Week 20 Flashcards

Question

when should a cough be refered to a respiratory physician?

Answer 1

arranged for people that do not respond to trials of treatment, if the diagnosis is uncertain or is systemically unwell Emergency referral should be arranged for people with: * Clinical features of foreign body aspiration.

Answer 2

common childhood disease usually caused by a virus

Answer 3

sudden onset of a seal-like barking cough accompanied by a strider hoarse voice respiratory distress symptoms are typically worse at night

Answer 4

6months- 6 years peak at 2 years old

Answer 5

mild =seal-like barking cough, but no strider or sternal/intercostal recession at rest moderate=seal-like barking cough with stridor and sternal reccesion at rest; no agitation or lethargy severe=seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy

Answer 6

all children with mild, moderate or severe croup should receive a single dose of oral dexamethasone if the child is too unwell to recieve medication, inhaled budesonide or intramuscular dexamethasone are possible alternatives mild croupo can be managed at home symptoms usually resolve within 48 hours

Answer 7

a highly infectius disease caused by the bacterium Bordetella pertussis it is spread by aerosol droplets released during coughing, and disproportionately affects infants and yough infants the incubation period is usually 7 days, and the person is infectious for 3 weeks after the onset of symptoms

Answer 8

➢The catarrhal phase lasts ~ a week and is characterised by the development of a dry, unproductive cough. ➢The paroxysmal phase may last for a month or more and is characterised 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 characterised by gradual improvement in the frequency and severity of symptoms.

Answer 9

* People who are seriously unwell should be admitted to hospital (a low threshold is required for children aged 6 months or less). * An antibiotic (usually a macrolide, such as erythromycin or clarithromycin) should be prescribed to all people with suspected or confirmed whooping cough with onset of cough within the previous 21 days. * Advice should be given on rest, adequate fluid intake, and the use of paracetamol or ibuprofen for symptomatic relief. * Children and healthcare workers should be advised to stay off nursery, school, or work until 48 hours of appropriate antibiotic treatment has been completed, or 21 days after onset of symptoms if not treated. * Close contacts may require antibiotic prophylaxis.

Answer 10

Aphthous, minor (about 80% of cases) * Often in groups of up to five * Small ulcers (<1cm) * “uncomfortable” * Heal within 10-14 days Aphthous, major (about 10% of cases) * Usually 1-3 ulcers * Larger than 1cm * Painful and may affect eating * Can take weeks to heal Herpetiform (about 10% of cases) * Groups of 10-50 small ulcers * Very painful * Heal within 10-14 days

Answer 11

Aphthous, minor (about 80% of cases) * Often in groups of up to five * Small ulcers (<1cm) * “uncomfortable” * Heal within 10-14 days Aphthous, major (about 10% of cases) * Usually 1-3 ulcers * Larger than 1cm * Painful and may affect eating * Can take weeks to heal Herpetiform (about 10% of cases) * Groups of 10-50 small ulcers * Very painful * Heal within 10-14 days

Answer 12

Usually unknown, but may sometimes be: Iron deficiency anaemia * Vegetarian/vegan diet often implicated * Heavy menstrual loss Hypersensitivity * Preservatives in food (benzoic acid/benzoates) * Foods (chocolate, tomatoes) * Sodium lauryl sulfate Psychological stress

Answer 13

Saline * Half a teaspoon of salt in a glass of warm water * Rinse frequently until ulcers subside * Any age Antiseptic (chlorhexidine) * Rinse (or spray) twice a day * Not within 30 minutes of toothpaste * Can cause temporary yellow staining of teeth * Can be used OTC from age 12 Anti-inflammatory (benzydamine) * Use every 1.5-3 hours * Can be used OTC from age 6 Steroid (hydrocortisone) * One tablet dissolved on ulcer four times a day * Can be used OTC from age12

Answer 14

Lasts longer than 3 weeks Keeps coming back Painless and persistent Grows bigger than usual At back of throat Bleeds or gets red and painful

Answer 15

a complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks

Answer 16

Severity varies from patient to patient (most: mild + intermittent) Upper abdominal pain or discomfort Burning sensation starting in stomach, passing upwards to behind the breastbone Gastric acid reflux Nausea or vomiting

Answer 17

*Gastro-oesophageal reflux disease (GORD) *Peptic ulcer disease (gastric or duodenal ulcers) *Functional dyspepsia * Epigastric Pain Syndrome * Post-prandial distress syndrome (fullness and early satiety) *Barrett’s oesophagus * A premalignant condition *Upper GI malignancy

Answer 18

1. Transient relaxation of lower oesophageal sphincter 2. Increased intra-gastric pressure 3. Delayed gastric emptying 4. Impaired oesophageal clearance of acid

Answer 19

* Smoking * Alcohol * Coffee * Chocolate * Fatty foods * Being overweight * Stress * Medicines (calcium channel blockers, nitrates, NSAIDs) * Tight clothing * Pregnancy

Answer 20

ulcers may be present in stomach or duodenum

Answer 21

* Helicobacter pylori infection * Medication, mainly NSAIDs (others can cause them) * Zollinger-Ellison syndrome (rare condition causing high acid secretion)

Answer 22

Can only confirm ulcers with endoscopy * H. pylori infection managed with eradication therapy (2 antibiotics and a PPI) * Therefore wouldn’t be managed OTC * However, patients frequently present asking for symptomatic relief

Answer 23

*Most patients have mild or intermittent symptoms which may be managed through non-pharmacological means and OTC treatments *Lose weight if overweight *Eating small, frequent meals rather than large meals *Eat several hours before bedtime *Cut down on tea/coffee/cola/alcohol *Avoid triggers, e.g. rich/spicy/fatty foods *If symptoms worse when lying down, raise head of bed (do not prop up head with pillows) *Avoid tight waistbands and belts, or tight clothing *Stop smoking Options *Non-pharmacological *Antacids *Alginates *H2 receptor antagonists *Proton pump inhibitors

Answer 24

compiunds that neutralise stomach acid

Answer 25

from a raft on top of stomach contents, creating a physical barrier to prevent reflux

Answer 26

block H2 receptors in stomack to prevent acid production

Answer 27

PPIs block proton pumps in stomach wall to prevent gastric acid production

Answer 28

frequently attending for dyspepdia remedies (sign of gastric cancer) Red flag signs: *55 years or over, especially with new onset *Dyspepsia hasn’t responded to treatment *Features including bleeding, dysphagia, recurrent vomiting or unintentional weight loss

Answer 29

*Age: very young and old most at risk of dehydration *Pregnancy: n&v common, consider in women of childbearing potential *Duration: adults >2 days cause for concern, young children (<2 years) any duration

Answer 30

* diarrhoea – may be gastroenteritis, question about food intake, could be rotavirus in children * blood in vomit – differentiate fresh blood from that of gastric/duodenal origin * faecal smell – GI tract obstruction

Answer 31

most established vomiting will require referral opioids NSAIDs antibiotics oestrogens steroids digoxin lithium

Answer 32

bowel movement less than three times a week difficult to pass stools hard, dehydrated stools

Answer 33

women and older people

Answer 34

* abdominal discomfort * cramping * bloating * nausea * straining

Answer 35

* unexplained weight loss * rectal bleeding * family history of colon cancer or inflammatory bowel disease * signs of obstruction * co-existing diarrhoea * long-term laxative use * failed OTC > 1 week

Answer 36

* Opioid analgesics * Antacids – aluminium * Antimuscarinics (anticholinergics) * Anti-epileptics * Anti-depressants * Anti-histamines * Anti-psychotics * Parkinson’s medication * Calcium-channel blockers * Calcium supplements * Diuretics * Iron * Laxatives (!)

Answer 37

increase fibre intake increase fluid intake increase excercise

Answer 38

bulk-forming osmotic stimulant faecal softer

Answer 39

90% of acute cases associated wit viral or bacterial infection most cases are short-lived, self-limiting and benign

Answer 40

acute: <14 days persistant: >14 days chronic: > 4 weeks

Answer 41

*Three or more lose, watery stools in 24 hours *Faecal urgency *Abdominal cramps *Abdominal pain *+/- nausea and vomiting

Answer 42

*Age: very young and old most susceptible to dehydration *Duration: in infants > 1 day of symptoms would be worrying, in adults a few days (unless anything else concerning) *Severity: “explosive”, blood, pus *Systemic symptoms: fever, nausea and vomiting *Food intake and fluid intake, esp.in young *Anyone else in household affected *Foreign travel *Any medicines already tried

Answer 43

oral re-hydration therapy loperamide kaolin +/- morphine

Answer 44

* Duration longer than:* 1 day in < 1year old * 2 days in < 3 year old or in older adults * 3 days in older children and adults * Pregnancy * Severe vomiting * Fever * Blood or mucous in stools * Suspected reaction to prescribed medicine * Suspected outbreak of “food poisoning” * Recent foreign travel * Persistent diarrhoea following antibiotic treatment

Answer 45

clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal

Answer 46

*Constipation and poor diet *Increased incidence between ages 45-65yrs *Pregnancy *Heavy lifting *Chronic cough *Certain toilet behaviours, such as straining or spending more time on a seated toilet than on a squat toilet

Answer 47

External haemorrhoids * lumps and bumps around the anus * itchy (irritation from faecal matter not being fully removed by wiping) * not usually painful unless severely swollen Internal haemorrhoids * discomfort/pain * feeling of fullness in rectum * when prolapsed, itchy and irritating * not usually painful unless prolapsed and strangulated Both may bleed (especially after passing stools)

Answer 48

*Usually self-limiting and heal within a week or so *Life-style measure in relation to diet and fluid intake *Analgesia as needed *Topical preparation may contain astringents, local anaesthetics, corticosteroids or a combination *Can be internal (creams, suppositories) or external (creams, gels, ointments)

Answer 49

teeth growing through the gums in children around 4-12 months until they have their full set of teeth at around 2-3 years old

Answer 50

teeth growing through the gums in children around 4-12 months until they have their full set of teeth at around 2-3 years old

Answer 51

mild and localised pain increased biting chewing dribbling drooling gum rubbing sucking irritability wakefulnes ear-rubbing (more serious) decreased appetite disturbed sleep red and swollen gums

Answer 52

temperature >38 degrees change in passage of stools systemically unwell or insevere distress

Answer 53

paracetamol 120mg in 5ml sugar-free oral suspension ibuprofen 100mg in 5ml sugar-free oral suspension

Answer 54

reassurance that the condition is self-limiting gentle rubbing of the gums with a clean finger could provide some relief teething ring wet flannel chilled friut or vegetable avoid objects that can be easily broken because they can be a choking risk

Answer 55

threadworms are small, thin, white worms about 12-13mm long common in children female worms lay eggs at night around the back passage

Answer 56

pregnant breastfeeding unwilling to undertake hygiene measures alone

Answer 57

mebendazole 100mg/5ml suspension (only >6 months) mebendazole 100mg chewable tablets (only >6 months)

Answer 58

hygeine measures should be undertaken for 2 weeks if combined with mebendazole and for 6 weeks if used alone

Answer 59

self-limiting condition which is defined clinically as repeated episodes of excessive and inconsolable crying in an infant that otherwise appears to be healthy and thriving may be due to indegestion, trapped wind or with a temporary gut sensitivity

Answer 60

crying that most often occur in the late afternoon or evening and the infant may bring their knees up to their abdomen or arch their back when crying

Answer 61

weak or high pitched cry seems floppy when you pick them up isnt feeding vomits green fluid has blood in their stool has a fever of 38 degrees or above has a bulging fontanelle has a seizure turns blue, blotchy or very pale has breathing problems

Answer 62

no treatment advice only holding the baby on their stmachs when crying may help relieve wind

Answer 63

small, whitish or grey brown insects that range from the sze of a pinhead to the size of a sesame seed. white eggs or egg cases may be visible in the hair behind the ears or at the back of the neck

Answer 64

itchy scalp rash on the back of the neck feeling as though something is moving through the hair

Answer 65

people with scalp inflamation

Answer 66

detection comb (first line treatment) dimeticone 4% lotion (second line treatment

Answer 67

mild rash restricted to the nappy area prolonged contact with urine or faeces candidal fungal infection presenting as sharply marginated redness involving the skin creases

Answer 68

sign of bacterial infection severe inflamation baby is sytemically unwell or has a fever

Answer 69

zinc and castor oil (apply a thin layer at each nappy change, do not use if a candidal infection, barrier protection) if nappy rash is causing discomfort: hydrocortisone 0.5% cream (>1 month old, maximum of 7 days use, apply and wait before putting barrier protection) if nappy rash persists despite topical hydrocortisone( suspected Candida): clotrimazole 1% cream (2-3 times a day for after the rash has healed)

Answer 70

reduce exposure to irritants use nappies with the greatest absorbancy leave nappies off for as long as practically possible

Answer 71

loss of taste or unpleasant taste in the mouth and white patches in the mouth that can be wiped off leaving behind white patches

Answer 72

symptom not resolved after 7 days difficulty or pain swallowing immunocompriised poorly controlled diabetis presents with red or white plaque that cannot be rubbed off (could be pre-malignant)

Answer 73

comedones (blackheads and whiteheads) and/or inflammatory lesions (papules) and pus-filled spots (pustules) can develop on the face, back and chest. the skin and hair may appear oily.

Answer 74

severe acne oral therapies have previously been used for acne when OTC have not worked under 12y/o

Answer 75

benzoyl peroxide 5% gel

Answer 76

try not to pick or squeze spots wash the affected area no more than twice a day with mild soap or cleanser avoid using too much makeup and cosmetics apply the gel sparingly 20 minutes after washing and drying the affected area of skin if irritation occurs it may e useful to reduce the frequency avoid getting on clothes (bleaching) avoid sunlight

Answer 77

itchy, white or red, scaly blistering , cracked rash most commonly found between the toes

Answer 78

severe or extensive disease signs of bacterial infection or recurrent episodes if there has been no improvement after 1 week of treatment or if there id pain and discomfort immuocompromised or if they have poorly controlled diabetes

Answer 79

clotrimazole 1% cream miconazole 2% cream hydrocortisone 1% cream (if skin is particularly inflammed)

Answer 80

wash and dry the affected skin before applying the treatment and clean your hands afterwards treatment should be applied to the affected skin and surrounding area in general: waer footwear that keeps feet cool and dry wear a fresh pair of cotton socks every day dry feet thuroughly

Answer 81

small blisters that develop on the lips or around the mouth self-limiting

Answer 82

pregnant women near term neonates immunocompromised frequent recurrences condition deteriorates no improvement after 5-7 days

Answer 83

no treatment -advice only

Answer 84

easily transmitable avoid touching the lesions avoid kissing until the lesions have completely healed avoid oral sex do not share items that come ino contact with lesions

Answer 85

common fungal infection that presents with a circular patch of skin, mild redness and more inflamed and scaly than the paler centre

Answer 86

severe or extensice disease sign of bacterial infection rash unresponsive to 2 weeks of treatment immunocompromised poorly controlled diabetes if scalp is involved as alternative formulations are available

Answer 87

clotrimazole 1% cream miconazole 2% cream hydrocotisone 1% cream each has 2 episodes per year (6 months after each other)

Answer 88

wash the affected skin daily and dry thouroughly afterwards wash clothes and bed linen frequently to eradicate the fungus do not share towels wear loose fitting clothes take your pet to the vet if they may have ring worm

Answer 89

Cutaneous warts are small, rough growths caused by infection of keratinocytes with certain strains of the human papilloma virus. They can appear anywhere on the skin but are most commonly seen on the hands and feet. A verruca (plantar wart) is a wart on the sole of the foot. There is a strong case for not treating warts for most people since they may clear spontaneously (usually within 2–3 years) and treatment may be prolonged or cause side effects (e.g. skin irritation

Answer 90

wart is on face, intertriginous or anogenital regions uncertain diagnosis warts with hair growing from them, bleeding or have changed appearance wart is associated with significant pain immunocompromised extensive areas are affected warts are persistent and unresponsive to salicylic acid diabetis poor circulation

Answer 91

salicyic acid 16.7% then followed with salicylic acid 12% if the lower strength hasnt worked then salicylic acid 50%

Answer 92

Although unsightly, warts are not harmful, do not usually cause symptoms and resolve eventually without treatment. Warts are contagious but the risk of transmission is low. When using salicylic acid - if the surrounding skin becomes sore, stop the treatment for a few days until it settles then re-start treatment. There is a small risk of skin allergy to the treatment. If this occurs, the surrounding skin becomes red and itchy. Salicylic acid formulations are flammable – keep them away from flames or ignition sources It is important to continue treatment until the wart has gone. Seek medical advice if the wart persists longer than 12 weeks of treatment. To reduce risk of transmission: * cover with waterproof plaster when swimming * wear flip-flops in communal showers * avoid sharing shoes, socks and towels * avoid scratching lesions, biting nails or sucking fingers that have warts * keep feet dry and change socks daily. There is no need to avoid sports or swimming, but take measures to avoid transmission as above

Answer 93

Dry skin has a dull surface with a rough, scaly quality. The skin is less pliable and cracked Dry areas of skin may become red and itchy; indicating a form of atopic dermatitis has developed40

Answer 94

skin infection rash failing to respond to therapy

Answer 95

cetraben zerobase doublebase diprobase cream hydromol ointment white soft parafin hydrocortisone ointment/ cream

Answer 96

appropriate usage of emollients avoid triger factors not to smoke or to be around naked flames clothing should be changed regularly

Answer 97

intesnse itch and rash, often worse at night and when hot, sometimes burrows can be seen in the interdigital web spaaces

Answer 98

severe rash secondary infection systematically unwell <2 years suspected crusted scabies continued treatment failure

Answer 99

permethrin 5% cream malathion 0.5% chlorophenamine 4mg tablets chlorphenamine 2mg in 5ml sugar-free oral solution

Answer 100

Red Flags9 : * age over 50 years * trauma * history of cancer * intravenous drug abuse * immunosuppression (e.g. due to cancer treatment or high doses of oral steroids (see BNF) or other immunosuppressants, or conditions that reduce immunity) * diabetes * tuberculosis or recent urinary tract infection. Other symptoms that require referral9 : * No improvement after 3–4 weeks of treatment, or a change (deterioration) in the type of pain. * Pain that prevents the person doing the usual activities of daily life. Emergency – seek immediate medical advice as the following symptoms require further investigation9,10: * Fever of 38ºC (100.4ºF) or above. * Unexplained weight loss. * Swelling in the back. * Constant back pain that doesn't ease after lying down. * Pain in the chest or high up in the back. * Pain down the legs and below the knees (neurological deficit in lower limbs [numbness, weakness]). * Loss of bladder or bowel control or inability to pass urine. * Numbness around the genitals, buttocks or back passage. * Pain that is worse at night.

Answer 101

ibuprofen 400mg tablets paracetamol 500mg tablets

Answer 102

* What is done in the early stages is very important. Resting for more than a day or two usually does not help and may actually prolong pain and disability11. * The back is designed for movement: it needs movement – a lot of movement. The sooner a person gets moving and doing ordinary activities as normally as possible, the sooner they will feel better11. * The people who cope best with back pain are those who stay active and get on with life despite the pain11. * Local application of heat or cold (ensuring that the skin is protected) may relieve pain and muscle spasm.

Answer 103

the characteristic chickenpox rash: small, red, raised spots on the scalp, face, trunk and proximal limbs which progress over 12–24 hours to blisters, papules, clear vesicles (which are intensely itchy), and pustules

Answer 104

If the pharmacist is unsure about the diagnosis, the child should be referred to the GP. Refer if the child is systemically unwell, their condition deteriorates, they develop complications or their symptoms have not started to improve within 6 days13. Neonates are at increased risk of disseminated or haemorrhagic varicella12. For this reason babies less than 4 weeks of age should be referred to their GP12,13. Children with chickenpox and parents/carers of young children with chickenpox should be aware of signs/symptoms of: * skin bacterial superinfection12 – sudden high-grade pyrexia (often after initial improvement), erythema and tenderness surrounding the original chickenpox lesions * dehydration12 – reduced urine output, lethargy, cool peripheries, reduced skin turgor * chest infection13 – persistent cough, difficulty breathing and chest pain.

Answer 105

paracetamol oral suspension/ tablets chlorphenamine oral solution/tablets

Answer 106

* Ensure adequate fluid intake to avoid dehydration. * Dress appropriately to avoid overheating or shivering. * Wear smooth, cotton fabrics. * Keep nails short and clean to minimise damage from scratching13. * Bathe in lukewarm or cool water – dab or pat the skin dry afterwards, rather than rubbing it. * Calamine lotion, moisturising creams or cooling gels may ease itching.

Answer 107

People with conjunctivitis will have a red eye and a discharge which may cause a sticky coating on the eyelid – usually on waking. There may also be a burning sensation and a feeling of grit in the eye but WITHOUT visual disturbance (in conjunctivitis, any visual disturbance is cleared by blinking). Bacterial conjunctivitis is usually associated with no or only mild pruritus.

Answer 108

Refer urgently to an optometrist or GP if: * vision is reduced or in any way impaired * person has significant photophobia * person has restricted or painful eye movements. People who have an eye problem that needs urgent attention or people with an apparent eye-related problem are entitled to have a free Eye Health Examination at an accredited optometrist practice. A list of optometrist practices that are accredited is available at Eye Health Examination Wales. Refer people to an accredited optometrist if: * red eye and no discharge * eye is painful * there is redness and swelling around the eye * there is a history of trauma or foreign body * contact lenses are worn * symptoms get worse despite treatment * there has been no improvement in the person’s signs or symptoms despite treatment. All Wales Medicines Strategy Group Page 16 of 67 Refer people to their GP if they: * are under 2 years old * are pregnant or breastfeeding and you consider they require treatment * have a personal or family history of blood dyscrasias

Answer 109

chloramphenicol 0.5% eye drops/ 1% eye ointment

Answer 110

* Condition is usually self-limiting and will resolve within 1 week. * Good eye hygiene is essential. Wipe with cooled boiled water. * Wash hands regularly, particularly after touching infected secretions. * If symptoms worsen despite treatment, seek medical advice. * Don’t share pillows or towels.

Answer 111

When the condition of dry eyes is suspected, the person can also be referred to an EHEW accredited optometrist to have a free eye health examination. Referral is recommended because certain underlying medical conditions can be associated with dry eye syndrome, e.g. allergic conjunctivitis, Sjögren's syndrome, facial or trigeminal neuropathy, herpes zoster affecting the eye, chronic dermatoses of the eyelids, previous ocular or eyelid surgery, trauma, radiation therapy, burns. If acute glaucoma, keratitis or iritis is suspected, refer immediately. Symptoms include: * moderate-to-severe eye pain or photophobia * marked redness in one eye * reduced visual acuity

Answer 112

hypromellose 0.3% eye drops carbomer '980' 0.2% drops polyvinyl alcohol 1.4% liquid paraffin

Answer 113

* Good eyelid hygiene to control the blepharitis – present in most people with dry eye syndrome. Eyelids should be cleaned in a stepwise manner twice daily, then once daily as symptoms improve37. * Limiting the use of contact lenses if these cause irritation (optometrist assessment required). * Reviewing medication that exacerbates dry eyes, such as topical and systemic antihistamines, tricyclic antidepressants, beta blockers, diuretics and selective serotonin reuptake inhibitors (SSRIs)37,39. * Using a humidifier to moisten ambient air. * Stopping smoking. * If using a computer monitor frequently for long periods, ensure that the monitor is placed at or below eye level. Advise person to avoid staring at the screen and to take frequent breaks to close or blink the eyes. * Avoid wearing eye make-up.

Answer 114

a common seasonal allergy to grass, tree or weed pollen

Answer 115

sneezing, rhinitis, conjunctivitis, itchy throat, mouth, nose, ears, and cough caused by post-nasal drip. Less commonly loss of smell, headache, earache, facial pain or tiredness may occur. People with asthma may experience worsening of their symptoms

Answer 116

* person is pregnant or breastfeeding * uncontrolled symptoms continue after 2–4 weeks despite correct use of medication45 * urgent resolution of severe symptoms affecting quality of life is required44 * person is a child under 2 years requiring treatment All Wales Common Ailments Formulary Page 31 of 67 * there is nasal blockage in the absence of rhinorrhoea, nasal itch and sneezing * there is unilateral nasal discharge, especially in a young child, to check for a trapped foreign body

Answer 117

cetirizine loratadine chlorphenamine sodium cromogglicate beclometasone

Answer 118

Regular treatment and good nasal spray/eye drop technique are important to control symptoms. People should be advised to check weather reports for the pollen count and stay indoors when possible when it is high Non-sedating antihistamines may still cause drowsiness which may affect driving ability especially if combined with alcohol. Consider buying a pollen filter for car air vents and change at each service. People who use a steroid nasal spray to control their symptoms should be advised to re-start treatment several weeks before the start of the pollination season When the pollen count is high the person should: * avoid pollen by closing windows, wearing wraparound sunglasses and avoiding grassy areas particularly during early morning, evening and night44,47 * avoid drying clothes outside * apply Vaseline® around their nostrils to trap the pollen * shower and wash their hair after being outdoors to remove pollen * vacuum regularly and dust with a damp cloth

Answer 119

Ingrowing toenails are a common problem (especially in teenagers and young adults) in which part of the nail penetrates the skin fold alongside the nail, creating a painful area, often on the big toe. The nail fold may be red, hot, tender, and swollen; occasionally a visible collection of pus may be present. Granulation tissue may also be seen

Answer 120

infection co-excisting nail disease

Answer 121

advice only

Answer 122

Soak the toe in water for 10 minutes to soften the folds of skin around the affected nail. * Then, using a cotton wool bud, push the skin fold over the ingrown nail down and away from the nail. Start at the root of the nail and move the cotton wool bud towards the end of the nail. * Repeat each day for a few weeks, allowing the nail to grow. * As the end of the nail grows forward, push a tiny piece of cotton wool or dental floss under it to help the nail grow over the skin and not grow into it. Change the cotton wool or dental floss each time the foot is soaked. * Do not cut the nail but allow it to grow forward until it is clear of the end of the toe. Then cut it straight across, not rounded off at the end. * Practise good foot hygiene by taking care of their feet and regularly washing them, using soap and water. * Trimming the nail straight across to help prevent pieces of nail digging into the surrounding skin. * Wearing comfortable shoes, tights and socks that are not too tight and provide space around their toes.

Answer 123

Intertrigo is an inflammation (rash) of the body folds, commonly affecting the groin, under the breasts and axillae. Skin may become moist and macerated, leading to fissuring (cracks) and peeling. Intertrigo can be classified as inflammatory (symmetrical; affecting armpits, groin, under the breasts and the abdominal folds) or infectious (unilateral and asymmetrical; caused by bacteria, yeasts or other types of fungi), but there is often overlap.

Answer 124

immunocompromised severe or extensive disease bacterial infection rash unresponsive to treaatment

Answer 125

clotrimazole miconazole hydrocortisone

Answer 126

* Wash the affected skin daily and dry thoroughly afterwards, particularly in the skin folds. * Wash clothes and bed linen frequently to eradicate the fungus. * Do not share towels, and wash them frequently. * Wear loose-fitting clothes made of cotton or a material designed to move moisture away from the skin.

Answer 127

Urgent referral (including to A&E if very unwell)69,70: * respiratory distress * drooling * systemically very unwell * unable to swallow * difficulty opening mouth * muffled voice – or making a high pitched sound as they breathe (stridor) * dehydrated or unable to take fluids * signs of being systemically unwell and at risk of immunosuppression. Refer to GP: * People with persistent symptoms that haven’t started to improve after a week. Refer sooner if symptoms worsen. * Where there is absence of a cough. * After 1 week if person has sore throat and lethargy (suggests possible symptoms of glandular fever, especially if 15 to 25 years old). * People who are immunocompromised (e.g. people receiving cancer treatment or high doses of oral steroids or other immunosuppressants [see BNF], or those with conditions that reduce immunity). * If the person is systemically unwell or has symptoms and signs suggestive of serious illness and/or complications. * If the person has a persistently high temperature over 38o C. * If the person is at high risk of serious complications because of pre-existing comorbidity. This includes people with significant heart disease (including valvular heart disease), history of rheumatic fever, diabetes, lung, renal, liver or neuromuscular disease, cystic fibrosis and young children who were born prematurely. * Repeated episodes (5 or more) per year or a lower threshold if other concerns. * Sore throat in combination with rash, flushed cheeks and swollen tongue could be a sign of scarlet fever. This normally occurs in children, but can occur at any age.

Answer 128

paracetamol ibuprofen

Answer 129

Be advised that the condition is self-limiting and is likely to get better within 7 days, with or without antibiotic treatment. * Seek further healthcare advice if symptoms do not improve within 7 days or worsen. * Simple analgesics will help temperature and discomfort. * Take painkillers at regular intervals to relieve pain and fever. * Adults and older children may find sucking throat lozenges, ice cubes or flavoured frozen desserts (e.g. ice lollies) provides symptomatic relief. * People may wish to try medicated lozenges to help reduce pain but their benefit is likely to be small. It is unclear if throat sprays containing an antiseptic plus local anaesthetic or benzydamine gargles help symptoms. * Avoiding smoking and smoky environments. * Drink plenty of cool or warm fluid and avoid very hot drinks that could irritate the throat. Eat cool and soft foods

Answer 130

white, odorless discharge with vaginal soreness and vulva itching

Answer 131

* people < 16 and > 60 years, pregnant or breastfeeding women and immunocompromised women * women with poorly controlled diabetes, who have not been reviewed by the GP in the last 3 months * if woman presents with foul smelling discharge, increased urinary frequency or abnormal vaginal bleeding * you are uncertain about the diagnosis e.g. patient has had a previous sexually transmitted infection and it may have returned.

Answer 132

clotrimazole fluconazole