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Asthma + COPD + ENT Flashcards

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1
Q

What is the first line investigation for someone suspected with asthma?

A

Spirometry with bronchodilator reversibility

Fractional exhaled nitric oxide

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2
Q

If there is diagnostic uncertainty after first line investigations for asthma then what follow up test could be done?

A

Peak flow diary - measure peak flow several time a day for 2-4 weeks

Direct bronchial challenge test with histamine or methacholine

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3
Q

What additional management should be given to pts with asthma other then the inhalers?

A

Individual asthma self-management programme
Yearly flu jab
Yearly asthma review
Advise on exercise and stop smoking

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4
Q

What is MART therapy?

A

Maintenance and reliever therapy - when SABA is stopped and only ICS/LABA (Fostair) is used for both daily preventer and reliever

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5
Q

What inhaler technique is used for aerosol inhalers?

A

Inhale slow and steady

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6
Q

What inhaler technique is used for DPI?

A

Inhale quick and deep

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7
Q

What is the aim of asthma treatment?

A

Control disease with minimal side effects

Control:

  • no daytime symptoms
  • no night time awakening due to asthma
  • no need for rescue medications
  • no exacerbations
  • no limitations on activity including exercise
  • normal lung function
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8
Q

Which conditions are included in atophy?

A

Asthma
Hay fever
Eczema
Allergic rhinitis

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9
Q

What should children under the age of 5 with asthmatic symptoms be suspected for?

A

Viral wheeze

Try treatment with SABA inhaler and see if symptoms improve

Monitor closely so see how often the use and if it works. Steroids may be tried for short period of time but if uncertainty then refer to resp paediatrician.

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10
Q

What is the MRC dyspnoea scale?

A

Used to assess the impact of breathlessness in COPD pts

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11
Q

What are the different grading of the MRC dyspnoea scale?

A

Grade 1 - breathless on strenuous exercise
Grade 2 - breathless on walking up hill
Grade 3 - breathless that slows walking on the flat
Grade 4 - stop to catch breath after waking 100 m on the flat
Grade 5 - unable to leave the house due to breathlessness

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12
Q

How can the severity of COPD be assessed?

A

Using the FEV1

Stage 1 - >80% of predicted
Stage 2 - 50-79%
Stage 3 - 30-49%
Stage 4 - <30%

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13
Q

What other investigations other then a spirometry can be done to help diagnosis COPD and exclude other conditions?

A 
Chest x-ray 
FBC - polycythaemia - raised hb in chronic hypoxia 
BMI - baseline weight to assess any weight change in the future 
Sputum culture 
ECG/ECHO 
CT thorax 
Serum alpha-1 antitrypsin 
TLCO - decreased in COPD
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14
Q

What is the most important intervention in COPD?

A

Smoking cessation

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15
Q

What should patients with COPD be offered alongside inhalers?

A

Pts with MRC score > 2 pulmonary rehab
Lifestyle advise + exercise
Vaccinations - flu/pneumococcal
Smoking cessation

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16
Q

What is an exacerbation of COPD defined as?

A

Change in sputum colour
Increased quantity of sputum
Increased breathlessness

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17
Q

What are additional options available in more severe cases of COPD?

A

Nebulisers (salbutamol and/or ipratopium)
Oral theophylline
Oral mucolytic therapy to break down sputum (e.g. carbocisteine)
Long term prophylaxis antibiotics - specialist only
Longe term oxygen therapy at home

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18
Q

When is LOT indicated in COPD?

A

Chronic hypoxia <92%
Polycythaemia
Cyanosis
Heart failure - cor pulmonale

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19
Q

When can LOT not be used in COPD?

A

If the pt smokes and this is a fire hazard

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20
Q

What is the medical treatment for an exacerbation of COPD if the pt is well enough to stay at home?

A

Prednisolone 30 mg OD for 7-14 days
Regular inhalers or home nebulisers
Antibiotics if there is evidence of infection

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21
Q

What is the initial management for acute bronchitis?

A

Smoking cessation
Adequate analgesia
Fluid intake

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22
Q

When are antibiotics indicated in acute bronchitis?

A

Systemically unwell
High risk of complications
Immunocompromised

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23
Q

What is the first line antibiotic for acute bronchitis in over 18 yrs?

A

Oral doxycycline: 200 mg on first day the 100 mg for 4 days - don’t give in pregnant women

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24
Q

What are alternative choices of antibiotics for acute bronchitis?

A

Amoxicillin - 500mg three times a day for 5 days - preferred in pregnant women - first line in 12-17 yr olds

Clarithromycin - 250mg to 500mg twice a day for 5 days

Erythromycin - 250-500mg 4 times a day for 5 days or 500-1000mg 2 times a day for 5 days (preferred in pregnant women)

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25
What tool is used to assess severity of community acquired pneumonia?
CRB-65 / CURB-65
26
What is the CRB-65 tool?
Confusion Resp rate >/= 30 Bp systolic < 90 or diastolic <60 65 yrs old
27
What is the antibiotics of choice if the CRB-65 score is 0 and no hospital assessment is required?
Amoxicillin 500mg 3 times a day for 5 days If allergic to penicillin then doxycycline or clarithromycin/erythromycin
28
What safety netting should be given to someone started on antibiotics for pneumonia?
See medical advise if: - symptoms worsen rapidly or significantly - symptoms do not start to improve in 3 days or as expected - become systemically unwell
29
What is the virus that causes the common cold?
Rhinovirus
30
What are the complications of the common cold?
LRTI Sinusitis Acute otitis media
31
What is important to assess in suspected allergic rhinitis?
Atophy/ family history Type, freq and location, severity, housing conditions, pets, occupation
32
What is the management of allergic rhinitis?
Info about disease Nasal irrigation with saline Avoid trigger if identified Mild to moderate - internasal antihistamine prn Moderate to severe - internasal corticosteroids Review in 2-4 weeks if don’t improve
33
What is the treatment for bacterial tonsillitis?
Penicillin V - 10 days If allergic the clarithromycin/erythromycin Arrange urgent bloods in immunodeficiency patient
34
What are the differential diagnosis for tonsillitis?
Common cold Glandular fever Epiglottis
35
What are the complications of tonsillitis?
Peritonsilar abscess | Acute otitis media
36
What is the tonsillectomy criteria?
7 episodes in past year 5 episodes in each of past two years 3 episodes in each of past 3 years
37
What are the causes of acute laryngitis?
``` Viral Bacterial Fungal Can co-exist Trauma Overuse e.g screaming/singing ```
38
What are the causes of chronic laryngitis?
``` Allergy Reflux Trauma Smoking Medications ```
39
What are the differential diagnosis for laryngitis?
Pharyngitis Malignancy Laryngeal nerve palsy Nodule/polyps/cysts on vocal cord
40
What questions would you ask in a history of someone with suspected laryngitis?
``` Ask red flags for cancer Symptoms of GORD History of asthma Allergies Trauma Surgical history Medication Family history (autoimmune) ```
41
What would you look for on examination in someone with suspected laryngitis?
Lumps in neck Airway obstructions signs Lymphadenopathy Systemic signs of autoimmune(rashes, joint deformity)
42
When is referral required for laryngitis?
If symptoms persist for 3 weeks or more
43
What is the management of laryngitis?
Self-limiting Rest voice Avoid smoking, alcohol Remain hydrated Antibiotics if have fever/sputum or immunocompromised
44
What should all children with croup receive?
Single dose of oral dexamethsone | If too unwell for oral then inhaled budesonide or IM dexamethsone
45
What is the management of croup after the steroids?
Managed at home if mild or moderate. Self-limiting, resolve in 48 hours and should give paracetamol/ibuprofen for fever and pain. Urgent advise if symptoms persist or get worse
46
What are the three classifications of croup?
Mild - barking cough Moderate - barking cough with stridor and some sternal/intercostal recession Severe - all of the above + signs of resp failure and lethargic unwell child - urgent hospital admission required
47
What are the three types of conjunctivitis?
Allergic Viral Bacterial
48
What are the clinical features of allergic conjunctivitis?
Itching Watery/mucoid discharge Conjunctival redness Oedema of the conjunctiva and eyelid
49
What non-pharmacological advise should be given for conjunctivitis?
Self care measures such as bathing and cleaning eyelids, cool compresses, lubricating drops or artificial tears and avoid contact lenses Advise on infection control
50
What should be prescribed for allergic conjunctivitis?
Topical ocular antihistamines e.g. Azelastine and mast cell stabilisers e.g. Nedocromil sodium
51
What should be prescribed if bacterial conjunctivitis is suspected?
Topical antibiotics e.g. chloramphenicol or fusidic acid
52
What advise should be offered to patient presenting with a stye?
Reassurance that it is self-limiting and self care advise: - apply warm compression to closed eyelid for 5-10 mins, 2-4 times a day until resolves - advise not to puncture stye - avoid eye make up or contact lenses until healed
53
What treatment options are available for a painful external stye in primary care for symptom relief?
Plucking the eyelash from infected follicle to facilitate drainage Incision and drainage of the stye using a fine sterile needle
54
What are the causes of otitis externa?
``` Swimmers ear Topical medication Hearing aid/earplugs Chemicals Hot climates Wax build up Trauma e.g. cotton buds ```
55
What are the symptoms of otitis externa?
Itching is main symptom May have discharge, jaw pain, slight fever, hearing may be impaired Usually bacterial but if chronic may be fungal
56
What are the differential diagnosis for otitis externa?
``` Contact dermatitis Forgiven bodies Impacted wax Otitis media Cholesteatoma Malignancy ```
57
What is a life-threatening extension of Otitis externa?
Necrotising otitis externa - extension into the mastoid and temporal bones. Usually in diabetics or immunocompromised
58
What is the management of otitis externa?
Topical antibiotic/anti fungal drops- Acetic acid, sprays, corticosteroids Oral antibiotics can be given e.g. flucloxacillin, clarithromycin Analgesia for pain
59
What are the clinical features of acute otitis media?
Usually bacterial or viral. Conductive hearing loss History of Coryza and affects children
60
What is the management for acute otitis media?
Self-limiting - 5 days Pain+fever managed by paracetamol + ibuprofen Antibiotics may be consider in systemically unwell or immunocompromised. 5-7 day course of amoxicillin, clarithromycin or erythromycin.
61
What are the potential complication of acute otitis media?
Recurrence Hearing loss Tympanic membrane perforation Rare: mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve palsy.
62
What measures can be taken to avoid recurrent AOM?
In children - avoid exposure to passive smoking, use of dummies and flat supine feeding, ensure vaccinations up to date Adults - avoid smoking and passive smoking
63
What are the clinical features of otitis media with effusion (glue ear)?
Not infectious Normally resolves over weeks or months Can lead to hearing impairment More common in children esp in winter months.
64
What is the management for otitis media with effusion?
Period of active observation for 3 months If signs and symptoms persist the refer to ENT
65
What are the complications of OME?
Conductive hearing loss Speech and language development issues and communications skills difficulty Chronic damage to the tympanic membrane
66
Which children is OME more common?
``` Cleft palate Down’s syndrome Cystic fibrosis Primary ciliary dyskinesia Allergic rhinitis ```
67
What is the most common cause of vertigo?
BPPV
68
Which manoeuvres are used to diagnose and treat BPPV?
Dix-hallpike to diagnose Epley to treat Also pt can do brandt-Daroff exercises May require referral if can’t perform or doesn’t work and also if severe nausea and can’t tolerate fluids
69
What are the differential diagnosis for Ménière’s disease?
``` Acoustic neuroma Otitis media Earwax Ototoxic drugs Intracrainal pathology ```
70
What investigation is recommended in suspected Meniere disease?
Audiometry - sensorineural hearing loss - low freq hearing loss or combined high and low freq with normal mid range
71
What is the management of Ménière’s disease?
Inform DVLA Acute attacks - antiemetics to alleviate any vertigo or nausea Life style - low salt diet, avoid caffeine, chocolate, alcohol, tobacco - Consider trial of betahistine (16mg three times a day) to reduce freq an severity of attacks - safety advise - vestibular rehab program - maintain mobility - hearing support - referral to ENT
72
What is the time frame for acute vs chronic sinusitis?
Acute <12 weeks | Chronic >12 weeks
73
When is acute sinusitis more likely to be bacterial rather then viral?
Present for more then 10 days or gets better before getting worse Unilateral dominance Fever greater then 38 degrees
74
What is the management for acute sinusitis?
Symptom relief Saline solutions Corticosteroid sprays Antibiotic in bacterial
75
When should referral be consider in sinusitis?
Freq + reccurent episodes(more then 3 which required antibiotics) Treatment failure after antibiotic course Unusual/resistant bacteria Anatomical defect or immunocompromised Suspected allergic/immunological cause Co-morbities that complicated management (e.g. polyps)
76
What should be prescribed after 10 days of symptoms of acute sinusitis?
Corticosteroid sprays
77
What is the management of chronic sinusitis?
``` Advise: Avoid allergic triggers Stop smoking Practice good dental hygiene to reduce risk of infection Avoid underwater diving ``` Nasal irrigation with saline solution Consider course of internasal corticosteroid e.g. mometasone or fluticasone for up to 3 months or seek specialist advice for children
78
What are the potential cause of thyroid nodules?
Thyroid cysts Chronic inflammation of thyroid - hyper/hypothyroidism Multinodular goitre Thyroid cancer
79
What investigations should be requested for in thyroid nodules?
TFTS Physical examination USS Thyroid scan
80
What is the management for nasal polyps?
Topical steroids
81
What are the red flags for nasal polyps?
Unilateral | Children with polyps
82
What is the management of nasal septum deviation?
Decongestant Anti-histamine Nasal steroid sprays Nasal strips If airway obstruction referral for septoplasty
83
What are the complications of nasal fracture ?
Septal haematoma Deviated septum Orbital fracture
84
What is the management of uncomplicated nasal fractures?
Advise on ice packs and simple analgesia Follow up appoint with ENT in 5-7 days after swelling gone down for manipulation and splinting 2-3 weeks to heal
85
What are the clinical features of vestibular migraines?
Vertigo, imbalance, nausea, sweating, photophobia, tinnitus, full ears, headache, alter sensation in face - build up over few hours Family history of migraines
86
What is the diagnostic criteria for vestibular migranes?
ICHD-3 diagnosis: >5 episodes, history of migranes, vestibular symptoms between 5 min and 72 hrs, migrane headache or associated symptoms in at least half the episodes
87
What is the management of vestibular migranes?
Avoid triggers Eat at regular time and maintain healthy diet Reduce stress Regular sleep routine Regular exercise Use simple analgesics during episodes, anti-emetics are also available If preventive drugs necessary the use Amitripytyline

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