List I - Core Conditions Flashcards

Question

What are the benefits of knowing a positive HIV result?

Answer 1

* Effective treatment reduces morbidity and mortality * Earlier treatment = better prognosis * HIV infection may alter treatment for co-existing medical conditions * Reduce risk of onward transmission * More control over who to tell before they become seriously ill and have no choice

Answer 2

* p24 antigen detected 2-4 wks after infection * HIV antibody 4-8 wks * 4th generation (Ag/Ab) HIV test will detect the majority of infected patients by 4 weeks after an exposure * If risk

Answer 3

* Rapid results in front of patient * Quick to perform and good for needle phobic patients * Cons - some are 3rd generation so only pick up antibodies not the antigen (12 week window period) * Reactive tests require a laboratory venous sample for results confirmation

Answer 4

* Accurate | * But result is not instant

Answer 5

* Assess need for on-going psychological support * Briefly explain HIV * Explain how it can be transmitted and how to protect against this * Refer patients to an HIV specialist clinic * Multidisciplinary care

Answer 6

* Treatment as prevention * Aim is to reduce viral load to undetectable levels * At this level there is effectively no risk of transmitting HIV to a sex partner

Answer 7

* Condom use * PrPEP * Does not protect against other STI's * Taken before, during and after sex

Answer 8

* PEP - Post Exposure Prophylaxis * Needs to be taken within 72 hours of risk * Take for 28 days * Can be obtained from sexual health clinics or A&E * Need for baseline HIV test and monitoring

Answer 9

* Mother to child transmission - In pregnancy - Labour and delivery - Breast feeding

Answer 10

* Routine antenatal screening (opt-out) * Positives discussed at MDT * PEP for baby for 4 weeks after birth * Formula feeding

Answer 11

* 3 types | * A, B, and C which account for the majority of clinical disease

Answer 12

* Children = live vaccine | * Elderly and at risk groups = inactivated vaccine

Answer 13

* Given intra-nasally * First dose is given at 2-3 years then annually after that * It is a live vaccine

Answer 14

* Children traditionally offered the flu vaccine e.g. asthmatics will now be given intranasal vaccine unless this is inappropriate e.g. immunosuppressed - in this case they should be given the inactivated injectable vaccine * Only children aged 2-9 years who have not received an influenza vaccine before need 2 doses * It is more effective than the injectable vaccine

Answer 15

* Immunocompromised * Aged <2 years * Current febrile illness or blocked nose/rhinorrhoea * Current wheeze (e.g. ongoing viral induced wheeze/asthma) or history of severe asthma (BTS step 4) * Egg allergy * Pregnancy/breast feeding * If the child is taking aspirin e.g. for Kawasaki disease due to risk of Reye's syndrome

Answer 16

* Blocked nose/rhinorrhoea * Headache * Anorexia

Answer 17

* Current vaccines are trivalent and consist of two subtypes of influenza A and one subtype of influenza B

Answer 18

* Department of Health recommends annual influenza vaccination for all people older than 65 years and those older than 6 months if they have: - Chronic respiratory disease (including asthma) - Chronic heart disease (heart failure, ischaemic heart disease, including hypertension) - CKD - Chronic liver disease: cirrhosis, biliary atresia, chronic hepatitis - Chronic neurological disease (stroke, TIA) - Diabetes mellitus - Immunosuppression due to disease or treatment (e.g. HIV) - Asplenia or splenic dysfunction - Pregnant women - Adults with a BMI >40kg/m2 Others at risk include: - Health and social care staff involved in patient care - People living in long stay residential care homes - Carers of the elderly or disabled whose welfare may be at risk if the carer becomes ill

Answer 19

* It is inactivated so cannot cause influenza - minority will develop fever and malaise which may last 1-2 days * Should be stored at between +2 and +8c and shielded from light * Contraindications include hypersensitivity to egg protein * Vaccination is around 75% effective in adults, although decreases in the elderly * Takes around 10-14 days after immunisation before antibody levels are at protective levels

Answer 20

* RNA Paramyxovirus

Answer 21

* Respiratory droplets

Answer 22

* Incubation period = 10-14 days | * Infective from prodrome until 4 days after rash starts

Answer 23

* Prodrome: irritable, conjunctivitis, fever * Koplik spots (before rash) = white spots on buccal mucosa * Rash - starts behind the ears then to the whole body, discrete maculopapular rash becoming blotchy and confluent

Answer 24

* IgM antibodies can be detected within a few days of the rash onset

Answer 25

* Mainly supportive * Admission may be considered in immunosuppressed or pregnant patients * Notifiable disease therefore public health England need to be informed

Answer 26

* Otitis media - most common * Pneumonia - most common cause of death from measles * Encephalitis - typically occurs 1-2 weeks following the onset of the illness * Subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness * Febrile convulsions * Keratoconjunctivitis, corneal ulceration * Diarrhoea * Increased incidence of appendicitis * Myocarditis

Answer 27

* If a child not immunised against measles comes into contact with measles then they should be offered the MMR (vaccine induced antibody develops faster than natural infection) * Should be given within 72 hours of contact

Answer 28

* Starts behind the ears then spreads to the whole body

Answer 29

* An acute infectious disease caused by a paramyxovirus * Characterised by bilateral parotid swelling * Spread by respiratory droplets or saliva

Answer 30

* From around 1 - 2 days before the onset of symptoms, to about 9 days afterwards * May be asymptomatic in 15-20% of people * Asymptomatic mumps infection is common in children * Nearly all people develop lifelong immunity to mumps after one episode of infection * 1 - 2% of cases are thought to be reinfections

Answer 31

* Parotitis (swollen parotid glands) — this is present in 95% of symptomatic cases. - Typically 1 parotid gland is affected first, reaching a maximal size after 2-3 days, ear lobe over the affected gland may be deflected up - Gland may be tender to touch * Non-specific symptoms of fever, headache, malaise, muscle ache, and loss of appetite. * Epididymo-orchitis — affects up to 38% of infected men. Unilateral mumps epididymo-orchitis can significantly, but only transiently, diminish the sperm count, mobility, and morphology. Bilateral mumps epididymo-orchitis occurs in 15–30% of affected men and causes infertility in 30–87% of them. * Oophoritis occurs in about 7% of women, but rarely causes infertility or premature menopause.

Answer 32

* Aseptic meningitis. * Transient hearing loss. * Pancreatitis. * Rarer complications include other central nervous system disorders (such as cerebellar ataxia, facial palsy, transverse myelitis, and Guillain–Barre syndrome), thyroiditis, mastitis, prostatitis, hepatitis, and thrombocytopenia

Answer 33

* Yes - any suspicion of infection with mumps, the local health protection unit should be notified

Answer 34

People should be advised that: * Mumps is usually a self limiting condition, will usually resolve over 1-2 weeks with no long term consequences, antibiotics not required * To rest, drink adequate fluids and take paracetamol or ibuprofen for symptomatic pain relief (avoid aspirin in children younger than 16 years) * Apply warm or cold packs to the parotid gland as it may ease the discomfort * Stay off school or work for 5 days after the initial development of parotitis

Answer 35

* Signs of mumps encephalitis (altered consciousness, focal neurological signs or seizures) * Person develops mumps meningitis (severe headache, neck ache, high fever, lethargy and vomiting) * Following epididymo-orchitis (particularly if bilateral), a man has an abnormal semen analysis or is experiencing infertility

Answer 36

* People should be offered immunisation with the combined MMR vaccine if they are not already immunised, unless they are pregnant, or severely immunocompromised

Answer 37

* Single stranded RNA virus from the Togaviridae family * Transmission occurs through direct contact with an infected person or droplet spread from nasopharyngeal secretions * The rubella virus replicates in the respiratory mucosa and local lymph nodes and is then spread haematologically to the rest of the body (including the placenta and fetus in the pregnant women) * Also known as German measles is a viral infection spread by direct contact with an infected person or by droplet from respiratory secretions

Answer 38

* Susceptible people will develop the disease 12-23 days later - rubella is most infectious when the rash is erupting but rubella can be contagious from up to 7 days before to 5-7 days after the rash appears

Answer 39

Mainly risks in pregnancy * Can cause miscarriage, still birth and severe birth defects known as congenital rubella syndrome

Answer 40

* Can lead to the development of one or more abnormalities including eye defects (such as cataracts), hearing impairment, cardiac abnormalities (such as PDA and pulmonary artery stenosis), central nervous system defects (such as microencephaly, mental and psychomotor retardation and progressive panencephalitis), IUGR, autism, and endocrine abnormalities such as diabetes mellitus and thyroid dysfunction

Answer 41

* Arthritis and arthralgia (most commonly in adult women) can occur but is rarely severe or persistent * Bleeding disorders (thrombocytopenia) 1/3000 * Encephalitis has been reported in about 1 in 6000 cases

Answer 42

* Most are mild with transient rash and lymphadenopathy and resolve spontaneously within a week * Maternal infection in non-immune women during pregnancy can cause serious congenital abnormalities

Answer 43

* There are no clinical features that are specific to rubella infection - diagnosis cannot be made on clinical features alone - Symptoms and signs of rubella infection are similar to many other conditions including other viral illnesses such as Parvovirus B19, toxoplasmosis and allergic reactions and may be asymptomatic in up to 50% of people

Answer 44

* Usually develop 2-3 weeks after exposure and include: - Rash - Lymphadenopathy - Arthritis and arthralgia - Non-specific - low grade fever <39c, headache, malaise, nausea, conjunctivitis

Answer 45

* Have a low threshold for suspicion for rubella in pregnant women especially before 20 weeks gestation * Be aware of women who may have spent their childhood outside of the UK * Incomplete immunisation and no evidence of previous infection * History of exposure to contacts with rubella within the last 3 weeks * Travel to an area endemic for rubella

Answer 46

* Clinical features including onset and progression. * Risk factors for rubella infection including: * Contact with a person who is unwell or has had a rash in the previous 3 weeks. * Lack of immunity — a person is considered to be immune if they are immunocompetent and have had either two doses of MMR vaccine or laboratory evidence of prior immunity. * Travel to country endemic for rubella. * Possibility of pregnancy. * Past medical history (including immunosuppression) and drug history.

Answer 47

* Notify the local Health Protection Team

Answer 48

* To stay away from school/work for at least 5 days after the initial development of the rash * Avoid contact with pregnant women who develop a rash or have been in direct contact with someone with a rash who is potentially infectious

Answer 49

* Contact the local Health Protection Team immediately - it is a notifiable disease * If <20 weeks: - Refer immediately to obstetrics (fetal medicine) for risk assessment and counselling - risk is dependent on the stage of pregnancy - 20 weeks + no reports of CRS - 16-20 weeks low chance of deafness - 11-16 weeks there is a 10-20% risk of CRS - Before 8-10 weeks there is a 90% risk of CRS and high likelihood of multiple defects

Answer 50

* If found to be non-immune - rubella immunisation should not be given in pregnancy but may be given post-partum

Answer 51

* Acute disease, predominantely occurring in childhood * Caused by VZV * Characterised by a vesicular rash and often fever and malaise * Usually a self limiting disease in healthy children

Answer 52

* Up to 90% of susceptible contacts of chicken pox develop the disease * Transmission is by personal contact or droplet spread with an incubation of 1-3 weeks * Chicken pox is infectious from 1-2 days before the rash appears until the vesicles are dry or have crusted over - usually about 5 days after the onset of the rash

Answer 53

* Sensory nerve ganglia of the dorsal root | * Years later it can reactivate and cause herpes zoster (shingles)

Answer 54

* Bacterial skin infection, most common in young children. * Lung involvement, more common in adults. * In pregnancy, severe maternal chickenpox and fetal varicella syndrome. * In later pregnancy, varicella can result in neonatal chickenpox infection. * In immunocompromised people, severe disseminated chickenpox with varicella pneumonia, encephalitis, hepatitis, and haemorrhagic complications

Answer 55

* Prodromal symptoms such as nausea, myalgia, anorexia, headache, general malaise, and loss of appetite. * Small, erythematous macules which appear on the scalp, face, trunk, and proximal limbs, and progress over 12–14 hours to papules, clear vesicles (which are intensely itchy), and pustules. * Vesicles can also occur on the palms and soles, and mucous membranes, with painful and shallow oral or genital ulcers. * Vesicles appear in crops. * Crusting occurs usually within 5 days, and crusts fall off after 1–2 weeks

Answer 56

* Paracetamol * Topical calamine lotion * Chloramphenamine (avoid in certain groups for example pregnant women and children less than 1 year of age) * Encourage adequate fluid intake to avoid dehydration * Dress appropriately to avoid overheating or shivering * Wear smooth, cotton fabrics * Keep nails short to minimise damage from scratching If serious complications such as pneumonia, encephalitis or dehydration are suspected, admission to hospital should be arranged * Seek immediate specialist advice if a pregnant woman, neonate, or immunocompromised person is infected. Urgent specialist advice is also required for breastfeeding women regarding whether she should continue to breastfeed and whether her baby requires treatment to minimize the risk of complications. * Aciclovir can be considered for an immunocompetent adult or adolescent (aged 14 years or older) who presents within 24 hours of rash onset, particularly for people with severe chickenpox or those at risk of complications. * Advice should be given about contact with other people and when to seek medical advice

Answer 57

Complications in children are rare however when they occur they can include the following: * Skin bacterial superinfection e.g. impetigo, furuncles, cellulitis, erysipelas, necrotising fasciitis and scarring * Such infections may manifest in high grade pyrexia often after initial improvement, erythema and tenderness surrounding the original chickenpox lesions * Neurological complications to be aware of include Reye's syndrome, acute cerebellar ataxia, encephalitis, meningoencephalitis, polyradiculitis, myelitis

Answer 58

* Can be more serious in adults therefore more likely to be admitted to hospital * Complications include: - Pneumonia, hepatitis and encephalitis - Smokers are particularly at risk of fulminating varicella pneumonia - Of the mortality related to chicken pox, 80% occurs in adults - Older age is a risk factor for severe varicella disease and the risk of dying from varicella is highest at extremes of age - Shingles can occur from reactivation of latent varicella zoster infection

Answer 59

* To the mother - Varicella in pregnancy can result in severe chicken pox - 1/10 pregnant women with chicken pox develop pneumonia, severity increases with later gestation * To the fetus - Infection in the first 28 weeks of pregnancy can lead to intrauterine infection and fetal varicella syndrome which is characterised as one or more of: - Skin scarring in a dermatomal distribution - Eye defects (micropthalmia, chorioretinitis and cataracts) - Hypoplasia of the limbs - Neurological abnormalities (microcephaly, cortical atrophy, learning difficulties, dysfunction of bowel and bladder sphincters) - Incidence of fetal varicella syndrome is less than 1% in the first 12 weeks and around 2% 13-20 weeks of pregnancy

Answer 60

* Neonates are at increased risk of disseminated or haemorrhagic varicella * If the mother becomes infected 1-4 weeks before delivery, up to half of babies will be infected and around a quarter will develop clinical varicella of the new born even though they have passively acquired maternal antibody * If the baby is born up to 7 days before or 7 after infection of the mothers rash it is more likely to develop severe infection which may be fatal * If the maternal infection occurs at 20-27 weeks of pregnancy the baby may develop shingles of infancy or early childhood due to reactivation of the primary in utero infection

Answer 61

* Severe disseminated chicken pox with haemorrhagic complications is more common in immunocompromised people than in other population groups * Immunocompromised people with chicken pox are also at greater risk of pneumonia, encephalitis, DIC and hepatitis

Answer 62

* Admit to hospital if a pregnant woman has chicken pox and any of the following: - Respiratory symptoms - Neurological symptoms other than headache - Haemorrhagic rash or bleeding - Severe disease e.g. dense rash - Significant immunosuppression * For all other pregnant women with chicken pox seek immediate specialist advice from an obstetrician - If primary care is considered appropriate by the specialist: - Only prescribe an oral antiviral drug in primary care with the informed consent of the woman on the advice of a specialist - Offer symptomatic treatment - Monitor the woman closely, if a high temperature develops, particularly after initial improvement, with redness and pain surrounding the chickenpox lesions, consider bacterial superinfection and manage accordingly - If fever persists or cropping of the rash continues after 6 days, refer for urgent hospital assessment

Answer 63

* Admit to hospital if serious complications are suspected e.g. pneumonia or encephalitis * For all others, consider prescribing aciclovir if the woman presents within 24 hours of rash onset, particularly if she has severe chickenpox or is at increased risk of complications

Answer 64

* Pregnant women - Establish their risk - Have they had chickenpox before or shingles? - If no history and a significant contact, seek specialist advice - Establish the stage of gestation (weeks from last menstrual period) - Test for VZIG antibodies if the results can be available within 2 working days of first exposure - if not possible, urgently seek specialist advice because testing in secondary care and/or VZV prophylaxis may be needed - If the test shows positive VZIG, reassure the woman that she is immune and cannot catch chickenpox - If the antibody status is negative seek immediate specialist advice for the need for VZIG

Answer 65

* Infectious disease caused by the Gram negative bacterium Bordella pertussis * Typically presents in children * There are around 1000 cases reported each year in the UK

Answer 66

* 2-3 days of coryza precede onset of: - Coughing bouts that are usually worse at night and after feeding, this may be ended by vomiting and associated central cyanosis - Inspiratory whoop - not always present (caused by forced inspiration against a closed glottis) - Infants may have spells of apnoea - Persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope and seizures - Symptoms may last 10-14 days and tend to be more severe in infants - Marked lymphocytosis

Answer 67

* Infants are routinely immunised at 2, 3, 4 months and 3-5 years * New born infants are particularly vulnerable which is why the campaign for pregnant women was introduced * Infection or immunisation does not result in lifelong protection - therefore adults and adolescents may develop whooping cough despite having had their routine immunisations

Answer 68

* Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause and has one or more of the following features: - Paroxysmal cough - Inspiratory whoop - Post-tussive vomiting - Undiagnosed apnoeic attacks in young infants

Answer 69

* Nasal swab culture for Bordetella pertussis - may take days to weeks to come back * PCR and serology are now increasingly used as their availability becomes more widespread

Answer 70

* Subconjunctival haemorrhage * Pneumonia * Bronchiectasis * Seizures

Answer 71

* Infants under 6 months with suspected pertussis should be admitted to hospital * Whooping cough/pertusis is a notifiable disease * Treatment with an oral macrolide (clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread * Household contacts should be offered antibiotic prophylaxis * Antibiotic therapy has not been shown to alter the course of the illness * School exclusion - 48 hours after commencing antibiotics (or 21 days from the onset of symptoms if no antibiotics

Answer 72

* Women who are between 20-32 weeks pregnant are offered the vaccine

Answer 73

Whooping cough has 3 phases of symptoms: * The catarrhal phase lasts approximately a week and is characterized by the development of a dry, unproductive cough. * The paroxysmal phase may last for a month or more and is characterized by coughing fits, whooping, and post-tussive vomiting. The person may be relatively well between paroxysms. * The convalescent phase may last an additional 2 months or more, and is characterized by gradual improvement in the frequency and severity of symptoms

Answer 74

* Infection of the gastro intestinal tract resulting in diarrhoea, vomiting and abdominal pain

Answer 75

* Travellers diarrhoea - May be defined as at least 3 loose to watery stools in 24 hours with or without one or more abdominal cramps, fever, nausea, vomiting or blood in the stool - Most common cause is Escherichia coli * Acute food poisoning describes the sudden onset of nausea, vomiting and diarrhoea after the ingestion of a toxin - Typically caused by Staphylococcus aureus, Bacillus cereus or Clostridium perfringens

Answer 76

* Common amongst travellers * Watery stools * Abdominal cramps and nausea

Answer 77

* Prolonged, non-bloody diarrhoea

Answer 78

* Profuse, watery diarrhoea * Severe dehydration resulting in weight loss * Not common amongst travellers

Answer 79

* Bloody diarrhoea | * Vomiting and abdominal pain

Answer 80

* Severe vomiting | * Short incubation period

Answer 81

* A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody * May mimic appendicitis * Complications include Guillain-Barre syndrome

Answer 82

* Two types of illness are seen - Vomiting within 6 hours, stereotypically due to rice - Diarrhoeal illness occurring after 6 hours

Answer 83

* Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks

Answer 84

* 1-6 hrs - Staphylococcus aureus, Bacillus cereus (vomiting subtype, diarrhoeal illness has an incubation period of 6-14 hours) * 12-48 hrs - Salmonella, E. coli * 48-72 hrs - Shigella, Campylobacter * > 7 days - Giardiasis, Amoebiasis

Answer 85

* Ask about signs and symptoms of dehydration (use NICE criteria for dehydration) * Ask about features that my indicate an alternative diagnosis e.g. high fever, non-blanching rash or neck stiffness * Document the frequency and consistency of stools, frequency of vomiting and whether blood or mucus are present in the stool * Ask about recent contacts and possible sources of infection * Arrange hospital transfer if: - Features of shock are described by the parent or carer - Alternative life threatening diagnosis e.g. non-blanching rash or severe breathing difficulty

Answer 86

* Symptoms suggest a serious diagnosis * Single acute episode of bloody diarrhoea * Child is dehydrated (according to the NICE framework) * Risk factors are present which indicate an increased risk of dehydration: - <1 year and especially those under 6 months - Low birth weight - Infants who have stopped breast feeding during their illness - Children who have passed six or more diarrhoeal stools in the past 24 hours - Children who have vomited three times or more in the past 24 hours - Social circumstances make the assessment over the phone unreliable

Answer 87

* No clinically detectable dehydration - Appears well - Alert and responsive - Normal urine output - Skin colour unchanged - Warm extremities * Clinical dehydration - Appears to be unwell or deteriorating - Altered responsiveness (irritable, lethargic) - Decreased urine output - Skin colour unchanged - Warm extremities * Clinical shock - Decreased level of consciousness - Pale or mottled skin - Cold extremities

Answer 88

* Encourage adequate fluid intake (discourage fruit juices and carbonated drinks) * Advise continued breast feeding and other milk feeds

Answer 89

* Washing hands thoroughly with soap (liquid if possible) in warm running water and careful drying is the best way to prevent the spread of gastroenteritis. * A flush toilet should be used, if possible. If a potty must be used, it should be handled with gloves, the contents disposed of into the toilet, and then washed with hot water and detergent and allowed to dry. * Hands should be washed after going to the toilet and changing nappies, and before preparing, serving, or eating food. * Toilet seats, flush handles, wash-hand basin taps, surfaces, and toilet door handles should be cleaned at least once daily with hot water and detergent. A disinfectant (if available) and a disposable cloth (or one dedicated for toilet use) should be used to clean toilets. * Towels and flannels used by infected children should not be shared. * Soiled clothing and bed linen should be washed separately from other clothes and at the highest temperature they will tolerate (for example 60°C or higher for linen), after removal of excess faecal matter into the toilet. Soaking in disinfectant is not necessary. The washing machine should not be more than half full to allow for adequate washing and rinsing. * Children should not attend school or other childcare facility while they have diarrhoea or vomiting. * Children should not go back to school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting. Public Health authorities will advise if a pathogen is isolated from a child's stool sample (for example Salmonella, Escherichia coli O157): longer periods of exclusion are required in some circumstances. * If cryptosporidiosis is suspected or confirmed, children should not enter swimming pools for 2 weeks after the last episode of diarrhoea

Answer 90

* Advise parents or carers to seek advice from a healthcare professional if their child's symptoms do not resolve within the following time frames: - Diarrhoea - 5-7 days and in most it stops in 2 weeks - Vomiting - 1 or 2 days and in most stops within 3 days * Safety net, advising the parents or carers how to recognise features of dehydration and shock * Access medical care if red flag features are identified

Answer 91

* Assess the severity of the illness - Frequency and consistency of stools - Presence of blood - Frequency of vomiting - Ability to eat and drink * Perform an appropriate examination - Temperature, BP, HR and RR - Assess for abdominal tenderness - Features of dehydration * Investigate potential causes or contributing factors - Recent contact with someone with acute diarrhoea and/or vomiting - Exposure - contaminated water - Recent travel - Recent antibiotic treatment or hospital admission within the last 8 weeks - suspect c. diff - Use of PPI and metformin drugs * Assess personal risk factors - Older age - Pregnancy - Immunocompromised * Review medications - Diuretics and ACEi can exacerbate dehydration and renal failure - Warfarin, anticonvulsants, COCP may be affected by severe diarrhoea

Answer 92

Symptoms include: - Lassitude. - Anorexia. - Nausea. - Light headedness. - Postural hypotension. There are usually no signs

Answer 93

* Symptoms include: - Apathy/tiredness. - Dizziness. - Nausea. - Headache. - Muscle cramps. Signs include: - Pinched face. - Dry tongue or sunken eyes. - Reduced skin elasticity. - Postural hypotension (systolic blood pressure > 90 mmHg). - Tachycardia. - Oliguria.

Answer 94

``` Symptoms include: - Profound apathy. - Weakness. - Confusion, leading to coma. Signs include: - Shock. - Tachycardia. - Marked peripheral vasoconstriction. - Systolic blood pressure. - Uraemia, oliguria, or anuria ```

Answer 95

* Arrange emergency admission to hospital if the person: - Is vomiting and unable to retain oral fluids. - Has features of shock or severe dehydration. * Other factors influencing admission (clinical judgement should be used) include: - Recent foreign travel. - Older age (people 60 years of age or older are more at risk of complications). - Home circumstances and level of support. - Fever. - Bloody diarrhoea. - Abdominal pain and tenderness. - Faecal incontinence. - Diarrhoea lasting more than 10 days. - Increased risk of poor outcome, for example: - Coexisting medical conditions — immunodeficiency, lack of stomach acid, inflammatory bowel disease, valvular heart disease, diabetes mellitus, renal impairment, rheumatoid disease, and systemic lupus erythematosus. - Drugs that can exacerbate dehydration and renal failure — immunosuppressants, systemic steroids, proton-pump inhibitors, H2-receptor antagonists, simple antacids, angiotensin-converting enzyme inhibitors, and diuretics

Answer 96

* Send stool sample if: - Systemically unwell. - Blood or pus in the stool. - Immunocompromised. - History of recent hospitalization and/or antibiotic treatment. - Diarrhoea occurs after foreign travel to anywhere other than Western Europe, North America, Australia, or New Zealand. - Diarrhoea is persistent and giardiasis is suspected. - Uncertainty about the diagnosis of gastroenteritis

Answer 97

* Send a single specimen (1 mL, or a pea-sized sample, is the minimum needed for routine investigation) for culture and sensitivity. * If the person has recently travelled abroad to anywhere other than Western Europe, North America, Australia, or New Zealand, also request tests for ova, cysts, and parasites. * If diarrhoea is recurrent and parasitic infection is suspected, send three specimens (5 mL each) 2–3 days apart, as ova, cysts, and parasites are shed intermittently. * Ensure the following details are stated on the request form: - Clinical features (for example systemic illness, fever, bloody stool, and/or abdominal pain; and onset, duration, and recurrence of symptoms). - History of immunosuppression. - Food intake (for example barbecue or restaurant, and types of food eaten). - Recent foreign travel (state the country visited). - Recent antibiotic or proton pump inhibitor treatment, or recent hospital admission. - Exposure to untreated water. - Contact with other affected individuals or outbreaks

Answer 98

* Metronidazole, followed by 10 day course of diloxanide * Mild to moderate intestinal amoebiasis - Metronidazole 400 mg x 3 per day for 5-10 days followed by diloxanide 500mg x 3 per day for 10 days * For amoebic dysentry - Metronidazole 800 mg x 3 per day for 5 days, followed by diloxanide 500 mg x 3 per day for 10 days * Tinidazole is an alternative to metronidazole

Answer 99

* Antibiotic are not usually required for mild symptoms * Consider for people who have severe symptoms, immunocompromised, worsening symptoms and lasting longer than 1 week * If antibiotics are indicated - Erythromycin 250 mg to 500 mg x 4 per day for 5 - 7 days - Ciprofloxacin 500 mg x 2 per day for 5 - 7 days is an alternative to macrolides

Answer 100

* Management is entirely supportive | * Most adults can go back to work 48 hours after the first normal stool

Answer 101

* Prescribe antibiotic treatment for all people with confirmed giardiasis * Metronidazole - 400 mg x 3 per day for 5 days - 500 mg x 2 per day for 7 - 10 days or 2 grams once a day for 3 days * Tinidazole is an alternative to metronidazole

Answer 102

* Most do not require antibiotic treatment * Those who do may include: - > 50 years - Immunocompromised - Cardiac valve disease * If indicated treat with: - Ciprofloxacin 500 mg x 2 per day for 1 day only

Answer 103

* Most do not require antibiotic treatment * Consider in those with: - Severe disease - Immunocompromised - Bloody diarrhoea * In those requiring antibiotic treatment prescribe: - Ciprofloxacin 500 mg x 2 per day for 1 day only (continued for 5 days if the organism is Shigella dysenteriae) or - Azithromycin or trimethoprim

Answer 104

If a case of any of the following is suspected: - Cholera. - Bloody diarrhoea presumed to be due to gastroenteritis. - Food poisoning (organisms that can be implicated in food poisoning include Campylobacter, Escherichia coli O157:H7, Salmonella, Shigella, Giardia, Yersinia enterolytica, Entamoeba histolytica, and norovirus). - Haemolytic uraemic syndrome (HUS). * Complete an official Formal Notification Certificate (from a pad supplied locally) immediately on diagnosis of a suspected notifiable disease and return it to where the pad was obtained within 3 days (this could be the Local Authority, Primary Care Trust, or Health Protection Unit).

Answer 105

* Life threatening illness caused by infection of red blood cells by plasmodium parasites which is spread by the female Anopheles mosquito

Answer 106

* Plasmodium falciparium * Plasmodium vivax * Plasmodium ovale * Plasmodium malariae

Answer 107

* Plasmodium falciparium

Answer 108

* Plasmodium vivax

Answer 109

* Sickle cell trait * G6PD * HLA-B53 * Absence of Duffy antigens

Answer 110

* Transmission of malaria to humans occurs through the bite of infected female Anopheles mosquitoes. * The infecting agent (sporozoite) is inoculated into humans in the saliva of infected mosquitoes during a blood meal. * The sporozoites travel in the bloodstream to the liver where they enter liver cells and mature into schizonts which eventually rupture and release tens of thousands of merozoites. * Each merozoite can infect a red blood cell where they mature and divide to form more parasites. These are released into the bloodstream when the red blood cell ruptures and go on to infect other red blood cells. The number of parasites in the blood increases rapidly and produces clinical illness. * Some parasites in the red blood cells form male and female gametocytes. * These mate if taken up by a mosquito and mature to release sporozoites ready to be inoculated into a new human host * Malaria can also occur (rarely) in the UK as a result of: * "Airport malaria" or "baggage malaria" — malaria imported to non-endemic areas by infected Anopheles mosquitoes hiding in planes or in baggage. * Person-to-person transmission during: - Blood transfusion or implantation of infected tissues. - Pregnancy. - Injecting drug use.

Answer 111

* Found worldwide in tropical and subtropical areas. It is the most prevalent malaria parasite on the African continent and is responsible for the majority of malaria deaths

Answer 112

* Found in Asia, Latin America, and some parts of Africa. It is the most common malaria parasite outside sub-Saharan Africa. P. vivax has dormant liver stages which can cause ‘relapses’ of malaria months or years after the initial infection

Answer 113

* Found mostly in Africa (especially West Africa) and the islands of the western Pacific. P. ovale has dormant liver stages which can cause ‘relapses’ of malaria months or years after the initial infection

Answer 114

* Found in South America, Asia and Africa. If untreated, P. malariae can cause lifelong chronic infection

Answer 115

* A malaria parasite of monkeys in South-East Asia which can cause severe and sometimes fatal illness in humans

Answer 116

* If identified promptly, appropriate treatment given and no organ dysfunction has occurred, most people make a rapid recovery * Severe malaria - Untreated severe malaria is fatal in the majority of cases - Progression to severe may take days or occur within hours - Prognostic factors include high levels of parasitaemia, peripheral p. falciparum blood schizonts, pigment deposits in leucocytes, metabolic acidosis, older age, coma and renal impairment - Most cases of severe malaria are due to p. falciparum infection but other species can also cause severe infection (p. vivax and p. knowlesi) - Infants, young children and pregnant women and older people are at particular risk of severe disease

Answer 117

* Cerebral malaria - severe malaria due to p. falciparum with GCS <11 or malaria with coma persisting for more than 30 minutes after a seizure * ARDS * Spontaneous bleeding and coagulopathy * Septicaemia * Severe anaemia * Hypoglycaemia * Metabolic acidosis * Acute kidney injury * Nephrotic sydnrome * Jaundice * Splenic rupture Pregnancy * Severe malaria is more likely, particularly in the second and third trimesters and is often associated with pulmonary oedema and hypoglycaemia * Cerebral malaria has a mortality of 50% * Foetal death, premature delivery and IUGR may occur

Answer 118

* Anyone who has recently returned from an endemic area for malaria who is unwell or has a fever or history of fever, regardless of malaria chemoprophylaxis * Almost all cases of p.falciparum malaria present within 6 months of exposure and most within 2 to 3 months * Infection with other species such as P. ovale and p. vivax may present months or years after exposure due to reactivation of hypnozoites (dormant liver stage) * Presentation may be delayed in people who have taken chemoprophylaxis * Most missed cases of malaria are wrongly diagnosed as non-specific viral infections, influenze, gastroenteritis and hepatitis

Answer 119

* Fever 39c or higher, sweats and/or chills - absence of fever should not remove suspicion * Headache * General malaise, lethargy and fatigue * Poor feeding in children * Myalgia and arthralgia * Sore throat, cough, lower respiratory tract symptoms and respiratory distress * Confusion

Answer 120

* Cerebral malaria (GCS <11) * Renal impairment * Acidosis * Hypoglycaemia <2.2mmol/l * Respiratory distress which may be due to pulmonary oedema or ARDS * Severe anaemia * Spontaneous bleeding/ DIC * Shock BP <90/60 mmHg * Sepsis - more common in pregnant women * Haemoglobinuria - dark red urine (black water fever) * Parasitaemia >10%

Answer 121

* Cerebral malaria - impaired GCS <11, seizures, altered respiration and posturing (decorticate or decerebrate) * Severe anaemia (may present with pallor) * Respiratory distress or acidosis * Hypoglycaemia 2.2 mmol/l * Prostration (inability to stand or sit) * Parasitaemia >2% red blood cells parasitised

Answer 122

Ask about: * Symptoms of malaria such as fever, sweats, chills, malaise, myalgia, headache, vomiting, diarrhoea and cough and timing of onset * Travel history including: - Country and area of travel - Stop overs and other countries transited through - Date of return - Type of travel and activities while abroad * Preventative measures - Malaria chemoprophylaxis (dose, adherence and cessation) - Full adherence does not guarantee protection against malaria - Travel immunisations - Insect repellant and bed nets used * Risk of severe malaria - Children, pregnant women, older people and immunocompromised * Possible differential diagnoses: - Ebola, Lassa fever or Marburg - if any of these are suspected immediately isolate in a side room

Answer 123

Look for: * Signs of severe malaria such as impaired consciousness, confusion, hypotension, respiratory distress or jaundice * Check vital signs BP, HR, RR, temperature, O2 sats * GCS * Pallor - suggestive of anaemia * Hepatomegaly or splenomegaly

Answer 124

* Microscopy of thick and thin blood films or an antigen detection test * EDTA should be used for blood samples * If the first blood films are negative, further blood testing must be arranged 12 to 24 hours later and again after a further 24 hours to rule out infection * In pregnancy thick films can be negative despite the presence of parasites in the placenta - expert advice should be sought if malaria is suspected

Answer 125

* Arrange for immediate admission for specialist assessment and treatment if the person: - Suspected severe or complicated malaria - Suspected falciparum malaria - Pregnant women - Children - >65 years - Urgently discuss all others with an infectious diseases specialist * Ensure all cases of malaria have been notified to Public Health England * Advise people who have been diagnosed the following: - Warn people they travelled with about the risk and to seek immediate medical help if symptoms develop - An acute episode of malaria will not protect them from future attacks - They will be notified to public health as part of routine surveillance - Relapses of malaria can occur - They may be excluded from blood donation for sometime following malaria infection

Answer 126

* Depends on a variety of factors including species of plasmodium parasite, severity of infection, tolerability of specific drugs and patterns of resistance * Anti malarial drugs recommended in the UK include: - Artesunate - for severe or complicated malaria - Quinine - may be used to treat severe malaria initially if Artesunate is not available - Artemisinin combination therapy (ACT) - may be used to treat uncomplicated malaria and is the preferred treatment for mixed infection - Atovaquone proguanil - may be used to treat uncomplicated falciparum malaria if ACT is unavailable - Quinine plus doxycycline - combination may be used to treat falciparum malaria if ACT is unavailable - Doxycycline should not be given to children under the age of 12 years - Chloroquine - may be used to treat uncomplicated P. malariae, P. ovale and P. knowlesi and most cases of P. vivax malaria but use depends upon patterns of resistance and tolerance - Primaquine - only currently effective drug for the eradication of hypnozoites (dormant parasites which persist in the liver after treatment of P. vivax and P. ovale). Screening for G6PD deficiency is essential before treatment with primaquine is started as it can cause haemolysis in G6PD deficient individuals, which can be fatal. It is contraindicated in pregnancy and breastfeeding

Answer 127

* Atovaquone + proguanil (Malarone) - Time before travel 1-2 days - Time to end after travel 7 days - Side effects GI upset * Chloroquine - Time before travel 1 week - Time to end after travel 4 weeks - Side effects headache - Contraindicated in epilepsy - Taken weekly * Doxycycline - Time before travel 1-2 days - Time to end after travel 4 weeks - Side effects photosensitivity, oesophagitis * Mefloquine (Lariam) - Time before travel 2 - 3 weeks - Time to end after travel 4 weeks - Side effects Dizziness, neuropsychiatric disturbance - Contraindicated in epilepsy - Taken weekly * Proguanil (Paludrine) - Time before travel 1 week - Time to end after travel 4 weeks * Proguanil + chloroquine - Time before travel 1 week - Time to end after travel 4 weeks - Side effects see above

Answer 128

* Chloroquine can be taken * Proguanil: folate supplementation (5mg od) should be given * Malarone (atovaquone + proguanil): the BNF advises to avoid these drugs unless essential. If taken then folate supplementation should be given * Mefloquine: caution advised * Doxycycline is contraindicated

Answer 129

* All should be assessed for evidence of sepsis * qSOFA score 2+ of the following indicates severe infection: - GCS <15 - Respiratory rate >22 - Systollic BP <100 * Follow local sepsis pathway (BUFALO) empirical therapy, referral to ITU * Assess immune status - have a low threshold for admission and be aware this may be compromised by malignancy, transplant, age, HIV status, diabetes, immunosuppressive drugs

Answer 130

* Isolation - are any of the following present: - Rash - Diarrhoea - Respiratory symptoms - Haemorrhage - Gastrointestinal or respiratory secretions * Not present - no isolation required * Present - isolate the patient according to risk * Assess their travel risk - Where did you go? - What did you do there? - When did you become unwell? * Is there evidence of viral haemorrhagic fever - Lassa fever risk - Crimmean-Congo Haemorrhagic fever - Ebola and Marburg virus disease risk * Is there risk of emerging severe acute respiratory illness * Is there risk of antimicrobial resistance * Is the patient at risk of malaria - Urgent diagnostic tests - Parasite count >10% = severe, >2% = at risk - Central nervous system, GCS <11, prostration, seizures - Organ dysfunction, AKI, jaundice, pulmonary oedema - Blood markers acidosis, hypoglycaemia, anaemia * Routine investigations - Blood cultures - Respiratory virus swab - Focal microbiology or virology samples - Imaging - HIV test - Routine blood tests * Specialist investigations

List I - Core Conditions Flashcards

(154 cards)