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Phase 2
Sarah Foster
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• Core pharmacology
• Antibiotics
• HIV
• TB
• Hepatitis
• Malaria
•Quiz
Aims
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BP = CO X PVR
CO = HR X SV
Pharmacology - Cardiac
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Hypertension
Angina
MI
Clotting
Hypercholesterolaemia
AF
Pharmacology - Cardiac
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Pharmacology - HTN
ACEi
ARB
Diuretics
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Pharmacology - HTN
ACE inhibitors What? Inhibit ACE in the lungs
Function? Reduces BP, vNa/H2O retention
Example? Ramipril
SE? Cough due to bradykinin -> switch to ARB
ARBs
What: Angiotensin II Receptor BlockersFunction? Reduces BP by inhibiting effects of AT II
Example? Losartan
SE? Dizziness, Headache, Hyperkalaemia
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Pharmacology - HTN
Calcium channel blockersWhat? Block influx of Ca into cells
Function? Reduces BP, Vasodilatation,
- Ionotrope (v contractn) - Dromotrope (v HR)
Example? Verapamil/diltiazem/amlodipine
SE? Ankle swelling
Diuretics PCT CA mannitol -> osmotic diuresis -> v ICP
Loop NKCC2 furosemide, bumetanide
DCT NCC bendroflumethiazide
C.duct ENaC amiloride/spironolactone -> K+ sparing
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Pharmacology - Angina
NitratesWhat? Generates NO
Function? Cause Vasodilatation = v PVR -> vBP
Example? Glyceryl Trinitrate (GTN) spray
SE? Postural Hypotension, Headaches
Myocardial Infarction
MORPHINE Pain relief, some vasodilatation OXYGEN ^O2 to ischaemic tissuesNITRATES Vasodilatation
ASPIRIN COX1 inhibitor, x platelet aggregation
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Pharmacology - MI
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Pharmacology - Clotting
ANTIPLATELETSClopidogrel Platelet aggregation inhibitor (ADP cant bind)
Ticagrelor Platelet aggregation inhibitor (binds P2Y12
receptor -> ADP cant bind)
Aspirin Inhibits thromboxane production, lasts 7 days
ANTICOAGULANTS
Dalteparin Direct thrombin inhibitor, LMWH
Warfarin Vitamin K inhibitor (Clotting factors II, VI, XI,X)
-> monitor INR, interactions
Dabigatran Direct thrombin inhibitor
Rivaroxaban Factor Xa Inhibitor
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Pharmacology - ^Cholesterol
STATINSWhat? HMG CoA Reductase Inhibitor
Function? Reduce cholesterol
Stabilise plaque
Anti-inflammatory properties
Example? Simvastatin
SE? Rhabdomyolysis
->Muscles break down
->Haematuria
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Pharmacology - AF
What: Atrial Tachyarrythmia, commonRapid irregularly irregular pulse
Why: ^ATRIAL PRESSURE e.g. HTN, Hyperthyroid
^ATRIAL MUSCLE MASS e.g CM, HF
ATRIAL INFLAMMATION e.g. Surgery, MI
PC: Asymptomatic, heart palpitations,
chest pain, stroke/TIA, dyspnoea,
fatigue, syncope, lightheadedness
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Pharmacology - AF
Types: PAROXYSMAL
PERSISTENT
PERMANENT
Ix: ECG
Underlying cause e.g. TFTs
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Pharmacology - AF
Tx: Underlying cause e.g. Alcohol, thyroid
Rate control e.g. beta blockers
Rhythm control i.e. Cardioversion
Anticoagulants based on CHA2DS
2-VASc score
e.g. Aspirin, Warfarin
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Pharmacology - AF
CHA2DS2-VASc
SCORE
O = Low risk No treatment
1 = Moderate risk Oral anticoagulants e.g. Aspirin
2+ = High risk Oral anticoagulants e.g. Dabigatran
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Pharmacology - AFBETA BLOCKERS
What? Block beta adrenoreceptors
Function? v HR and force of contraction, v BP
Example? Bisoprolol
SE? Bradycardia -> dizzy
CARDIOVERSION
What? Drugs/Transthoracic electrical shock
Function? Restore sinus rhythmExample? Pharmacological e.g. Amiodarone
Electrical
SE? Failure, VF with ECV, emboli
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Asthma
COPD
Pneumonia
TB
Pharmacology - Respiratory
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What: Reversible bronchoconstriction due toinflammation in hyperactive airways.
Type 1 HS
Tx: SABA (Salbutamol = Ventolin) -> RELIEVE
Beta agonists are sympathomimetics
Cause bronchodilatation
Steroids (Beclemetasone) -> PREVENT
Inhibit Phospholipase A2, v inflammation
Pharmacology – Asthma
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Steroids (Beclemetasone, Budesonide) -> PREVENT
Pharmacology – Asthma
INFLAMMATION
AIRWAY INFLAMMATION
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Tx: Poor control:
LABA (Salmetarol)
Leukotriene Receptor Antagonist (Montelukast)
Oral SteroidsLAMA (Ipratropium Bromide = Atrovent)
Life threatening Asthma attack: O2
IV Salbutamol, Theophyllines (aminophylline),
MgS04
, Hydrocortisone
Pharmacology – Asthma
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What: Progressive airflow limitation, not fullyreversible
Bronchitis/emphysema
Tx: Stop smoking
Inhaled LABA, SABA and LAMA
Mucolytics (Carbocysteine)
O2
Vaccines
Pharmacology – COPD
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Epilepsy
Myasthenia Gravis
Parkinson’s Disease
Huntington’s Disease
Alzheimer’s Disease
Headaches
Pharmacology - Neuro
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What: Spontaneously recurring seizures otherthan febrile convulsions without metabolic
abnormality or acute cerebral insult.
A seizure is a clinical event due to abnormal XS
neuronal DC leading to a sudden disturbance of
neurological function
Types: FOCAL – any age, intracerebral defectGENERALISED –
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FOCAL
1. Simple Partial -> no LOC, Jacksonian march
2. Complex Partial -> usually temporal, smell/taste, visual
hallucinations
3. 2o
generalised -> whole brain affected w/LOCTx: Carbamazepine
IDIOPATHIC 1o GENERALISED
1. Childhood absence -> petit mal
2. 1o generalised tonic-clonic -> grand mal on waking
3. Juvenile myclonic epilepsy -> morning clumsiness
Tx: Sodium Valproate
Pharmacology - Epilepsy
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CarbamazepineFunction: Inhibits sodium channels
SE: Drowsiness, ataxia, dizzy, vNa, Neutropenia
Sodium Valproate
Function: Inhibits Na/Ca channels, ^GABA -> inhibitory
SE: Teratogenic, hepatotoxic
Lamotrigine
Function: Inhibits Na/Ca channels
SE: Steven-Johnson Syndrome
Pharmacology - Epilepsy
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What: Autoimmune disease with AChR antibodies,inhibit action of Ach on postsynaptic membrane
PC: Fatiguable muscle weakness, N reflexes
Ix: Tensilon Test (edrophonium), Antibody screenTx: Acetylcholinesterase Inhibitor – Pyridostigmine
Stops breakdown of ACh so around longer to
stimulate receptor
Remember LEMS in SCLC
->VGCC -> v Reflexes
Pharmacology - MG
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What: Degeneration of dopaminergic neurons in the SNpc
PC: Tremor, Rigidity, Bradykinesia
Ix: Clinical diagnosis
Tx: L-dopa (can cross BBB -> DDC -> Dopamine)
DA agonists e.g. Bromocriptine, Pramipexole
MAO-B Inhibitors e.g. Seligiline, ^ synaptic DA
COMT inhibitors e.g. Entacapone, v L-dopa metabolism
Cholinergic antagonists e.g. Orphenadrine, v SEs
Manage Depression
Respite care
Pharmacology - PD
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What: v GABA synthesis in basal gangliaPC: Chorea, Psychosis, Dementia
Tx: GABA agonist e.g. Baclofen
DA antagonist e.g. Chlorpromazine
What: Loss of cholinergic neurons in nuclei
Neurofibrillary tangles with tau protein
Tx: Cholinesterase Inhibitors to ^ Ach
e.g. Donepezil, Rivastigmine
Pharmacology – Alzheimer’s
Pharmacology - HD
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ClusterTriptans e.g. Sumatriptan (5HT agonists vasoconstrict -> v inflamm)
Ca Channel blockers e.g. Verapamil
Trigeminal Neuralgia
Antiepileptics e.g. Carbamazepine
HeadacheCOX1 Inhibitor e.g. Aspirin
Triptans
Ergotamine (vasoconstriction, inhibit trigeminal NT)
Pharmacology - Headache
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Temporal ArteritisSteroids e.g. Prednisolone ASAP before Bx
Bacterial Meningitis
3rd generation Cephalosporin e.g. Ceftriaxone ASAP
Pharmacology - Headache
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Vomiting
Constipation
Pharmacology - GI
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ANTI-EMETICSH2 Receptor Antagonist e.g. Cyclizine
(v gastric acid)
D2 Receptor Antagonist e.g. Metoclopramide, Domperidone
(CTZ in CNS)
5HT antagonists e.g. Ondansetron( vagus nerve and CTZ)
Pharmacology - Vomiting
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LAXATIVESBulking agents e.g. Methylcellulose, Fybogel
(^ faecal mass = ^ peristalsis)
Stimulants e.g. Docusate, Glycerol suppository
(^motility)
Stool softeners e.g.Arachis Oil enema
Osmotic e.g. Lactulose, Phosphate enema
(retain fluid in bowel)
Pharmacology - Constipation
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RHEUMATOID ARTHRITISWhat: Chronic systemic inflammatory disease
Symmetrical deforming peripheral polyarthritis
Does not affect DIP joints
Ix: RhF 70%, Anti-CCP 98%Anaemia of Chronic Disease, ^Platelets, ^ ESR/CRP
Tx: NSAIDs
Steroids for acute flareDMARDs
e.g. Methotrexate – folic acid antagonist
pancytopenia, teratogenic, pneumonitis, ulcers
Pharmacology - MSK
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TNF alpha INHIBITORSWhy? NICE – failed 2 DMARDs after adequate trial
Examples: Infliximab anti-TNF antibody
Etanercept TNF alpha receptor
Adalimumab Monoclonal TNF IgIssues: Expensive, 35% no response
RITUXIMAB
What? Anti-CD20 monoclonal antibody -> B cell cytopenia
+MTX in severe RA if no response MTX/anti-TNF
Pharmacology - MSK
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Acromegaly
Thyroid
Conn’s Syndrome
Hypokalaemia
Hyperkalaemia
Pharmacology - Endocrine
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What: Excessive growth hormone after fusion of epiphyses(growth plates)
Why: Pituitary adenoma (99%)
PC: Due to XS hormones, local pressure and hypopituitarism,
sweating headache, increase size of hands feet jaw,
oligo/amenorrhoea, infertility
O/E: Coarse facies (prominent supraorbital ridges, prognathism)
increased interdental spacing, macroglossia, doughy spade
like hands, CTS, bitemporal hemianopia
Pharmacology - Acromegaly
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Ix: OGTT and GH, normally ^ gluc would inhibit GH releaseMRI pituitary fossa
Tx: Transphenoidal removal of the tumour
Somatostatin analogues inhibit GH release from a.pituitarye.g.Octreotide
Issues: DM
Vascular (HTN, Cardiomyopathy, HF)OP
OSA
Pharmacology - Acromegaly
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HYPERTHYROIDThyroidectomy
Radioactive Iodine
Carbimazole
->stops coupling and iodination of thyroglobulin by TPO
-> Reduce T3 and T4
HYPOTHYROIDThyroxine
T4, metabolised slowly so OD
Replaces deficiency
Pharmacology - Thyroid
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What: Primary Hyperaldosteronism
Why: Adrenal adenoma 2/3, Adrenal hyperplasia 1/3
PC: Hypertension, Polyuria, Polydipsia, weakness due to vK+,headaches, lethargy
Ix: Bloods - ^Na+, vK+, v Renin
ABG – metabolic alkalosisCT/MRI
Tx: Surgical removal of adenoma
Spironolactone (aldosterone antagonist) ^ K+
Pharmacology – Conn’s
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What:
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Ix: Bloods -> U&Es vK+, vNa+ (diuretics), Mg2+, GlucoseECG
Tx: K+ replacement – Sando K
Pharmacology - HypoK
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What: >5.5mmol/LMEDICAL EMERGENCY
Myocardial excitability -> VF -> Arrest
Why: Oliguric renal failure K + sparingMetabolic acidosis (DKA) Addison’s
Crush # Haemolysis of sample
PC: Asymptomatic, Fast irregular pulse, Chest pain,
Palpitations, Weakness, Lightheadedness
Pharmacology - HyperK
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Ix: Bloods - ^K+ECG
Tx: Stabilise heart, Shift K+ to IC , Promote renal excretion
IV access, Cardiac monitor
10mL Calcium Gluconate 10% IV -> ^ threshold potentialInsulin -> moves K+ into cells, Glucose
?Nebulised Salbutamol -> moves K+ IC
Polystyrene Sulfonate Resin
Dialysis
Pharmacology - HyperK
http://4.bp.blogspot.com/-LE4drC0qT6I/TaXbs79DNZI/AAAAAAAAFi0/ftTks3a4pj0/s1600/hyperkECG.jpg
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BACTERIA
Obligate IC ? Gram Stain?
C.Trachomatis
Yes No M. Tuberculosis
Rods Cocci Clostridium, Listeria Staph, Strep
E.coli, Salmonella, Neisseria
Shigella, Pseudomonas
Helicobacter
Microbiology
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GRAM + COCCI
Chains? Clusters?
Streptococcus Staphylococcus
Blood agar? Coagulase/DNAse?
Alpha haemolysis Beta haemolysis Positive Negative
Optochin? Strep. Pyogenes (GBS) S.Aureus S.epidermidis
Tx: Flucloxacillin/Vancomycin MRSA
+ Strep. Pneumoniae - Strep. Viridans Tx: Amoxicillin
Microbiology
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GRAM – RODSFerment lactose on Maclonkey/CLED?
Yes No
Escherichia Coli Oxidase?
+ -
Pseudomonas Proteus
Microbiology
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INHIBIT CELL WALL SYNTHESIS = Beta lactams
e.g. Penicillins, Cephalosporins, Carbapanems
Antibiotics
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INJURE PLASMA MEMBRANE
e.g. Antifungals - Nystatin
Antibiotics
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INHIBIT NUCLEIC ACID REPLICATION
e.g. DNA Gyrases – Ciproflaxacin (C.diff) Rifampicin
Antibiotics
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INHIBIT PROTEIN SYNTHESIS
e.g. Chloramphenicol , Erythromycin, Doxycycline (teeth)
Antibiotics
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INHIBIT METABOLITE PRODUCTION
e.g. Trimethoprim for UTIs (creatinine)
Antibiotics
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What: Infection with Mycobacterium Tuberculosis/
Mycobacterium Bovis.
Who: 1/3 of the world population affected
How: Airborne droplets.
Risks: Immunodeficiency, overcrowding, poor
ventilation, household contact, extremes age
TUBERCULOSIS (TB)
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Bacilli settle
in lung Apex
The Lungs
Macrophages + lymphocytes
seal in and contain and kill
Infecting bacilli
Pulmonary TB
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Bacilli settle
in apex andgranuloma
forms
In apex of lung there
Is more air and less
blood supply
The Lungs
Bacilli taken in
lymphatics
to hilar lymph
nodes
Granuloma + Lymphatics + Lymph nodes = Primary Complex
Pulmonary TB
TB d b d h l
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Bacilli settle
in lung Apex
The Lungs
Bacilli taken
to hilar lymph
nodes
TB Meningitis
Miliary TB
Pleural TB
Bone and Joint TB
Genito urinary TB
TB spreads beyond the lungs
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PC: GeneralWeight loss
Night sweats
Lethargy
Pulmonary TB
Haemoptysis
Chest pain
Chronic dry cough
TB Meningitis
MSK TbPott’s Disease
Septic Arthritis
Abdominal TBPeritonitis
Ascites
Genitourinary TB
Dysuria
Sterile Pyuria
TB
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Ix: Sputum culture x 3 Ziehl Neelson/Lowenstein-Jenson stain
CXR
Mantoux test Latent/vaccination
Quantiferon
TB
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Tx: Rifampicin (6/12) – red/orange urine
Isoniazide (6/12) – Hepatitis (severe)
Pyrazinimide (2/12) – Hepatitis (common)Ethambutol (2/12) – Ocular toxicity
12/12 for TB Meningitis
Up to 2 years for MDR-TB
TB
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What: Retrovirus (RNA) affecting CD4 cells (Th)
Who: 33 million people affected worldwide
UK – 77,400 (>80% heterosexual sex)
Sheffield 700 patients
How: Mother to child
Risky sexual behaviour
Blood-blood (transfusions/ IVDU’s)
HIV
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HIV
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PC: Acute sero-conversion illness
2-6 weeks after exposure
Non-specific illness. Fever, myalgia, lethargy.
Late presentation of HIV
Chronic diarrhoea (>3months)
Persistent generalised lymphadenopathy (PGL)Weight loss, infections, night sweats,fever.
Opportunistic infections.
HIV
HIV
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HIV
HIV AIDS
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What: Acquired Immunodeficiency Syndrome
PC: Usually CD4
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Ix: HIV ELISA test (> 3 months after exposure)
RDT
Tx: HAART – usually combination
Contact tracing
Prophylaxis - co-trimoxazole (septrin)
Prevention!
Pregnancy – Csection, Bottle feed, Tx baby
HIV
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What: Blood borne parasitic infection
Vector: Female anopheles mosquito saliva
Types: Plasmodium falciparum
Plasmodium Malariae
Plasmodium Vivax
Plasmodium Ovale
Malaria
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Lifecycle:
Malaria
Hypnozoites
RELAPSE
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Who:Pregnancy, kids, foreign travelers, HIV
PC: Fever in a returning traveller
Myalgia, Malaise, D&V, Headache
OE: Splenomegaly Hypoglycaemia
Jaundice Tachycardia
Anaemia Tachypnoea
Malaria
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Ix: Serial thick and thin blood films
Tx: ABCDE – Supportive
Antimalarials e.g. Quinine, Artesenate
Issues: Cerebral Malaria, Resp. Acidosis, Anaemia
Hypoglycaemia, Co-infection
Malaria
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Prevention:
1. Vector Control
e.g. mosquito nets, residual spraying
2. Appropriate anti-malarial prophylaxis
e.g. Malarone, Doxycycline, Chloroquine
Malaria
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What: Inflammation of the liver
Why: Infection (Hepatitis, Herpes) , Malignancy,
Inflammation (cholecystitis/pancreatitis)
Drugs ( paracetamol, alcohol)
PC: Jaundice, Fever, Abdo Pain, Malaise, N&V
OE: Jaundice, ^Temp, Tender RUQ
Hepatitis
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Types: A/E Faecal Oral Route
B/C Blood products
D IVDU users, need Hep B
Who: 90% babies chronic Hep B
90% adults clear Hep B
Tx: Supportive
Prevent hepatic failure
Hepatitis
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Core Antigen cAg = ACUTE ^^^ Virus replication
Envelope Antigen eAg = Over time
Surface Antigen sAg =
Protection, clearance, vaccination
Hepatitis Serology
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^^^LFTs, AntiHBc IgM = ACUTE
^LFTs, AntiHBc IgG = CARRIER
N LFTs, AntiHBs = VACCINATION
N LFTs, AntiHBs, Anti HBc IgG = RECOVERY
Hepatitis Serology
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Arthur, 60 year old male diabetic has sore, hot red legafter tripping over 3 days ago. No calf tenderness, leg
swelling or chest pain.
What: ?
Bug: ?
Ix: ?
Tx: ?
Quiz
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Arthur, 60 year old male diabetic has sore, hot red legafter tripping over 3 days ago. No calf tenderness, leg
swelling or chest pain.
What: Cellulitis
Bug: Staphylococcus Aureus/Epidermidis
Ix: Blood cultures, wound swab
Tx: Flucloxacillin/Vancomycin
Quiz
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Scarlett, 18 year old female student, 2 day history of fever,vomiting and headache.
What: ?
Bug: ?
Ix: ?
Tx: ?
Quiz
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Scarlett, 18 year old female student, 2 day history of fever,vomiting and headache.
What: Meningitis
Bug: NHS N.MeningitidesH. Influenzae
Strep.Pneumoniae
Ix: LP, Bloods, blood cultures, ABG, ECG
Tx: Benzylpenicillin, CEFTRIAXONE STAT
Quiz
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Betty, an adorable 87 year old lady has had a cough for3/7. She becomes very short of breath, pyrexic and is
coughing up green sputum.
What: ?
Bug: ?
Ix: ?
Tx: ?
Issues: ?
Quiz
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Betty, an adorable 87 year old lady has had a cough for3/7. She becomes very short of breath, pyrexic and is
coughing up green sputum.
What: Community acquired pneumonia
Bug: Strep.Pneumoniae
Ix: CXR, Sputum culture, NPA, FBC
Tx: Amoxicillin, ?O2
Issues: CURB65 score (score 5 = ^^^mortality)
Quiz
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Andy, a 22 year old med student has just got back from hiselective in Namibia. He is feeling very tired and has a
fever.
What: ?
Bug: ?
Ix: ?
Tx: ?
Quiz
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Andy, a 22 year old med student has just got back from hiselective in Namibia. He is feeling very tired and has a
fever.
What: Malaria until proven otherwise!
Bug: Plasmodium
Ix: Serial thick and thin blood films, Bloods
Tx: Antimalarials, Tx Hypoglycaemia, Fluids
Quiz
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Andy’s friend Lee, went to Ibiza for a lads holiday. He hashad R-sided chest pain, SOB and a dry cough for 8/7. He
now has a headache, chills and myalgia.
HR 125, BP 75/50, RR 40, Temp 38.5oC, O2 89%
What: ?
Ix: ?
Bug: ?
Tx: ?
Quiz
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Andy’s friend Lee, went to Ibiza for a lads holiday. He hashad R-sided chest pain, SOB and a dry cough for 8/7. He
now has a headache, chills and myalgia.
HR 125, BP 75/50, RR 40, Temp 38.5oC, O2 89%
What: An atypical pneumonia
Ix: CXR (Right apex), Bloods (vNa), Cultures (Gram -)
Bug: Legionella Pneumophila
Tx: IV Erythromycin
Quiz
h k i ?
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Thank you – questions?