PH1122 - ENT Flashcards
what is the time frame from a cough to be classed as being “acute” ?
less than 3 weeks
what is the time frame from a cough to be classed as being “sub-acute” ?
3-8 weeks
what is the time frame from a cough to be classed as being “chronic”
when the cough is present for more than 8 weeks
what is the most likely cause of an acute cough in primary care for all ages ?
viral infection
what is the colour of normal sputum
clear and white (mucoid) - no infection is present
what is the colour of sputum if there is an infection present ?
yellow, green or brown sputum normally indicates infection
- mucopurulent sputum is generally caused by a viral infection and does not require automatic referral.
what is the colour of sputum if the patient has Haemoptysis ?
rust coloured
what is the colour of the sputum if the patient has left ventricular failure ?
pink tinged
what is the colour of sputum if the patient has carcinoma ?
Dark red
would a single time occurrence of sputum with bright red blood be serious
Usuall not. it would normally have been caused by rupturing a blood vessel when coughing to hard.
It does not require automatic referral.
what does thin and frothy sputum suggest ?
left ventricular failure
what does thick mucoid to yellow sputum suggest ?
asthma
what does offensive foul smelling sputum suggest ?
bronchiectasis or lung abscess.
if your cough is worse in the morning what does it suggest ?
may suggest upper airways cough syndrome, bronchiectasis or chronic bronchitis.
how long can it take an acute cough to resolve ?
Acute cough can sometimes take 4 weeks or more to resolve
However, coughs lasting longer than 3 weeks should be viewed with caution – the longer the cough is present, the more likely serious pathology is responsible.
if a Childs family has a history of eczema, asthma, or hay fever and the child has a recurrent cough what does this suggest ?
This might suggest asthma and referral would be required for further investigation.
what may smokers cough lead to ?
Patients who smoke are more prone to chronic and recurrent cough. Over time, this might develop into chronic bronchitis and chronic obstructive pulmonary disease
what are some clinical features of an acute viral cough ?
- present with sudden onset and associated fever.
- Sputum production is minimal, and symptoms are often worse in the evening.
- Associated cold symptoms are also often present; these usually last between 7 and 10 days.
- A duration of longer than 14 days might suggest postviral cough or possibly indicate a bacterial secondary infection
what are likely symptoms of Upper airways cough syndrome
patients describe something stuck in the throat
Allergies are one cause of UACS.
what age does “croup” affect ?
infants aged between 3 months and 6 years
what are some symptoms of croup ?
violent coughing
child may be breathless and may struggle to breathe properly
Typically, symptoms improve during the day and often recur again the following night
if the symptoms occur for longer than 48 hours then medical attention should be seeked.
what are some symptoms of asthma ?
coughing, wheezing, chest tightness, and shortness of breath.
usually the symptoms are worse at night
the symptoms are often bought on by triggers (e.g., allergens, infections, irritant exposure).
what are some symptoms of pneumonia
Initially, the cough is nonproductive and painful (first 24–48 hours),
but it rapidly becomes productive, with sputum being stained red. The intensity of the redness varies, depending on the causative organism.
The cough tends to be worst at night.
The patient will be unwell, with a high fever (> 38 o C), malaise, headache, and breathlessness and experience pleuritic pain
urgent referral is required so the patient can be put on antibiotics
what medication commonly causes a cough
(ACE) inhibitors
NSAIDs
Beta blockers
what is the bacterial infection tuberculosis caused by ?
Mycobacterium tuberculosis that is transmitted primarily by inhalation
When should TB be considered ?
When the patient is at high risk and have symptoms of fever, weight loss, night sweats anorexia or malaise.
sputum production can vary from mild to severe, with associated haemoptysis
A patient with a productive cough for more than 3 weeks and who exhibits one or more of the associated symptoms should be referred for further investigation
what are symptoms of carcinoma
cough, fatigue, shortness of breath, chest pain, weight loss and appetite loss. If a person older than 40 years has two or more of these symptoms, he or she needs to be referred to the GP for a chest x-ray.
The cough produces small amounts of sputum that might be blood-streaked
which is the only expectorant to have any supporting evidence
guafenesin
but not massively effective
out of codeine, pholcodine and dextromethorpran which is most effective for acute coughs ?
all are antitussive (aid cough symptoms) but only dextromethorpran is proven to show significant suppression against acute coughs.
does honey help treat a cough
there is some evidence to suggest honey would suppress a cough more than no treatment- not allowed for children under 1 as it can make them ill due to possible toxins in the intestines.
which combinations of drugs should be avoided in a cough medicine ?
- expectorant and suppressant
- expectorant and antihistamine
as expectorants help cough up mucus whilst a suppressant stops the cough (illogical combinations)
what other advise should patients with a cough be given ?
drink plenty of fluids
what should children with acute coughs be advised ?
no medication available for acute coughs.
drink plenty of fluids and they could potentially try demulcents like honey (if older than 1), simple lintus and glycerine.
has dextromethorpran got any drug interactions
yes it should not be taken with SSRI’s:
- citalopram
- sertraline
- fluoxetine
- paroxetine
- fluvoxamine
or tramadol
or MAOIs and more
care should be taken with asthma patients as cough suppressants could cause respiratory depression.
how long does it take flu symptoms to come on compared to colds
flu = a matter of hours
colds = 1-2 days
which symptoms are more prominent in flu ?
Marked myalgia (pain in muscle), chills and malaise(discomfort) are more prominent in flu than in the common cold.
Loss of appetite is also common with flu.
what are symptoms of a common cold ?
the patient develops a sore throat and sneezing, followed by profuse nasal discharge and congestion. Cough and UACS commonly follow.
In addition, headache, mild to moderate fever
what are the main symptoms of rhinosinusitis
• Blockage or congestion
• Discharge or UACS
• Facial pain or pressure
• Reduction or loss of smell
what treatment would babies be able to have for congestion ?
Saline drops however 40% of babies experience irritation
How should nasal drops be administered ?
The best way to administer nose drops is to have the head in the downward position facing the floor. Tilting the head backward and towards the ceiling is incorrect because this facilitates the swallowing of the drops. However, most patients will find the latter way of putting drops into the nose much easier than the former.
phenylephrine and pseudoephedrine (Sympathothimetics) react with MAOIs which can cause a fatal hypertensive crisis. give some examples of MAOIs.
c
how would you perform an examination of the throat ?
- Get the person seated so that the examiner can be at eye level.
- Ask the patient to say ‘ah’; this should allow you to see the posterior throat. Pay particular attention to the size of the tonsils. Are they red and swollen? Is there any exudate present? Is there any sign of ulceration?
- Check for the posterior wall of the throat. It should appear pink and moist, without exudate or lesions when healthy. Redness or exudate suggests pharyngitis.
what’s the problem with treating throat infections
its hard to differentiate viral or bacterial
therefore use of antibiotics or antibacterial products may have no effect
Which anti inflammatory showed a significantly greater relief of pain than a placebo when gargled ?
Benzydramine
should aspirin and salt water gargles be recommended to treat a throat?
no, no trials have been conducted on their effectiveness so no evidence.
Do local anaesthetics like lidocaine and benzocaine have any drug interactions when used for treating a throat.
No
Whats the minimum age for difflam sore throat rinse ?
12
what’s the minimum age for difflam spray
For those under the age of 6, the dose is based on mg/kg dosing, for those aged 6 to 12, they should use 4 puffs and adults 4 to 8 puffs.
what is the minimum age for strefen (fluribiprofen) lozenges ?
Strefen lozenges (8.75 mg flurbiprofen) can only be given to adults and children over the age of 12 years.
contraindicated in patients with peptic ulceration and those patients allergic to flurbiprofen, and must be avoided in the last trimester of pregnant patients but are suitable for breastfeeding women.
what are common symptoms of otitis media ?
Earache (Otalgia)
Discharge (Otorrhoea) if tympanic membrane (TM) perforates (sometimes relieves pain, heals naturally)
Children feel unwell
Hot, irritable, sleeplessness, ear pulling/rubbing, crying.
Temporary deafness – conductive
Fever
Red/yellow/cloudy/bulging TM on examination
What is otitis media ?
An infection in the middle section of the ear ?
What is treatment for otitis media ?
Over 75% of cases will resolve within 3 days without treatment.
Current guidelines do not advocate routine use of antibiotics unless systemically unwell.
Symptomatic management with analgesics.
Paracetamol / Ibuprofen at age appropriate doses.
The situation usually resolves spontaneously but decongestants and inhalants can also be helpful.
What are symptoms of allergic rhinitis (hay fever)?
Red, itchy watery eyes
Sneezing, congestion, runny nose
Itchy or sore throat. Post nasal drip cough
what is non-pharmaceutical advice for treating hay fever ?
- Wearing wraparound sunglasses to stop pollen getting in your eyes when outdoors.
- Taking a shower and changing clothes after being outdoors.
- Staying in doors when pollen count is high (>50 grains per cubic metre of air)
- Keeping windows closed when pollen count is high – particularly morning and evening.
- Apply a small amount of pertroleum gel to nasal openings to trap pollen grains.
- Don’t keep fresh flowers in the house.
- Vacuum regularly – high-efficiency particle arresting (HEPA) filter.
- Damp dust.
- Avoid cutting grass, playing or walking in grassy areas.
Keep car windows closed - pollen filter can be bought for air vents in cars.
what self care advise should be given to people with swimmers ear (otitis external) ?
Cotton buds should not be used to treat the ear canal.
Keep the ears clean and dry by using ear plugs when swimming.
using a hair dryer on the lowest setting to dry the ear canal after hair washing.
Consider using acidifying ear drops like earcalm before swimming, after and at bed time.
What should Sudafed be avoided with ?
Tricyclic antidepressants eg amitriptyline
MAOIS
beta blockers
and moclobemide
What treatments could be used for a sore throat ?
Lidocaine and benzocaine throat sprays or lozenges
Benzydamine - difflam spray
paracetamol, ibuprofen
What are some symptoms of oral thrush ?
with creamy white, soft, elevated patches that can be wiped off, revealing underlying erythematous mucosa
Burning or irritation is associated with the infection
what factors could cause oral thrush ? (children and adults)
in children: immature immune system
antibiotics from child or mother
steroid inhaler
adults:Diabetes
dry mouth
immunocompromised
ill fitting dentures
recent antibiotics
inhaled corticosteroids
What is the treatment for oral thrush (adults and children)?
DAKTARIN 2% oral gel
children: Daktarin unlicensed under 4 months
Infants: 4 – 24 months: 1.25 ml (¼ measuring spoon of gel) applied four times a day after meals. Each dose should be divided into smaller portions and the gel should be applied to the affected area(s) with a clean finger. The gel should not be applied to the back of the throat due to possible choking.
Adults and children 2 years of age and older: 2.5 ml (½ measuring spoon of gel) applied four times a day after meals. The gel should not be swallowed immediately, but kept in the mouth as long as possible/.
Which medication should Daktarin 2% miconazole oral gel be avoided with ?
WARFARIN
When would you refer someone with otitis media ?
If they are in severe pain, vomiting, have hearing loss and fluid coming from the ear.
What is a summarised treatment for flu ?
Fluids
paracetamol and ibuprofen
bed rest
What are some reasons to refer someone presenting a cough ?
Chest pain
Haemoptysis (coughing up blood)
Pain on inspiration
Wheezing and/or shortness of breath All symptoms suggest possible sinister pathology or severe cases of simple viral infection Urgent same-day referral. Depending on severity, may mean referring to hospital rather than GP
Duration > 3 weeks
Cough that recurs on a regular basis Suggests nonacute cause of cough and requires further investigation As soon as practicable
Debilitating symptoms in older adults This patient group at greater risk of complications Urgent same-day referral
Persistent nocturnal cough in children Suggests possible asthma As soon as practicable
What are some reasons to refer someone with rhinitis ?
Failed medication
Medicine-induced rhinitis Requires discussion with a doctor for alternative treatment As soon as practicable
Nasal blockage that fails to clear Suggests polyp
Unilateral discharge, especially in children Possible trapped foreign body Same-day GP referral
Reasons to refer someone with a sore throat :
Duration >2 weeks- Suggests nonacute cause and requires further investigation- As soon as practicable
Marked tonsillar exudate, accompanied with high temperature and swollen glands Possible bacterial cause and may require antibiotics
People taking medications that can interfere with the immune response (e.g., immunosuppressants, disease-modifying antirheumatics) or those known to cause agranulocytosis - Requires doctor involvement to monitor
Dysphagia (swallowing difficulties) - Suggests sinister pathology - Urgent referral
What are reasons to refer someone presenting a common cold ?
Acute sinus involvement that fails to respond to OTC decongestant therapy Possible need for nasal steroids or antibiotics As soon as practicable
Middle ear pain that fails to respond to analgesia Possible need for antibiotics As soon as practicable
Patients with symptoms indicative of flu; vulnerable
patient groups, such as the very old Need an assessment of symptom severity by physician Same-day referral
How long does the flu usually last for ?
Symptoms improve after approximately 5 days, with resolution after 1 week or more.
What are some hints and tips for people presenting a cough ?
Treatment for children <6 years Parents should be advised to make the child drink more fluid and potentially try a nonpharmacological cough mixture, such as a demulcent.
Insulin-dependent diabetics People with insulin-dependent diabetes should be asked to monitor their blood glucose level more frequently because insulin requirements increase during acute infections.
Avoid theophylline Theophylline is available as a pharmacy-only medicine, but is best avoided because patients requiring medication to help with shortness of breath or wheeze need further assessment.
What are some reasons to refer someone suffering from earwax impaction ?
Dizziness or tinnitus Suggests inner ear problem; requires further investigation As soon as practicable
Fever and general malaise in children Middle ear infection?
Associated trauma-related conductive deafness
Foreign body in the EAM
Over-the-counter (OTC) medication failure Requires further investigation by a doctor
How long should it take otitis media to resolve ?
Over three-quarters of episodes resolve within 3 days (but it can last up to 1 week) without treatment; current UK guidelines do not advocate the routine use of antibiotics. Patients should be managed with analgesia (paracetamol or ibuprofen) unless they are systemically unwell. These cases should be referred for consideration of antibiotics (a 5- to 7-day course of amoxicillin).
What are some reasons to refer someone suffering from otitis external ?
Generalized inflammation of the pinna
Mucopurulent discharge
Systemically unwell Possibly indicates perichondritis
Otitis media? Same-day referral
Impaired hearing in children not associated with earwax Development of glue ear? As soon as practicable
Slow-growing growths on the pinna in older adults Possibly indicate malignancy
What are key questions to ask someone with a sore throat ?
Age of the patient Although viruses are the most common cause of sore throat, there are epidemiological variances with age: Streptococcus is uncommon those < 3 years, Streptococcal infections more prevalent in people <30 years, particularly those of school age (5–10 years) and young adults (15–25 years); glandular fever is most prevalent in adolescents.
Tender cervical glands On examination, patients suffering from glandular fever and streptococcal sore throat often have markedly swollen glands. This is less so in viral sore throat.
Tonsillar exudate present Marked tonsillar exudate is more suggestive of a bacterial rather than a viral cause.
Ulceration Herpetiform and herpes simplex ulcers can also cause soreness in the mouth, especially in the posterior part of the mouth.
