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Passmedicine Flashcards

1
Q

Contraindication of ear irrigation?

A

0 Grommets - currently in or has a history of use. - can be done if grommets have been removed 18 months ago & discharged from ENT (Head & Neck ) clinic.

0 Otitis media (middle ear infection) within the last 6 weeks.

0 otitis externa infection
0 Tympanic memebrane peforation / history of mucous discharge in the last year.

0 difficulty with ear irrigation in the past. (unpredictable experience)

0 Previous ear surgery of any kind e.g. mastoidectomy etc.

0 Has a cleft Palate. (opening in the roof of the mouth)

EAR IRRIGATION - removal of wax , foreign bodies - cleanses ears by using fluid to flush it.

GROMMETS - (Tympanostomy tube, also known as a grommet or myringotomy tube, is a small tube inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time, and to prevent the accumulation of fluid in the middle ear.)

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2
Q

What is Baker’s Cyst ?

A

Popiliteal cyst (fluid filled swelling develops at the back of the knee) - typically found on medial aspect.

CAUSES :

MOST ARE SECONDARY - put can be primary (idopathic - there would be no connection btw bursa & knee joint - mostly found in children )

0 Osteoarthritis
0 Sports related injury / blow to the knee
0 Inflammatory arthritis
0 Gout - uric acid build - big toe - arthritis.
( more likely in women as more prone to autoimmune conditions )
CHILDREN - Juviline idopathic athritis

SYMPTOMS

0 pain in knee / calf
(if cyst ruptures- might feel a sharp pain, swelling & redness in calf )

0 build u[ of fluid - around knee

0 Joint can lock or click

DIAGNOSIS / INVESTIGATION

1ST - Duplex ultrasound
 of leg (cause it is fluid filled )

(can do MRI of lg - to look for underlying pathology e.g torn ligament)

SOME DIFFENTIALS

  • Politeal (P) muscle tear
  • P Haemotoma
  • P aneurysm
  • P Lymphocele
  • P abscess
  • Knee effusion
  • DVT etc.

TREATMENT

Asymptomatic - no treatment

Symptomatic - conservative management e.g simple angalesoa / physiotherapy (aspirin / para/ ibuprofen)

Refractory to conservative management

1ST - Correction of underlying joint pathology

ADJUNCT - inarticular corticosteriods
e.g. Betamethasone sodium phosphate / acetate

  • Methylprednisolone acetate
  • Triamcinalone acetonide.

ADJUNCT - support - simple analgesia
- Physiotherapy

2ND LINE
Surgery

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3
Q

Treatment of Trunk limb Psoriasis in children / young people ?

A

Topical therapy

0 Calcipotriol once daily - over age 6
(Vitamin D derivative )

(Vitamin D - found to improve symptoms and deficiencies been linked to flare ups - Vitamin D helps to strengthen immune system & psoriasis is an autoimmune condition)

0 A potent Corticosteriod once daily - over age 1 .

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4
Q

Treatment of Trunk limb Psoriasis in Adults ?

A

1ST LINE

  • Potent Corticosteriod + vitamin D / analogue - 4 weeks duration - both once daily

2ND LINE-
If 1st line does not work after 8 weeks maximum

  • Vitamin D / analogue twice daily

3RD LINE -
if 2nd line not work for maximum 8 -12 weeks.

  • Potent corticosteroid - twice daily - up to 4 weeks

or

  • Coal tar preparation - once/ twice daily.

4TH LINE

Calcitriol monohydrate + betamethasone propionate
- once daily - up to 4 weeks

  • potent steroids - only given when other topicals have failed & for maximum of 4 weeks under specialist acre & supervision.
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5
Q

Treatment of Scalp Psoriasis ?

A

1ST LINE

  • Potent corticosteroid - up to 4 weeks.

if not working - try different formulation e.g shampoo , mousse.

and/or

  • Topical agents to remove adherent scale (e.g salicylic acid agents , oils , emollients ) before steroid application

2ND LINE

calcipotriol monohydrate and betamethasone dipropionate

OR

  • Vitamin D / analogue - twice daily (only for mild - moderate or if potent steroid intorable / not working)

3RD LINE

  • Very potent corticosteriod - 2 weeks only

or

  • Coal tar - twice daily
  • referral to specialist
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6
Q

Treatment of Psoriasis of face , flexures or genitals ?

A
  • these areas particularly vulnerable to steroid atrophy - steroid only used short term (1 -2 weeks a month)
  • NEVER USE VERY POTENT ON THESE AREAS.

1ST LINE

  • Mild / moderate potency corticosteroid - once / twice daily.

2ND LINE - if 1st not working or risk f local corticosteroid induced side effects.

Calcineurin inhibitor

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7
Q

Treatment of atopic dermatitis ?

A

1ST LINE

Topical corticosteriods & emollients

(ADJUCNT - if sign of infection - oral antibiotics )

2ND LINE - CHILDREN (12 -16)

Topical Calcneurin inhibitors e.g

0 Tarcolimus - (for moderate - severe )

0 Pimecromlimus - for moderate on neck or face

2ND LINE - ADULTS with AE of hand eczema
(after trying w

0 Topical calneurin inhibitors

3RD LINE - UV light therapy or Coal tar

4TH LINE

0 Systemic immunosuppressant therapy e.g azathioprine , methotrexate , ciclosporin , mycophenolate mofetil etc.

5TH LINE

0 Baricitinib - JAK 2 inhibitor

or

0 Dupilumab - monoclonal antibody

(biological DMARDS - used in Rheumatoid A treatment as well)

in general if not sleeping - can give antihistamine or doxepine

e.g.
Chlorphenamine
Diphenydramine

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8
Q

Bulbous pemphigoid
Pemphigus
syphillis - e.g primary , secondary , tertiary
Molluscum contagiosum

rhinophyma
rosacea

spider navei have been linked to use of oral contraceptive pill - increase of estrogen or during pregancy

artinic keratonosis.
zollinger ellison syndrome 
peptic ulcer disease 
pyloric stenosis - projectile vomiting. 
anal fissure

look at gastrointestinal therapeutics - 557

stimulant laxatives e.g senna etc cause colicky pain - act on enteric nervous system to stimulate peristalsis.
celiac crisis

pre-eclampsaia
mumps
rubella
haemolytic disease of the new born. 
opiod overdose- naloxone (antidote)
aspitin overdose treatment (sodium biocarbonate)

Ones to write notes on.

large cell carnoma
small cell carninoma - linked to endocrine syndromes - purple stretch marks ?

A

Flurouracil - artinic keratinosis , basal cell carinoma

imiquimod

art

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9
Q

Examples of antihistamines.

A

loratadine: 10 mg orally once daily

OR

desloratadine: 5 mg orally once daily

OR

cetirizine: 10 mg orally once daily

OR

levocetirizine: 5 mg orally once daily

OR

fexofenadine: 180 mg orally once daily

Secondary options
diphenhydramine: 25-50 mg orally every 4-6 hours when required

OR

hydroxyzine: 25 mg orally every 6-8 hours when required

OR

chlorphenamine: 4 mg orally (immediate-release) every 4-6 hours when required, maximum 24 mg/day

OR

doxepin: 10-100 mg orally once daily at bedtime when required

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10
Q

What drugs cause dyspepsia?

A

Alpha blockers

0 Beta Blockers

0 Calcium channel blockers

NSAIDS - including aspririn

0 Corticosteriods - oral not inhaled.

0 Biphosphonates

0 Benzodiazepines

0 Antimuscarnics

0 TCA - Tricyclic antisepressants

0 Nitrates

Theophyllines

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11
Q

What is oculogyric crisis ?

A

Type of acute dystonia
(ACUTE DYSTONIA - abnormal face and body movements which occur as a result of sustained muscle contractions. They manifest as facial
grimacing, tongue dystonia, torticollis (neck), oculogyric crisis (eye), trismus (mouth) or other abnormal posturing.)

Oculogyric - bilateral elevation of the visual gaze,
(prolonged involuntary upward deviation of the eyes)

Capsule definition - sudden involuntary contractions of her eye muscles, fixing her eyeballs in an upward gaze

- Can be caused by drugs/ medications e.g. 
0 Metaclopramide - anti -emetic. 
0 
- antipsychotic medications
- anticholinergics 
-
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12
Q

What can Metaclopramide not be used in?

A 
Because it increases gut motility, it must not be used in:
0  gastrointestinal obstruction
0 perforation
0 haemorrhage.
(anything to serious)
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13
Q

1st line of anti emetic use in pregnancy ?

A

1ST LINE promethiazine or cyclizine

ALTERNATIVE - Prochloperazine and chlorpromzine

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14
Q

A 65 year old woman presents to the emergency department with profuse vomiting. She is diagnosed with small bowel obstruction. What is the most important initial treatment?

A

Nasogastric tube placement

If a patient has a mechanical obstruction causing their vomiting, no anti-emetic will help. Decompression of the stomach with an NG tube is the only way to stop them vomiting. Metoclopramide is specifically contra-indicated in such patients as it promotes gut motility and as such may cause encourage perforation.

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15
Q

Side effect of GTN ?

A

Is a vasodilator - dilates the vessels in brain - cerebral vasodilation - cause headaches - can be intorable for some .

give paracetamol for headaches

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16
Q

What is Ditiazem ?

A

Calcium channel blocker.

17
Q

Treatment of Anal fissure ?

A

Conservative management

ADJUNCT - GTN Topical (intranal)

or Diltiazem topical - if GTN not tolerated e.g headaches.

2ND LINE - Failure after topical treatment

Botulinum toxin injection

or Sphincterotomy - anal sphincter is stretched or cut - risk of incontinence (especially after pregnancy)

3RD LINE -anal advancement flap - worse outcome than spincterectomy but less chance of incontinence.

18
Q

contra-indications to the use of laxatives ?

A

contra-indications to the use of laxatives include :

  • Bowel obstruction.
  • known or suspected perforation
  • severe inflammatory conditions of the GI tract
    0 severe Crohn’s
    0 severe ulcerative colitis
    0 toxic megacolon
19
Q

Laxative commonly used to empty bowel before colonscopy ?

A

Magnesium citrate with sodium picosulfate (Picolax)

(This situation calls for formal bowel preparation. Normal laxatives will not be sufficient to clear the colon completely. Picolax (sodium picosuphate with magnesium citrate) is commonly used for bowel preparation prior to investigation or colorectal surgery. Two or three sachets are taken the day before the procedure – it begins to act within 3 hours of the first dose. Most endoscopy units will have protocols for bowel preparation so it is important to ensure you are following the protocol for the hospital you are working in. It is usually combined with a low residue diet on that day, to reduce the amount within the bowel. Bowel preparation must be used with caution in children, the elderly or debilitated and those with renal impairment. It can cause dehydration and electrolyte disturbances so it is important to advise patients to drink plenty when taking the medication. Side effects include nausea, vomiting, abdominal pain and distension, rarely, it causes headache and dizziness.
JUST READ !!!!!!!!!!!!!)

20
Q

Diagnosis of coeliac disease .

A

Immunoglobulin A tissue transglutimase

followed by duodenal biopsy and histology

21
Q

Schistosomiasis = treatment

A

pranzquantel - high risk . (extended exposure)

rash can occur a fews days after infection - for rash & pruitus (itchiness)

mometasone topical (Topical corticosteriod)

and

diphenhydramine: (antihistamine)

calamine lotion topical

22
Q

What is Seborrhoeic dermatitis?

  • appearance
  • risk factors
  • key diagnostic factors
A

Seborrhoeic dermatitis (called cradle cap on scalp- child vs dandruff or pityriasis capitis in adults)

Chronic inflammatory condition

APPEARANCE

0 Erythema (reddening and scaling patches)
commonly on scalp and nasolabial folds.

Also on :
- Glabella (area of forehead above eyebrows and between them)

  • posterior auricular skin
  • anterior chest

(also key diagnostic factor - scaling on these areas & itching and white flakes )

RISK FACTORS

  • HIV/AIDS - explosive and often generalized onset of SD - may appear as central facial rash similar to SLE.
  • Under 3 months - common in infancy - cradle cap

STRESS CAN WORSEN SD.

23
Q

Diagnosis. and investigations of SD?

A
  • Clinical diagnosis
  • when diagnosis in doubt:
    0 Skin biopsy.
24
Q

Treatment of SD?

A

SCALP

0 CRADLE CAP

infants

  • 1ST Line :
    Emollients e.g. olive oil topical
  • 2ND Line :
    Topical corticosteriods e.g Hydrocortisone (HC)

if recalicitrant (stubborn - treatment needed beyond 3 months) - refer to dermatologist)

Children & adults - limited to scalp
- 1ST Line
Topical shampoo e.g coal tar , salicyclic acid , ketoconazole (K) , pyrithione zinc etc)

C & A - not limited to scalp

  • 1ST Line:
    Topical corticosteriods or antifungals
    K , HC , Betamethasone dipropionate) , sertaconazole, desonide.
  • 2ND Line
    Topical Calcineurin inhibitors
    e.g Pimecrolimus or tarcolimus

WIDESPREAD OR RECALCITRANT -

ADULTS

  • 1ST Line
    Oral antifungal therapy e.g ketoconazole, itraconazole

CHILDREN

referal - dermatology.

25
Q

Differential diagonosis Of SD ?

A

Psorasis - can look very similar to scalp SD.

SLE - SLE plaques are less scaly , carmine (more red) coloured ad have more firmly adherent scale.
(ANA , anti - ENA positive)

Tinea capitis -
may not be erythematous or inflammatory.

Common in pre -adolescent children unlike SD. if symptoms of SD happen in this group TC should be suspected.

Impetigo - has golden crusts

Dermatitis contact - found at site of contact - patch testing can be done.

OTHERS:
Atopic dermatitis 
- Acne rosacea
- Acne Vulgaris
- Leiner's disease
- Lichen planus 
- Erythroderma
- Dermatitis , atopic 
-Histocytosis X
- Actinic Keratosis
- Lichen planus 
- erythroderma
26
Q

What are the different types of tinea infection?

A

Tinea pedia- feet
Tinea capitus - head
Tinea Corporis - trunks , legs , arms, neck - can present as red inflamed patches.
Tinea unguium - nails (fingernails & toenails)
Tinea cruris - body folds

0 Tinea mannum - infection of 1 or both hands (rare but can occur with tinea pedis (one hand , two feet syndrome)
SIGNS
- diffusely drug palmar surface with hyperkeratosis.

ALL lesions can present as erythematous , scaling rash with central clearing (centre looks healed)

Tinea capitus -
Skin discomfort
Scaling scalp lesions
Patchy alopecia

TINEA infections are dermatophyte infections

RISK FACTORS

  • Exposure to infected people , animals , soil
  • chronic steriod use
  • HIV
  • Hot, humid weather
  • Occulsive weather
  • frequent public bathing barefoot
    deformities of feet
  • trauma to skin.
  • diabetes & other metabollic disorders
  • obesity.

INVESTIGATIONS

CONFIRM DIAGNOSIS

  • Potassium hydroxide microscopy (POH) - needs to be done before starting treatment for capitius & nail infections

If high index of suspcision but negative POH - fungal culture

27
Q

Treatment of Tinea capitius ?

A

1ST LINE

DIAGNOSIS

  • Scaling , itching of scalp
  • Single or circular patches of hair loss (Alopecia ) which is asymmetrical.
  • black dot appearence (broken off swollen hair follicles - may be present )
  • erythema , scattered pustules , crusting
  • Systemic antifungal therapy
    e..g either Oral terbinafine , Griseofulvin
    or Itraconazole - if Grise contraindicated

ADJUNCT - consider co-prescribing Topical antifungal (to reduce risk of transmission ) e..g Ketocanzole , selenium sulfide

IF KERION PRESENT REFER.

Majocchi’s granuloma / nodular granulomatous perifolliculitis (fungal infection of the hair , hair follicles caused by dermatophyte infection)

Tinea Barbae - infection of skin , hair , hair follicles of bread & mustache

(All these require systemic therapy first line).

28
Q

Treatment of tinea on body & groin ( faciale , corporis , cruris , pedis)?

& Diagnosis , typical appearence

A

Single or multiple red or pink , flat slightly raised ring shaped patches . - enlarge outwards

0 active red scaling advancing edge with clear centre

0 usually asymmetrical in distribution

Groin involvement - inguinal folds , promximal medial thighs , perianal skin , buttocks .

DIAGNOSIS

Skin scrapings & microscopy

1ST LINE

LIFESTYLE MODIFICATION (loose clothing , not share towels etc) - for all lines of treatment

+

  • Topical antifungal e.g terbinafine
    if does not work try other topical :
    Imidazole , clotrimazole , miconazole or econazole.

2ND LINE - oral antifungal - Terbinafine
( if contraindiacted Oral itraconazole or griseofulvin.)

ADJUNCT -Topical steriods ( if signs of inflammation)

29
Q

Treatment of nail infection - tinea ?

A

SELF CARE advice (keep nails short , stop wearing occuslive footwear etc.)

1ST LINE

Topical antifungals -amorolafine 5 % nail lacquer

Or

1ST LINE - if self - care measures & topical not working OR Not appointed i.e nail infection is more severe (e.g can’t walk properly etc) & nail infection confirmed

Oral antifungal - terbinafine , if alternative needed - itraconazole
(if either contraindicated -Griseofulvin)

NOTE - if nail infection is not a tinea / dermatophyte infection for example is candida infection instead - Itracnazole is used first line.

30
Q

What is bullous pemphigoid ?

A

Chronic , aqcquired autoimmune blistering disease

(NICE - blistering disease of the elderly which starts with uriticaria but can be eczematous rarely) —> Later large , tense blisters develop.

SIGNS /SYMPTOMS

  • Pruritis ( may precede clinical symptoms by 3-4 months)
  • Erythematous or uticarial plaques
  • *Tense blisters on normal or erythematous skin.
  • Oral lesions (not common - 30% of patients) - but does not usually involve mucousal membranes e.g mouth, gut etc - differiates from pemphigus.

RISK FACTORS

  • Age - 60 -90 years
  • Major histocompatibility complex (MHC) class II allelle (DQB1*0301)
31
Q

Diagnosis of Bullous pemphigoid?

A

0 Skin biopsy for direct immunofluorescence testing

0 Skin biopsy for histology (with light microscopy)

(both needed in people presenting with blisters to rule out immunobullous disease e.g Bullous pemphigoid , , Dermatits herpetiformis , Pemphigus vulgaris , folliaceus, pemphigoid gestationis etc.)

CONSIDER - ELISA test if diagnostic info not produced by the skin biopsies.

32
Q

Treatment of bullous pemphigoid ?

A

1ST LINE

Topical corticosteriods
(topical tarcolimus can be used in special cases)

WIDESPREAD LESION - in adults

1ST LINE - Oral corticosteriods (prednsolone)

2ND LINE - Oral steriods + antibiotics (cyclines e.g. tetracycline etc or ethromyocin + /-nicotinamide (form of vit B3)

IF Steriods contraindiacted :
replace with Dapsone or Suppressants (Methotrexate, azathropine etc.)

if metho given supply folic acid or calcium folinate)

IF NO ADEQUATE RESPONSE

3RD LINE - Pred + immunosupression OR Immunosupression ALONE

4TH - Plasmapheresis or IVIG

CHILDREN - are the same as adults except if steriods contraindicated just have DASPONE or ANTIBIOTIC THERAPY ALONE AS 2ND LINE
& if inadquate response dasponse or high dose IV methylprednisolone.

ADJUNCT - sedatimg antihistamines e.g hydrozyzine or diphendramine. (IF ITCH VERY HARD TO DEAL WITH)

33
Q

What is pemphigus?

A

Group of autoimmune blistering diseases affecting the epidermal surface of skin , mucosa.

TYPES

0 Pemphigus vulgaris (PV)- skin & mucous membranes
0 Pemphigus foliaceus (PF)- just skin
0 Paraneoplastic pemphigus (PNP) - pemphigus associated with underlying maligancies (Least common most serious)

SIGNS /SYMPTOMS

PV - erosions & painful blisters on irritated or healthy skin.
Located around lining of:
- Mouth
- Nose
- throat
- genitals
(Can occur in mouth & burst making it difficult to eat/swallow (& if there is oesophageal involvement) & prone to blisters around body prone to infection if they burst)

MAIN POINT -

-Usually develop in mouth (oral lesions) —————–> then other areas (most common seborrhoeic areas - chest , face , scalp, interscapular region (back)) ——————–>Flaccid (Loose hanging) Blisters containing clear liquid develop on non -erythematous skin , quickly transforming into post-bullous lesions (scabs)

0 Dysphagia

PV & PNP

PNP & PV have similar symptoms :

0 Chronic mouth erosions (MOUTH INVOLVMENT IS KEY TO DIAGNOSIS OF PV & PNP)
0 Bloody nose
0 Painful skin (also PF)
0 Conjunctivitis

0 Pruritic scalp, skin (ONLY PV & PF)

PNP - Pulmonary involvement is a characteristics & life threatening.

0 Painful lips - Intractable (unstoppable muscositis - inflammation of the gut & mouth - hallmark of PNP & side effect of chemo & radiotherapy)

  • SOB - associated with type of bronchiolitis obliterans pnemonia. (lung condition -inflammatory condition involving both bronchioles & alveoli)

PF -
Flaccid blisters r crusty erosions in mostly seborrhoeic areas NO MUCOSAL INVOLVEMENT (e.g no mouth , oesphagus , gut etc)

RISK FACTORS FOR ALL

  • Increasing age
  • HLA DR4, HLA DR1 (PV)
  • HLA BRB1 (PNP)
  • Associated maligancy (PNP)
34
Q

Diagnosis of Pemphigus ?

A

0 Skin biopsy , Haematoxylin and eosin stain

0 Skin biospy , direct immunofluroscence.

CONSIDER:

0 Serum ELISA - detection of autoantibodies - Desmogein 1 & 3 -positive test indicates disease.
(some people have the antibodies but no active disease)

0 Upper GI endscopy - if oesopheageal involvement suspected .

0 CXR , PFTs, Chest CT scan - PNP - pulmonary involvement
e.g bronchiolitis obliterans.

Serum Immunoblot - western blot (similar to ELISA - autobodies)

35
Q

Treatment of PV ?

A

1ST LINE

Oral corticosteriod (Pred) +/- Immunosuppressant (Azathioprine mycophenolate, rituximab)

ADJUNCT - Bone protection (Ca , vitamin D , biphosphonate)

ADJUNCT - SUpportive measures - dental acre , intralesional injection of corticosteriod , antiseptic baths (bacterial skin infections ) etc )

2ND LINE - Rituximab (if 1st line not working or steriods contraindicated )

36
Q

Treatment of PF?

A

Topical corticosteriod (Betamethasone dipropionate)

or Daspone +/- topical steriods

or Rituximab +/- topical (betamethasone) or oral steriods (Pred)

2ND LINE

Oral pred +/- azathroprine or Mycophenolate

ADJUNCT - Bone protection & supportive treatment.

37
Q

SEVERE - MODERATE PV & PF or severe /refractory Treatment ?

A

SEVERE - MODERATE

Oral pred + aza /myco
or ritximumab +/- oral pred. (same for PF)

-if after 6 months not complete remission - change to Rituximab
(if remission continue on existing treatment)

SEVERE / REFRACTORY PEMPIHIGUS

  • IVIG or IV steriod or immunoadsorption

ADJUNCT - Bone protection & supportive treatment

38
Q

Treatment of PNP?

A

Refer to oncologist

monitor PFTs ,
check for respiratory failure (most common cause of death), bronchiolitis obliterans

0 ELISA monitoring - check levels of ant i -Dsg1/3) - autoantibodies

AMK (92 decks)

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