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Other Medicine Flashcards

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1
Q

Most common cause of fever after travel to Sub-Saharan Africa and tropical areas

A

Malaria

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2
Q

Most common cause of fever after travel to Latin America or Asia

A

Dengue

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3
Q

Definition of severe malaria

A

Fever in last 48 hours

P falciparum infection, >100 parasites/200 leukocytes, no other causative organism

At least one of:
- Impaired consciousness, GCS <10
- Multiple grand mal seizures
- Jaundice
- Hypoglycaemia (<2.5)
- Hyperparasitaemia (parasite density >100000)
- Renal impairment
- Cardioresp distress

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4
Q

Causes of fever + haemorrhage

A

Viral haemorrhagic disease
- Dengue
Leptospirosis
Meningicoccaemia
Rickettsial infection

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5
Q

Investigation for malaria

A

Malaria antigen rapid diagnostic test (RDT)
Thick and thin blood films taken on 2 occasions
- >3 negative blood films on 3 consecutive days to rule out

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6
Q

Investigation for travellers diarrhoea

A

Only test stools if prolonged diarrhoea (10-14 days) or severe symptoms (fever, tenesmus, bloody stools)
- Stool culture
- Shiga toxin assay
- Ova and parasites
- Giardia and cryptosporidium antigen

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7
Q

Treatment of uncomplicated malaria

A

P. falciparum or unidentified species: artemether+lumefantrine (Riamet, Coartem) or atovaquone+proguanil (Malarone)

P. vivax, P. ovale, P. malariae, P. knowlesi: Chloroquine, hydroxychloroquine, artemethar+lumefantrine (Riamet, Coartem)
If P. vivax, P. ovale liver hypnozoites: Primaquine (do not give in G6PD deficiency-haemolysis)

Chloroquine resistant P. vivax: artemethar+lumefantrine + Primaquine

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8
Q

Management of traveller’s diarrhoea

A

Antiemetic
Oral fluid + electrolyte replacement
Loperamide for profuse diarrhoea

Empiric abx:
Ciprofloxacin 750-1000mg stat, or 500mg BD 3 days
Or azithromycin 1g stat or 500mg BD 3 days if South/SE Asia (high fluoroquinolone resistance)

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9
Q

Symptoms and incubation for traveller’s diarrhoea

A

Bacterial + viral - 6-48 hours incubation
- vomiting more prominent in Norovirus
- Rice water diarrhoea in cholera

Parasitic infection 1-2 week incubation
Slower onset, low grade symptoms

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10
Q

Malaria presentation

A

Plasmodium parasite
<1 month incubation
P. vivax hypnozoites can stay dormant for months-years
Fever, chills, sweats
Headache
Nausea, vomiting, anorexia
Body aches, general malaise

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11
Q

Fever, arthralgia/myalgia, rash

3 possible traveller’s infections:

A

Dengue
Zika
Chikungunya

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12
Q

Dengue presentation

A

Aedes aegypti mosquito
Incubation 4-10 days
Most asymptomatic or subclinical
Sudden onset fever
Arthralgia
Maculopapular or macular confluent rash 2-5 days after fever
Minor haemorrhage - epistaxis, heavy menstrual bleed, petechiae, gum bleeding
Extreme malaise
Headache behind eyes
Sore throat, conjunctival injection, abdo pain

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13
Q

Chikungungya presentation

A

Fever >39 several days-1 week
Bilateral, symmetrical arthralgia - small joints of hands and feet
Tenosynovitis
2-5 days after fever onset - maculopapular rash of trunk and extremities. Petechial or vesiculobullous in infants

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14
Q

Causes of travellers diarrhoea

A

Enterotoxic E coli (most common)
Enteroinvasive E coli
Enteroaggregative E coli
Shigella
Campylobacter
Salmonella
Norovirus (10-20%)
Protozoal parasites

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15
Q

Transmission of Hepatitis strains
Acute vs chronic

A

A, E - orofaecal, gastro symptoms, usually self-limiting

B, C, D - bloodbourne: intercourse, transfusion, vertical transmission, blood to blood
D always co-infected with B, indicator of worse prognosis. Cirrhosis, failure, ca.
C - 80% chronically infected
B - 50% chronically infected

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16
Q

Risk factors for
Hep A
Hep B, C, D

A

A - travel to high risk areas, sewage workers, MSM, IVDU

B, C, D - IVDU, tattoos, MSM.

B - endemic countries

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17
Q

HIV risk factors

A

Travellers and immigrants from Sub-Saharan Africa, SE Asia
MSM
IVDU
Related infections - Hep B, C, STI, TB

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18
Q

Symptoms of HIV

A

60% asymptomatic of acute infection
Fever
Malaise
Sore throat
Rash
Arthralgia/myalgia
Anorexia, weight loss, oral ulcers

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19
Q

Causes of meningitis

A

Viral - most common
Neisseria meningitidis
Strep pneumoniae
Haemophilus influenzae

Children:
Listeria monocytogenes
E coli
Enterococci
Herpes simplex

Consider partially treated meningitis, parameningeal focus (ears, sinus, cerebral abscess)

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20
Q

Management of suspected meningitis

A

Treat as bacterial until proven otherwise
Urgent medicine referral
IVabs if >20min delay to hospital

Neonates <3 months: Benzylpenicillin 50mg/kg, max 2g
Children 3 months to 10 years: Ceftriaxone 100mg/kg, max 2g
Adults: Ceftriaxone 2g + dexamethasone 10mg

IV access x2
IV bolus - 1L adult, 20mL/kg child
Bloods + blood cultures x2

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21
Q

Risk factors for meningitis

A

Infants, children, adolescents
Maori, Pacific
Exposure to smoke
Binge drinking
Other respiratory infection
Crowded house, institutionalism
Close contact with positive meningitis case
Immunocompromised

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22
Q

Cellulitis vs erysipelas

A

Cellulitis - Infection of dermis and subcutaneous tissue

Erysipelas - Infection of superficial dermis

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23
Q

Symptoms less likely to be cellulitis

A

Itch
Bilateral
Symptoms of nec fasc

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24
Q

Necrotising fasciitis
Symptoms
Management

A

Severe pain, systemic symptoms, purple discolouration, necrotic tissue, crepitus

IV ceftriaxone
Immediate referral

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25
Risk factors for cellulitis
Elderly with poor circulation Smoking Immunocompromised Diabetes Overweight
26
Differential diagnoses for cellulitis
Thrombophlebitis Lipodermatosclerosis Radiation damage Dermatitis Fungal infection Insect bite Inflammatory breast ca
27
Antibiotics for cellulitis
Flucloxacillin Children: 12.5-25mg QID 5 days Adults: 500mg-1g tds/qid 5 days Cefalexin 12.5-25mg/kg, 2-4 times/day, 5 days 500mg QID 5 days Erythromycin 10-12.5mg/kg, QID 5 days 400mg QID 5 days Co-trimoxazole 24mg/kg BD 5 days 960mg BD 5 days
28
Causes of UTI
E coli Staph saporphyticus Proteus Klebsiella Enterococcus
29
Diagnosis of catheter associated UTI
Fever >38 Suprapubic tenderness Costovertebral angle tenderness Urine dipstick or culture positive No other cause of fever Pyuria is common in catheter
30
Management of asymptomatic bacteriuria in pregnancy
Risk of preterm birth and low birth weight Treat empirically, urine for culture
31
Treatment of UTI with haeamaturia
Macroscopic - treatment for 10 days, repeat urine 2 weeks post treatment Microscopic - treatment for 7-10 days, repeat urine 1 week post treatment
32
Empiric antibiotic treatment for UTI Men Women Pregnant Child
Men: Nitrofurantoin 100mg BD 7 days Trimethoprim 300mg nocte 7 days Cefalexin 500mg BD 7 days Women: Nitrofurantoin 100mg BD 5 days Trimethoprim 300mg nocte 3 days Cefalexin 500mg BD 3 days Pregnancy: Treat for 7 days Not for trimethoprim first trimester Not for nitrofurantoin after 36 weeks Child: Cotrimoxazole 24mg/kg BD 3 days Cefalexin 12.5-25mg/kg BD 3 days Augmentin 15m/kg tds 3 days Nitrofurantoin - do not give in renal failure, CrCl <30
33
Symptoms of acute pyelonephritis
Fever Flank pain Nausea and vomiting Augmentin Co-trimoxazole Cefalexin
34
Treatment of pyelonephritis
Cotrimoxazole 960mg BD 10 days Augmentin 625mg tds 10 days Cefalexin 1g tds/qid 10 days - only if susceptible and resistant to other choices Refer pregnant women Low threshold referral for elderly
35
Cause of Herpes zoster (shingles)
Varicella zoster virus Recurrence in nerve root - stress, immunocompromisation, old age
36
Herpes zoster presentation
Blistering rash, allodynia, within dermatomal distribution, does not cross midline Resolves in 10-15 days Itching, tingling, pain along distribution and viral prodrome prior to appearance of rash
37
Treatment of Herpes zoster
Antiviral most useful within 72 hours of rash Over 72 hours use if - new lesions, HZO, age >50, immunocompromised, prodrome presence, severe/disseminated rash, severe pain Valaciclovir 1g tds 7 days Aciclovir 800mg 5 times/day 7 days Famiciclovir 500mg tds 7 days Ice, calamine Capsaicin cream (post herpetic neuralgia) Lidocaine Codeine Tramadol Oxycodone Sometimes: prednisone, TCA, gabapentin
38
Complications of Herpes zoster
Uncommon in immunocompetent patients Highest risk in lymphoproliferative cancers Mortality 5-15% Encephalitis Meningitis Pneumonitis Blindness/permanent visual impairment - HZO Post herpetic neuralgia
39
Causes of infectious mononucleosis
Epstein-Barr virus Cytomegalovirus Toxoplasmosis HIV
40
Infectious mononucleosis symptoms and signs
Classic triad: Fever, pharyngitis, lymphadenopathy (posterior cervical) Splenomegaly (50% in first 2 weeks) Hepatomegaly + jaundice (uncommon) Generalised maculopapular/urticarial/petechial rash - especially after amoxicillin Fever + sore throat - 1 month Fatigue - 2-3 months
41
Encephalitis diagnosis criteria
3 or more of: Fever Seizures Focal neurological signs CSF pleicytosis (WCC >5x10^6) EEG slowing Abnormal MRI
42
Causes of encephalitis
30-50% infective Herpes simplex - most common Measles Varicella zoster Adenovirus Mumps EBV Enterovirus Toxoplasmosis gondii Mosquito, tick-borne virus Mycoplasma pneumoniae Influenza Non-infective acute demyelinating encephalomyelitis antibody-mediated autoimmune disease Paraneoplastic syndromes Treat all suspected as infective until proven otherwise - antivirals + abx
43
Complications of encephalitis
Seizure Hydrocephalus Neurological sequelae - behaviour, motor disturbance Herpes encephalitis in children 70% mortality untreated
44
Risk factors for encephalitis
Immunosuppression <1 or >65 Unvaccinated Exposure to infected contacts (cold sores) Concurrent or recent viral infection Animal/insect bite Occupations - farming, abbatoir Recreations - hiking, swimming, spelunking Travel history
45
Causes of upper GI bleed
Peptic ulcer, oesophageal-gastric varices (most common) Mallory-Weiss tears Acute stress erosions (shock, NSAIDs) Oesophagitis Gastritis Duodenitis Upper GI cancer Arteriovenous malformation
46
Forms of upper GI bleed
Haematemesis Coffee ground vomit Malaena Haematochezia
47
Vital signs of moderate and severe haemorrhage
Moderate (25-50%) - Postural drop 10mmHg - Severe lightheadedness rising from supine - Increase in HR by >30bpm rising from supine Severe (>50%) - Systolic BP <90mmHg - Tachycardia >120bpm
48
Rockall score for upper GI bleed
Need for emergency endoscopy Age 60-79 = 1 Age >80 = 2 Tachycardia >100, SBP >100 =1 Hypotension SBP <100 = 2 Renal failure, liver failure, disseminated malignancy = 2 Other significant comorbidity = 1
49
Glasgow Blatchford bleeding score
Score higher than 0 = urgent intervention Hb <100 BUN >18.2 Systolic BP (initial) <100 Sex HR >100 =1 Melaena =1 Recent syncope =2 Hepatic disease =2 Cardiac failure =2
50
Management of H pylori
Omeprazole 20mg BD 7-14 days Clarithromycin 500mg BD 7-14 days Amoxicillin 1g BD or metronidazole 400mg BD 7-14 days
51
Causes of lower GI bleed
Internal haemorrhoid, diverticular bleed - most common Ischaemic colitis Inflammatory bowel Cancer Rectal ulcer Angiodysplasia Post procedure
52
Discharge criteria for lower GI bleed
Age <60 Haemodynamically stable No ongoing gross rectal bleed PR or sigmoidoscopy reveals anorectal source
53
Causes of GORD
Functional - most common Oesophagitis Peptic ulcer disease H pylori NSAIDs coeliac disease Malignancy
54
GORD vs dyspepsia symptoms
GORD - heartburn, acid regurgitation Dyspepsia - bloating, early satiety, epigastric pain/discomfort after meals, nausea
55
Management of GORD
GORD: Lifestyle modification - spicy food, caffeine, ETOH, smoking, stress, obesity Stepdown therapy - omeprazole 20mg OD 4-12/52 > 10mg OD > ranitidine > PRN antacids Dyspepsia: r/o H pylori If bloating/early satiety - domperidone > ranitidine Stepdown therapy
56
Risk factors for H. pylori (>30%)
From South Auckland, East Cape, Porirua From low-middle income countries Maori, Pacific, Asian
57
Red flag symptoms for upper GI malignancy
FHx gastric cancer <50 Unexplained weight loss Progressive oesophageal dysphagia Protracted vomiting, persistent regurgitation Abdominal mass Iron deficiency anaemia Age >55 with persistent heartburn
58
Conditions with high risk of constipation
IBS Dehydration Diabetes Neuro: Parkinson's, MS Electrolytes: hypercalcaemia, hypokalaemia Psych: depression Coeliac Hypothyroidism GI obstruction Pelvic floor damage
59
Medications causing constipation
Antacids with calcium, aluminium Antispasmodics Antidepressants Antihistamines Antipsychotics Anti-Parkinsons Calcium supplements CCB Iron Ondansetron Opiates Oxybutynin PPI Vinca alkaloids (chemo)
60
Management of constipation
Exercise Dietary changes (water and fibre) Response to urge to defecate Bulk laxatives - psyllium, bran (2-3 days) Stimulant laxatives - docusate + Senna (Laxsol), bisacodyl (Fleet), Faecal softeners - docusate, Coloxyl Osmotic laxatives - lactulose, molaxole, glycerol supps, Fleet
61
Identification of Seniors at Risk (ISAR) score
Before illness - needing regular help? Since illness - needing more help than usual? Hospitalised >1 night in last 6 months? Generally see well? Serious problems with memory? 3+ medications daily? 2 or more is high risk
62
Geriatric presentation that is a marker of frailty and risk factor for adverse outcomes
Urinary incontinence
63
Causes of falls in elderly
Syncopal - cardiac, polypharmacy Non-syncopal - strength, balance, vision, proprioception, vestibular, environmental hazards (20%), acute medical illness
64
Delirium presentation
Acute onset over hours-days Fluctuating course, impaired attention, altered awareness, cognitive + neuropsychiatric disturbance Mood disturbance Caused by underlying medical disorder Independent risk factor for 6-month mortality rate Hyperactive - hallucination, delusion, agitation, disorientation Hypoactive - confusion, sedation Mixed
65
Richmond Agitation Sedation Scale
Likelihood for delirium 57% if score >1 or <-1 +4 - combative, violent +3 - agitated, aggressive, pulling tubes +2 - agitated, non-purposeful movements, fights ventilator +1 - restless, anxious 0 - alert and calm -1 - drowsy, >10s sustained awakening to voice -2 - light sedation, <10s brief awakening to voice -3 - movement/eye opening to physical stimulation -4 - unrousable
66
Common meds causing delirium
Opioids Antihistamines Benzos CCB Less clear: H2 receptor antagonists TCA Antiparkinsons Steroids NSAIDs Anticholinergics
67
Types of diabetes and features
Type 1 - 6 month - young adult onset - Often acute onset - Ketosis present - Autoimmune condition - Parental diabetes 2-4% Type 2 - Onset after puberty - Obesity related - Ketosis uncommon - Acanthosis nigricans, striae - Parental diabetes in 80% Maturity onset diabetes of the young (MODY) - Onset after puberty - Autosomal dominant - Parental diabetes in 90% Maternally inherited diabetes and deafness - Onset after puberty - Maternal mitochondrial inheritance - Maternal diabetes 85%
68
Acute presentations of diabetes - hyperglycaemic crises
Diabetic ketoacidosis - Usually T1DM Hyperosmolar hyperglycaemic state - More commonly T2DM 33% have combination of both Polyuria Polydipsia Nausea/vomiting Abdo pain Dehydration Altered mental state - lethargy, drowsy, coma
69
Elderly diabetic patient with chronic ear discharge and sudden onset severe otalgia
Malignant otitis externa Can be life threatening
70
Symptoms specific to Grave's disease
Pretibial myxoedema, exophthalmos, periorbital oedema, conjunctival oedema Causes 85% hyperthyroidism
71
General symptoms of hyperthyroidism
Appetite stimulation Flush, sweats, heat intolerance Abdo pain Restlessness, agitation Tremor, weakness Palpitations Amenorrhoea Hair thinning SOBOE Urinary frequency, hyperdefecation
72
Management of hyperthyroidism
Radioactive iodine 131 Carbimazole Propylthiouracil Surgical thyroidectomy Beta blockers
73
Symptoms of thyroid storm
CNS - restlessness, delirium, psychosis, somnolence, seizure GCS <14 Fever >38 Tachycardia >130, AF Heart failure, pulmonary oedema Nausea, vomiting, diarrhoea, jaundice
74
Management of thyroid storm
Urgent transfer to hospital ABCs IV fluids Dextrose if hypoglycaemic ECG Bloods, infection screen Passive cooling Beta blockers for tachycardia Benzos for agitation rule out other causes - pregnancy, DKA, infection, embolism NEVER use aspirin - releases more thyroid hormone
75
Symptoms of hypothyroidism
Fatigue, myalgia Weight gain Cold intolerance Depression Constipation Dry skin Menstrual irregularity Bradycardia Diastolic hypertension Decreased reflex Hyponatraemia Hypercholesterolaemia Macrocytic anaemia
76
Risks of hypothyroidism
Women Treatment for hyperthyroidism Turner, Down syndrome T1DM, Addison's disease, coeliac Hx postpartum thyroiditis Lithium, amiodarone Calcium, antacids, phenytoin, carbamazepine, hormone replacement - increased thyroxine requirements
77
Myxoedema symptoms
Bradycardia Cool peripheries, hypothermia Non-pitting oedema Hypoglycaemia Hypotension Thin hair Altered consciousness
78
Management of myxoedema
Urgent referral to hospital ABCs IV fluids IV dextrose (if hypoglycaemic) Passive warming Bloods, septic screen ECG Consider other causes - drugs, sepsis, DKA
79
Precipitants of adrenal crisis
Sepsis Trauma Surgery Burn Cardio/metabolic event Meds: Heparin Warfarin Azole antifungals Phenytoin Rifampicin
80
Symptoms of adrenal insufficiency
Fatigue Weight loss, anorexia Hypotension, syncope Nausea, vomiting, diarrhoea Abdo pain Myalgia, arthralgia Body hair loss Irritability Hyperpigmentation (primary only)
81
Symptoms of adrenal crisis
Shock and fever **Hypotension refractory to fluids Variable and non-specific: Weakness, fatigue, delirium/altered mental state, vomiting, diarrhoea, abdo pain Hyponatraemia, hyperkalaemia
82
Causes of primary adrenal insufficiency
Addison's disease - autoimmune Congenital adrenal hyperplasia - enzyme deficiency Adrenal haemorrhage (Waterhouse-Friedrichsen) - meningococcaemia Tumours - breast, melanoma Infection - TB, HIV
83
Causes of secondary adrenal insufficiency
Panhypopituitarism Pituitary apoplexy - infarction or haemorrhage of tumour Chronic steroid therapy Tumours Granulomas
84
Management of adrenal crisis
IV fluids IV steroids - hydrocortisone 100mg Urgent referral
85
3 most common cause of acute monoarthritis
Infection Crystals Trauma
86
Common locations for septic arthritis
Knee (50%) Hip Shoulder Elbow
87
Risks for septic arthritis
Joint prosthesis Foreign body Previous joint damage Overlying skin infection Recent joint surgery/injection RA Diabetes Elderly >80 Immunosuppression IVDU
88
Organisms in septic arthritis
Staph aureus Streptococci Neisseria gonorrhoea Pseudomonas aeroginosa E coli
89
Xray features of osteoarthritis
Narrow joint space Subchondral sclerosis Subchondral cysts Osteophytes
90
Insidious onset Morning stiffness resolving in 30 mins Stiffness after inactivity, resolving in minutes Pain worse with use, better with rest Polyarticular, symmetrical. Usually sparing wrist and elbows Heberden's nodes Bouchard's nodes
Osteoarthritis
91
Over days-weeks Morning stiffness Preceding systemic illness - fever, myalgia, fatigue Often asymmetric presentation
Rheumatoid arthritis
92
SI joints, axial spine, ribs Often associated with iritis, heel pain
Ankylosing spondylitis HLA-B27 in 90-95%
93
Arthritis in greater joints, lower > upper extremities Erythema nodosum
Arthritis associated with inflammatory bowel disease - Crohn's - Ulcerative colitis
94
No joint pain Tender points in muscles Headache Irritable bowel
Fibrositis syndrome/Fibromyalgia
95
Asymmetric polyarthritis involving great and small joints, especially IPJ of toes Associated enthesitis (inflammation of tendon insertion) Absence of nodules
Psoriatic arthritis
96
Asymmetric arthritis of greater joints, lower > upper extremities Also IP joints of feet Associated keratodermia, geographic tongue, conjunctivitis, urethritis, Achilles tendonitis
Reactive arthritis Commonly post GI/GU infections
97
Symmetrical polyarthritis involving greater and smaller joints Skin rash - butterfly rash Multisystem involvement
Systemic Lupus Erythematosus ANA in 95%
98
Synovial fluid in septic arthritis vs gout vs psuedogout
SA: Cell count >50x10^6/L >90% neutrophils Bacteria on gram stain Gout: Monosodium urate crystals (birefringent) Psuedogout: Calcium pyrophosphate dihydrate crystals
99
Gout diagnosis scoring system
Male = 2 Prev patient-reported arthritis attack = 2 Onset within 1 day = 0.5 Joint redness = 1 First MTP involvement = 2.5 Hypertension or CVD = 1.5 Serum uric acid >0.35 = 3.5 4 or less = gout ruled out 8 or more = 80% gout
100
Gout risks
Family hx Purine rich foods - seafood, ETOH, red meat Dehydration Diuretics Maori, Pacific
101
Management of gout
Paracetamol NSAIDs - if no contraindications Colchicine - if no contraindications Prednisone - if infection ruled out GP follow up to start allopurinol Cont allopurinol if on it already Use minimal amount of medications to control flare
102
Referral/discussion criteria for DVT
Bilateral Pregnant Proximal DVT (above popliteal fossa) with comorbidities Suspicion of PE Social situation
103
Pulmonary Embolism Rule out Criteria (PERC)
Age <50 HR <100 Sats >95% RA No unilateral leg swelling No haemoptysis No recent surgery/trauma No prior DVT/PE No hormone use
104
Definition of anaphylaxis
Acute onset illness - Typical skin features PLUS - Respiratory, cardiovascular, or persistent severe GI symptoms OR: - Hypotension or bronchospasm or upper airways obstruction - Even if typical skin features not present
105
Prevalence of biphasic reaction in anaphylaxis
3-20%
106
Management of anaphylaxis
Adrenaline 0.5mg/0.01mg/kg IM stat - Repeat as required Antihistamine Steroids Consider nebulised adrenaline for stridor Nebulised salbutamol for wheeze Monitor for 4-6 hours Refer to hospital if requiring more than 1 dose adrenaline Refer to immunology/paeds/gen med for follow up

UCPEX (13 decks)

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