Management

Question 1

STEMI Management

Answer 1

Question 2

NSTEMI Management

Answer 2

Question 3

Acute LV Failure Management

Answer 3

Question 4

Tachycardia >125bp, + shock Management

Answer 4

Amiodarone 300mg IV over 20-20mins

Question 5

Anaphylaxis Management

Answer 5

Question 6

Acute Exacerbation Asthma/COPD

Answer 6

Add ABx if infective exacerbation

In COPD, hypoxia will kill a lot faster than hypercapnia –> In acute setting, apply high flow then review after an ABG.

If patient not in per-arrest, 28% O2 safer with ABG 30min later to assess affect

Question 7

Pneumonia Management

Answer 7

Question 8

Pulmonary Embolism Management

Answer 8

Question 9

Bacterial meningitis Management

Answer 9

A GP will usually give patients 1.2g benzylpenicillin if there is any suspicion of meningitis.

Question 10

Status Epilepticus

Answer 10

Ensure airway is patent, recovery position with O2

Status Epilepticus: Seizure lasting more than 30 mins

Question 11

Stroke Management

Answer 11

If CT shows haemorrhage of any type, refer to neurosurgery, do not give aspirin or thrombolysis

Question 12

DKA Management

Answer 12

Question 13

Hypoglycaemia (BM glucose <3 mmol/L) Management

Answer 13

If patient can eat –> sugar rick snack e.g. orange juice, biscuits

If unable to eat (drowsy/vomiting) –> IV glucose 100ml 20% glucose)

Unable to eat and no cannula –> IM glucagon 1mg

Question 14

Hypertension Management

Answer 14

Lifestyle advice to those with BP > 135/85

Anti-Hypertensives if BP>150/95 or >135/58 + over 8-, CV or renal disease, Diabetes

Question 15

Target Blood pressure on treatment?

Answer 15

<80yo = aim for <140/90 at clinic

> 80yo = add 10 to systolic values

Question 16

Chronic Heart Failure Management

Answer 16

• ACEi + B-blocker.
  If intolerant of ACEi use ARB
  If intolerant of ARB use hydralazine or nitrate
• If inadequate, increase dose as tolerated
• If still inadequate add aldosterone receptor antagonist e.g. spironolactone

Question 17

AF Management

Answer 17

2 Aims of treatment: Prevent stroke + control rhythm and rate of the heart

Rate control: B-blocker + CCB

Question 18

Stroke Prevention - using CHA2DS2-VASc Score

Answer 18

Congestive Heart failure 
Hypertension
Age > 75 (2 points)
Diabetes Mellituse 
Stroke TIA previous  (2 points)
Vascular disease (Peripheral arterial disease or IHD)
Age 65-74
Sex (female)

Score = 0 –> may not require anticoagulation

1 = consider antigoagulation in men –> DOAC

2 or more = Anticoagulation in men and women –> consider bleeding risk (HAS-BLED)

Question 19

Bleeding Risk for anticoagulation in AF - Using HAS-BLED score

Answer 19

Hypertension - uncontrolled BP

Abnormal renal function (cr >200/transplant/dialysis. Abnormal liver function (cirrhosis or bilirubin 2x normal, AST/ALT/ALP >3xnormal)

Stroke

Bleeding tendency

Labile INR

Elderly >65yo

Drugs (concomitat aspirin or NSAIDs) or alcohol

0 = low risk bleeding, strongly consider anticoag

1-2 = low-mod risk - consider anticoag

> 3 = high risk - alternatives to anticoags to be considered

Question 20

stable angina management

Answer 20

GTN spray PRN for symptomatic relief

secondary prev: aspirin, statin, CV RF modification

1 anti-anginal drug: b-blocker, CCB

Question 21

COPD Management

Answer 21

1) Offer smoking cessation
Offer pneumococcal + influenza vaccinations
Offer pulmonary rehab if indicated
Co-develop personalised self-management plan

2) INHALED THERAPIES: SABA/SAMA

3) No asthmatic features: LABA + LAMA
If symptoms still impacting QOL/experiencing exacerbations: LABA + LAMA + ICS

4) Asthmatic features/responds to steroids: LABA + ICS
If symptoms still impactinf QOL/Exacerbations : LABA + LAMA + ICS

Question 22

Asthma Management

Answer 22

Question 23

Type 2 Diabetes: Blood Glucose lowering therapy

Answer 23

Question 24

Parkinson’s First line Management

Answer 24

Co-beneldopa or co-careldopa

unless very mild disease: Ropinirole (Dopamine agonist) or rasagiline (MAOI)

Question 25

Epilepsy Management ``` Myoclonic Seizures Tonic seizures All other focal seizures Absence seizures Generalised tonic clonic seizures ```

Answer 25

Myoclonic Seizures : Valproate (M), Levetiracetam (F) Tonic seizures: Valproate (M), Lamotrigine (F) All other focal seizures: Carbamazepine or lamotrigine Absence seizures: Ethosuximide or valproate Generalised tonic clonic seizures: Valproate (M), Lamotrigine (F)

Question 26

Lamotrigine SEs

Answer 26

Rash, rarely Stevens-Johnson syndrome

Question 27

Carbamazepine SEs

Answer 27

``` Rash Dysarthria Ataxia Nystagmus Hyponatraemia ```

Question 28

Phenytoin SEs

Answer 28

Ataxia Periph. neuropathy gum hyperplasia hepatotoxicity

Question 29

sodium valproate SEs

Answer 29

Tremor teratogenicity weight gain

Question 30

Levetiracetam

Answer 30

Fatigue mood disorders agitation

Question 31

which anti-epileptics cause a rash

Answer 31

Lamotrigine | Carbemazepine

Question 32

Alzheimer's disease management

Answer 32

Mild/Mod: AChEi --> Donepezil, rivastigmine, galantamine Mod/Sev: NMDA antag --> Memantine

Question 33

``` Crohns Management Inducing Remission (treating a flare) ```

Answer 33

Mild flare: Prednisolone Severe flare: Hydrocortisone + supportive care if rectal disease, use rectal hydrocortisone too

Question 34

``` Crohns management: Maintaining remission (preventing a flare) ```

Answer 34

Azathioprine Check TPMT levels before starting (Azathioprine is a pro drug, metabolised by the liver, the metabolite is inactivated by TPMT - thiopurine S-methyl transferase) 10% pop has low TPMT activity which would lead to abnormal accumulation of metabolites, increasing liver and bone marrow toxicity. If TPMT is low = lower dose azathioprine If TPMT is deficient/absent offer methotrexate

Question 35

Rheumatoid Arthritis Management

Answer 35

Methotrexate + additional DMARDs During a flare: Short term glucocorticoids e.g. IM methylprednisolone 80mg, short term NSAIDs with PPI protection, reinstate DMARDs if dose previously reduced IF failure to respond to 2 DMARSs + severely active RA --> TNF alpha inhibs e.g. Infliximab

Question 36

Constipation Management

Answer 36

Never give a laxative if there is evidence of obstruction Stool Softener: Arachis oil/Docusate - good for faecal impaction or reduced gut motility Bulking agents: Isphagula husk - good for reduced gut motility, can take days to cause effect - do not use in faecal impaction Stimulant laxatives: Senna/Bisacodyl. - may exacerbate abdo cramps Osmotic laxatives: Lactulose phosphate enema = CI in IBD. may exacerbate bloating

Question 37

Diarrhoea management

Answer 37

Most common cause is GI infection (Norovirus and C diff). Removal of infectious agents should not be intentionally inhibited by drugs. Chronic diarrhoea (proven to be non-infectious) = Loperamide or Codeine (also provides pain relief

Question 38

Insomnia management

Answer 38

Corticosteroids can cause insomnia - give in the AM Deal with any modifiable aspects e.g. noise in hospital first. Beware elderly can become drowsy and incr risk of falls Zopiclone 7.5mg PO nightly / 3.5mg nightly in elderly