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Year 5 Conditions > Throat and Skin > Flashcards

Throat and Skin Flashcards

1
Q

definition of tonsillitis

A

An acute infection of the parenchyma of the palatine tonsils.

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2
Q

when should you be concerned when a patient present with ‘sore throat’

A 
night sweats 
fever 
weight loss 
drolling 
stridor - same data referral 
SOB 
dysphagia - > 3 weeks need a 2 week referral
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3
Q

aetiology of tonsillitis

A

most are virus , 10-30% are bacterial
rhinovirus, coronavirus and adenoviurs
EBV for teenagers

bacterail

  • children aged 5-10 –> group A haemolytic strep
  • scarlet fever - strep pyogenes
  • streptococcus pneumoniae
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4
Q

clinical features of tonsilitis

A

sore throat
otalgia - earache
dec oral intake (pain when eating/swallowing)
fever - > 38
tonsillar exudate (purulent - esp if caused by group A haemolytic strep)
cervical lymphadenopathy

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5
Q

which criteria is used to estimate the probability that tonsillitis is due to a bacterial infection

A

CENTOR criteria (>3 = offer Abx)

  • fever > 38
  • tonsillar exudate
  • absence of cough
  • tender anterior cervical lympho nodes (lymphadenopathy)

or FeverPAIN criteria - the higher the score, the more likely it is to be bacterial

  • Fever (during previous 24 hrs)
  • Purulence (pus on tonsils)
  • Attend rapidly (within 3 days after onset of symptoms)
  • severely Inflammed tonsils
  • No cough or coryza (inflammation of mucous membrane in the nose)
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6
Q

what are the investigations required for tonsilitis

A

CENTOR criteria

FBC, U&E, LFT, CRP, cloting (EBV), monospot or galndular fever, EBV titres (more specific but less likely to be used)

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7
Q

differential for tonsilitis

A 
glandular fever 
Scarlet fever 
epiglottitis 
Quinsy - tonsiliar abscess
mouth cancer
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8
Q

what are the red flags for mouth cancer

A

mouth ulcers - painful and do not heal within several weeks
unexplained persistent (>3 wks) lumps in the mouth/neck
unexplained loose teeth
unexplained/persistent numbness on the lip/tongue
leukoplania/erythoplakia (white/red patches in the mouth)

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9
Q

Mx for tonsilitis

A 
rehydration (avoid hot drinks)
simple analgesia (oral/thorat spray)

ABx - if bacterial or hx of rheumatic fever - phenoxymethylpenicillin 500mg QDS for 10 days (if allergic give clarithromycin)

Tonsillectomy - if
> 7 episodes in the last 12 months
> 5 episodes every year for the past 2 years
> 3 every year for the past 3 years

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10
Q

complications of tonsilitis

A

rheumatic fever
post strep glomerulonephritis
deep facial space infection
peri-tonsillar abscess (quinsy) - inc sore throat (worse on one side), hot potato voice, deviated uvular -away from swelling, swelling above tonsil

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11
Q

definition of acute pharyngitis

A

= rapid onset of sore throat and pharyngeal inflammation (with or without exudate)

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12
Q

what makes bacterial acute pharyngitis more likely to be bacterial

A

abscess of cough, nasal congestion and nasal discharge

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13
Q

aetiology of acute pharyngitis

A

virus –> EBV, adnovarious, enterovirus, influenza A and B, parainfluenza, HIV, gonorrhoea

bacterial - group A strep most likely

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14
Q

clinical features of acute pharyngitis

A 
sore throat 
pharyngeal exudate - in Group A strep infection 
pain when swallowing 
cervical lymphadenopathy 
fever 
headache 
N+V
abdo pain

viral infection - coryzal, otalgia, cough
measles - conjunctivitis, maculopapular rash, koplik spots

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15
Q

investigation for acute pharyngitis

A

rapid antigen test for Group A strep
FBC, monospot for glandular fever
gonococcus or chlamydia throat swab
throat swab culture

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16
Q

management of acute pharyngitis

A

1) Keep hydrated – avoid hot drinks
2) Salt water gargling, medicated lozenges (containing a local anaesthetic and NSAID or an antiseptic analgesia)
3) Antibiotics if bacterial cause  phenoxymethylpenicillin 500mg QDS for 10 days
4) tonsillectomy  if 7 times in the past year, if > 5 times in 2 years, if > 3 times in 3 years

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17
Q

what is considered to be upper respiratory tract infection

A

infection in the nose, sinuses, pharynx, larynx

which translate into conditions such as common cold, sinusitis, pharyngitis, epiglottitis, laryngotracheitis (croup)

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18
Q

aetiology of the URTI

A

rhinovirus
coronavirus
influenza

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19
Q

clinical features of URTI

A

rapid onset, with symptoms peaking after 2-3 days and typically resolving after 7 days in adults, 14 days in younger children, although a mild cough may persist for 3 weeks

sore throat 
cough 
rhinitis 
upper airway swelling 
sneezing 
general malaise
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20
Q

investigation for URTI

A

clinical diagnosis

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21
Q

management for URTI

A

1) Reassure and symptomatic management: keep hydrated, eat well, rest, paracetamol/ibuprofen
2) Reduce transmission via: washing hands, avoid sharing towels/toys

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22
Q

what pathogens causes acute epiglottis

A

Haemophilus influenza B

or less commonly Strep Pneumoniae

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23
Q

clinical features of acute epiglottis

A 
acute onset 
not vaccinated against HiB
stridor
dysphagia, odynophagia 
drooling 
SOB +/- tripod position 
fever 
toxic looking
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24
Q

investigation for acute epiglottis

A

clinical diagnosis
laryngoscopy - both to confirm and theraptic
material x-ray - thrumbprinting

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25
Q

management for acute epiglottis

A

emergency - fast bleep anesthetist and call a senior pediatrician

1) A-E assessment
2) secure airway
3) IV dexamethasone
4) IV cefotaxime
5) inhaled adrenaline
6) O2

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26
Q

what is the most common type of cancer in oral tumours

A

Squamous cell carcinoma

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27
Q

clinical features of tongue cancers

A 
75% - SCC
chronic glossitis 
large area of swelling 
speech and swallowing dysfunction 
pain - can refer to ear 
can be under the tongue - need to check thoroughly
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28
Q

clinical features of tonsillar cancers

A 
SCC (70%) & lymphoma 
neck mass 
cervical lymphadenopathy 
sore throat, ear pain, foreign body or mass sensation 
bleeding 
Trismus - locked jaw 
weight loss and fatigue
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29
Q

clinical features of buccal mucosa cancer

A

painless in early stages, then ulcerated and secondarily infection or invades adjacent nerve

pain in later stages

bleeding & difficult chewing

warty exophytic growth - little fixation or deeply ulcerative invasive lesion

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30
Q

when should you refer a patient with suspected oral tumour

A

persistent and unexplained lump in the neck
unexplinaed ulceration in oral cavity for > 3 weeks
lump on the lip or oral cavity
red/white patch in oral cavity

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31
Q

management of oral tumour

A

MDT approach
- chemo + radio +/- surgical

if oral - can do brachytherapy

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32
Q

definition of trigeminal neuralgia

A
  • facial pain syndrome in the distribution of more than 1 divisions of trigeminal nerve
  • characterised by some combination of paroxysms of sharp, stabbing, intense pain lasting up to 2 minutes and/or a constant component of facial pain, without associated neurological deficit
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33
Q

causes of trigeminal neuralgia

A

o majority due to nerve compression of the trigeminal nerve root by aberrant vascular loop
o demyelinating disease – MS
o brainstem infarcts and amyloid or calcium deposition along the trigeminal

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34
Q

clinical features of trigeminal neuralgia

A

• facial pain
o trigeminal distributions and quality, duration and consistency
o bilateral involvement is more common in patient with symptomatic trigeminal neuralgia

35
Q

investigation of trigeminal neuralgia

A

Clinical diagnosis
Intra-oral X-ray
MRI – demonstrate presence of abnor vessel loop in association with trigeminal nerve, presence of other pathologies
Trigeminal reflex testing  jaw jerk and cornea reflex

36
Q

tx for trigeminal neuralgia

A

Anticonvulsants – carbamazepine or baclofen (if unresponsive to carbamazepine)
Open neurosurgical microvascular decompression
Ablative surgery – reserve for persistent conditions
Neurostimulation

37
Q

what is a macules

A

flat lesion < 10 mm in diameter

38
Q

what is a papules

A

elevated > 10 mm

39
Q

what plagues

A

palpable > 10 mm

40
Q

what is a nodule

A

elevated

41
Q

what is a vesicles

A

fluid filled < 10 mm

42
Q

what is a bullae

A

fluid filled > 10mm

43
Q

what is a pustules

A

fluid filled with pus

44
Q

what is a petechia

A

small subcutaneous bleed

45
Q

what is a purpura

A

large subcutaneous bleed

46
Q

what is acne vulgaris

A

A skin disease affecting the pilosebaceous unit. Characterised by comedones, papules, pustules, nodules, cysts and/or scarring

47
Q

aetiology of acne vulgaris

A

blockage to the pilosebaceous unit due to

  • inc sebum production (typically in response to androgen inc such as during puberty)
  • the colonisation of bacteria, Propionibacterium, on skin lead to infection
  • all of the above lead to inflammation and swelling
48
Q

Risk factor of acne vulgaris

A 
genetics 
race/ethnic factors 
diet - high glycaemic diet 
truma 
cosmetics
topical corticosteroids
oral meds - lithium, corticosteroids, iodides, antiepileptic drugs
49
Q

what are the different types of acnes

A
  1. Mild - predominantly non-inflammed acne
  2. moderate -widespread with an inc number of inflammatory papules and pustules
    3) severe - widespread inflammatory papules, pustules and nodules or cyst, scarring maybe present

acne fulminans - systemic manifestation - fever, arthralgia, myalgia, hepatosplenomeglay, lytic bone lesions

50
Q

clinical features of acne vulgaris

A

non-infllammatory lesions - comedones which maybe open (blackheads), closed (Whiteheads) or microcomodones (clinically invisible)

inflammatory lesions - typically, papules and pustules, but can develop into nodules

scarring

pigmentations

seborrhoea - excessive discharge of sebum from the sebaceous gland

51
Q

differentials for acne vulgaris

A

rosacea

conglobate - sever form of acne affecting men, presents with extensive inflammatory papules and cyst

acne fulminans - sudden and severe

perioral dermatitis

folliculitis and boils

drug induced

52
Q

management of mild acne vulgaris

A

o No treatment may be acceptable if mild
o Topical benzoyl peroxide reduces inflammation, helps unblock the units and is toxic to P.acnes bacteria.
o topical azelaic acid – topical antimicrobial
o Topical retinoids (chemical to vitamin A) -tretinoin/ adapalene topical slow down sebum production  if no response, try dapsone topical

53
Q

management of moderate and severe acne vulgaris

A

o Topical or oral abx can be used in moderate to severe acne to acute management and maintenance (e.g. lymecycline/ doxycycline for 3 months) topical Abx also used in pregnancy
o Oral contraceptive pill: stabilise hormones and slow production of sebum
• Oral retinoids for severe acne (e.g. isotretinoin) but requires careful monitoring under dermatology

54
Q

SE of oral retinoid acid

A 
dry skin and kips 
photosensitivity 
teratogenic 
depression, anxiety and suicidal ideation 
rarely SJS and TEN
55
Q

definition of eczema

A

An inflammatory skin condition characterised by dry, pruritic skin with a chronic relapsing course. Caused by a breakdown in the normal continuity of the skin barrier, leading to inflammation.

56
Q

aetiology of eczema

A

FHx of atopy
multifactorial theory - overactive immune response to an irritant (not local) which is exposed to the body by breakdown in skin

57
Q

RF for eczema

A
  • Soap and detergent
  • Animal dander
  • House-dust mites
  • Extreme temperatures
  • Rough clothing
  • Pollen
  • Certain foods
  • Stress
58
Q

clinical features of eczema

A 
periods of flares and remission 
infants 
- dry, red, itchy, sore patches of skin 
- extensors (outside elbows and knees), face, scalp and neck 
- nappy area is spared

adults

  • dry, red, itchy, sore patches of skin
  • flexor surfaces (inside knees and elwbos)
  • infected - fever, pustules, yellow fluid and crustations
  • chronic
  • chronic eczema - rough, thick, leathery skin (lichenification)
59
Q

what is the diagnostic criteria used to diagnose eczema

A

UK working party criteria

A itchy rash + 3 or more of the following
• Hx of a flexural involvement (antecubital or popliteal fossa, front of ankles, wrist or neck)
• Visible flexural eczema
• Personal Hx eczema or hayfever
• Personal hx or first degree relative Hx of asthma or allergic rhinitis
• Onset of symptoms < 2 years

60
Q

investigation for eczema?

A

clinical diagnosis

• can do allergy testing (elevatd), IgE levels (elevated), skin biopsy

61
Q

Mx for eczema

A

Acute/mild

1) Emollient
2) Mildly potent topical steroid (hydrocortisone 1%) for inflamed skin : continued for 48hrs after flare controlled
3) Oral Abx if suspected infection  flucox?
4) Antihistamine or doxepin  cetirizine, loratadine
5) Active follow-up rarely required.

Moderate
 Consider need for urgent admission (e.g. eczema herpeticum)
 Emollient
 Moderately potent topical corticosteroid (betamethasone valerate 0.025% or clobestasone butyrate 0.05%) for inflamed skin: treatment continued till 48hrs after flare controlled (max use 5 days0`
 Occlusive dressing/dry bandages
 Severe pruritis: non-sedative antihistamine (cetirizine, loratadine)
 Prevention/ maintenance
o steroids
- Step down : low potency steroid
- Intermittent : weekend or twice weekly steroid therapy
o Specialist: Topical calcineurins inhibitors (tacrolimus, pimecrolimus) to stop the itchiness
 Review emollient annually, review steroid use 3-6 monthly, review antihistamine use 3 monthly.

Severe
 Consider need for urgent admission (eczema herpticum)
 Emollient
 Potent steroid (betamethasone 0.1%) for inflamed areas (max use 5 days)
 Occlusive dressing/bandages
 Severe itch: non-sedative antihistamine (cetirizine, lordatane)
 If severe itch and difficulty sleeping: sedative anti-histamine (chlorphenamine)
 If severe itch + psychological distress: oral corticosteroids.
 if still resistance  UV light therapy + topical coal tar
 Prevention/maintenance
o Steroids
- Step down
- intermittent
o Specialist: topical calcineurins inhibitors (tacrolimus)
 Review emollient annually, review steroids 3-6 monthly, review antihistamine use 3 monthly.

Infected
 Consider the need for admission or referral
 Swab skin
 Extensive areas: Oral abx (flucloxacillin)
 Localized areas: topical abx
 After infection cleared prescribe new emollient’s and topical steroids and discard old.
 Refer urgently (2 weeks) if not responded to treatment.

62
Q

when will you refer a patiwth with eczema to skin specialists?

A 
facial eczema 
2 episodes of flare up in 1 month 
treatment application device needed eg bandages 
contact dermatitis suspected 
recurrent secondary infection
63
Q

complication of eczema

A

eczema herpticum
-  Disseminated herpes simplex infection which is indicated by grouped vesicles/ blister and punched out lesions
 Systemic features: fever, lymphadenopathy and malaise
 Medical emergency
 Treat anti-viral

psychological
lichenification
sleep disturbance
bacterial infection from scratching

64
Q

what is psoriasis

A

A chronic inflammatory skin disease characterised by erythematous, circumscribed scaly papules and plaques

65
Q

aetiology of psoriasis

A

autoimmune, genetics and infections (after URTI, strep pharyngitis)

mean age onset = 28 yrs old

66
Q

Risk factor/trigger for psoriasis

A

strep infection eg strep pharyngitis - guatte psoriasis

drugs - lithium, b-blocker. chloroquine, NSAIDs, ACEi, penicillin

UV light exposure

trauma - trigger psoriasis in 7-14 days later - Koebner phenomenon

Hormonal changes - puberty, post-partum and menopause

HIV

psychological stress

smoking, alcohol

67
Q

what are the different types of psoriasis?

A

plaque

Guatte

Pustular

erythroderma - erythrodermic psoriasis

68
Q

clinical features of plaque psoriasis

A

raised inflammed plaque lesions with superficial silvery white scaly eruption

typically on extensor surface + scalp + face

well demarcated lesions

halo like plaque due to vasoconstriction - Wornoff sign

general psoriasis signs - itchy, irritation, burning pain, bleeding, scaling, pinpoint bleeding (Auspitz’s sign) - where scab is peeled and revealed underlutign

69
Q

clinical features of guatte psoriasis

A

following URTI infection eg strep pharyngitis

widespread, erythematous, fine scaly papules (water drop appearance) on trunk, arm and leg

70
Q

clinical features of pustular psoriasis

A

Acute generalised pustular: Rapidly developing widespread erythema, followed by the eruption of white, sterile non-follicular pustules which coalesce to form lakes

 systemic features - fever, malaise, tachycardia, weight loss, arthralgia.

 Palmoplantar pustulosis affects palms and soles of feet.

71
Q

clinical features of erythrodermic psoriasis

A

 Generalised/diffuse erythema with fine scaling
 Associated with pain, irritation and severe itching.
 Lesions feel warm and may be associated with systemic illness such as fever, malaise, tachycardia, lymphadenopathy, peripheral odeama.

72
Q

what are some psoriasis associated conditions?

A

psoriatic arthritis + nail changes

symptoms - joint swelling pain and stiffness 
dactylitis 
enthesis 
pitting nails 
onycholysis

metabolic syndrome - obesity, hyperlipidemia, HTN, T2DM, NAFLD

ischaemic heart disease

IBD - crohns

uveitis

anxiety and depression

VTE

non-melaenoma skin cancer

73
Q

investigation for psoriasis

A

• clinical diagnosis, can do biopsy if uncertain

74
Q

management of erythrodermic & pustular psoarisis

A
  • Medical emergency: same-day dermatology review

* oral retinoid (acitretin)

75
Q

management of plaque psoarisis

A

mild - topical steriods (hydrocortisone) +/- topical Vit D (Calcipotriol)

mod to severe

  • 1st line - phototherapy + methotrexate + apremilast + infliximab + acitretin
  • 2nd line - cyclosporin
76
Q

management of guatte psoarisis

A

1st line - phototherapy

2nd line - methotrexate, oral retinoid, cyclosporin

77
Q

complication of psoarisis

A

psychological

erythrodermic psoarsis - life-threatening due to its impact on temperature regulation, haemodynamic, intestinal absorption and protein and water metabolism.

Genralised pustular psoriasis - life-threatening due to its impact on temperature regulation, haemodynamic, intestinal absorption and protein and water metabolism.

78
Q

definition of wart

A

small rough growths which are caused by infection or keratinocytes with certain strains of HPV

79
Q

which population is most suspectible to wart

A

children as they have yet to develop immunity to HPv

80
Q

what are the different types of wart

A

common wart - verruca vulgaris
flat or plane wart - verruca plana
plantar wart - on the sole of the foot - curruca plantaris

81
Q

aetiology of wart

A

HPV virus

82
Q

investigation of wart

A

clinical diagnosis

  • common wart - resembles a cauliflower (knuckes, knees, fingers)
  • plane.flat wart - round, flat-topped and yellow (back of hands)
  • filiform warts - long and sender face and neck
  • palmar and plantar wart - verruca, may have central dark spots and maybe painful
  • moasic warts - when palmar-plantar coalesce into larger plaques on hands and feet
83
Q

management of wart

A

no treatment needed - resolve in 2 years
consider treatment if
- wart is painful
- wart is cosmetically unsightly
- patient request treatment and wart is persistent

if so, cryotherapy and topical salicylic acid (12 weeks)

84
Q

complication of wart

A

spread by picking at wart
malignant changes - rare except in immunocompromised pts - SCC
cryotherapy can be painful which can also cause blistering, infection, scarring and depigmentation
topical salicytc acid can cause skin irritation

Year 5 Conditions (19 decks)

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