other Flashcards
1
Q
What are the safety concerns with moxifloxacin
A
Increased risk of life-threatening liver reactions
Cardiac reactions
Skin reactions
2
Q
features of optiate intoxication
A
euphoria sedation miosis = excessive constriction of the pupil of the eye. decreased concentration hypotension bradycardia respiratory depression impaired consciousness death
3
Q
features of opiate withdrawal
A
anxiety / aggitation anorexia + weight loss myalgia muscle weakness tremor nausea + vomiting diarrhoea + abdominal cramps yawning lacrimation / rhinorrhoea / sweating
4
Q
features of alcohol withdrawal
A
anxiety irritability insomnia headaches malaise weakness nausea + vomiting hyperension tachycardia
5
Q
What is the PPV?
A
The likelihood that patients with an initial positive test have the infection
6
Q
What happens to the PPV as the provenance of the infection drops
A
PPVs become lower as prevalence drops
7
Q
What is the NPV?
A
The likelihood that patients with an initial negative test result do not have the infection
8
Q
Define sensitivity
A
sensitivity = ability of the test to correctly identify those patients with the disease
9
Q
Define specificity
A
Specificity = ability of the test to correctly identify those patients without the disease
10
Q
Arterial supply of the vagina
A
Vaginal artery
and anastomoses with the uterine artery superiorly
11
Q
Dermatome supply of anterior upper arm
A
C5
12
Q
Dermatome supply of level of the nipple
A
T5
13
Q
Dermatome supply of level of umbilicus
A
T10
14
Q
Dermatome supply of medial ante-cubital fossa
A
T1
15
Q
Dermatome supply of the acromio-clavicular joint
A
C4
16
Q
Dermatome supply of the axilla
A
T2
17
Q
Dermatome supply of the little finger
A
C8
18
Q
Dermatome supply of the mid anterior thigh
A
L2
19
Q
Dermatome supply of the middle finger
A
C7
20
Q
Dermatome supply of the perianal area
A
S5
21
Q
Dermatome supply of the thumb
A
C6
22
Q
Duration for spermatogenesis
A
70-75 days
23
Q
Length of the inguinal canal in adults
A
4cm
24
Q
Length of vagina
A
6 - 7.5cm anteriorly
9cm posteriorly
25
Lymph drainage of base of cervix
Internal iliac lymph nodes
26
Lymphatic drainage of the bladder
External Iliac nodes
Fundus to internal iliac nodes
Some to common Iliac and sacral
27
Lymphatic drainage of the distal rectum
Internal iliac nodes
28
Nerve root control of knee-jerk
L3/4
29
Nerve root of the femoral nerve
L2-4
30
Nerve root of the sciatic nerve
L4-5, S1-3
31
To what lymph group does the cervix drain to
Internal iliac
32
To what lymph group does the distal rectum drain to
Internal iliac
33
To what lymph group does the majority of the breast drain to
Pectoral group of
| the axillary lymph nodes
34
To which lymph nodes does lymph from the scrotum and penis first pass?
Superficial inguinal lymph nodes
35
Venous drainage of the bladder
Internal iliac veins
36
Venous drainage of the right ovary
Direct into inferior Vena cava
37
Venus drainage of the left ovary
Left renal vein
| into inferior Vena cava
38
Venous drainage of the vagina
Vaginal plexus
| With vaginal vein to internal iliac vein or uterine vein
39
What are the 3 sites of constriction of the ureters
Crossing the Pelvic brim
Pelvo-ureteric junction
vesico-uretreic junction
40
What is the nerve root supply for the muscle group of the ankle reflex
S1-2
41
What is the nerve root supply for the muscle group of the biceps reflex
C5 - 6
42
What is the nerve root supply for the muscle group of the knee reflex
L3 - 4
43
What lymph group does the vulva drain to
Superficial inguinal lymph nodes
44
What muscle is mainly responsible for knee extension
quadriceps
45
What muscles does the median nerve innervate
LOAF muscles
Flexor carpi radialis
Pronator teres
46
What muscles does the radial nerve supply
Triceps,
brachioradialis,
supinator,
abductor pollicis longus
47
What nerve roots mediates the anal reflex
S3-4
48
What roots supply the pudendal nerve
Anterior rami of S2-4
49
What structures prevent prolapse of the uterus and vagina
Uterosacral ligaments
Cardinal ligaments
Levator ani muscles
50
Where does lymph from the Fallopian tube drain to?
Para-aortic nodes
51
In what patients should ciprofloxacin be avoided
| fluroquinolones or quinolones
```
ciprofloxacin resistant bacteria
unknown susceptibility
previous SE from fluroquinolones / quinolones
caution in >60yo
or on corticosteroids
or kidney disease
or organ transplant
```
52
What serious side effects can occur from
| fluroquinolones or quinolones
Muscle / tendon rupture
pain
peripheral neuropathy
CNS effects - hallucinations / depression
53
What is Chemsex
the use of drugs in a sexual context
- methamphetamine (crystal, meth, Tina)
- mephedrone (meph/drone, miaow miaow, m-cat)
- GHB/GBL (G, Gina)
54
What is slamming
Injecting the drugs used for chemsex
55
What factors contribute to the high burden of HIV among trans-women
```
high levels of discrimination
structural barriers to healthcare
violence - physical and sexual
poverty
high unemployment
housing instability
```
56
What does Chemsex do?
```
Better sex / increased pleasure
Increased stamina / longer sex / multiple partners
Increase confidence
Disinhibition
Mild anaesthetic
```
57
What % of HIV +ve MSM report chemsex
7% HIV positive MSM report recreational drug use in past 3 months
29% engaged in chemsex in last year
10% in slamsex
58
What % of HIV -ve MSM report chemsex
5% during last time sex
54% engaged in chemsex in last 3 months
59
Risks associated with Chemsex
```
High risk sexual behaviour - increased number of partners / less condom use / aero-sorting
Increased STI risk
Delayed obtaining PEPSE
Decreased adherence to ARVs for PEPSE / PrEP or HIV tx
Mental health issues
Physical health
financial issues
crime
```
60
Which patients are likely to benefit from safer sex advice?
adolescents
people from, or who have visited countries with high rates of HIV and/or other STIs
MSM
```
history of:
frequent partner change
multiple concurrent partners
early onset sexual activity
previous bacterial STI
attendance as a contact of STI
alcohol or substance abuse
```
61
What impacts condom effectiveness
```
late application
early removal
Condom slippage and errors
condom associated erection loss
Use of oil based lubricant -
```
Lubricant use reduces condom breakage for anal but not vaginal sex
The risk of condom slippage may be doubled with the use of lubricant for vaginal sex
62
Safer sex advice for Oral Sex
Advise of risks of transmission of STIs from oral sex
Advise condom use / dental dams for oral sex
Avoiding oral sex with ejaculation - reduces risk of HIV and possibly other infections
Insertive fellatio is lower risk than receptive
Avoid brushing teeth or flossing before oral sex reduces risk of HIV and possibly other infections
Avoiding oral sex if oral cuts / sores a or a sore throat
63
What STIs are transmissible through Oral Sex
```
Herpes simplex virus (HSV)
human papilloma virus (HPV)
gonorrhoea
Chlamydia
syphilis
HIV
Hepatitis B
possibly Hepatitis C
```
64
Which drugs are commonly used in chemsex
GHB/GBL
Mephedrone
Crystal Methamphetamine
others - MDMA, Cocaine, Poppers, Speed, ketamine, viagra
65
Harm reduction advice for people using GHB / GBL
GBL is a depressant
Advise against mixing it with alcohol or ketamine due to the sedative effect
Start with small volumes (0.5ml)
Avoid re-dosing too soon (aim for 3 hours min)
Advise against using others' G as the strength is not known
Measure using a syringe or pipette
G can become physically addictive after a short time
66
Signs of dependence to GHB / GBL
sweats
shaking
insomnia
anxiety
67
Harm reduction advice for people using Crystal Meth
Avoid injecting if possible - carries the additional risk of sharing needles, damage to veins and abscesses
Can lower inhibitions leading to more risky injecting and sexual practices. Sharing needles and equipment leads to increased risk of blood borne virus (BBV) transmission.
Can lead to hallucinations / feelings of depressions/low mood
Individuals at risk of forgetting to take ARVS / PrEP or missing window for PEPSE
68
Harm reduction advice for people using mephedrone
No safe way to take it
Least risk from 'bombing it' = swallow wrapped in paper
Causes irritation when snorted - nose bleeds
Causes a sore throat when swallowed
Try to avoid injecting - due to added risk.
Advise re local needle exchanges and drug services
69
contraindications to Azithromycin
Severe hepatic impairment
drugs which prolong the QT interval
hypokalaemia (risk of QT prolongation)
history of prolonged QT interval
70
mechanism of action of Azithromycin
bacteriostatic
Inhibits some gram -ve, some gram +ve and many aytipicals
Azalide = type of macrolide
71
Side effects of Azithromycin
<1% stop azithromycin due to SE
```
Nausea / vomiting
diarrhoea
abdo discomfort
pseudomembranous colitis (c. diff)
anaphylaxis
hepatotoxicity +/- jaundice
```
72
drug interactions with Azithromycin
warfarin - may increase INR
statins - increased risk of rhabdomyolysis
Ciclosporin - affects clearance of cyclosporin
any drugs which prolong the QT interval (amiodarone, sotalol, amisulpride, terfenadine)
Any drugs which cause hypokalaemia (risk long QT)
73
What type of drug is doxycycline
| + MOA
```
Tetracycline class
broad spectrum
bacteriostatic
```
74
Contraindications to doxycycline
```
Pregnancy
breastfeeding
liver disease
SLE
Myasthenia
Porphyria
```
75
Side effects of doxycycline
Nausea / vomiting
diarrhoea
photosensitivity
benign intracranial hypertension (rare)
76
Drug interactions with doxycycline
accelerated metabolism of doxycycline is caused by - pentobarbital / carbemazebine / phenytoin / primidone
Decreased levels of doxycycline caused by - Rifampicin
Decreased absorption of doxycycline - Sucralfate / antacids
77
What impact does doxycycline use in pregnancy have on the infant
Affects feral tooth and bone development
FDA category D
78
History to determine risk for MSM
frequency and number of condomless anal sex partners
serosorting
seropositioning
negotiated safety
understanding of ARVs as HIV treatment-as-prevention
Knowledge / use of PrEP and PEPSE
Sexual activities conferring risk for enteric infections and Hepatitis C or hepatitis A = oro-anal sex (rimming) / fisting;
Discuss ways of meeting partners - use of internet/ apps
sex-on- premises or cruising venues
alcohol intake
use of recreational drugs during sex
problems with sexual dysfunction
79
What is negotiated safety
Partners begin the relationship exclusive and stay monogamous
Both partners test for HIV and repeat this after the window period and share their results
Both partners use condoms until both partners know they're HIV-negative
Both partners develop a clear spoken / written agreement about their sex practices within and outside of the relationship
e.g. not having other sexual partners / not having anal sex outside the relationship / only having oral sex outside the relationship / always using condoms for sex outside the relationship.
Agreement kept by both partners.
If the agreement is broken it's discussed right away.
And condoms are used until both partners test HIV negative after the window period
80
In men with rectal symptoms, the presence of tenesmus and constipation is significantly associated with which infection
lymphogranuloma venereum
| LGV
81
Why should GUM clinics routinely ask about drug and alcohol use
Excessive alcohol use is associated with STI diagnosis
Alcohol use is more common among adult and adolescent MSM
Binge drinking, use of inhaled nitrites and methamphetamine are markers of increased STI risk in MSM
Ask re injected drug use and equipment sharing +/- offer Hep B / C tests
82
Asymptomatic screening offered to MSM
```
CT and GC NAAT
from all sites = urethra, pharynx and rectum - irrespective of HIV status or sexual history
HIV and STS serology
+/- Hep B - unless immunity known
+/- Hep C
+/- Hep A
```
83
Risk factors for LGV
```
MSM
HIV-positive
practicing higher risk sex.
Hepatitis C infection
Chemsex (specifically the use of GHB)
condomless anal sex
fisting
```
84
When is routine LGV typing recommended
In HIV positive MSM with symptomatic or asymptomatic CT
But NOT in HIV-negative MSM with CT (unless symptomatic proctitis)
85
A bidirectional transmission synergy exists between HIV infection and which type of HSV
HSV-2
86
3 monthly STI screening including HIV should be offered to which MSM
- Unprotected anal intercourse with partner(s) of unknown or serodiscordant HIV status over last 12 months
- >10 sexual partners in last 12 months
- Drug use (methamphetamine, inhaled nitrites) during sex over last 6 months (Or GBL, ketamine, other NPSs - evidence less robust)
- Multiple or anonymous partners since last tested
- Any unprotected sexual contact (oral, genital or
anal) with a new partner since last tested
87
Causes of sexually transmitted enteric infections
```
Shigella spp.
VTEC
Campylobacter spp.
Salmonella spp.
Entamoeba histolytica
Cryptosporidium spp.
Cytomegalo virus
Giardia duodenalis
Microsporidium spp
Hepatitis A
```
88
Infectious causes of gastrointestinal infections in MSM
* Viruses - Hepatitis A / norovirus
* Bacteria: Campylobacter spp., E. coli, Salmonella spp., Shigella spp., Yersinia enterocolitica
* Parasites: Cryptosporidium spp., Entamoeba histolytica, Giardia lamblia/intestinalis, Blastocystis spp., Dientamoeba fragilis, Isospora spp., Microsporidium spp.
89
Symptoms of proctitis
rectal pain
rectal discharge
rectal bleeding
+/- tenesmus
aetiology is usually classic STI pathogens
90
Symptoms of enteric infections
diarrhoea and/or dysentery
abdominal pain
usually have colitis or enterocolitis that is caused by enteric pathogens
91
Investigations for proctitis
full sexual health screen
Microscopy of a Gram-stained rectal smear - >5 or >10 polymorphonuclear cells/high power field = proctitis
culture for NG from all sites prior to treatment
swabs for HSV PCR and T. pallidum PCR
92
Empirical therapy in symptomatic men with proctitis
Cover CT, LGV and GC
(treatment for LGV also covers STS)
Doxycycline 100 mg twice daily orally for 21 days
+ Ceftriaxone 1g IM STAT
93
Risk factors for AIN
```
HPV
Receptive anal intercourse
immunosupression (including HIV)
smoking
increased age
```
94
Anal cancer is usually what type
SCC
| usually preceded by AIN
95
Symptoms of AIN
```
pruritus
anal discharge
suspicious skin lesions (white / erythematous / scaly / pigmented)
fissures
eczematous changes
```
96
Diagnosis of AIN
biopsy
97
Management of AIN
Observation - may spontaneously regress - FU every 6-12months
local excision if <1/3 of anal circumference
imiquimod 5%
98
Symptoms of anal cancer
```
Anal pain
bleeding
discharge
pruritus
ulceration
```
if anal sphincter infiltrated --> faecal incontinence and tenesmus
99
Characteristics of enteric infections
sudden onset diarrhoea
with or without vomiting
usually transient
due to enteric infection with viruses, bacteria or protozoa,
typically affect large bowel (the colon)
less commonly - small bowel
Other symptoms =
- blood and/or mucous in the faeces (dysentery)
- fever
- malaise
100
History required for a MSM presenting with acute diarrhoea
```
Question re severity of illness
medication hx - incl recent abx
exposure to untreated water
animals
occupational risk of transmission
risk factors - including travel abroad / food history
```
Sexual risks in 2 weeks preceding onset
- receptive oro-anal (both direct and indirect, i.e. performing oral sex after anal penetration)
- multiple sexual partners
- group sex
- chemos sex
- sexual activities involving faeces (e.g. scat play).
101
Investigations for acute onset diarrhoea in MSM
Full sexual health screen
Microbiology examination of stool
- for ova, cysts + parasites
- culture + antibiotic susceptibility testing
102
Management of patients with STEI
conservative management
Oral rehydration
+/- use oral rehydration salts after each loose stool passed for up to 48 h
AVOID Antidiarrhoeal drugs e.g. loperamide = contraindicated in infectious diarrhoea
AVOID empirical antibiotic therapy,
Consider empirical therapy guided by microbiology advice when:
• patient pyrexial (temperature >38C)
• stools are bloody
• Diarrhoea lasts > 7 days
• Co-morbidities (frailty, IBD, immunocompromised)
103
Advice on sexual practices for preventing spread of enteric infections
* Wash hands, genitals and perianal skin before and after sexual activities - including intercourse / rimming / fingering / handling used condoms or sex toys.
* Use condoms for anal sex
* Use latex gloves for digital penetration or fisting
* Dental dams or a condom cut into a square as a barrier for rimming
* Avoid sharing sex toys or douching equipment.
* Avoid sexual contact until 7 days after the last episode of diarrhoea
104
Ovarian blood supply
Right + left ovarian arteries - arise from descending abdominal aorta
Right + left ovarian veins
Rt ovarian vein drains to IVC
Lt ovarian vein drains to Lt renal vein then IVC
105
which ligament do the ovarian arteries and veins travel in
infundibula-pelvic ligament
106
blood supply to the fallopian tubes
Uterine artery and ovarian artery
Ovarian veins + uterine veins
107
arterial supply to the penis
3 arteries - arise from internal pudendal artery
= dorsal artery of penis
+ deep cavernosal artery
+ bulbo-urethral artery
108
venous drainage of penis
superficial dorsal vein of penis
deep dorsal vein of penis
109
lymphatic drainage of penis
skin + prepuce drain to superficial inguinal lymph nodes
glans drains to
- superficial inguinal lymph nodes
- or directly into deep inguinal nodes
- or into external iliac nodes
110
Treatment of acute bacterial prostatitis
4 weeks of antibiotics
e.g. trimethoprim
check sensitivities
111
Common organisms causing acute bacterial prostatitis
60% = E.coli / proteus / klebsiella
enterococci
anaerobes
urethral GC
112
Chronic bacterial prostatitis symtoms and treatment
recurrent UTI
persistent focus of infection in prostate
treatment = 4 weeks of ciprofloxacin 500mg BD
or 4 weeks Ofloxacin 200-400mg BD
