SLA 3 - Minor Illnesses Flashcards
1
Q
What is acute bronchitis?
A
A self-limiting lower respiratory tract infection, causing inflammation of the bronchial airways.
2
Q
Presentation of acute bronchitis.
A
- duration of cough <30 days
- productive cough
- no history of chronic respiratory illness
- fever
- wheeze
- rhonchi
3
Q
Risk factors of acute bronchitis.
A
- viral or bacterial infection exposure
- cigarette smoking
4
Q
Which class of organism most commonly causes acute bronchitis.
A
Viral infections (e.g. rhinovirus, coronavirus, respiratory syncytial virus, adenovirus).
5
Q
Although rare, which bacterial species most commonly cause acute bronchitis.
A
- Chlamydia pneumoniae
- Mycoplasma pneumoniae
6
Q
What is the management of acute bronchitis?
A
Reassure the pt it is usually a self-limiting illness and usually resolves within 4/52.
Advise the person on self-care strategies (e.g. fluid intake, paracetamol / ibuprofen for symptomatic relief, honey, OTC cough medicines).
Do not routinely offer an antibiotic unless the pt is systemically unwell or at high risk of complications (e.g. immunosuppressed).
Advise the pt to seek medical help if symptoms worsen rapidly or do not improve within 4/52.
7
Q
Give 5 features of acute bronchitis infection that indicate the need for abx.
A
- Comorbidities (e.g. asthma, COPD, bronchiectasis)
- Extremes of age
- Crackles on auscultation
- Abnormal vitals (ie. fever, tachycardia, tachypnoea)
- Purulent sputum
8
Q
What is acute sinusitis?
A
A symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal air sinuses.
9
Q
What is the aetiology of acute sinusitis?
A
Most commonly viral aetiology.
Note sx > 10/7 and fever indicate bacterial aetiology.
10
Q
Presentation of acute sinusitis.
A
- cough
- myalgia
- purulent nasal discharge
- sore throat
- hyposmia
- facial pain or pressure
11
Q
Outline the management of acute sinusitis.
A
Sx < 10 days do NOT offer abx prescription - symptomatic management incl. paracetamol and ibuprofen.
Sx > 10 days consider prescribing a high-dose nasal corticosteroid.
Note a back-up prescription can be considered if sx > 10 days, however there is evidence abx make little difference to how long symptoms last.
12
Q
What is the aetiology of tonsillitis?
A
Viral aetiology most common (ie. rhinovirus, coronavirus, adenovirus).
Bacterial aetiology less common (~20%) but group A beta-haemolytic streptococci (GABHS) main bacterial cause.
13
Q
Presentation of tonsillitis.
A
- pain on swallowing
- fever
- tonsillar exudate
- headache
- tonsillar erythema
- coryzal sx
14
Q
Outline the management of tonsillitis, including the use of FeverPAIN score.
A
Calculate FeverPAIN score:
- Fever (+1)
- Purulence (+1)
- Attend within 3 days after onset of sx (+1)
- Inflamed tonsils (+1)
- No cough or coryza (+1)
FeverPAIN <4 do NOT prescribe abx as likely viral aetiology.
FeverPAIN >3 prescribe abx as GABHS likely.
15
Q
If prescribing abx for tonsillitis, what is first line?
A
Phenoxymethylpenicillin
Note if there is true penicillin allergy, clarithromycin or erythromycin (ie. pregnant) is an alternative.
16
Q
What is pneumonia?
A
Inflammation of the lungs with consolidation or interstitial lung infiltrates.
17
Q
What is community acquired pneumonia (CAP)?
What is the most common causative orgaism?
A
Pneumonia acquired outside hospital or healthcare facilities.
Most commonly caused by Streptococcus pneumoniae or viral aetiology.
18
Q
What is hospital acquired pneumonia (HAP)?
What is the most common causative organism?
A
Pneumonia acquired after >48 hours of admission to hospital.
19
Q
What are the most common viral causes of pneumonia?
A
- influenza virus
- respiratory syncytial virus
- coronavirus
20
Q
Give some causes of atypical pnuemonia.
A
Atypical bacterial pneumonia is caused by atypical organisms that are not detectable on Gram stain and cannot be cultured using standard methods.
The most common organisms are:
- mycoplasma pneumoniae,
- chlamydophila pneumoniae
- legionella pneumophila.
21
Q
What is aspiration pneumonia?
A
Results from the inhalation of contents into the lower airways leading to lung injury and resultant bacterial infection.
Most commonly occurs in pts with impaired gag or swallowing reflexes (ie. brain injury, alcohol intoxication).
22
Q
Presentation of CAP.
A
- productive cough
- dyspnoea
- pleuritic chest pain
- rigor / night sweats
- fever
- confusion
- tachypnoea
23
Q
Which auscultatory findings would be consistent with a diagnosis of pneumonia.
A
Evidence of consolidation in lungs:
- crackles
- increased vocal resonance
- dull percussion note
24
Q
Outline the management of CAP, including the use of CRB-65 score.
A
For all pts with CAP, offer abx:
- Amoxicillin
- Clarithromycin (if penicillin allergic)
- Erythromycin (as 2. and pregnant)
Calculate CRB-65 score:
- Confusion (+1)
- Respiratory rate > 30 breaths/min (+1)
- Blood pressure < 90/60mmHg (+1)
- Age > 65 (+1)
CRB-65 = 0, community treatment
CRB-65 = 1/2, hospital assessment
CRB-65 = 3/4, urgent admission to hospital
25
What are the features of uncomplicated influenza infection?
- fever
- coryza
- headache
- malaise
- myalgia
- arthalgia
- gastrointestinal symptoms
Note there are no features of complicated influenza.
26
What are the features of complicated influenza infection?
Influenza requiring hospital admission and/or symptoms and signs of LRTI:
- hypoxaemia
- dyspnoea
- neurological involvement
Note also includes influenza infection causing significant exacerbation of underlying condition.
27
Describe the pathogenesis of:
a) Influenza A
b) Influenza B
c) Influenza C
a) most common and cause of major influenza outbreaks
b) circulate with A in yearly outbreaks and cause less severe illness
c) causes mild or asymptomatic illness akin to the common cold
28
Name and describe the purpose of the surface antigens present on influenza A serotypes.
H (haemagglutinin) facilitates entry of the virus into the host respiratory cell.
N (neuraminidase) facilitates release of virons from the infected host cell.
29
Describe antigenic drift in relation to the pathogenesis of Influenza A.
Influenza A undergoes minor mutations to one or both of its surface antigens (A or N), causing seasonal epidemics where people only have partial immunity from previous inection.
30
Describe antigenic shift in relation to the pathogenesis of Influenza A.
Influenza A undergoes major and sudden mutations to the H and N surface antigens to produce a new virus subtype. There is little population immunity and subsequently major epidemics may ensue.
31
Describe the treatment of:
a) uncomplicated influenza infection
b) complicated influenza infection
a) advise pt the infection is self-limiting and no anti-viral treatment is indicated
b) offer antiviral (oseltamivir) first line and consider admission to hospital.
32
Define the following terms in relation to urinary tract infections (UTIs):
a) bacteriuria
b) lower UTI
c) upper UTI
d) recurrent UTI
e) uncomplicated UTI
f) complicated UTI
a) presence of bacteria in the urine (symptomatic or asymptomatic)
b) infection of the bladder (ie. cystitis)
c) infection of urinary tract above the bladder (ie. pyelitis and pyelonephritis)
d) >1 episode of UTI 6/12 or >2 episodes of UTI 12/12
e) UTI by a usual pathogen in a person with a normal urinary tract and normal kidney function
f) anatomical (ie. male), functional or pharmacological factors predispose the person to persistent infection, recurrent infection or treatment failure.
33
What is the most common causative organism of UTI?
Escherichia coli
Other causative organisms are:
- Staphylococcus saprophyticus
- Proteus mirabilis
- Enterococci
34
Suggest female anatomical features that predispose women to a greater incidence of UTI verus the male anatomy.
- shorter urethra
- vagina closer to the anus
Note poor wiping technique and receptive sexual intercourse increase risk.
35
Presentation of UTI.
- polyuria
- dysuria
- haematuria
- offensive / cloudy urine
- pyrexia
- nausea and vomiting
- acute confusional state (particularly in elderly pts)
36
NICE recommends which additional examination in men presenting with symptoms consistent with UTI?
PSA and DRE to assess for prostate cancer in men with lower urinary tract symptoms or visible haematuria.
37
Outline the management of UTIs for:
a) non-pregnant women with mild symptoms
b) pregnant women with mild symptoms
c) men
a) nitrofurantoin (or trimethoprim) BDS 3/7
b) nitrofurantoin BDS 7/7
c) nitrofurantoin (or trimethoprim) BDS 7/7
38
Presentation of pyelonephritis.
Symptoms of UTI and flank/renal angle pain.
The triad of flank pain (typically unilateral), fever, and nausea and vomiting occurs much more often in people with pyelonephritis than in those with lower urinary tract infection.
39
Outline the management of pyelonephritis.
Cefalexin or co-amoxiclav TDS 10/7.
40
What is the most common causative organism of vaginal candidiasis?
Candida albicans (approx 90%).
41
Give some risk factors for vaginal candidiasis.
- pregnancy
- diabetes mellitus
- treatment with empirical abx
- chemotherapy
- vaginal foreign body
42
Presentation of vaginal candidiasis.
- vulval pruritis and soreness
- 'cottage-cheese', non-offensive discharge
- dyspareunia
- dysuria
- vulval oedema or erythema
Note an offensive discharge would suggest bacterial infection (e.g. bacterial vaginosis or Trichomonas vaginalis).
43
Management of vaginal candidiasis.
**General advice:**
- emollient to moisturise vulval skin
- wear loose fitting underwear
- good hygeine (but avoid vaginal douching)
**Pharmacological:**
- antifungal pessaries
- oral antifunal
- topical antifungal
Note topical treatment may worsen burning symptoms in the first few days.
Advise the women to resolve if symptoms have not resolved within 2/52.
Note OTC medications also available from pharmacy.
44
What is the most common cause of abnormal vaginal discharge in women of reproductive age?
Bacterial vaginosis
45
Describe the pathophysiology of bacterial vaginosis.
Overgrowth of anaerobic organisms replace lactobacilli, increasing the vaginal pH.
46
Give some risk factors for bacterial vaginosis.
- sexual activity (BV is not thought to be directly sexually transmitted; however, it is identified more frequently in those who are sexually active)
- new sexual partner
- other sexually transmitted infections (STIs)
- ethnicity (more common in women of Afro-Caribbean descent)
- presence of a copper intrauterine contraceptive device (IUCD)
- vaginal douching
- bubble baths
- receptive oral sex
- smoking
47
Presentation of bacterial vaginosis.
- offensive vaginal discharge
- no soreness or irritation
- thin layer of white discharge covering vaginal wall
Note approx. 50% asymptomatic.
Note can use pH paper in primary care to measure the pH of the vagina (pH > 4.5 consistent with diagnosis of BV).
48
Management of bacterial vaginosis.
Advise avoidance of:
- vaginal douching
- use of shower gel, bubble baths or antiseptic agents when washing
Prescribe oral metronidazole BDS 7/7.
Note asymptomatic women do not need treatment unless they are pregnant.
Note oral metronidazole can be prescribed to pregnant women however pessary preferred if breast-feeding.
49
What is chronic diarrhoea?
The persistant alteration from the norm with stool consistency between types 5 and 7 on the Bristol Stool Chart, and increased frequency greater than four weeks in duration.
Persistant diarrhoea suggests a non-infectious aetiology.
50
Give some causes of acute diarrhoea.
Viral causes are often seen in primary care:
- norovirus
- rotavirus
- sapovirus
Clostridium difficile is a common cause of infectious diarrhoea in older people who have taken antibiotics.
Note some drugs are associated with diarrhoea:
- antibiotics
- digoxin
- magnesium-containing antacids
- metformin
- NSAIDs
- PPI
- statins
Other causes of acute diarrhoea include anxiety, food allergy, acute appendicitis and intestinal ischaemia.
51
Name infections that can present with blood acute diarrhoea.
- Campylobacter jejuni
- Escherichia coli
- Shigella
- Chlostridium difficile
- Entamoeba histolytica
- schistosomiasis
- Ebola virus
52
What are the red flag symptoms of diarrhoea?
- haematochezia
- recent hospital or abx treatment
- persistent vomiting
- weight loss
- painless, water, high-volume diarrhoea
- nocturnal symptoms disturbing sleep
53
What are the clinical features of:
a) mild dehydration
b) moderate dehydration
c) severe dehydration
a) anorexia, nausea, light-headedness, postural hypotension (note NAD of signs)
b) apathy, tiredness, dizziness, muscle cramps, dry tongue or sunken eyes, reduced skin elasticity, tachycardia, oliguria
c) confusion, tachycardia, hypotension, oligura / anuria
54
When is a stool sample indicated in a patient presenting with acute diarrhoea?
Send a stool specimen for culture and sensitivity if:
- person has received abx or had recent hospital admission (ie. think C. difficile)
- blood or pus in stool
- diarrhoea >1 week
- diarrhea occurs after foreign travel to anywhere other than Western Europe, North America, Australia or New Zealand
55
Outline the management of acute diarrhoea.
Management is usually supportive, encouraging fluid intake and adequate nutrition (ie. encourage OTC Andrew's salts to maintain hydration).
Abx unnecessary for most cases of gastroenteritis, but are required for systemic bacterial infection or some bacterial causes of gastroenteritis.
Arrnage an emergency admission to hospital if the patient has features of severe dehydration or shock, or is inable to retain oral fluids.
56
Which bacterial causes of gastroenteritis indicate the need for abx?
- Campylobacter
- Shigella
- Salmonella
57
Suggest some causes of chronic diarrhoea.
- Giardia infection
- irritable bowel syndrome (IBS)
- ulcerative colitis and Crohn's disease
- coeliac disease
- colorectal cancer
- hyperthyroidism
- alcohol abuse
58
What is coeliac disease?
An inflammatory disorder provoked by gluten and related prolamines in genetically susceptible individuals, leading to malabsorption of nutrients.
59
Which genetic mutations place an individual susceptible to coeliac disease?
HLA-DQ2 or HLADQ8
60
Outline the pathophysiology of a peritonsillar abscess.
Usually a complication of acute tonsillitis, where pus is trapped between the tonsillar capsule and the lateral pharanygeal wall.
61
Presentation of peritonsillar abscess.
Usually presents upon a background of tonsillitis:
- severe throat pain (?unilateral)
- fever
- drooling
- offensive breath
- trismus
- otalgia
- neck stiffness
- headache
Note upon examination the uvula may be displaced from the lesion.
62
Management of peritonsillar abscess.
- ensure adequate hydration
- analgesia
- IV abx
- tonsillectomy
Note abx need to cover the broad spectrum of Gram +ve, Gram -ve and anaerobic organisms. Amoxicillin with metronidazole appropriate.
63
Give some complications of peritonsillar abscess.
- necrotising fasciitis
- retropharngeal abscess
- sepsis
64
What is the anatomical difference between:
a) internal haemorrhoids
b) external haemorhoids
a) above the dentate line
b) below the dentate line
65
Presentation of internal haemorrhoids.
Usually painless unless they become strangulated, as the upper anal canal has no pain fibres.
First-degree haemorrhoids (grade I): do not prolapse.
Second-degree haemorrhoids (grade II): prolapse on straining; reduce spontaneously.
Third-degree haemorrhoids (grade III): prolapse on straining; can be reduced manually.
Fourth-degree haemorrhoids (grade IV): permanently prolapsed; cannot be reduced.
66
Presentation of external haemorrhoids.
Occur distal to the dentate line and are covered by squamous epithelium with sensory innervation, so may become painful and itchy.
May be visible on external examination.
67
What are the signs and symptoms of haemorrhoids?
- asymptomatic
- bright-red, painless rectal bleeding with defecation
- anal itching
- feeling of rectal fullness
Note strangulated haemorrhoids ma thrombose which is intensely painful.
68
How can haemorrhoids be prevented?
Avoid constipation:
- increase fluid and fibre intake
- avoid caffeine and alcohol
69
Outline the management of haemorrhoids.
- analgesia (e.g. paracetamol)
- topical corticosteroids
- good perianal hygeine
- avoid straining at stool
Note rubber band ligation and haemorrhoidectomy can be used if conservative measures unsuccessful.
70
Why is codeine contraindicated as analgesia in the symptomatic relief of haemorrhoids?
Common side effect of codeine is constipation, which is a risk factor for and may aggrevate haemorrhoids.
71
The MMR vaccine provides protection against:
Measles, mumps and rubella
72
Give some risk factors of GORD.
- increased abdominal pressure
- smoking, alcohol, fat, coffee
- pregnancy
- obesity
- large meals
73
Presentation of GORD.
- heartburn
- retrosternal discomfort
- acid brash (regurgitation of acid or bile)
- pain on swallowing
Note less commonly GORD can cause chest pain, epigastric pain and bloating.
74
What investigations can be considered for GORD?
- endoscopy
- perform FBC to exclude significant anaemia
75
Suggest three differentials for GORD.
- oesophagitis from swallowed corrosives
- peptic ulceration
- GI cancer
76
What lifestyle advice can be given to manage GORD?
- reduce weight
- smoking cessation
- reduce alcohol intake
- raise head of bed at night
- small, regular meals
- avoid eating three hours before going to bed
77
Which pharmacological treatment can be used to manage GORD?
Proton pump inhibitors - reduce acid secretions to the stomach.
For example, omeprazole or lansoprazole.
Initial treatment should be PPIs for 1/12, however if symptoms return after treatment, a step-down strategy to the lowest dose of a PPi that provides effective relief of symptoms can be prescribed.
78
Name the categories of primary headaches.
1. Tension headache
2. Migraine
3. Cluster headache
79
Presentation of tension headache.
- generalised, bilateral headache
- frontal-occipital
- non-pulsatile
- mild to moderate in severity
- described as a pressure or tightness, like a tight band around the head
Note clinical examination will be normal, but can be performed to exclude other causes and to reassure the patient.
80
Outline the management of a tension headache.
Lifestyle changes to improve posture and reduce stress / anxiety.
Simple analgesia (ibuprofen > naproxen > ketoprofen) and aspirin (age >16yrs).
Note pt should be encouraged to use analgesia sparingly as may cause a medication-overuse headache if persistently used.
81
Presentation of migraine.
- severe, unilateral pain
- photophobia
- tiredness / irritable
- aggrevated by routine physical activity
- nausea and vomiting
- phonophobia
82
Outline the management of a migraine.
1. Simple analgesia (ie. ibuproen or aspirin)
2. Rectal analgesia
3. Triptans
An antimetic can be co-prescribed at any stage if nausea / vomiting is also a feature of the migraine presentation.
83
Risk factors for cluster headache.
- male sex
- smoking history
- age 30-40yrs
84
Presentation of a cluster headache.
- unilateral pain, around eye (sharp, intense, disabling)
- simple analgesics ineffective
- ipsilateral autonomic symptoms (e.g. red, water eye, blocked runny nose)
85
Outline the management of a cluster headache.
Offer oxygen (100% at 12L/min) and triptans for acute treatment.
Can offer verapamil as prophylaxis.
Note referral to neurology may be needed if treatment failure etc.
86
Suggest some causes of secondary headaches.
- intracranial haemorrhage
- space occupying lesion
- trigeminal neuralgia
- temporal arteritis
87
Presentation of a space occupying leion.
- gradual, progressive onset of headache
- worse in mornings
- worsened with posture (ie. leaning forwards) and coughing
- nausea and vomiting
88
Management of space occupying lesion.
Referral to neurology.
89
What is trigeminal neuralgia?
Compression of trigeminal nerve (CN V) results in a unilateral pain felt in at least one division of CN V.
90
Presentation of trigeminal neuralgia.
- unilateral pain felt in at least 1 divison of CN V
- sharp, stabbing, electric shock
- sudden onset
- severe, lasts a few minutes
- worsened by light touch to face/scalp, eating, cold wind, combing hair
Note simple analgesics not effective and difficult to treat.
91
What is temporal arteritis?
Vasculitis of large and medium sized arteries of the head, most commonly the superficial temporal artery.
92
When should a diagnosis of temporal arteritis be considered?
In any patient aged >50yrs with an abrupt onset of temporal headache, visual disturbance and jaw claudication.
Note there is a risk of irreversible loss of vision to involvement of blood vessesls suplying CN II.
93
What is the management of temporal arteritis?
Immediate prescription of glucocorticoids (e.g. prednisolone) and referral to rheumatology within 3 days.
Note if a patient is presenting with visual loss, same-day-referral to opthalmology should be arranged.
94
What is an aphthous ulcer?
A mouth ulcer, commonly presenting with pain, swelling and discomfort, which is recurrent in onset.
95
Management of aphthous ulcers.
Most apthous ulcers heal within 2/52 spontaneously.
Medications can be used to control symptoms, available from pharmacist:
- topical corticosteroids
- antibacterial mouthwash
- topic analgesics
96
What is nappy rash?
An acute inflammatory reaction of the skin in the nappy area, commonly caused by irritant contact dermatitis.
97
Management of nappy rash.
Self management:
- nappy with high absorbency
- ensure nappy is not too tight or loose
- leave nappies off as long as possible
- change nappy regularly
- use emollient (e.g. sudocreme)
Note in extreme cases a topical hydrocortisone (1%) OD 1/52 can be prescribed.
98
Outline the:
a) cause
b) signs and symptoms
c) investigations
d) treatment
of allergic conjuncitivitis.
a) allergy to pollen (ie. hayfever)
b) itchy, gritty eye with watery discharge and redness of the eye. Note vision and extra-ocular movements are not affected.
c) No investigations
d) maintain good eyelid hygeine with warm water, using a compress to reduce swelling. Prevent the spread by good hand hygiene and using separate towels.
99
Outline the:
a) cause
b) signs and symptoms
c) investigations
d) treatment
of infective conjuncitivitis.
a) viral infection (ie. adenovirus) or bacterial infection (ie. Streptococcus pneumoniae or Staphylococcus aureus) of the conjunctiva.
b) conjuncitival erythema with an itchy, gritty eye. There may be discharge and crusting from the eye which blurs vision.
c) swabs of discharge
d) lid hygiene measures AND treatment with topical abx if severe.
100
What is a stye?
An acute, localised Staphylococcal infection of the eyelid margin.
101
What are the red flag of orbital cellulitis?
- eyelid oedema
- eyelid erythema
- failure to respond to abx
- painful eye movements
- altered visual acuity
Severe infection requires emergency referral to opthalmology.
