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My General Practise > Oxford summary 7 > Flashcards

Oxford summary 7 Flashcards

1
Q

head lice tx

A 
•	Dimeticone- 
•	Insecticide: effective. Four types 
o	Melathion 
o	Phenothrin 
o	Permethrin 
o	Carbaryl- prescription
o	Use 2 applications 7 days apart. Detector comb before and every 2 days until 2-3 after second application 
•	Mechanical: wet-comb conditioned hair with fine-tooth comb every 3-4 days for 2 weeks
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2
Q

HIV 1st presentation

A

Primary: half are symptomatic or
o Mononucleosis- like: fever, fatigue, myalgia/ arthralgia ± lymphadenopathy
o Blotchy rash on trunk and orogenital/ perianal ulceration
o Neurological symptoms, diarrhea

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3
Q

HIV Tx: antiretrovirals

A

Entry inhibitors, II, NRTI, NNRTI, PI

Aim is undetectable viral load in <6months

Prophylaxis for opportunistic infection

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4
Q

HIV opportunistic infections

A

CD4 <200: PCP, toxoplasmosis, esophageal candidiasis

CD4 <100: MAC, cytomegalovirus

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5
Q

HIV Immunizations

A

Inactivated vaccines- influenza, pneumococcal, HBV, HAV

Live are contraindicated- (BCG, typhoid) but do give varicella, MMR to child-bearing age women CD>200

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6
Q

Scabies tx

A

permethrin 5% or malation lotion, reapply after 1 wk

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7
Q

Malaria Symptoms:

P/C

A

headache, malaise, myalgia, anorexia –> recurring high fevers, rigors, drenching sweats for 8-12h at a time

anemia, jaundice ± hepatosplenomegaly

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8
Q

Malaria Investigations:

A

malaria blood test 3x

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9
Q

Falciparum malaria:

A

can present up to 3mo later

Can be fatal in <24 hours esp if Preggo or <3 years

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10
Q

Malaria Complications:

A

cerebral malaria, hypoglycaemia, renal failure, pulmonary oedema, splenic rupture, DIC, death

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11
Q

Benign malaria:

A

P. vivax, P. ovale, P. malariae
Can px up to 18months later. Low mortality
Lie dormant in liver- viva and ovale or blood

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12
Q

Diphtheria: corynebacterium diphtheria

A

Spread by droplet or fecal contact
Px: inflammatory exudate with grey membrane in resp tract. Cutaneous form in countries with poor hygiene
Toxin affects myocardium, nervous and adrenal tissues
Tx: antitoxin, IV abx
Prevention: vaccination + booster

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13
Q

Orf: on hand

A

Solitary, red, rapidly growing papule <1cm diameter
History of close contact with sheep, cause- parapox virus
Incubation 6 days, resolve spontaneously in 2-4 weeks
Complications: 2° infection, erythema multiforme, lymphangitis

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14
Q

Molluscum contagioisum: on face, neck, trunk

A

Preschool kids, DNA pox virus spread by contact
Px: discrete pearly pink umbilicated papules 1-3mm diameter, if you squeeze= cheesy discharge
Lesions are multiple and grouped
If untreated- spontaneously resolve after 12-18moths
Can remove contents with forceps, curettage or cryotherapy

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15
Q

Necrotizing fasciitis

A

Life- threatening soft tissue infection after surgery/ trauma
Ill-defined erythema + high fever, wound becomes necrotic
Tx: admit for IV abx emergency ± surgical debridement

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16
Q

Wound infection

A

Px: swelling, erythema, tenderness ± pus
Risk: malnutrition, DM, steroids, infection, carcinomatosis
Management- swab for M,C&S
o Indurated + localized= staph: flucloxacillin 500mg qds or clarithromycin 500mg bd
o + cellulitis= strep: penicil V 500mg qds or clarithromycin
Foul smell= anaerobes- metronidazole 400mg tds

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17
Q

Staphylococcal whitlow (felo)

A

Infection that involves bulbous distal pulp of finger after trauma or extension from acute paronychia

Px: red, hot, oedematous, tender bulb. Sudden onset of pain

Management
Fluctuant: admit for drainage and abx
Non-fluctuant: elevate, apply moist head and po abx

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18
Q

Folliculitis

A

Superficial infection of hair follicle- S. aureus
Px: pustule in hairy area
Risks: obesity, DM, occlusion from clothing, topical steroids
Tx: antiseptic  topical abx- fusidic acid  flucloxacillin
If recurrent/ chronic tx like boil

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19
Q

Herpes simplex infection:

Transmission

A

direct contact with lesions- anywhere on body- mouth, lips, conjunctiva, cornea, genitalia

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20
Q

Primary HSV stomatitis: prodromal period <6h

A

Propromal period <6h: tingling, discomfort, itching  small vesicles with erythematous base
Burt  multiple, small, painful mouth ulcers
+ systemic: f, m, tender LN
Tx: analgesic mouthwash- benzydamine- healing in 8-12d. if <48 since onset= acyclovir 200mg 5x/d for 5 d

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21
Q

Herpes simplex Recurrent:

A

precipitated by too much sunlight, febrile illness, physical or emotional stress, immunosuppression.
o Less severe, more localized
o Tx; acyclovir cream 5% 5x/d for 5 d

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22
Q

Herpetic whitlow: HSV inoculation through skin break- HCW>

A

Swollen, painful, erythematous lesion of distal phalynx
o Reccurent/ chronic: swab for culture. Topical bx- naseptin qds 10d, hygiene, antiseptic in bath chlorhexidine, long-term abx- clarithromycin 500mg od

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23
Q

Viral warts: common and benign

A

Common warts: on hands
o Dome- shaped papules with papilliferous surface
o In children 30-50% go spontaneously in <6mo

Plantar warts (verrucas): on soles of feet
o	Pressure makes them grow into dermis, painful 
o	Dark punctate spots on surface, group together= mosaics
Plane warts: on face and back of hands
o	Brown smooth, flat-topped papules 
o	Resolve spontaneously 
o	May show koebner phenomenon 
Tx: topical salicylic acid
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24
Q

Impetigo

A

Superficial infection due to S. aureus
Thin walled blister ruptures yellow crusted lesion
Most commonly on face, lesions spread and are contagious

Localized tx: topical abx- fusidic acid cream
Widespread tx: oral flucloxacillin or clarithromycin

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25
Q

Erysipelas and cellulitis

A

Acute infection of dermis. Px as flu like
Affects face/ lower leg- painful, tender erythema with well-defined border. Can be swollen and blister
Management:
Severe: admit and IB abx
Systemically unwell: flucloxacillin 500mg qds or clarithyromycin 500mg bd for 7-14d
Facial: penicillin V 500mg qds – flux if staph, clarithyromycin if allergic to penicillin
o Resurrent: prophylactic penicciln V 250mg od or bd

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26
Q

Boil

A

acute infection of hair follicle. Usually S. aureas
Hard, tender, red nodule around follicle + fever ± malaise
Can have pus and central core then heals, can scar

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27
Q

Carbuncle

A

group of hair follicles deeply infected. S. aureus
Swollen, painful with pus from several areas + fever + m
Management:
Non- fluctuant: moist heat for discomfort, help localize infection and promote drainage
Fever/ surrounding cellulitis/ facial lesion: flucloxacillin 500mg qds for 7d or clarithromycin if allergic
Large, localized, painful, fluctuant: incision and drainage
Recurrent/ chronic: swab for culture. Topical bx- naseptin qds 10d, hygiene, antiseptic in bath chlorhexidine, long-term abx- clarithromycin 500mg od

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28
Q

Kawasaki Disease: <5 years

Px with ≥5 of:

A

Fever for ≥5days
Bilateral conjunctivitis
Polymorphous rash
Lips/ mouth: red, dry, cracked lips, strawberry tongue
Extremities: red palms/ soles, oedema, peeling
Cervical lymphadenopathy >15mm, single, painful

Management: IV ig <10days after onset + aspirin
Complications: coronary arteritis + aneurysms, atherosclerosis

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29
Q

Scarlet fever: group A haemolytic strep
Incubation 2-4 days
Px:

A

fever, malaise, headache, tonsilitis, fine punctate erythematous rash sparing face, “scarlet” facial flushing+ strawberry tongue (white at first)

Tx: penicillin V 250-500mg qds for 10days

Complications: rheumatic fever and acute glomerulonephritis

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30
Q 
Hep B
Transmission: 
Px:  
Dx: 
Management:  
Prognosis:
A

Transmission: blood, sex, vertical, human bites
Incubation: 6-23 weeks
Px: asymptomatic or fever, malaise, fatigue, arthlagia, urticaria, pale stools, dark urine and/or jaundice

Dx: LFTS, serology
o HBsAg: 1-6mo post exposure. If >6mo later then chronic
o HBeAg: 6-3mo after acute infection = infectivity
o Anti-HBs: >10mo after infection= immunity

Management: avoid alcohol, supportive if acute. IFN + lamivudine if chronic

Prognosis: 85% recover, 10% become carrier, 5-10% chronic hepatitis cirrhosis/ carcinoma

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31
Q

Lyme disease: Borrelia burgdoferi

A

Spread: ticks from deer or sheep
Px: flu like + enlarged LN + arthralgia + splenomegaly + erythema migrans- red macule/ papule 7-10d later and expands to form ring with central clearing
Dx: serology, tx with 2-3wks of doxycycline

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32
Q

Hep A

A

Transmission via faecal- oral, infectious 2wks before being ill
Incubation 2-7weeks
Px: asymptomatic (kids), fever, malaise, anorexia, N/V, abdo pain, D, tender hepatomegaly, pale stool, dark urine, jaundice
Management: LFTs, IgM= acute, IgG=detectable life-long
Prevention: vaccinate travellers, chronic liver disease
Monovalent vaccine: Havrix
o HBV + HAV: Twinrix
o HAV + typhoid: Hepatyrix
o Passive with human Ig- protect for ≤3mo

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33
Q

Poliomyelitis

A

Spread: droplet or faecal-ral
Incubation=7d. Px 2d flu like then fever, tachycardia, headache, V, stiff neck + unilateral tremor (pre-paralytic stage)
65% with pre-paralytic state paralysis – myalgia, LMN ± RF
Management: supportive. 10% with paralysis die

Prevention
o 3 doses of 6:1 given at 2,4,6mo
o Booster in preschool and at 13-18years

Late effects: 20-30years later due to immobility
Weakness, fatigue, pain in muscles/ joints
Respiratory difficulty

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34
Q

Viral URTI

A

Coryza, runny eyes, malaise ± pyrexia, maculopapular rash

Management: exclude tonsillitis and otitis media. Self limiting

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35
Q

Pneumonia
Viral, bacterial (pneumococcal, HiB or staph, mycoplasma)

PC

A 
Present with ≥1:
o	Fever, recurrent or persistent >38.5°
o	Cough 
o	Chest and/or abdominal pain 
o	Tachypnea, creps, BS ± bronchial breathing
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36
Q

Pneumonia Tx

A

Severe: O2 sat <92%, RR >77 if <1y or >50 if >1y, not responding to abx- admit

Less severe: fluids, amoxicillin ± macrolide if atypical, penicillin allergy or not responding

Use co-amoxiclav if a/w influenza

Prevention: pneumococcal vaccine at 2, 4, 13 months

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37
Q

Bronchiolitis

A

Occurs in epidemics- winter> in infants <1 year
Due to RSV
Px: coryza ± fever  irritable cough, rapid breathing ± difficulty feeding
Ex: tachypnea, tachycardia, widespread creps ± high-pitched wheeze
Management
Mild: Paracetamol and fluids
Severe: lethargy, taking < ½ of feeds, dehydrated, intercostal recession ± nasal flaring, grunting, RR >70, cyanosis, O2 saturation <95% or apnoeid- admit

High- risk
Premature, <6weeks
Underlying lung disease, CHD or immunosuppression
Prophylaxis: palivizumab

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38
Q

Whooping cough: Bordetella pertussis

A

Incubation: 7 days
Stages
Catarrhal: 1-2wk- signs/ symptoms of URTI
Coughing: 2-6wk- severe and paroxysmal cough + spasms of coughing followed by whoop + V, cyanosis, exhaustion. Cough takes 2-3wks to improve
Examination: normal chest between bouts

Investigations: paranasal swabs- M, C and FBC

Tx: erythromycin in catarrhal stage then symptomatic

Prevention
Prophylaxis for contacts with erythromycin
Vaccination

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39
Q

Prevention of chickenpox

A

Varicella immunization 2 doses 4-8wks apart
Not contraindicated in preggos or Immunocompromised
If non-immune and exposed Vz-IG <3 after contact

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40
Q

Shingles

A

Cant be acquired by exposure to chickenpox but patients with shingles can get chicken pox
Px: unilateral pain before vesicular rash by 2-3d, crops over vesicles appear over 3-5d in dermatome distribution
Tx: oral acyclovir 800mg 5x/d if started <48h after rash
Px: shingles vaccine
Complications: post herpetic neuralgia, dissemination, eye involvement, Ramsay Hunt Syndrome

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41
Q 
Measles 	10 days	
Incubation: 10-14 days
Early symptoms:
Later sx: 
Com:
A

Early symptoms: fever, conjunctivitis, cough, coryza, LNs

Later sx: rash- maculopapular after 4days- becomes confluent, koplik’s spot- white spot on red background on buccal mucosa of cheeks

Com: bronchopneumonia, OM, stomatitis, corneal ulcers, gastroenteritis, appendicitis, encephalitis, SSPE

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42
Q

Rubella 10 days
Incubation: 14-21 days
Symptoms:
Complications:

A

Symptoms: mild- fever, LN, pink maculopapular rash for 3 days
Complications: birth defects, arthritis, thrombocytopenia, encephalitis

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43
Q

Mumps 10 days
Incubation: 16-21 days
Symptoms:
Complications

A

Symptoms: subclinical is common.
Fever, malaise, tender parotid enlargement ± submandibular

Complications:
aseptic meningitis, epididymo-orchitis, pancreatitis

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44
Q

Chickenpox 14 days Incubation: 10-21 days- infectious 1-2d before rash and 5d after

Sx:
Complications:

A

Sx: rash ± fever. Spots for 5-7d on skin/ mucous membrane. Macule  papule  vesicle  dry and scab

Complications: eczema herpeticum, encephalitis, pneumonia, birth defects, neonatal infection

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45
Q

Roseola infantum 4-7 days Child <2

Symptoms:

A

high fever, sore throat, lymphadenopathy, macular rash after 3-4d when fever decreases

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46
Q

Erythema infectiosum- 5th disease/ slapped cheek
4-7 days
Parvovirus infection
Sx:

A

erythematous maculopapular rash starts on face,
reticular, lacy rash on trunk and limbs,
mild fever,
arthralgia

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47
Q

Hand, foot, mouth disease 5-7 days
Coxsackie virus infection
Symptoms:

A

oral blisters/ ulcers,
red-edged vesicles on hands and feet,
mild fever

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48
Q

Type 1 DM

A

Any age but more common in younger
Autoimmune ± islet cell Ig. HLA DR3/4
Prone to weight loss and ketoacidosis

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49
Q

Type 2 DM

A

Risk: >65, obesity, Fhx, impaired glucose tolerance, south Asians, Africans, gestational diabetes
Progressive and leads to impaired insulin secretion + resistance
Insidious onset and complications at dx

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50
Q

Latent autoimmune diabetes in adulthood (LADA)

A

6-10% of patients with T2DM and:
No features of metabolic syndrome
Uncontrolled hyperglycemia with medications
Other AI disease
Anti-glutamic acid decarboxylase (GAB) Ig
Higher risk of ketoacidosis and need for insulin

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51
Q

Maturity onset diabetes of the young (MODY)

A 
Px <25 years with fhx. AD 
Gene mutations: 
HNF1- α, 
HNF1- β, 
HNF4-α, 
glucokinase- treatment different for each
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52
Q

DM Secondary causes

A

steroids, thiazides

pancreatitis, surgery, ca, haemochromatosis, CF

Endocrine: cushings, acromegaly, thyrotoxicosis, phaeochrom

glycogen storage disease, insulin R Ig

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53
Q

DM PC

A

Acute
ketoacidosis
hyperosmolar non-ketotic coma

Subacute: weight loss, polydipsia, polyuria, lethargy, irritability, infections, genital pruitis, blurred vision, tingling hands/ feet

Complications: skin changes, nephropathy, arterial/ eye prob

Asymptomatic: incidental or through risk stratification

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54
Q

DM Dx

A

Symptomatic:
Random blood glucose ≥11.1mmol/L or fasting ≥7mmol/ L
HBA1c ≥48mmol/L

Asymptomatic
RBG ≥11.1mmol/L or fasting ≥7mmol/ L x2
HBA1c ≥48mmol/L + random/fasting

Prediabetes: FBG ≥6.1 and <7mmol/L or HbA1c 42-47mmol/L

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55
Q

Routine diabetic review- 6monthly

A

Problems: live events, symptoms, difficulties with management

Review: 
o	HbA1c, lifestyle, injection technique 
o	Diabetes education, foot care
o	BG, lipid and BP therapy and results
o	Immunizations

Review complications: CV, nephropathy, neuropathy, eye disease, foot, erectile dysfunction

Planning: target for coming months, changes in therapy

56
Q

Monitoring blood glucose DM

A

Fingerprick capillary glucose monitoring- need if taking insulin

HbA1c: measure 2x/year. Average BG over previous 6-8weeks

57
Q

Indices of DM control

A

Adults FBG: 4-7 and PPBG: <9/
kids FGB: 4-8 and PPBG: <10

Urine: -ve

HbA1c: normal 20-43mmol/mol

Total cholesterol <4 and LDL <2
BMI: 25-30
BP <140/80- uncomplicated T2DM or <135/85- uncomplicated T1DM or <130/80 if any complications

58
Q

Metformin

A

DECREASED gluconeogenesis and INCREASED peripheral utilization of glucose
Need some endogenous insulin production
Avoid in elderly, CVD, RF, LF, alcoholics= risk lactic acidosis
Hypoglycaemia not a problem

59
Q

Sulfonylureas

A

First line if not obese, need rapid response or when met fails
Augment insulin secretion- so need endogenous insulin
SE: hypoglycaemia- take before meals and weight gain

60
Q

Piogliatazone

A

INCREASE insulin secretion/ sensitivity, DECREASE BP and total cholesterol
No hypos, can cause weight gain, bladder ca, fluid retention, HF
Use with metformin and/ or sulfonlurea if poor control

61
Q

DDP-4 inhibitors

A

INCREASE incretin levels. No hypos or weight gain
Use with metformin and/ or sulfonlurea if poor control
Linagliptin good for RF patients bc excreted by gall bladder

62
Q

DM Treatment
Eating and exercise
THEN
First- line oral hypoglycaemics:

A

Biguanides: metformin 500mg-1g bd
±
Sulfonylureas: gliclazide 80-160mg bd

63
Q

2nd/ 3rd line DM oral hypoglycaemics:

A

Pioglitazone 15mg od

DDP-4 inhibitors:
sitagliptin 100mg od, saxagliptin 5mg od, vidagliptin 5mg od/bd, linagliptin 5mg od

64
Q

OTHER hypoglycaemics

A

Exenetide- bd/wk, lixisenatide- od, liraglutide od- obese. INCREASE insulin and DECREASE glucose absorption. Use w/ met or sulfon

Rapid acting insulin secretagogues: neteglinide, repaglinide: INCREASE insulin release. Rapid onset and short duration. Use with met if erratic lifestyle

65
Q

DM Start insulin if poor control

A

combo with met + sulf

66
Q

Types of insulin

A

Rapid acting
Soluble human, porcine or bovine
Intermediate/ longer actingLong- acting insulin analogues
Pre-mixed

67
Q

Rapid acting insulin:

A

insulin lispro
Peak 0-3hours after injection, last 2-5 hours
Give prior to meals

68
Q

Soluble human, porcine or bovine insulin:

A

actrapid- short acting
Peak 2-6 hours after injection, last 8 hours
Take 15-30 minutes before meals

69
Q

Intermediate/ longer acting insulin:

A

humulin I
Peak 4-12 hours after injection, last 30 hours
Take alone, od/bd as background ± short acting

70
Q

Long- acting insulin analogues:

A

insulin glardine
Last 24hours- background insulin
Lower isk of hypos

71
Q

Pre-mixed insulin:

A

short acting + long acting

72
Q

DM Cardiovascular complications

A

Increased risk of MI, stoke, PVD
Aspirin 75mg od as secondary prevention
Control SBP <145/90 mmHg before

73
Q

DM

Statin: simvastatin 40mg or atorbastatin 20mg nocte

A

All T1DM with risk of arterial disease
All T2DM >75years
T2DM with any high-risk factors
T2DM >$0 with no high risk factors but 10y CVD risk >20%
Recheck lipid profile 1-3 months after starting therapy
Aim for total <4 and LDL <2

74
Q

DM Fibrate: fenofibrate

A

If TG >4.5mmol/L- to  pancreatitis risk

If doesn’t work- try omega 3 fish oil trial

75
Q

DM HbA1c

A

<48mmol/mol: if T1 or T2DM treated with lifestyle or 1-2 meds
<58mmol/mol for everyone else

76
Q

BP
T1DM

T2DM:

A

treat when SBP >135 or DBP >85, if proteinuria or signs of metabolic syndrome tx when SBP >130 or DBP >80

SBP ≥130 or DPB ≥80
Monitor every 4-6 months when stable

77
Q

DM Renal disease complications

UTI

A

Can exacerbate RF and lead to renal scarring

Consider papillary necrosis if recurrent

78
Q

DM Renal disease complications Nephropathy

A

More common in Asians and Africans
Proteinuria + HT + progressive worsening RF
Check renal function annually- first pass urine for albumin: Cr, dipstick for protein and haematuria, serum Cr and eGFR
Microalbuminuria when
o Ratio ≥2.5mg/mmol in males or ≥3.5mg/mmol in females OR
o [albumin]= ≥20mg/L without overt proteinuria or UTI

79
Q

DM Renal disease complications Management

A

Optimize BG, monitor BP and treat
Modify diet
Microalbuminaemia or CKD with ACEI/ARB even if normal BP

80
Q

DM Neuropathy types

A

Symmetrical sensory progressive polyneuropathy
Amyotrophy
Autonomic neuropathy

81
Q

Symmetrical sensory progressive polyneuropathy

A

Starts distally- feet> hands- glove and stocking distribution
Px: asymptomatic or numbness, tingling, neuropathic pain

Management for pain:

  1. Duloxetine 60-120mg/d
  2. Change to amitriptyline 10-75mg taken at 5-7pm
  3. Change to or add pregabalin 75-300mg bd
  4. Change to or add tramadol 50-100mg qds
  5. Refer to pain clinic or endocrinology
82
Q

Amyotrophy

A

Painful wasting of quadriceps- reverse with blood sugar control

83
Q

Autonomic neuropathy

A

Postural hypotension: common in elderly. Increase salt intake
Fludrocortisone 100-400mcg od (SE: odema) ± flurbiprogen or ephedrine hydrochloride 30-60mg tds to relieve odema
Midodrine- α- agonist

Urinary retention
Diabetic diarrhoea: tx with 2-3 doses of tetracycline 250mg or codeine phosphate 30mg tds/qds prn

Erectile dysfunction
Gastric paresis: tx with antiemetic- domperidone 30mg tds
• Gustatory sweating: tx antimuscarinic propantheline bromide

84
Q

DM Eye complications

A

Blurred vision: due to osmotic changes in lens

Cataract: “snowflake”- develop over days. Senile occur 10y earlier

Glaucoma

Retinopathy: most common cause of blindness
• BV get blocked, aneurysms, leaky leading to exudate formation, odeama or new vessels
• Tx: laser- photo-coagualtion to halt progression

Referral
• E: sudden LOV, rubeosis irdis, pre-retinal or vitreous haemorrhage, retinal deatachment
• U: new vessel formation
R: maculopathy, pre-proliferative retinopathy, cataract, drop in visual acuity

85
Q

DM Skin changes

A
  • Predisposition to infection
  • Pruitis
  • Xanthomas
  • Vitilido- T1DM
  • Neuropathic and/or ischaemic ulcers
  • Fat atrophy/ hypertrophy at injection site
  • Necrobiosis lipoidica: small, dusky red nodules with well defined borders. Single or multiple on shins. Slowly grow and turn brown. Yellow, irregular and flat. Can ulcerate
  • Diabetic dermopathy: pigmented scars on shins
  • Granuloma annulare: asymptomatic dermal nodules
  • Diabetic cheiroarthropathy: waxy skin thickening over dorsum of hand with restricted mobility
86
Q

Diabetes Mellitus

Diabetic Foot

A 
Neuropathic 
Warm foot, bounding pulses, normal ABPI 
Found in pressure points 
Painless 
“punched out” 
Surrounded by callus
Vascular
Cool foot, no pulses,  ABPI
Located at extremIties- between toes 
Painful 
Less clearly delineated
87
Q

Charcot osteoarthropathy (charcot’s joint)

A

Neuropathic damage due to loss of pain sensation

88
Q

TFTs

A

Thyrotoxic: low TSH, high T4
Hypothyroid: high TSH, low T4
Subclinical hypothyroid: high TSH, normal T4

89
Q

Graves disease

Px:

A

30-50 years. Smoking and stressful life

Hyperthyroidism
Diffuse goiter ± thyroid bruit due to increased vascularity
Thyroid eye disease, pretibial myxedema, acropachy, onycholysis

90
Q

`Thyroid eye disease px

A

Double vision, ophthalmoplegia (upward gaze>)
Exophthalmos and proptosis
Lid lag

91
Q

Hypothyroidism (myxedema)
Causes: chronic AI thyroiditis

Px

Screening

Management

A
  • Depression, fatigue, lethargy, mailaise, weight gain, constipation, hoarse voice, dry skin/ hair
  • Signs: goiter, slow reflexes, non-pitting oedema

• TFT in tiredness without cause, on amiodarone, 131I, hypercholesterolaemia, infertility, turners/ downs, depression, dementia, obesity, DM, other AI

• <65: lexothyroxine 100mcg. Check TFT after 4-6wksyearly
• Elderly/ with heart disease: levothryoxin 25mg then increase every 4-6 weeks (+ propranolol bc can provoke angina)
• Overcorrection = AF and osteoporosis
Need for life time

92
Q

thyroid tx β- blocker:

A

propranolol, atenolol for symptoms

93
Q

thyroid tx Carbimazole:

A

inhibit synthesis of thyroid hormone
o Not for thyroiditis
o Can give short term before radioactive I or surgery
o Long- term (12-18months) to induce remission
o SE: agranulocytosis, hepatitis, aplastic anemia, SLE- like

94
Q

thyroid tx 131I:

A

radioactive- need 3-4 months to work, TFT monitoring
o If on carbimazole, stop >4 days before and >3 after
o Avoid pregnancy for 4 months
o Risk of thyroid malignancy

95
Q

thyroid tx Surgery:

A

partial or total thyroidectomy. Risk damage to PT, RLN

96
Q

Pyloric stenosis

A

• Develops in first 3-6wks, failure to relax  hypertrophy of adjacent pyloric muscle
• First born, boys>
• A/w fhx, Turners, PKU, esophageal atresia
• Px
o Projectile non-billous vomiting
o Failure to thrive, dehydration, constipation “rabbit pellet”
o Pyloric mass- olive palpable in right upper abdomen
o Visible peristalsis after test feed
• Management: surgical with Ramstedt’s pyloroplasty

97
Q

Failure to thrive

A

• HC usually preserved relative to length and weight
• Weight consistently <3 centile or progressive  in weight over ≥2 major centiles
• Non-organic causes:
o Lack of food due to neglect, poverty, lack of education
o Emotional neglect- family problems
• Organic causes
o Chronic infection
o GI- coeliac, chronic diarrhoes
o Heart, metabolic, respiratory (CF) disease
o Physical feeding probz: cleft palate, pyloric stenosis
• Assessment
o Amount and quantities fed
o Feeding problems, physical problems
o Full examination, look for signs of neglect, family size
• Management
o Treat reversible cause
o Refer if: no cause found, treatment not effective

98
Q

Fever and acute illness in <5

Red- high risk symptoms/ signs

A
  • Appear ill- pale, mottled, ashen or blue
  • No response to social cues, doesn’t wake or stay awake
  • Weak, high- pitched or continuous cry, grunting
  • RR>60/min, moderate/ severe chest indrawing, T≥38C <3mo
  •  skin turgor, non-blanching rash
  • Bulging fontanelle, neck stiffness,
  • Focal neuro signs, seizures, status epilepticus
99
Q

Fever and acute illness in <5

Amber- intermediate risk symptoms/ signs

A
  • Pallor
  •  response to social cues, wake with excessive stimulation
  •  activity, no smile, nasal flaring
  • RR, O2 saturation ≤95%, crackels in chest
  • Tachycardia, capillary return ≥3sec, T ≥39° 3-6mo, rigors
  • Dry mucous membranes, poor feeding,  urine output
  • Swelling of limb/joint, not using extremity
100
Q

Fever and acute illness in <5

Green- low risk symptoms/ signs

A
  • Normal color, normal skin/ eye turgor
  • Respond to social cues, smiles, stays awake or waken easily
  • Strong normal cry or not crying
  • Moist mucous membranes
101
Q

Common cause of Apyrexia

A
  • Infections- UTI, TB, endocarditis
  • Malignancy- lymphoma, leukaemia
  • Immunological: stills or Kawasaki
  • Drugs: Abx
  • Liver/ renal disease
102
Q

Temperature

A

<4 weeks: axilla with electronic thermometer

≥4 weeks: axilla or infared tympanic thermometer in ear

103
Q

Acute illness in non-febrile kids

Can be sick without fever. Refer when:

A

o Red symptoms/ signs
o Persistent vomiting- > ½ of previous 3 feeds or bile stained
o Frank blood if stool or urine
o History suggestive of apneic episodes

104
Q

UTI in childhood

risk factors

A

• Poor flow, dysfunctional voiding, enlarged bladder
• Hx of previous UTI, reccurent PUL
• Renal abnormality, fhx of vesicoureteric reflux or renal diease
Constipation, abdominal mass, spinal lesion, poor growth, HT

105
Q

UTI in childhood

complications

A

• 5-15%  renal scarring <2 years after first infection
• A/w pyelonephritis, HT, impaired renal function, RF in adults
Worse prognosis when recurrent, VUR, scarring at 1st px

106
Q

UTI in childhood

PC

A

• Infants/ toddlers: V, irritability, fever, abdo pain, failure to thrive, prolonged jaundice
• Older: dysuria, frequency, abdo pain, haematuria, enuresis
Site: upper UTI/acute pyelonephritis: fever >38° ± loin pain

107
Q

UTI in childhood

Tx

A

• Suspect in any child with fever >38°
• Urine testing if S/S of UTI, PUL, failure to recover from fever
o >3y: dipstick- M, C&S if +ve nitrate or leukocytes
o <3y: dipstick if acutely unwell and urent microscopy not available. Send for M, C&S
• Treatment: trimethoprim bd for 3 day for lower and 7-10 for upper. Review after 24-48hours if not better and urine M,C&S
o >3: start right away if +nitrates
<3: start right away if symptomatic

108
Q

Congenital causes of childhood UTI

A

Horseshoe kidney
Ectopic kidney
Double ureter
Don’t affect function but predispose to UTI –> renal damage

109
Q

Funny turns:
exclude fit and underlying cause- heart disease

Hx
Exam

A
  • Ask witness about what happened
  • General health
  • Birth hx- problems in pregnancy, birth trauma
  • Family hx- epilepsy
  • Examination: full general/ neuro + developmental milestones
110
Q

Funny turns DDX:

A

non-epileptic or epileptic- febrile or childhood epilepsy

111
Q

Non-epileptic attacks DDx

Self- limiting and harmless

A

Simple blue breath-holding attacks: >6mo. Common due to frustration or upset
Signs: +ve valsalva, cyanosis, stiffening, coma
No tx- spontaneous recovery. Grow out by 3years

White reflex asystolic (anoxic) attacks: 6mo-2years. Due to minor injury or anxiety
Signs: vagal asystole, pallor, rapid coma, stiffening, upward eye movement ± incontinence
No tx- spontaneous recovery

Cardiac arrhythmia, hyperventilation 
Sleep phenomena 
Hypoglycaemia 
Benign myoclonus of infancy
Benign paroxysmal vertigo
112
Q

Febrile convulsions
Causes

Epileptic seizure due to fever in normal kid
Often fhx
<5min and generalized

A

o Viral infection
o Otitis media
o Tonsillitis
o UTI, gastroenteritis, LRTI, meningitis, post- vaccine

113
Q

Febrile convulsions

Serious pathology if

A

> 10min
focal febrile convulsion
Not recovered within 1 hour

114
Q

Febrile convulsions

Admit if

A

Complex, drowsy prior, irritable, systemically unwell, cause unclear
Meningitis suspected- petechial rash, abx or <18mo

115
Q

Febrile convulsions

If not admitted

A

Reassure that they aren’t harmful
Paracetamol doesn’t prevent but symptom control
Advise to seek help if deterioration, non-blanching rash, fits again or if worried

116
Q

Febrile convulsions

Outpatient referral if

A

Unsure if febrile convulsion
Frequent, severe and/or complex –> prophylaxis with buccal midazolam, rectal diazepam or anticonvulsants

High risk of epilepsy- fhx, coexistent neurological or developmental conditions

117
Q

Asthma in Children
Diagnosis: >1 of following

Particularly if:

A
  • Wheeze
  • Cough
  • Difficulty breathing
  • Chest tightness
  • Frequent and recurrent
  • Occur without URTI
  • Worse at night/ early morning
  • Due to or worse after exercise and other triggers
118
Q

Asthma in Children

Factors that increase likelihood:

A
  • Atopy- +ve skin test, esoniphilia ≥4 and/ or  specific IGE
  • Fhx atopy and/or asthma- maternal atopy>
  • Widespread wheeze, improvement of symptoms with tx
119
Q

Asthma in Children

Factors that decrease likelihood:

A

• Symptoms only with cold, cold without wheeze or difficult breathing, moist cough
• Dizziness, light-headedness, peripheral tingling
• No chest signs, normal PEFR/ spirometry when symptomatic
No response to asthma therapy

120
Q

Severe asthma in >2

A
  • O2 saturation <92%, RR >40 in 2-5y, >30 in >5yrs
  • PEFR 33-50%, cant talk, use of accessory muscles
  • HR >140 in 2-5y and >125 in >5
121
Q

Life threatening asthma signs in >2: O2 saturation <92% +≥1 of:

A
  • PEFR <33%, silent chest, poor respiratory effort

* Agitation, cyanosis, altered consciousness

122
Q

Significant asthma attach <2

A
  • O2 sat <92%, resp distress, too breathless to feed, cyanosis
  • Life threatening: apneoa, poor resp effort, bradycardia
123
Q

childhood asthma

Exacerbations: treat early.

A

Prednisolone 30-40mg/d >5y or 20mg/d if 2-5y for 3-14 days.

124
Q

Episodic childhood asthma

A

use leukotriene antagonists- start at onset of asthma/ coryzal symptoms and continue for 7 days

125
Q

childhood asthma Intermediate probability (usually <5) TX

A 
o	Watchful waiting with review: mild, intermittent wheeze and/ or symptoms with viral UTIs 
o	Trial of tx: bronchodilators and/or corticosteroids
o	Spirometry (usually >5): if evidence of airway obstruction, assess FEV1 change in response to tx, if  of >12% = asthma.  If no obstruction- test for atopic status, bronchodilator reversibility when symptomatic and/or bronchial hyper-responsiveness (exercise challenge)
126
Q

childhood asthma referral

EUR

A

E: severe exacerbation/ URTI, unexpected clinical findings- focal signs, abnormal voice/ cry, dysphagia, stridor

U: persistent productive cough, failure to thrive, unclear dx, failure to response to >400mcg/d corticosteroid

R: excessive V, symptoms since birth/ perinatal lung problem, fhx unusual chest disease, nasal polpys, parental anxiety

127
Q

childhood asthma Step management in <5

A
  1. Mild intermittent: inhaled short acting β2 agonist prn
  2. Regular preventer therapy:
    • + inhaled beclometasone dipropionate 200-400mcg/d
    • or leukotriene R antagonist if cant use steroid
  3. Add on therapy
    • 2-5y: leukotriene R antagonist, is used alone add inhaled steroid
    • <2: refer to respiratory pediatrician
  4. Persistent poor control
128
Q

Selection of inhaler device

A
  • MDI: inhale slowly and hold breath for 10s
  • Show inhaler technique before prescribing and at check-ups
  • Spacers and breath-activated devices if finding difficult or <5
  • Dry powder alternative for older
129
Q

Short acting βs agonist: salbutamol prn

A
  • Work quickly and with fewer SE

* Poor control if using ≥2 canisters/month or >10-12 puffs/day

130
Q

Inhaled corticosteroids

A
  • Most effective preventer. Consider if:
  • Exacerbations of asthma needing oral CS in last 2 years
  • Using inhaled βs agonist ≥3x/week
  • Symptomatic ≥3x/week or ≥1 night/week
131
Q

Add on therapy:

1. Inhaled LABA:

A

salmeterol
1st choice in >5 - improve lung function and symptoms
Don’t use with inhaled steroids

132
Q

Add on therapy:

2. Leukotriene receptor antagonist:

A

montelukast
decrease symptoms and exacerbations. Improve lung function
1st choice in <5

133
Q

Add on therapy:

3. Theophylline or βs agonist

A

slow release tablets

decrease symptoms and improve lung function but SE common

134
Q

Add on therapy:

Stepping down:

A

at ≥3mo intervals.

Lowest dose inhaled steroids.

135
Q

Step management in <5

A
  1. Mild intermittent: inhaled short acting β2 agonist prn
  2. Regular preventer therapy:
    • + inhaled beclometasone dipropionate 200-400mcg/d
    • Use other preventer therapy if cant use steriods
  3. Add on therapy
    • + LABA
    • Assess control of asthma
    o Good: continue LABA
    o Control inadequate:  steroid to 400mcg/d
    o No response: stop and  steroid to 400mcg/d, if doesn’t respond try LRA or SR theophylline
  4. Persistent poor control
    • Increased inhaled steroids to 800mcg/day
  5. Continuous or frequent use of oral steroids
    • Use daily steroid tablet in lowest possible dose
    • Keep inhaled steroid at 800mcg/d
    • Refer to respiratory pediatrician

My General Practise (8 decks)

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