Royston week 3/4 Flashcards
a) Why is nitrofurantoin used for UTI here?
b) What must you check before prescribing nitrofurantoin?
Local microbiology recommendation. Trimethoprim has higher resistance
Check eGFR
Infective asthma exacerbation:
a) Treatment
a) Doxicycline/amoxicillin and prednisolone for a week; step up inhaler dosage
PVD:
a) Signs of critical limb ischaemia (6 Ps)
b) Signs of intermittent claudication
a) Pale, pulseless, paraesthesia, painful, paralysed, perishing cold
Abdominal distention:
a) 5 Fs
b) Organise for what tumour markers?
c) Imaging modality?
a) Faeces, Fluid, Flatus, Fat, Foetus
b) CA125, CA19-9, CEA
c) USS
Venous leg changes.
a) Give 3 common
b) Differentiating between DVT/cellulitis and venous leg changes
a) Haemosiderin deposition, atrophie blanche, lipodermatosclerosis, varicose veins, venous eczema
b) DVT - unilateral, LOF, hot and tender, RFs (cancer, recent immobility, previous VTE, recent surgery, coagulopathy) . Cellulitis - fever, recent injury/infection
Heart failure.
a) DD for fluid overload
b) While awaiting BNP/Echo, may trial what?
c) Why ask about cough?
a) Kidney failure, liver failure (low albumin)
b) Furosemide 40mg OD
c) Pink frothy sputum, respiratory differentials
What risks of asthma exacerbation are there?
Previous exacerbation/admission for asthma, brittle asthma, smoker, stress, infection, poor compliance with medication, non-attendance at asthma reviews, poor self-management strategies, poor inhaler technique
Tonsillitis/sore throat
a) Why not use tongue depressor if stridor present?
b) What pathogen is the CENTOR criteria useful for detecting the presence of?
c) Outline the CENTOR criteria
d) What score indicated antibiotics may be useful?
e) Give 2 other possible features of systemic GABS infection
f) Recurrent sore throat and lymphadenopathy - DD?
g) Other than the CENTOR, give some other indications for prescribing immediate antibiotics for a sore throat
h) Give some complications of a sore throat (local and systemic)
I) Give some indications for urgent same-day referral
j) Give 3 post-strep complications
a) Could result in laryngeal obstruction (especially if caused by epiglottitis)
b) GABS
c) •Tonsillar exudate. •Tender anterior cervical lymph nodes. •Absence of cough. •History of fever
d) At least 3 out of 4 (~50% chance of GABS)
e) Strawberry tongue and maculopapular rash (scarlet fever)
f) Glandular fever
g) •Are systemically very unwell. •Have signs of serious illness and/or complications such as peritonsillar abscess or cellulitis. •Are immunosuppressed. •Have valvular heart disease. •Have a significant comorbidity (eg, heart, lung, renal, liver or neuromuscular disease, CF).
h) Peritonsillar abscess, quincy, sinusitis, otitis media, acute glomerulonephritis
I) Stridor, abscess, dehydration, severe systemic illness, suspected epiglottitis/Kawasaki disease
j) Guttate psoriasis, acute GN, rheumatic fever
Sciatica.
a) Press where to induce sciatic pains?
b) Do what 2 tests?
a) On the buttocks (lower inner quadrant)
b) SLR,
Mechanical lower back pain.
a) Where does it arise from? And give 2 E/R factors
b) 4 risk factors
c) Management of simple lower back pain: pharmacological
d) Non-pharm management
a) Mechanical back pain arises from the spinal joints, vertebrae or soft tissues and characteristically it varies with posture and is exacerbated by movement
b) •Highly demanding jobs, prolonged standing and awkward lifting, obesity, psychosocial work-related stress and family history
c) Consider regular pain relief; lowest dose, short course of NSAIDs. Consider also a short course of muscle relaxants. Offer weak opiods if non-steroidal anti-inflammatories are ineffective, contraindicated or not tolerated. Paracetamol mono-therapy has been shown to be ineffective and should not be recommended.
d) Reassure, Do not prescribe bed rest. Advise the patient to stay as active as possible. Cognitive behavioural therapy, physio (e.g. McKenzie exercises - a programme of exercises that patients can be taught to do at home
Back pain: red flags
a) CES - 5 Qs to ask
b) Spinal fracture - onset, precipitant, relieved by..?, o/e
c) Cancer/infections - HPC, other symptoms, RFs, o/e
a) Faecal/urinary incontinence or change in habit, sexual dysfunction, saddle anaesthesia, leg weakness
b) Sudden, trauma/fall (low stress if OP), relieved by lying down, point tenderness of vertebral body
c) Pain that remains when lying down, nocturnal pain, thoracic pain (exclude AAA), Age of onset > 50 or below 20 years. History of cancer. Constitutional symptoms, such as fever, chills, or unexplained weight loss. Recent bacterial infection - e.g, urinary tract infection, IVDU, TB (or risk factors), Immune suppression, Structural deformity of the spine (such as scoliosis)., Point tenderness over the vertebral body.
Sinister back pain: causes
a) Primary malignancy - most common? Other?
b) Secondary - from what 5 primaries?
c) Bone diseases
d) Infection - of spine (2), Elsewhere (2)
e) Inflammatory disease
f) Non-back related referred pain
a) Myeloma (common), osteosarcoma (rare!)
b) Breast, Bronchus, Brostate, Byroid and Bidney
c) Paget’s, osteoporosis, spinal stenosis
d) TB (esp if HIV+ or other RFs), OM. Extra-osteo: UTI, pyelonephritis
e) AS - slow progression in young men, check the sacroiliac joints, ask SPINE ACHE.
f) Dissecting aortic aneurysm, posterior DU, pancreas, pyelonephritis or kidney stones.
In consideration of pain in any joint, always ask about pain in the ….? And consider examining these
E.g. Shoulder - ask about….?
Joint above and below
Shoulder pain: ask about neck pain and elbow - examine movements here.
Examination of the spine:
a) May also need to examine the _____ to palpate for any possible _____. (e.g. ?)
b) If possible CES - also examine what 2 things?
c) What are Waddell’s 5 signs? What are they used for?
d) Tenderness: i) Bone on palpation/percussion - DD? ii) Between the bones, iii) Over buttocks, iv) Over sacroiliac joints
e) If AS suspected, you should do what other test?
a) Abdomen - masses (e.g. AAA)
b) Lower limb neurology and anal tone.
c) •Superficial non-anatomical tenderness. •Overreaction. •Pain on simulated manoeuvres: pain on axial loading of skull, pain on passive rotation of shoulders and pelvis.
•Straight leg raise testing discrepancy: straight leg raising when sitting and when supine not consistent; sitting test performed while distracting the patient.
•Non-physiological examination: non-dermatomal sensory loss, cogwheel or give-way weakness
d) i) Infection, malignancy, fracture, ii) prolapse, mechanical, iii) Sciatica, iv) Sacro-ilitis (AS), mechanical
e) Chest expansion / FVC via spirometry
What cause of back pain (usually thoracic) should be considered in obese women?
Large breasts and incorrectly fitting bras can predispose to thoracic pain, usually in post menopausal women.
