Other Medicine Flashcards
Most common cause of fever after travel to Sub-Saharan Africa and tropical areas
Malaria
Most common cause of fever after travel to Latin America or Asia
Dengue
Definition of severe malaria
Fever in last 48 hours
P falciparum infection, >100 parasites/200 leukocytes, no other causative organism
At least one of:
- Impaired consciousness, GCS <10
- Multiple grand mal seizures
- Jaundice
- Hypoglycaemia (<2.5)
- Hyperparasitaemia (parasite density >100000)
- Renal impairment
- Cardioresp distress
Causes of fever + haemorrhage
Viral haemorrhagic disease
- Dengue
Leptospirosis
Meningicoccaemia
Rickettsial infection
Investigation for malaria
Malaria antigen rapid diagnostic test (RDT)
Thick and thin blood films taken on 2 occasions
- >3 negative blood films on 3 consecutive days to rule out
Investigation for travellers diarrhoea
Only test stools if prolonged diarrhoea (10-14 days) or severe symptoms (fever, tenesmus, bloody stools)
- Stool culture
- Shiga toxin assay
- Ova and parasites
- Giardia and cryptosporidium antigen
Treatment of uncomplicated malaria
P. falciparum or unidentified species: artemether+lumefantrine (Riamet, Coartem) or atovaquone+proguanil (Malarone)
P. vivax, P. ovale, P. malariae, P. knowlesi: Chloroquine, hydroxychloroquine, artemethar+lumefantrine (Riamet, Coartem)
If P. vivax, P. ovale liver hypnozoites: Primaquine (do not give in G6PD deficiency-haemolysis)
Chloroquine resistant P. vivax: artemethar+lumefantrine + Primaquine
Management of traveller’s diarrhoea
Antiemetic
Oral fluid + electrolyte replacement
Loperamide for profuse diarrhoea
Empiric abx:
Ciprofloxacin 750-1000mg stat, or 500mg BD 3 days
Or azithromycin 1g stat or 500mg BD 3 days if South/SE Asia (high fluoroquinolone resistance)
Symptoms and incubation for traveller’s diarrhoea
Bacterial + viral - 6-48 hours incubation
- vomiting more prominent in Norovirus
- Rice water diarrhoea in cholera
Parasitic infection 1-2 week incubation
Slower onset, low grade symptoms
Malaria presentation
Plasmodium parasite
<1 month incubation
P. vivax hypnozoites can stay dormant for months-years
Fever, chills, sweats
Headache
Nausea, vomiting, anorexia
Body aches, general malaise
Fever, arthralgia/myalgia, rash
3 possible traveller’s infections:
Dengue
Zika
Chikungunya
Dengue presentation
Aedes aegypti mosquito
Incubation 4-10 days
Most asymptomatic or subclinical
Sudden onset fever
Arthralgia
Maculopapular or macular confluent rash 2-5 days after fever
Minor haemorrhage - epistaxis, heavy menstrual bleed, petechiae, gum bleeding
Extreme malaise
Headache behind eyes
Sore throat, conjunctival injection, abdo pain
Chikungungya presentation
Fever >39 several days-1 week
Bilateral, symmetrical arthralgia - small joints of hands and feet
Tenosynovitis
2-5 days after fever onset - maculopapular rash of trunk and extremities. Petechial or vesiculobullous in infants
Causes of travellers diarrhoea
Enterotoxic E coli (most common)
Enteroinvasive E coli
Enteroaggregative E coli
Shigella
Campylobacter
Salmonella
Norovirus (10-20%)
Protozoal parasites
Transmission of Hepatitis strains
Acute vs chronic
A, E - orofaecal, gastro symptoms, usually self-limiting
B, C, D - bloodbourne: intercourse, transfusion, vertical transmission, blood to blood
D always co-infected with B, indicator of worse prognosis. Cirrhosis, failure, ca.
C - 80% chronically infected
B - 50% chronically infected
Risk factors for
Hep A
Hep B, C, D
A - travel to high risk areas, sewage workers, MSM, IVDU
B, C, D - IVDU, tattoos, MSM.
B - endemic countries
HIV risk factors
Travellers and immigrants from Sub-Saharan Africa, SE Asia
MSM
IVDU
Related infections - Hep B, C, STI, TB
Symptoms of HIV
60% asymptomatic of acute infection
Fever
Malaise
Sore throat
Rash
Arthralgia/myalgia
Anorexia, weight loss, oral ulcers
Causes of meningitis
Viral - most common
Neisseria meningitidis
Strep pneumoniae
Haemophilus influenzae
Children:
Listeria monocytogenes
E coli
Enterococci
Herpes simplex
Consider partially treated meningitis, parameningeal focus (ears, sinus, cerebral abscess)
Management of suspected meningitis
Treat as bacterial until proven otherwise
Urgent medicine referral
IVabs if >20min delay to hospital
Neonates <3 months: Benzylpenicillin 50mg/kg, max 2g
Children 3 months to 10 years: Ceftriaxone 100mg/kg, max 2g
Adults: Ceftriaxone 2g + dexamethasone 10mg
IV access x2
IV bolus - 1L adult, 20mL/kg child
Bloods + blood cultures x2
Risk factors for meningitis
Infants, children, adolescents
Maori, Pacific
Exposure to smoke
Binge drinking
Other respiratory infection
Crowded house, institutionalism
Close contact with positive meningitis case
Immunocompromised
Cellulitis vs erysipelas
Cellulitis - Infection of dermis and subcutaneous tissue
Erysipelas - Infection of superficial dermis
Symptoms less likely to be cellulitis
Itch
Bilateral
Symptoms of nec fasc
Necrotising fasciitis
Symptoms
Management
Severe pain, systemic symptoms, purple discolouration, necrotic tissue, crepitus
IV ceftriaxone
Immediate referral
Risk factors for cellulitis
Elderly with poor circulation
Smoking
Immunocompromised
Diabetes
Overweight
Differential diagnoses for cellulitis
Thrombophlebitis
Lipodermatosclerosis
Radiation damage
Dermatitis
Fungal infection
Insect bite
Inflammatory breast ca
Antibiotics for cellulitis
Flucloxacillin
Children: 12.5-25mg QID 5 days
Adults: 500mg-1g tds/qid 5 days
Cefalexin
12.5-25mg/kg, 2-4 times/day, 5 days
500mg QID 5 days
Erythromycin
10-12.5mg/kg, QID 5 days
400mg QID 5 days
Co-trimoxazole
24mg/kg BD 5 days
960mg BD 5 days
Causes of UTI
E coli
Staph saporphyticus
Proteus
Klebsiella
Enterococcus
Diagnosis of catheter associated UTI
Fever >38
Suprapubic tenderness
Costovertebral angle tenderness
Urine dipstick or culture positive
No other cause of fever
Pyuria is common in catheter
Management of asymptomatic bacteriuria in pregnancy
Risk of preterm birth and low birth weight
Treat empirically, urine for culture
Treatment of UTI with haeamaturia
Macroscopic - treatment for 10 days, repeat urine 2 weeks post treatment
Microscopic - treatment for 7-10 days, repeat urine 1 week post treatment
Empiric antibiotic treatment for UTI
Men
Women
Pregnant
Child
Men:
Nitrofurantoin 100mg BD 7 days
Trimethoprim 300mg nocte 7 days
Cefalexin 500mg BD 7 days
Women:
Nitrofurantoin 100mg BD 5 days
Trimethoprim 300mg nocte 3 days
Cefalexin 500mg BD 3 days
Pregnancy:
Treat for 7 days
Not for trimethoprim first trimester
Not for nitrofurantoin after 36 weeks
Child:
Cotrimoxazole 24mg/kg BD 3 days
Cefalexin 12.5-25mg/kg BD 3 days
Augmentin 15m/kg tds 3 days
Nitrofurantoin - do not give in renal failure, CrCl <30
Symptoms of acute pyelonephritis
Fever
Flank pain
Nausea and vomiting
Augmentin
Co-trimoxazole
Cefalexin
Treatment of pyelonephritis
Cotrimoxazole 960mg BD 10 days
Augmentin 625mg tds 10 days
Cefalexin 1g tds/qid 10 days - only if susceptible and resistant to other choices
Refer pregnant women
Low threshold referral for elderly
Cause of Herpes zoster (shingles)
Varicella zoster virus
Recurrence in nerve root - stress, immunocompromisation, old age
Herpes zoster presentation
Blistering rash, allodynia, within dermatomal distribution, does not cross midline
Resolves in 10-15 days
Itching, tingling, pain along distribution and viral prodrome prior to appearance of rash
Treatment of Herpes zoster
Antiviral most useful within 72 hours of rash
Over 72 hours use if - new lesions, HZO, age >50, immunocompromised, prodrome presence, severe/disseminated rash, severe pain
Valaciclovir 1g tds 7 days
Aciclovir 800mg 5 times/day 7 days
Famiciclovir 500mg tds 7 days
Ice, calamine
Capsaicin cream (post herpetic neuralgia)
Lidocaine
Codeine
Tramadol
Oxycodone
Sometimes: prednisone, TCA, gabapentin
Complications of Herpes zoster
Uncommon in immunocompetent patients
Highest risk in lymphoproliferative cancers
Mortality 5-15%
Encephalitis
Meningitis
Pneumonitis
Blindness/permanent visual impairment - HZO
Post herpetic neuralgia
Causes of infectious mononucleosis
Epstein-Barr virus
Cytomegalovirus
Toxoplasmosis
HIV
Infectious mononucleosis symptoms and signs
Classic triad: Fever, pharyngitis, lymphadenopathy (posterior cervical)
Splenomegaly (50% in first 2 weeks)
Hepatomegaly + jaundice (uncommon)
Generalised maculopapular/urticarial/petechial rash - especially after amoxicillin
Fever + sore throat - 1 month
Fatigue - 2-3 months
Encephalitis diagnosis criteria
3 or more of:
Fever
Seizures
Focal neurological signs
CSF pleicytosis (WCC >5x10^6)
EEG slowing
Abnormal MRI
Causes of encephalitis
30-50% infective
Herpes simplex - most common
Measles
Varicella zoster
Adenovirus
Mumps
EBV
Enterovirus
Toxoplasmosis gondii
Mosquito, tick-borne virus
Mycoplasma pneumoniae
Influenza
Non-infective
acute demyelinating encephalomyelitis
antibody-mediated autoimmune disease
Paraneoplastic syndromes
Treat all suspected as infective until proven otherwise - antivirals + abx
Complications of encephalitis
Seizure
Hydrocephalus
Neurological sequelae - behaviour, motor disturbance
Herpes encephalitis in children 70% mortality untreated
Risk factors for encephalitis
Immunosuppression
<1 or >65
Unvaccinated
Exposure to infected contacts (cold sores)
Concurrent or recent viral infection
Animal/insect bite
Occupations - farming, abbatoir
Recreations - hiking, swimming, spelunking
Travel history
Causes of upper GI bleed
Peptic ulcer, oesophageal-gastric varices (most common)
Mallory-Weiss tears
Acute stress erosions (shock, NSAIDs)
Oesophagitis
Gastritis
Duodenitis
Upper GI cancer
Arteriovenous malformation
Forms of upper GI bleed
Haematemesis
Coffee ground vomit
Malaena
Haematochezia
Vital signs of moderate and severe haemorrhage
Moderate (25-50%)
- Postural drop 10mmHg
- Severe lightheadedness rising from supine
- Increase in HR by >30bpm rising from supine
Severe (>50%)
- Systolic BP <90mmHg
- Tachycardia >120bpm
Rockall score for upper GI bleed
Need for emergency endoscopy
Age 60-79 = 1
Age >80 = 2
Tachycardia >100, SBP >100 =1
Hypotension SBP <100 = 2
Renal failure, liver failure, disseminated malignancy = 2
Other significant comorbidity = 1
Glasgow Blatchford bleeding score
Score higher than 0 = urgent intervention
Hb <100
BUN >18.2
Systolic BP (initial) <100
Sex
HR >100 =1
Melaena =1
Recent syncope =2
Hepatic disease =2
Cardiac failure =2
Management of H pylori
Omeprazole 20mg BD 7-14 days
Clarithromycin 500mg BD 7-14 days
Amoxicillin 1g BD or metronidazole 400mg BD 7-14 days
Causes of lower GI bleed
Internal haemorrhoid, diverticular bleed - most common
Ischaemic colitis
Inflammatory bowel
Cancer
Rectal ulcer
Angiodysplasia
Post procedure
Discharge criteria for lower GI bleed
Age <60
Haemodynamically stable
No ongoing gross rectal bleed
PR or sigmoidoscopy reveals anorectal source
Causes of GORD
Functional - most common
Oesophagitis
Peptic ulcer disease
H pylori
NSAIDs
coeliac disease
Malignancy
GORD vs dyspepsia symptoms
GORD - heartburn, acid regurgitation
Dyspepsia - bloating, early satiety, epigastric pain/discomfort after meals, nausea
Management of GORD
GORD:
Lifestyle modification - spicy food, caffeine, ETOH, smoking, stress, obesity
Stepdown therapy - omeprazole 20mg OD 4-12/52 > 10mg OD > ranitidine > PRN antacids
Dyspepsia:
r/o H pylori
If bloating/early satiety - domperidone > ranitidine
Stepdown therapy
Risk factors for H. pylori (>30%)
From South Auckland, East Cape, Porirua
From low-middle income countries
Maori, Pacific, Asian
Red flag symptoms for upper GI malignancy
FHx gastric cancer <50
Unexplained weight loss
Progressive oesophageal dysphagia
Protracted vomiting, persistent regurgitation
Abdominal mass
Iron deficiency anaemia
Age >55 with persistent heartburn
Conditions with high risk of constipation
IBS
Dehydration
Diabetes
Neuro: Parkinson’s, MS
Electrolytes: hypercalcaemia, hypokalaemia
Psych: depression
Coeliac
Hypothyroidism
GI obstruction
Pelvic floor damage
Medications causing constipation
Antacids with calcium, aluminium
Antispasmodics
Antidepressants
Antihistamines
Antipsychotics
Anti-Parkinsons
Calcium supplements
CCB
Iron
Ondansetron
Opiates
Oxybutynin
PPI
Vinca alkaloids (chemo)
Management of constipation
Exercise
Dietary changes (water and fibre)
Response to urge to defecate
Bulk laxatives - psyllium, bran (2-3 days)
Stimulant laxatives - docusate + Senna (Laxsol), bisacodyl (Fleet),
Faecal softeners - docusate, Coloxyl
Osmotic laxatives - lactulose, molaxole, glycerol supps, Fleet
Identification of Seniors at Risk (ISAR) score
Before illness - needing regular help?
Since illness - needing more help than usual?
Hospitalised >1 night in last 6 months?
Generally see well?
Serious problems with memory?
3+ medications daily?
2 or more is high risk
Geriatric presentation that is a marker of frailty and risk factor for adverse outcomes
Urinary incontinence
Causes of falls in elderly
Syncopal - cardiac, polypharmacy
Non-syncopal - strength, balance, vision, proprioception, vestibular, environmental hazards (20%), acute medical illness
Delirium presentation
Acute onset over hours-days
Fluctuating course, impaired attention, altered awareness, cognitive + neuropsychiatric disturbance
Mood disturbance
Caused by underlying medical disorder
Independent risk factor for 6-month mortality rate
Hyperactive - hallucination, delusion, agitation, disorientation
Hypoactive - confusion, sedation
Mixed
Richmond Agitation Sedation Scale
Likelihood for delirium 57% if score >1 or <-1
+4 - combative, violent
+3 - agitated, aggressive, pulling tubes
+2 - agitated, non-purposeful movements, fights ventilator
+1 - restless, anxious
0 - alert and calm
-1 - drowsy, >10s sustained awakening to voice
-2 - light sedation, <10s brief awakening to voice
-3 - movement/eye opening to physical stimulation
-4 - unrousable
Common meds causing delirium
Opioids
Antihistamines
Benzos
CCB
Less clear:
H2 receptor antagonists
TCA
Antiparkinsons
Steroids
NSAIDs
Anticholinergics
Types of diabetes and features
Type 1
- 6 month - young adult onset
- Often acute onset
- Ketosis present
- Autoimmune condition
- Parental diabetes 2-4%
Type 2
- Onset after puberty
- Obesity related
- Ketosis uncommon
- Acanthosis nigricans, striae
- Parental diabetes in 80%
Maturity onset diabetes of the young (MODY)
- Onset after puberty
- Autosomal dominant
- Parental diabetes in 90%
Maternally inherited diabetes and deafness
- Onset after puberty
- Maternal mitochondrial inheritance
- Maternal diabetes 85%
Acute presentations of diabetes - hyperglycaemic crises
Diabetic ketoacidosis
- Usually T1DM
Hyperosmolar hyperglycaemic state
- More commonly T2DM
33% have combination of both
Polyuria
Polydipsia
Nausea/vomiting
Abdo pain
Dehydration
Altered mental state - lethargy, drowsy, coma
Elderly diabetic patient with chronic ear discharge and sudden onset severe otalgia
Malignant otitis externa
Can be life threatening
Symptoms specific to Grave’s disease
Pretibial myxoedema, exophthalmos, periorbital oedema, conjunctival oedema
Causes 85% hyperthyroidism
General symptoms of hyperthyroidism
Appetite stimulation
Flush, sweats, heat intolerance
Abdo pain
Restlessness, agitation
Tremor, weakness
Palpitations
Amenorrhoea
Hair thinning
SOBOE
Urinary frequency, hyperdefecation
Management of hyperthyroidism
Radioactive iodine 131
Carbimazole
Propylthiouracil
Surgical thyroidectomy
Beta blockers
Symptoms of thyroid storm
CNS - restlessness, delirium, psychosis, somnolence, seizure
GCS <14
Fever >38
Tachycardia >130, AF
Heart failure, pulmonary oedema
Nausea, vomiting, diarrhoea, jaundice
Management of thyroid storm
Urgent transfer to hospital
ABCs
IV fluids
Dextrose if hypoglycaemic
ECG
Bloods, infection screen
Passive cooling
Beta blockers for tachycardia
Benzos for agitation
rule out other causes - pregnancy, DKA, infection, embolism
NEVER use aspirin - releases more thyroid hormone
Symptoms of hypothyroidism
Fatigue, myalgia
Weight gain
Cold intolerance
Depression
Constipation
Dry skin
Menstrual irregularity
Bradycardia
Diastolic hypertension
Decreased reflex
Hyponatraemia
Hypercholesterolaemia
Macrocytic anaemia
Risks of hypothyroidism
Women
Treatment for hyperthyroidism
Turner, Down syndrome
T1DM, Addison’s disease, coeliac
Hx postpartum thyroiditis
Lithium, amiodarone
Calcium, antacids, phenytoin, carbamazepine, hormone replacement - increased thyroxine requirements
Myxoedema symptoms
Bradycardia
Cool peripheries, hypothermia
Non-pitting oedema
Hypoglycaemia
Hypotension
Thin hair
Altered consciousness
Management of myxoedema
Urgent referral to hospital
ABCs
IV fluids
IV dextrose (if hypoglycaemic)
Passive warming
Bloods, septic screen
ECG
Consider other causes - drugs, sepsis, DKA
Precipitants of adrenal crisis
Sepsis
Trauma
Surgery
Burn
Cardio/metabolic event
Meds:
Heparin
Warfarin
Azole antifungals
Phenytoin
Rifampicin
Symptoms of adrenal insufficiency
Fatigue
Weight loss, anorexia
Hypotension, syncope
Nausea, vomiting, diarrhoea
Abdo pain
Myalgia, arthralgia
Body hair loss
Irritability
Hyperpigmentation (primary only)
Symptoms of adrenal crisis
Shock and fever
**Hypotension refractory to fluids
Variable and non-specific: Weakness, fatigue, delirium/altered mental state, vomiting, diarrhoea, abdo pain
Hyponatraemia, hyperkalaemia
Causes of primary adrenal insufficiency
Addison’s disease - autoimmune
Congenital adrenal hyperplasia - enzyme deficiency
Adrenal haemorrhage (Waterhouse-Friedrichsen) - meningococcaemia
Tumours - breast, melanoma
Infection - TB, HIV
Causes of secondary adrenal insufficiency
Panhypopituitarism
Pituitary apoplexy - infarction or haemorrhage of tumour
Chronic steroid therapy
Tumours
Granulomas
Management of adrenal crisis
IV fluids
IV steroids - hydrocortisone 100mg
Urgent referral
3 most common cause of acute monoarthritis
Infection
Crystals
Trauma
Common locations for septic arthritis
Knee (50%)
Hip
Shoulder
Elbow
Risks for septic arthritis
Joint prosthesis
Foreign body
Previous joint damage
Overlying skin infection
Recent joint surgery/injection
RA
Diabetes
Elderly >80
Immunosuppression
IVDU
Organisms in septic arthritis
Staph aureus
Streptococci
Neisseria gonorrhoea
Pseudomonas aeroginosa
E coli
Xray features of osteoarthritis
Narrow joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes
Insidious onset
Morning stiffness resolving in 30 mins
Stiffness after inactivity, resolving in minutes
Pain worse with use, better with rest
Polyarticular, symmetrical. Usually sparing wrist and elbows
Heberden’s nodes
Bouchard’s nodes
Osteoarthritis
Over days-weeks
Morning stiffness
Preceding systemic illness - fever, myalgia, fatigue
Often asymmetric presentation
Rheumatoid arthritis
SI joints, axial spine, ribs
Often associated with iritis, heel pain
Ankylosing spondylitis
HLA-B27 in 90-95%
Arthritis in greater joints, lower > upper extremities
Erythema nodosum
Arthritis associated with inflammatory bowel disease
- Crohn’s
- Ulcerative colitis
No joint pain
Tender points in muscles
Headache
Irritable bowel
Fibrositis syndrome/Fibromyalgia
Asymmetric polyarthritis involving great and small joints, especially IPJ of toes
Associated enthesitis (inflammation of tendon insertion)
Absence of nodules
Psoriatic arthritis
Asymmetric arthritis of greater joints, lower > upper extremities
Also IP joints of feet
Associated keratodermia, geographic tongue, conjunctivitis, urethritis, Achilles tendonitis
Reactive arthritis
Commonly post GI/GU infections
Symmetrical polyarthritis involving greater and smaller joints
Skin rash - butterfly rash
Multisystem involvement
Systemic Lupus Erythematosus
ANA in 95%
Synovial fluid in septic arthritis vs gout vs psuedogout
SA:
Cell count >50x10^6/L
>90% neutrophils
Bacteria on gram stain
Gout:
Monosodium urate crystals (birefringent)
Psuedogout:
Calcium pyrophosphate dihydrate crystals
Gout diagnosis scoring system
Male = 2
Prev patient-reported arthritis attack = 2
Onset within 1 day = 0.5
Joint redness = 1
First MTP involvement = 2.5
Hypertension or CVD = 1.5
Serum uric acid >0.35 = 3.5
4 or less = gout ruled out
8 or more = 80% gout
Gout risks
Family hx
Purine rich foods - seafood, ETOH, red meat
Dehydration
Diuretics
Maori, Pacific
Management of gout
Paracetamol
NSAIDs - if no contraindications
Colchicine - if no contraindications
Prednisone - if infection ruled out
GP follow up to start allopurinol
Cont allopurinol if on it already
Use minimal amount of medications to control flare
Referral/discussion criteria for DVT
Bilateral
Pregnant
Proximal DVT (above popliteal fossa) with comorbidities
Suspicion of PE
Social situation
Pulmonary Embolism Rule out Criteria (PERC)
Age <50
HR <100
Sats >95% RA
No unilateral leg swelling
No haemoptysis
No recent surgery/trauma
No prior DVT/PE
No hormone use
Definition of anaphylaxis
Acute onset illness
- Typical skin features PLUS
- Respiratory, cardiovascular, or persistent severe GI symptoms
OR:
- Hypotension or bronchospasm or upper airways obstruction
- Even if typical skin features not present
Prevalence of biphasic reaction in anaphylaxis
3-20%
Management of anaphylaxis
Adrenaline 0.5mg/0.01mg/kg IM stat
- Repeat as required
Antihistamine
Steroids
Consider nebulised adrenaline for stridor
Nebulised salbutamol for wheeze
Monitor for 4-6 hours
Refer to hospital if requiring more than 1 dose adrenaline
Refer to immunology/paeds/gen med for follow up
