Corrections - Vaccinations, Infections & ENT

Question 1

Mx of wound if tetanus vaccination history is incomplete or unknown?

Answer 1

Regardless of wound severity –> booster dose of vaccine.

Tetanus prone & high risk wounds –> booster dose of vaccine + tetanus immunoglobulin

Question 2

What are 7 examples of live attenuated vaccines?

Answer 2

1) BCG

2) MMR

3) Influenza (intranasal)

4) Oral rotavirus

5) Oral polio

6) Yellow fever

7) Oral typhoid

Question 3

What is included in the ‘6 in 1’ vaccine?

Answer 3

Diptheria
Tetanus
Hep B
Polio
Pertussis
Hib

Question 4

Where in the childhood immunisation schedule is the Meningitis B vaccine given?

Answer 4

2 months
4 months
12 months

Question 5

When is the HPV vaccine offered?

Answer 5

Boys and girls aged 12-13 y/o

Question 6

What is the most suitable management option for epistaxis where the bleed site is difficult to localise?

Answer 6

Anterior packing

(Note - cautery with silver nitrate requires bleeding vessels to be visible).

Question 7

Mx of bleeding 5-10 days post tonsillectomy?

Answer 7

Admit for IV Abx as usually due to wound infection.

Question 8

Who should all post-tonsillectomy haemorrhages be assessed by?

Answer 8

ENT

Question 9

Who should be vaccinated against Hep A?

Answer 9

1) people travelling to or going to reside in areas of high or intermediate prevalence, if aged > 1 year old

2) people with chronic liver disease

3) patients with haemophilia

4) MSM

5) IVDU

6) individuals at occupational risk: laboratory worker; staff of large residential institutions; sewage workers; people who work with primates

Question 10

Is oral polio a live vaccine?

Answer 10

Yes

Question 11

Why is Little’s area in the nasal septum a common site for epistaxis to originate?

Answer 11

As it is the confluence of 4 arteries.

Question 12

Is there a hep C vaccine?

Answer 12

No

Question 13

Describe a ‘clean’ wound in regards to tetanus

Answer 13

• Wounds less than 6 hours old
• Non-penetrating with negligible tissue damage

Question 14

Describe a ‘tetanus prone’ wound

Answer 14

• puncture-type injuries acquired in a contaminated environment e.g. gardening injuries
• wounds containing foreign bodies
• compound fractures
• wounds or burns with systemic sepsis
• certain animal bites and scratches

Question 15

Describe a ‘high risk’ tetanus prone wound

Answer 15

• heavy contamination with material likely to contain tetanus spores e.g. soil, manure
• wounds or burns that show extensive devitalised tissue
• wounds or burns that require surgical intervention

Question 16

In epistaxis that has failed all management (e.g. cautery, and anterior and posterior packing), what is the next step?

Answer 16

Ligation of the sphenopalatine artery in theatre.

Question 17

When is the first dose of the MMR vaccine typically administered?

Answer 17

Around 12 months of age

Question 18

Mx of quinsy?

Answer 18

IV Abx + surgical drainage

Tonsillectomy should be considered in 6 weeks

Question 19

What vaccine do people receive between the ages of 13 and 18?

Answer 19

3 in 1 teenage booster (tetanus, diptheria and polio)

Men ACWY

Question 20

When is the BCG vaccine given at birth?

Answer 20

If the baby is deemed at risk of tuberculosis (e.g. Tuberculosis in the family in the past 6 months).

Question 21

When is a bone marrow biopsy indicated in ITP?

Answer 21

If there are atypical features e.g.

• lymph node enlargement/splenomegaly, high/low white cells
• failure to resolve/respond to treatment

Question 22

What does the BCG vaccine provide the most protection against?

Answer 22

TB meningitis in children

Note –> the BCG vaccine is unreliable in protecting against pulmonary TB.

Question 23

When is the rotavirus given?

Answer 23

2 months and 3 months

Question 24

What type of vaccine is the rotavirus vaccine?

Answer 24

Oral, live attenuated

Question 25

Initial management of epistaxis?

Answer 25

Pinch the nasal ala (nostrils) firmly and lean forward for 20 minutes

Question 26

Mx of tetanus wound if patient has had 5 doses of tetanus vaccine, with the last dose < 10 years ago?

Answer 26

No booster vaccine nor immunoglobulins required, regardless of how severe the wound is.

Question 27

How many tetanus vaccinations are there in the UK schedule?

Answer 27

5 --> 2 months, 3 months, 4 months, 3-5 years and 13-18 years.

Question 28

When is the final tetanus dose given?

Answer 28

13-18 years

Question 29

What type of vaccine is the influenza vaccine?

Answer 29

Inactivated

Question 30

Which 2 vaccines are routinely offered to pregnant women in the UK?

Answer 30

Influenza + pertussis

Question 31

How soon ago must patients have received their last tetanus dose to not require a booster vaccine nor immunoglobulins with a wound?

Answer 31

<10 years

Question 32

Features of botulism (i.e. infection with clostridium botulinum)?

Answer 32

- patient usually fully conscious with no sensory disturbance - FLACCID paralysis - diplopia - ataxia - bulbar palsy

Question 33

What vaccines should patients diagnosed with chronic hepatitis be offered?

Answer 33

Annual influenza + one off pneumococcal vaccine.

Question 34

How is the influenza vaccine given in children?

Answer 34

Intranasally

Question 35

When is the influenza vaccine in children given?

Answer 35

Dose at 2-3 years then annually

Question 36

Contraindications for influenza vaccine in children?

Answer 36

1) immunocompromised 2) aged < 2 years 3) current febrile illness or blocked nose/rhinorrhoea 4) current wheeze (e.g. ongoing viral-induced wheeze/asthma) or history of severe asthma --> wait until child is better 5) egg allergy 6) pregnancy/breastfeeding 7) if the child is taking aspirin (e.g. for Kawasaki disease) due to a risk of Reye's syndrome

Question 37

What type of vaccine is the influenza vaccine in children?

Answer 37

Live

Question 38

What is the most common infective cause of diarrhoea in HIV patients?

Answer 38

Cryptosporidium

Question 39

What investigation may be indicated in Cryptosporidium diarrhoea in HIV?

Answer 39

Modified Ziehl-Neelsen stain (acid-fast stain)

Question 40

What may a modified Ziehl-Neelsen stain (acid-fast stain) reveal in Cryptosporidium infection?

Answer 40

Characteristic red cysts of Cryptosporidium

Question 41

Mx of Cryptosporidium infective diarrhoea in HIV?

Answer 41

Supportive therapy

Question 42

What is the mainstay of treatment of PCP?

Answer 42

Co-trimoxazole (trimethoprim + sulfamethoxazole)

Question 43

What organism causes typhoid?

Answer 43

Salmonella typhi

Question 44

Features of typhoid?

Answer 44

- systemic upset: headache, fever, arthralgia - relative bradycardia - abdominal pain, distension - constipation (although Salmonella is a recognised cause of diarrhoea, constipation is more common in typhoid) - rose spots: present on trunk in 40% of patients

Question 45

What are 3 recognised medical benefits of circumcision?

Answer 45

1) reduces the risk of penile cancer 2) reduces the risk of UTI 3) reduces the risk of acquiring sexually transmitted infections including HIV

Question 46

Give 4 medical indications for circumcision?

Answer 46

1) phimosis 2) recurrent balanitis 3) balanitis xerotica obliterans 4) paraphimosis

Question 47

What is it important to exclude before circumcision?

Answer 47

Hypospadias (as the foreskin may be used in surgical repair)

Question 48

What anaesthetic is circumcision performed under?

Answer 48

Local or GA

Question 49

What is Ludwig's angina?

Answer 49

A life-threatening cellulitis which occurs on the floor of the mouth. Infection is rapidly progressive and can cause potential airway obstruction.

Question 50

Risk factors for Ludwig's angina?

Answer 50

1) Recent infection or injury to area 2) Diabetes 3) Oral malignancy 4) Alcoholism 5) Malnutrition 6) Immunocompromised status

Question 51

What type of pneumonia does a peripheral blood smear showing red blood cell agglutination indicate?

Answer 51

Mycoplasma pneumoniae

Question 52

What childhood infection is characterised by a prodrome of irritability, conjunctivitis & fever?

Answer 52

Measles

Question 53

What childhood infection is characterised by white spots ('grain of salt') on buccal mucosa (Koplik spots)?

Answer 53

Measles

Question 54

Which childhood infection can cause vesicles in the mouth and on the palms and soles of the feet?

Answer 54

Hand, foot and mouth disease (coxsackie A16 virus)

Question 55

What virus is hand, foot and mouth disease caused by?

Answer 55

coxsackie A16 virus

Question 56

What condition are Koplik spots pathognomonic of?

Answer 56

Measles

Question 57

When do Koplik spots in measles appear?

Answer 57

Appear 1 to 2 days before the onset of the rash and may persist for a further one to two days.

Question 58

Where does rash typically begin in measles?

Answer 58

starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent

Question 59

Where does rash typically begin in rubella?

Answer 59

Pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day

Question 60

What is known as 'slapped cheek syndrome'?

Answer 60

Erythema infectiosum caused by parvovirus B19

Question 61

What condition does large swollen tonsils together with a palpable mass in the left hypochondriac region indicate?

Answer 61

Infectious mononucleosis

Question 62

Is Scarlet fever a notifiable disease?

Answer 62

Yes

Question 63

Features of Hep A?

Answer 63

- flu-like prodrome - abdominal pain: typically right upper quadrant - tender hepatomegaly - jaundice - deranged liver function tests

Question 64

What is Kaposi's sarcoma caused by?

Answer 64

HHV-8

Question 65

How does Kaposi's sarcoma present?

Answer 65

Purple papules or plaques on the skin or mucosa (e.g. GI and respiratory tract). Skin lesions may later ulcerate. Note - respiratory involvement may cause massive haemoptysis and pleural effusion

Question 66

What is the 1st line HIV screening of asymptomatic individuals or patients with signs and symptoms of chronic infection?

Answer 66

Combined HIV antibody/antigen tests e.g. HIV-1/2 Ab/Ag Immunoassay

Question 67

Why is shellfish a common source of hep A?

Answer 67

as the virus is transmitted via the faecal-oral route

Question 68

Cirrhosis, malignancy & RHF are 3 common causes of hepatomegaly. How does the liver feel in RHF?

Answer 68

Rirm, smooth, tender liver edge. May be pulsatile.

Question 69

What can acute toxoplasmosis in the immunocompetent patient mimic?

Answer 69

Acute EBV infection (low-grade fever, generalised lymphadenopathy with prominent cervical lymph nodes and malaise).

Question 70

What accounts for around 50% of cerebral lesions in patients with HIV?

Answer 70

Cerebral toxoplasmosis

Question 71

What is oral hair leukoplakia associated with?

Answer 71

EBV infection

Question 72

Is oral hairy leukoplakia malignant?

Answer 72

No

Question 73

What is acute epididymo-orchitis in sexually active younger adults most commonly caused by?

Answer 73

Chlamydia trachomatis

Question 74

What lymph nodes are typically affected in rubella infection?

Answer 74

1) Suboccipital 2) Postauricular

Question 75

What is the strongest risk factor for anal cancer?

Answer 75

HPV infection

Question 76

What does triple antiretroviral therapy consist of in HIV?

Answer 76

2x nucleoside reverse transcriptase inhibitors (NRTI) + 1x protease inhibitor

Question 77

How often is CD4 count checked in HIV?

Answer 77

First diagnosis Every 3-6 months

Question 78

What is the most common and important viral infection in solid organ transplant recipients?

Answer 78

Cytomegalovirus

Question 79

Mx of cytomegalovirus infection in solid organ transplant recipients?

Answer 79

Ganciclovir

Question 80

When is the decision made to start Abx without a LP in meningitis?

Answer 80

If the LP cannot be done within the first HOUR, give IV Abx after blood cultures have been taken.

Question 81

CSF findings in viral meningitis?

Answer 81

Raised lymphocytes & raised proteins

Question 82

What is the steroid of choice in bacterial meningitis?

Answer 82

Dexamethasone

Question 83

When should steroids be avoided in bacterial meningitis?

Answer 83

- Septic shock - Meningococcal septicaemia - Immunocompromised - Meningitis following surgery

Question 84

What 2 vaccines are pregnant women offered?

Answer 84

Whooping cough (pertussis) + injectable influenza (not nasal - this is a live vaccine)

Question 85

What is the most common cause of viral meningitis in adults?

Answer 85

Enteroviruses e.g. Coxsackie B virus

Question 86

If SAH is suspected but a CT head done >6 hours after symptom onset is normal, what should be done next?

Answer 86

LP to confirm or exclude the diagnosis

Question 87

What is used as prophylaxis for contacts of patients with meningococcal meningitis?

Answer 87

Oral ciprofloxacin (or rifampicin) But ciprofloxacin is 1st line

Question 88

Fontanelle in meningitis in neonates?

Answer 88

Typicall bulging

Question 89

Fontanelle in sepsis in neonates?

Answer 89

Typically sunken

Question 90

What condition do Koplik spots indicate?

Answer 90

Measles

Question 91

What is the most common complication of measles?

Answer 91

Otitis media (as the respiratory virus can easily spread to the ear canals).

Question 92

What is pituitary apoplexy?

Answer 92

Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) 2ary to haemorrhage or infarction.

Question 93

What are some precipitating factors for pituitary apoplexy?

Answer 93

- HTN - Pregnancy - Trauma - Anticoagulation

Question 94

features of pituitary apoplexy?

Answer 94

1) Sudden onset headache (similar to that seen in SAH) 2) Vomiting 3) Neck stiffness 4) Visual field defects: classically bitemporal superior quadrantic defect 5) Extraocular nerve palsies 6) Features of pituitary insufficiency e.g. hypotension/hyponatraemia 2ary to hypoadrenalism

Question 95

What investigation is diagnostic for pituitary apoplexy?

Answer 95

MRI

Question 96

Mx of pituitary apoplexy?

Answer 96

1) Urgent steroid replacement due to loss of ACTH 2) Careful fluid balance 3) Surgery

Question 97

What is a dendritic ulcer?

Answer 97

An ulcer or inflammation on the cornea caused by HSV-1. Complication of eczema herpeticum.

Question 98

How can herpetic keratitis be diagnosed?

Answer 98

Fluorescein stain --> stained dendritic ulcer.