections), autoimmune
111
Q

S+S

Urticaria

A
  1. Central, itchy white papule or plaque surrounded by erythematous flare; lesions vary in size and shape;
  2. associated with swelling of soft tissue of eyelids/lips/tongue (angioedema) - individual lesions usually transient
  3. Time scale: acute= syx develop quickly but normally resolve within 48hrs;
  4. chronic = rash persists for >6wks
112
Q

Investigations

Urticaria

A
  1. Usually clinical - tests may be required for chronic urticaria - FBC, ESR/CRP, patch testing, IgE test
113
Q

Definition

Benign paroxysmal positional vertigo

A
  1. Vertigo lasting seconds to minutes on changing head position - lying down or turning the head suddenly
  2. Displacement of otoliths (from degen, trauma or post-viral) into semi circular canals
114
Q

S+S

BPPV

A
  1. Dizziness,
  2. Vertigo,
  3. loss of balance/unsteadiness,
  4. N/V
115
Q

Investigations

BPPV

A

Hallpike tests

116
Q

Definitions

Meniere’s disease

A
  1. Recurrent episodes of tinnitus, paroxysmal vertigo and unilateral fluctuating hearing loss
  2. Disturbed homeostasis of endolymph (fluid in inner ear)
117
Q

S+S

Meniere’s disease

A
  1. Vertigo,
  2. loss of hearing in affected ear,
  3. tinnitus,
  4. loss of balance,
  5. headaches,
  6. N/V
118
Q

Definition

Thyroglossal cyst

A
  1. Epithelium lined cyst found along course of descent of thyroid gland
  2. Thyroid duct is embryonic remnant of path of descent of thyroid gland from mouth;
  3. duct normally disappears in 6th week, but if some tissue remains, it could develop into cyst
  4. RF: rare familial variants
119
Q

S+S

Thyroglossal cyst

A
  1. Swelling/lump noticed in midline of the ant neck;
  2. usually asyx;
  3. tenderness/rapid enlargement due to infection
  4. Midline, smooth, rounded swelling;
  5. typically found between thyroid notch and hyoid bone;
  6. moves upwards with swallowing - transilluminated;
  7. DDx - LN, dermoid cyst, ectopic erythroid tissue
120
Q

Definition

Tonsilitis

A
  1. Inflammation due to infection of tonsils
  2. Usually viral (common cold or influenza);
  3. bacterial - group A strep)
  4. RF: immune deficiency, FHx of tonsillitis or atopy
121
Q

S+S

Tonsillitis

A
  1. Pain in throat, painful swallowing, may have referral to ears, abdo pain (small children), headache, loss/change voice
  2. Red throat, swollen tonsils (white flecks of pus), high temp (sometimes), swollen LN,
  3. classic strep tonsilitis = acute onset, headache, abdo pain, dysphagia
  4. Exam: intense erythema of tonsils and pharynx;
  5. yellow exudate;
  6. tender enlarged anterior cervical glands
122
Q

Investigations

Tonsillitis

A
  1. Throat swabs and rapid antigen tests can be performed but NOT recommended;
  2. swabs may not be able to distinguish between infection and colonisation
123
Q

Definition

Abscess

A
  1. Painful collection of pus usually caused by bacterial infection
  2. Can develop anywhere in the body;
  3. 2 main types:
    1. skin and internal;
    2. bacterial infection leads to activation of immune response and recruitment of neutrophils to the site of infection;
    3. as white cells attack the bacteria, surrounding tissue is damaged creating a cavity which fills with pus to form an abscess
  4. Pus = mixture of dead tissue + white cells + bacteria
124
Q

S+S

Abscess

A
  1. Swollen, pus filled lump under surface of skin with associated fever and chills;
  2. internal not visualised by characterised by: pain in affected area/referred pain, swinging fevers, malaise
125
Q

Management

Abscess

A
  1. Some small skin abscesses may disappear by themselves;
  2. Incision and drainage: first check whether foreign object is causing the abscess;
  3. abscess cut open and drained
  4. ABx: alongside incision and drainage
126
Q

Definition

Candidiasis

A
  1. Infection caused by candida
  2. 15 diff species - candida albicans most common in humans
  3. Main types: oral/oesophageal candidiasis, Candidal vulvovaginitis/skin infections and invasive candidal infections
  4. RF: broad spectrum ABx, immunocomprise (HIV, corticosteroids), central venous lines, cushing’s disease, DM, GIT surgery
127
Q

S+S

Candidiasis

A
  1. Oral candidiasis: oral thrush (pseudomembranous oral candidiasis) - curd like white patches in mouth, removed easily revealing red base - common in neonates;
    1. main features: redness of tongue and mouth, white plaques
  2. Oesophageal: dysphagia, pain on swallowing food/fluids, AIDS defining illness
  3. Candidal skin infections: soreness and itching, skin appearance can be variable, red/moist skin area with ragged/peeling edge and possibly papules and pustules
128
Q

Investigations

Candidiasis

A
  1. Oral candidiasis - swabs and cultures not particularly useful as in many people’s mouths
  2. Swabs relevant for drug resistance check;
  3. therapeutic trials of anti-fungal can help with dx
  4. Oesophageal candidiasis definitive dx by endoscopy
  5. Invasive candidiasis: blood cultures required if candidaemia is possible
129
Q

Definition

Cellulitis

A
  1. Acute non-purulent spreading infection of subcut tissue causing overlying skin inflammation
  2. Often results from penetrating injury, local lesions, fissuring
  3. Most common organisms: strep pyogenes, staph aureus -> beware of MRSA
  4. Cellulitis of the orbit usually caused by H. influenzae
  5. RF: skin break, poor hygeine, poor vascularisation of tissue (due to DM)
130
Q

S+S

Cellulitis

A
  1. Hx of cut, scratch or injury;
  2. periorbital cellulitis: painful swollen red skin around the eye;
  3. orbital cellulitis: painful or limited eye movements, visual impairment
  4. Lesion: erythema, oedema, warm tender indistinct margins, pyrexia (suggest systemic spread), exclude abscess and aspirate pus if suspected
  5. Periorbital: swollen eye lids, conjunctival infection
  6. Orbital cellulitis: proptosis, impaired visual acuity and eye movements; test RAPD, visual acuity and colour vision
131
Q

Investigations

Cellulitis

A
  1. Bloods: WCC, blood culture
  2. Discharge: sample and send for MC&S
  3. Aspiration - if pus suspected
  4. CT/MRI - orbital cellulitis is suspected (helps assess posterior spread of infection
132
Q

Management

Cellulitis

A
  1. Medical: oral penicillins or tetracyclines effective;
  2. if hospital acquired -> treat empirically based on local guidelines and change depending on the sensitivity of cultured organisms
  3. Surgical: orbital decompression may be needed in orbital cellulitis (emergency)
  4. Abscess: aspirate, incision and drainage, excised completely
133
Q

Definition

Herpes simplex

A
  1. Disease resulting from HSV1 or HSV2 infection
  2. Transmitted via close contact (kissing/sexual intercourse), with an individual that is shedding the virus
  3. Pathophysiology: after 1ry infection, virus becomes dormant (within nerve ganglia), reactivation occur in response to physical and emotional stresses or immunosuppresion;
  4. virus causes cytolysis of infected epithelial cells leading to vesicle formation
134
Q

S+S

Herpes simplex

A
  1. HSV1- 1ry infection often asyx;
    1. possiible syx = pharyngitis, gingivostomatitis (eating may be painful), herpetic whitlow (abscess at end of finger caused by infection with HSV
    2. tender cervical lymphadenopathy, erythematous/oedematous pharynx, oral ulcers filled with yellow slough (gingivostomatitis), herpetic whitlow
  2. reactivation of HSV1: prodrome of perioral tingling and burning, vesicles appear - they will ulcerate and crust over, complete healing within 8-10d
  3. syx of HSV2: painful blisters and rash in the genital, perigenital and anal area; dysuria, fever and malaise; maculopapular rash, vesicles, ulcers, all of these are found on the external genitalia, anal margin, upper thighs;
    1. others: inguinal lymphadenopathy, pyrexia
  4. syx of HSV encephalitis: usually caused by HSV1 so causes HSV1 type syx; sx of encephalitis
  5. Syx of HSV keratoconjunctivitis: watering eyes, photophobia, dendritic ulcer on the iris
  6. Herpes labialis (reactivation affecting the mouth) perioral vesicles/ulcers/crusting
135
Q

Definition

HIV

A
  1. Infection with human immunovirus
  2. Transmitted by: sexual intercourse (heterosexual most common mode of transmission, homosexuals at greater risk in the west);
    1. blood/other body fluids: mother to child (intrauterine, childbirth, breastfeeding), needles, blood transfusions, organ transplantation
  3. Path:HIV enters CD4+ lymphocytes by binding to their g120 receptors;
  4. reverse transcriptase allows the incorporation of HIV genetic material into the host genoma;
  5. leads to dissemination of HIV, cell death and eventual T-cell depletion
136
Q

S+S

HIV

A
  1. 3 phases of HIV:
    1. seroconversion: self limiting, fever, night sweats, generalised lymphadenopathy, sore throat, others: oral ulcers, rash, myalgia, headache, encephalitis, diarrhoea
    2. Early/asyx: apparently well, some may have persistent lymphadenopathy, progressive minor syx (rash, oral thrush, wt loss)
    3. AIDS: syndrome of 2ry diseases resulting from immunodeficiency
  2. Direct effects of HV infection:
    1. Neuro - polyneuropathy, dementia
    2. Lung: lymphocytic interstitial pneumonitis
    3. Heart: cardiomyopathy, myocarditis
    4. Haem: anaemia, thrombocytopaenia
    5. GI: anorexia, wasting
    6. Eyes: cotton wool spots
  3. 2ry effects from immunodeficiency:
    1. Bacterial infection: TB, pneumococcal infections, skin infections
    2. Viral: CMV, HSV, VZV, HPV, EBV
    3. Fungal: pneumocystic jirovecii pneumonia, cryptococcus, candidiasis, invasive aspergillosis
    4. Protozoal: toxoplasmosis, cryptosporidia
    5. Tumours: Kaposi sarcoma, SCC, NHL, hodgkin’s lymphoma
137
Q

Investigations

HIV

A
  1. HIV testing: HIV ab, PCR for viral RNA, CD4 count, viral load
  2. Others: pneumocystic pneumonia (CXR), cryptococcal meningitis (brain CT/MRI or LP), CMV colitis (colonoscopy and biopsy), toxoplasmosis (brain CT or MRI), cryptosporidia (stool microscopy)
138
Q

Definition

Infectious mononucleosis

A
  1. Clinical syndrome caused by primary EBV infection - glandular fever
  2. EBV is a gamma-herpes virus (dsDNA), found in pharyngeal secreions of infected individuals and is transmitted by close contact - kissing
  3. EBV infection of epithelial cells of oropharynx leads to b cell infection which then disseminate EBV across the body -> humoral and cellular immune response
  4. Atypical lymphocytes in peripheral blood are a classic feature of infectious mono
  5. EBV remains latent in lymphocytes - reactivation following stress/immunosuppression may occur
139
Q

S+S

Infectious mononucleosis

A
  1. Incubation is 4-8wks;
  2. abrupt onset of syx:
  3. sore throat, fever, fatigue, headache, malaise, anorexia, sweating and abdo pain
  4. Pyrexia; oedema and erythema of the pharynx;
  5. white/creamy exudate on the tonsils;
  6. palatal petechiae;
  7. cervical/generalised lymphadenopathy;
  8. spleno/hepatomegaly, jaundice (5-10%);
  9. widespread maculopapular rash in pts who received ampicillin
140
Q

Investigations

Infectious mononucleosis

A
  1. Bloods: FBC leucocytosis, LFTs: high ALT/AST
  2. Blood film: lymphocytosis with atypical lymphocytes
  3. Heterophil Ab test (monospot test/aul bunnell test) - based on EBV ag being similar to Ag on RBC of animals but NOT humans;
    1. mixing blood of EBV+ human with animal blood, makes animal RBC aggregate and precipitate out of solution -> may give false negatives in early stages of infection before Ab generated
  4. Throat swab: exclude strep tonsilitis
  5. IgM/IgG to EBV viral capsid Ag
  6. IgG against EB nuclear Ag
141
Q

Management

Infectious mononucleosis

A
  1. Bed rest; paracetamol and NSAIDs for fever and malaise
  2. Corticosteroids in severe cases
  3. DON’T give amoxicillin/ampicillin if suspected as develop maculopapular rash
  4. Advice: avoid contact sports for 2wks (rupture spleen)
142
Q

Definition

Malaria

A
  1. infection with protozoan plasmodium; 5 types:
    1. Plasmodium falciparum (most serious)
    2. P. vivax
    3. P. ovale
    4. P. malariae
    5. P. knowlesi
  2. Transmitted by bite of female anopheles mosqiuito and rotozoa grow in RBC
  3. Life cycle: injection of sporozoites into blood stream by mosquito, invasion and replication in hepatocytes;
  4. parasites reinvade blood and enter RBC, replicate and develop ring forms;
  5. RBC rupture and release merozoites which reinfect other RBC;
  6. Gametocytes taken up when another mosquito feeds, develop into sporozoites in gut of mosquito;
  7. then move into salivary gland of mosquito to be transmitted
  8. Innate immunity: sickle cell trait, G6PD deficiency, pyruvate kinase def, thalassaemia
143
Q

S+S

Malaria

A
  1. Feverish traveller with incubation up to 1yr;
  2. cyclical syx: high fever, flu-like syx, severe sweating, shivering cold/rigors
  3. Cerebral syx: headache, disorientation, coma
  4. Pyrexia, anaemia (haemolytic), hepatosplenomegaly
144
Q

Investigations

Malaria

A
  1. Thin/thick blood films: thick for quantifying and thin for ID type of malaria
  2. Bloods:FBC (haemolytic), U+E. LFTs, ABG
  3. Urinalysis to check for blood/protein
  4. Thin/thick blood films: thick for quantifying and thin for ID type of malaria
  5. Bloods:FBC (haemolytic), U+E. LFTs, ABG
  6. Urinalysis to check for blood/protein
145
Q

Definition

Varicella zoster

A
  1. 1ry infection is called varicella (chicken pox);
  2. reactivation of dormant virus causes zoster (shingles) -> varicella zoster also known as herpes zoster
  3. VZV is herpes ds-DNA;
  4. highly contagious;
  5. transission by aerosol inhalation or direct contact with vesicular secretions
146
Q

S+S

Varicella Zoster

A
  1. Chicken pox:
    1. prodromal malaise, mild pyrexia, sudden appearance of intensely itchy spreading rash mainly affecting face and trunk;
    2. vesicles weep and crust over;
    3. new vesicles have all crusted over (7-10d)
    4. maculopapular rash, areas of weeping and crusting, skin excoriation (scratching), mild pyrexia
  2. Shingles: may occur after a period of stress;
    1. tingling/hyperaesthesia in dermatomal distribution (virus remains dormant in dorsal root ganglia and reactivation makes virus travel down sensory axon);
    2. painful skin lesions;
    3. recovery 10-14d
    4. vesicular maculopapular rash, dermatomal distribution, skin excoriation
147
Q

Investigation

Varicella zoster

A
  1. Usually clinical dx;
  2. vesicle fluid may be sent for electron microscopy viral PCR (RARE);
  3. chicken pox in adult with PMH of varicella infection = HIV test
148
Q

Management

Varicella zoster

A
  1. Chickenpox: children - tx syx;
  2. adult: consider acyclovir
  3. Shingles: aciclovir, valaciclovir, famciclovir
  4. Prevention: VZIg - in immunosuppressed/pregnant
149
Q

Definition

Alcohol dependence

A
  1. Characterised by 3+ of:
    1. Withdrawal on cessation of alcohol
    2. Tolerance
    3. Compulsion to drink, difficulty controlling termination or levels of use
    4. Persistent desire to cut down/control use
    5. Time spent obtaining/using/recovering from alcohol
    6. Neglect of other interests
    7. Continued use despite physical and psych problems
    8. Recommended weekly amount <14u/week
  2. Genetic/env factors; pts with depressive/anxiety states are at increased risk
  3. Withdrawal path: alcohol enhances GABA activity, inhibiting glutamate neurotransmission
  4. Chronic alcohol exposure leads to compensatory reduction in GABA receptor function and upreg of glutamate receptors
  5. Abrupt alcohol cessation leads to overactivation of those glutamate receptors
150
Q

S+S

Alcohol dependence

A
  1. Hx of heavy drinking;
  2. CAGE: felt you should cut down on drinking; annoyed by people telling you to stop drinking?; guilty about how much you drink; do you feel like you need a drink to wake up? (eye opener)
  3. other comorbidities/RF - smoking/depression
  4. Features of acute intox: amnesia, ataxia, dysarthria, disorientation, palpitations, flushing, coma
  5. Syx of withdrawal: Nausea, sweating, tremor, restlessness, agitation, visual hallucinations, confusion, seizures
  6. Sx of chronic misuse: ddupuytren’s contracture, palmar erythema, bruising, spider naevi, telangiectasia, facial mooning, bilat parotid enlargement, gynaecomastia, smell of alcohol
  7. Sx of complications: alcoholic hepatitis, liver failure
151
Q

Investigation

Alcohol dependence

A
  1. Bloods: macrocytic anaemia, high GGT, AST/ALT, others: high uric acid, triglycerides, markers of organ damage
  2. Acute overdose: blood alcohol, glucose, ABG, U+Es, tox screen - drug OD
152
Q

Definition

Anxiety disorder

A
  1. Group of mental disorders characterised by feelings of anxiety or fear
  2. Syndrome of ongoing anxiety and worry about many events or thoughts that the pt generally recognises as excessive and inappropriate;
  3. RF: 35-54, divorced/separated, living alone/single parent
153
Q

S+S

Anxiety disorder

A
  1. Dx criteria: excessive anxiety/worry occurring more days than not for 6m, pt finds it difficult to control worry, anxiety and worry associated with 3+ of:
  2. restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
  3. Autonomic arousal syx: palpitations, sweating, trembling, dry mouth
  4. Chest/Abdo syx: difficulty breathing, feeling of choking, chest pain/discomfort, nausea/abdo pain
  5. Syx involving mental state: dizziness/light-headedness, feeling of losing control, fear of dying
  6. General syx: hot flushes/cold chills, numbness/tingling sensation, mmuscle tensions/aches and pains, restlessness, globus
154
Q

Definition

Depressive disorder

A
  1. Mood disorder that causes persistent feeling of sadness and loss of interest
  2. NICE recommends use of DSM-IV classification to dx depression;major dep requires
  3. at least 1 of core syx: persistent sadness/low mood nearly every day, loss of interests or pleasures in most activities
  4. Along with some of: fatigue/loss of energy, worthlessness, excessive/inappropriate guilt;
  5. suicidal thoughts, diminished ability to think/conc, psychomotor agitation and retardation, insomnia, changes in appetite/wt loss
  6. Syx persist for >2wks
  7. RF: female, hx of depression, significant physical illness causing disability/pain, other mental health problems, part of refugee community
155
Q

S+S

Depressive disorder

A
  1. Look at aetiology;
  2. somatisation (physical syx due to psych illness) is very important;
  3. elderly people may present with depressive pseudodementia
  4. Assessment tool: pt health questionnaire, hospital anxiety and depression scale and beks depression inventory
156
Q

Investigations

Depressive disorder

A
  1. Consider organic causes - hypothyroidism, hypercalcaemia, addisons disease, cushing’s disease
  2. Inv for other causes: blood glucose, U+Es, TFT, Cal, FBC, MRI/CT
157
Q

Definition

Cataracts

A
  1. Opacification of the lens of the eye
  2. Most are idiopathic (age-related);2ry causes:
  3. Local: previous eye trauma, uveitis
  4. Systemic: diabetes, metabolic (wilson’s disease), skin disease (scleroderma), drug (steroids)
  5. Congenital: congenital rubella syndrome
158
Q

S+S

Cataracts

A
  1. Gradual onset painless loss of vision;
  2. glare from bright light, vision may worsen in bright light, some may experience monocular diplopia with haloes around lights;
  3. some may begin to be able to read without glasses (sclerotic cataract may increase the lens’ converging power)
  4. Loss of red reflex, hazy lens appearance, reduced visual activity
159
Q

Definiton

Conjunctivitis

A
  1. Inflammation of the conjunctiva;
  2. associated inflammation of the cornea -> keratoconjunctivitis;
  3. associated eye lid involvement -> blepharoconjunctivitis
  4. Infectious: viral, bacterial;
  5. non-infectious: allergic, mechanical/irritative/toxic, immune-mediated, neoplastic
  6. RF: contact lens use
160
Q

S+S

Conjunctivitis

A
  1. Red eye (usually generalised and bilat);
  2. irritation, discomfort and grittiness;
  3. discharge (may be watery, mucoid, sticky or purulent depending on cause);
  4. photophobia (suggest corneal involvement);
  5. visual acuity usually unaltered
  6. Conjunctival injection;
  7. dilated conjunctival vessels, conjunctival chemosis (swell of conjunctiva), conjunctival follicles (round collections of lymphocytes appearing as small dome shaped nodules), conjunctival papillae (associated with allergic immune response)
161
Q

Definition

Glaucoma

A
  1. Optic neuropathy with typical field defect usually associated with ocular hypertension (intra-ocular pressure > 21mmHg)
  2. Primary causes: acute closed-angle, chronic closed angle, 1ry open angle
    1. 2ry: trauma, uveitis, steroids rubeosis iridis (formation of new blood vessels on the surface of the iris)
    2. Congenital: Buphthalmos - enlargement of the eye balls
  3. Pathophysiology: ocular HTN leads to compression and stretching of the retinal nerve fibres -> scotomas and visual field defects;
  4. ocular HTN due to reduced outflow of aqueous humour caused by:
    1. AOAG: Obstruction to outflow (caused by narrowing of the iridocorneal angle and hence, narrowing of the canal of schlemm leading to rapid and severe rise in IOP)
    2. POAG: Resistance to outflow through trabecular meshwork -> blockage of trabecular meshwork by blood or inflammatory cells
162
Q

S+S

Glaucoma

A
  1. ACAG: painful red eye, vomiting, impaired vision, haloes seen around lights, red eye, hazy cornea, loss of red reflex, fixed/dilated pupil, eye tender and hard on palpation, cupper optic disc, visual field defect, moderated raised IOP
  2. POAG: usually asyx, peripheral visual field loss, optic disc may be cupped, usually no sx
  3. Congenital: buphthalmos, watering, cloudy cornea
163
Q

Investigations

Glaucoma

A
  1. Goldmann applanation tonometry: standard method of measuring IOP, normal = 15mmHg
  2. Pachymetry: using US or optical scanning to measure central corneal thickness;
  3. CCT < 590mm = higher risk of glaucoma
  4. Fundoscopy: detects pathologically cupped optic disc
  5. Gonioscopy: assess iridocorneal angle
  6. Perimetry (visual field testing)
164
Q

Definition

Uveitis

A
  1. Inflammation of the iris and ciliary body
  2. May be caused by infection (HSV);
  3. can occur as a manifestaton of systemic inflammatory conditions (reactive arthritis, ankspond, IBD, sarcoidosis, Behcet’s disease)
  4. Sympathetic ophthalmia: inflammation of the contralateral eye wks/months after penetrating injury;
  5. due to recognition of eye Ag in contralat eye by T cells that were activated by initial penetrating injury to the opposite eye
165
Q

S+S

Uveitis

A
  1. Pain due to inflammation, during accommodation;
  2. photophobia, red eyes, blurred vision, lacrimation, rarely associated with tubulointerstitial nephritis (causing flank pain/hameaturia/proteinuria)
  3. Reduced visual acuity;
  4. ciliary flush;
  5. hypopyon (exudate and inflammatory cells in inferior angle of ant chamber);
  6. small irreg pupil due to adhesions of iris to lens
  7. Slit lamp - keratitic precipitates - leucocyte deposits on corneal endothelium
  8. Fundoscopy: exclude reinal detachment
  9. Sx of complications: increased IOP, cataract
  10. Sx of underlying aetiology

Year 3 (13 decks)

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