Management

Question 1

Management of asymptomatic PAD

Answer 1

My management would include non-pharmaceutical and pharmaceutical management targeting modifiable risk factor reduction.
Risk factor reduction- smoking, DM, start Clopidogrel, start a statin
investigation of other vascular beds= AAA once off

Question 2

Management of intermittent claudication

Answer 2

My management for this patient would be both non-pharmacological and pharmacological with emphasis on modifiable risk factor reduction and intervention tailored to lifestyle limitations.
all patients: Reduction of risk factors: smoking, DM, start an antiplatelet, statin,
check the vascular beds: AAA
Patients IC greater than 100: rehabilitation program- supervised exercise
and education about foot care
Patients life style impact: imaging of duplex US and angiography
consider surgical intervention: taking into account patient preference, risk benefit (angioplasty and bypasses limited lifespan about a year). only 10% develop CLI.

Question 3

Management of critical limb ischemia

Answer 3

My management of this patient would involve non-pharmacological and pharmacological treatment with emphasis on risk factor reduction and revascularisation.
RF: smoking, diabetic control, start a statin, checking the other vascular beds: AAA
imaging: arterial tree using CT angiogram and duplex scan if revascularisation is appropriate. (for use in elderly with severe comorbities- primary amputation no imaging needed)

Question 4

Discuss your revascularisation options in this patient with chronic limb ischemia?

Answer 4

The three main options are angioplasty, endarterectomy, and arterial bypass.
Angioplasty- is the procedure where a wire is inserted peripherally from the femoral artery to the site of the lesion (illiac and superficial femoral artery lesions) Then the balloon (using the wire guidance) is inflated at the site of the lesion. Stenting can be considered in illiac but not SFA.
Tight blockages of the common femoral- endarectomy while long occlusions and multi-level stenosis can be treated by bypass.

Question 5

So as you mentioned the pulse is irregularly irregular. What is the management of atrial fibrillation?

Answer 5

My management of atrial fibrillation can be divided into general treatment which includes investigation of underlying precipitants and management of those, specific treatment which can be subdivided into rate and rhythm control and ongoing management.
My first consideration would be red flags: HF, hypotension, a decreasing GCS, and chest pain. This would indicate that the patient is heamodynamically unstable.- senior help. RESUS ATLS guidelines. shock.
conservative: treatment of the underlying cause. Investigations: ECG,
FBC (WBC), UE, TFT, alcohol, Mg, Ca, plus or minus D dimer (PE), troponin *chest pain and suggestive ECG. CXR, ECHO and CTCA (if CAD)
Rate and rhythm control

Question 6

So the patient with A fib is heamodynamically unstable as you before mentioned… out line your steps of management.

Answer 6

1. ATLS guidelines- Airway high flow non-rebreather mask.
   Breathing (lowering GCS less than 8 calling for anaesthetic review)
   Circulation: wide bore 13G needle IV access.
   First shock, then DC cardioversion, then IV amiodarone
   Important to keep in mind that chronic A fib is unlikely to cause shock, so be vigilant in looking for an alternative cause of shock like sepsis.

Question 7

So the patient is heamodynamically stable you mentioned the options of rate or rhythm control which do you want and why?

Answer 7

if the rate is less than 110 bpm
Beta blockers or non-dihydropyridine calcium channel blockers
heart failure use digoxin as well

Question 8

So the patient is young and has new onset A Fibrilliation what is your management?

Answer 8

rhythm control (not a great choice in elderly, established AF, LA dilatation, and mitral valve disease.
This can be chemical or electrical cardioversion
chemical (flecainide if no structural heart disease or amiodarone- if structure heart disease)
second line is AV ablation

Question 9

Should this patient be put on anticoagulation?

Answer 9

almost all patient’s with A fib need lifelong anticoagulation including 4 weeks prior to DC cardioversion (unless negative TOE)
and 4 weeks afterwards (atrial stunning). To determine the risk /benefit of starting anticoagulation the HASBLED score (risk) and CHA2DS2VASc score. Warfarin, NOACS (apixaban, dabigatran, edoxaban, and rivero alban) or dalteparin

Question 10

Outline your management for supraventricular tachycardia?

Answer 10

My management would include acute and chronic treatement using both non-pharmacological and pharmacological approaches. Noting any red flag signs of heart failure, hypotension, decreased GCS, and chest pain, which would need immediate emergency management.

Question 11

What is your acute treatment for SVT

Answer 11

Presence of red flags: ATLS protocol- ABCs calling for senior help

Question 12

Management of rheumatoid arthritis

Answer 12

Management of this patient can be divided into pharmacological and non-pharmacological with the latter involving a multidisciplinary team.
Pharmacological: induce remission and symptom control
non-pharmacological: physiotherapy, OT, podiatry, psychological interventions, rheumatology, and integration with primary care.
Surgery= refractory to medical treatment, stress fracture, worsening function, imminent actual tendon rupture.

Question 13

You mentioned pharmacological treatment for RA can you elaborate?

Answer 13

induce remission:
Disease modifying anti-rheumatic drugs
Methotrexate, Leflunomide, and sulfasalazine
bridging therapy with glucocorticoids (DMARDS takes three months)
failure of two DMARDS (MTX)- biological therapy- TNF inhibitors Etanercept or inflixamab (do chest X-ray before and also interferon test)
symptom control= NSAIDS with PPI

Question 14

Management of Psoriasis

Answer 14

Management of this patient can be divided into pharmacological and non-pharmacological approaches.
non-pharmacological: removal/ avoidance of trigger infection (strep), trauma, drugs (lithium, Beta blockers, anti-microbial, NSAIDS, stress
pharmacological:
topical
systemic
phototherapy

Question 15

What are the topical treatments for psoriasis?

Answer 15

emollients- relieve dryness, fissures, irritation E45 
vitamin D analogues= calcipotriol 
topical steriods- not for face
tar-steriod- descale 
calcineurin inhibitors- tacrolimus

Question 16

When would you give systemic therapy in psoriasis?

Answer 16

large surface area 
pustular psoriasis 
erythrodermic psoriasis 
psoriatic arthropathy
failure of topical agents  
first line is methotrexate 
if rapid response required ciclosporin

Question 17

What is the management of Giant cell arthritis

Answer 17

Management of this patient would involve urgent systemic steroid treatment to preserve vision and induction of remission of the condition.
urgent management:
prednisolone PO bone protection and PPI
gradual dose reduction once sx resolved
treat relapses similarly
long term management *if relapsing disease
methotrexate and toculizumab anti- IL6

Question 18

Management of gout

Answer 18

Management of this patient can be divided into pharmacological and non-pharmacological, with the avoidance of triggers being of particular importance.
Pharmacological can be subdivided into acute and chronic:
acute: symptom relief- NSAIDS indomethacin plus PPI
colchicine (poor compliance due to GI side-effects)
corticosteroids (last resort)
chronic: (2nd time) bridging therapy with NSAID or colchicine (3 months) and do a 24 hour urine uric acid test
little uric acid—{ uricosuric agents- probenecid) greater than 800mg secreted (allopurinol xanthine oxidase inhibitor)
avoid drugs: thiazides, loop diuretics
certain foods: seafood, red meat

Question 19

Management of scleroderma

Answer 19

The management of scleroderma is dependent on it’s severity. It involves the management of the symptoms, which differ depending on organ involvement. This can be divided into pharmacological and non-pharmacological.
no cure—- sx
Raynaud’s= vasodilators CCB, endothelin receptor antagonist
digital ulcers- phosphodiesterase inhibitors- sildenafil
ILD- cyclophosphamide, azathioprine, steriods
pulmonary HTN- endothelin receptor antagonists, sildenafil
GORD- antacids
malnutrition SBO- tetracycline
kidney involvement- ACE inh, ARBs
non pharm- PT, OT, rheumatologist, depression screening, support, integration into primary care

Question 20

Management of Lupus

Answer 20

Management of this patient would involve pharamacological and non-pharmacological treatment. Treatment depends on disease severity and organ involvement.
Pharm-
flares- * mild/moderate/severe
for maintenance

Question 21

mild flare SLE

Answer 21

hydrochloroquine, low dose steriods, skin flare topical steriods

Question 22

moderate flare of SLE

Answer 22

organ involvement steriods, DMARDS, mycophenolate may be needed.

Question 23

severe life threatening SLE

Answer 23

high dose steriods
mycophenolate
rituximab

Question 24

For SLE maintenance

Answer 24

NSAIDS
steriod sparing agents- azathioprine, MTX
belimumab- add on therapy in antibody and disease where disease activity is high

Question 25

What are the non- pharmacological management of SLE?

Answer 25

``` general: sun block high SPF cover skin when in sun MDT physiotherapy rheumatology specialities- dermatology, cardiology, respiratory screen for depression, support integration into primary care ```

Question 26

Management of osteoarthritis

Answer 26

management fo OA can be divided into pharmacological and non-pharmacological and also surgical in selected cases. non-pharm avoid aggrevating factors but remain active weight loss foot wear physio OT pharm- topical- NSAIDS capsaicin, oral- paracetamol, NSAIDS injection- intraarticular or periarticular corticosteroids

Question 27

What is the surgical management of OA

Answer 27

``` indications- uncontrolled pain, progressive immobility, functional impairment surgical procedures- washout and debridement joint replacement arthrodesis- fuse joint osteotomy- realign joint ```

Question 28

Management of Ank spond

Answer 28

``` Management of ankylosing spondylitis involves both pharmacological and non-pharmacological approaches. non-pharm patient education assess disease severity- BATH index avoidance of aggrevating activities PT, OT Pharmacological pain relief (nsaids, opioids if severe) sulfasalazine - peripheral involvement anti- TNF alpha infliximab and etanercept ```

Question 29

What is the Bath index

Answer 29

6 questions fatigue, morning stiffness duration, severity spinal pain, arthralgia, enthesitis (inflammation at the site where the tendon meets the bone- achilles)

Question 30

Management of interstitial fibrosis

Answer 30

Management of this patient once confirmed to be interstitial pulmonary fibrosis can be divided into non-pharmacological and pharmacological management and potentially surgical. non-pharm- using GAP model (gender, age, physiology- FVC and DLCO) RF = smoking, vaccination pulmonary rehab and education, assistive breathing techniques, incorporation into a MDT PT, OT, respiratory nurse specialist, SW and resp physician Pharm- anti-reflux microaspiration of gastric and oesophageal contents (omeprazole) avoid- sildenafil, warfarin, azathioprine, co-trimoxazole nintedanib- receptor blocker for multiple tyrosine kinases that mediate elaboration of fibrogenic growth perfinidone- anti-fibrotic agent (monitor LFTs for both) LTOT palliative care

Question 31

When would you consider surgery for pulmonary fibrosis

Answer 31

consider: DLCO less than 40% FVC less than 80% decrease in pulse ox less than 89% transplant list: decrease in FVC greater than 10% 6 month follow up decrease in DLCO greater than 15% during 6 month follow up 6 minute walk test- oxygen less than 80% pulmonary HTN

Question 32

What are the contraindication for lung transplantation?

Answer 32

end stage HF chronic substance abuse mets psychosis

Question 33

What is the pharmacedical therapy after lung transplant?

Answer 33

steriods calcineurin inhibitor (tacrolimus) nucleoside blocking agent azathioprine

Question 34

Management of sarcoidosis

Answer 34

Management fo this patient is depenendent of organ involvement, but can be divided into pharmacological and non-pharmacological treatment. non-pharm- * most patients do not require tx if asymptomatic, non-progressive, or have spontaneous remission. serveillance- serial imaging, serial PFTs, depending on the center. MDT- PT, resp nurse, SW, intergration into primary care Pharm- steriods... second line methotrexate, azathioprine

Question 35

Management of COPD

Answer 35

Management of this patient can be divided into non-pharmacological and pharmacological the latter being dependent on the GOLD classification of the patient. non- pharm- education, vaccination, oxygen therapy, pulmonary rehab, nutrition, co-morbid depression and anxiety, integration into primary care, and MDT GOLD classification divided into ABCD the severity is dependent on the mMrC score and the exacerbation history. mMrc greater than 2 higher level. and a exacerbation history of greater than 2 in the past 12 months is considered significant. A SAMA/ SABA B LAMA/ LABA C ICS plus LABA or LAMA D triple therapy- ICS/ LABA/ LAMA consider antibiotic prophylaxis azithromyocin

Question 36

Pharmacological management of COPD= inhaler types

Answer 36

beta agonists SABA- salbutamol inh (100-200 mcg) or nebs 2.5 mg 4 hourly LABA salmeterol amtimuscarinics- SAMA ipratropium (40 mcg QDS) LAMA tiotropium inhaled steriods beclomethasone 100 mcg 2 buds BD mucolytics- carbocystine phosphodiesterase 4 inhibitors Roflumilast 500 mcg OD * anti-inflammatory

Question 37

What is your management for an acute exacerbation of COPD

Answer 37

scoring to local hospital guidelines Amoxicillin 1 g TDS if penicillin allergic Clarithromycin 500 mg BD

Question 38

what is the management for Bronchiectasis?

Answer 38

Managment of this patient would focus on treating the underlying cause, any exacerbations, exacerbation prevention, pharmacological therapy and surgery if localised disease exacerbation - broad spectrum antibiotics, P. Aeruginosa colonisation (difficulty in eradicating) chest prevention: chest physiotherapy, smoking cessation, nutrition, saline, mucolytics, vaccinations.

Question 39

Management of CF

Answer 39

management of this patient requires long term follow-up and management of acute exacerbations. This can be subdivided into pharmacological and non-pharmacological therapy. Non- pharm: MDT dietitation- high caloric intake PT, respiratory consultant annual check up survallience- DM, psych, malabsorption

Question 40

What are the routine bloods for CF?

Answer 40

FBC, Coag, B12, creatinine, Calcium, IG G/m/e Vitamen A and E coag, CRP. LFTs, phosphate, aspergillosis serology, U and E, eGFR, TFTs, Mg, iron

Question 41

What is the pharmacological treatment for CF

Answer 41

Pharmacological respirtory- mucolytics, bronchodilators, endocrine- insulin digestive- enzyme replacement creon, fat soluble vitamin supplement, diabetic drugs if ddx, ursodeoxycholic acid, CFTR modulators

Question 42

What are come examples of CFTR modulators?

Answer 42

``` Ivacaftor G551D Lumicaftor F508 del mutation reduced exacerbation and better FEV1 ```

Question 43

What is the acute management for Cf?

Answer 43

oxygen IV antibiotics mucolytics chest physiotherapy

Question 44

Management fo RA lung disease?

Answer 44

same as RA symptoms RA- ILD with steriods, and steriod sparing agents mycophenolate, azathioprine, cyclophosphamide

Question 45

Management of a pleural effusion

Answer 45

Management is based upon diagnostic aspiration and chest drain. fluid removal is best if slow less than 2 litres in 24 hours if recurrent: pleurodesis with talc surgery: rarely needed plerectomy

Question 46

Management of kyphoscoliosis

Answer 46

Management of kyphoscoliosis depends on the degree of deformity and how it is affecting the patient, but can involve conservative, pharmacological therapies and definitive surgical correction. conservative: PT, shoe lift (leg length des), braces, weight loss, mobility aids referral: if pain, neurogenic claudication, cauda equina medical: analgesia and epidural analgesia plus or minus glucosteriods if radicular pain surgical- relieve of sx and restoration of normal anatomy.

Question 47

Management of pulmonary HTN

Answer 47

Management of this patient would involve a pharmacological and non pharmacological approach based upon treating the underlying causes and reducing pulmonary vascular resistance. HF pharm- ACE inh, B blocker, duiretics, anticoagulation non-pharm same as weigh HF reduction of pulmonary vascular resistance pharm- LTOT, CCB nifedipine, selective vasodilator tx NO pathway- sildenafil prostaglandin analogues- lioprost bosentan- endothelin receptor antagonists Heart and lung transplant Pharm

Question 48

Management of asthma

Answer 48

Management of this patient is based on the relief and control of symptoms (using the gina assessment of asthma control) and also the management fo any acute exacerbations. Acute management is subdivided into mild, moderate, and severe this is based on the Peak flow of the patient, the ox sats, speech, respiratory rate and pulse.

Question 49

Acute management of asthma

Answer 49

management is according to Advanced Trauma Life support guidelines. ABCs and ABG constantly reassess ox oxygen maintain sats 94-98% Beta 2 agonist- nebulised salbutamol 5 mg 4 hourly Predisolone 40-50 mg or IV hydrocortisone 100 mg 6 hourly Ipratropium bromide 0.5 mg via nebuliser consider ICU and Mg sulphate 1.2 -2 mg over 20 minutes r/p PEF 15-30 minutes after initiation of tx

Question 50

Chronic management fo Asthma (right before discharge)

Answer 50

on discharge meds for 12-24 hours and education about inh tech PEF grater than 75% best or predicted tx with oral and inh steriods plus bronchodilator tx write an asthma action plan GP follow up in 2 working days follow up appointment in 4 weeks.

Question 51

Chronic management of asthma

Answer 51

``` short acting b agonist regular preventor steriods add on therapy LABA to low dose ICS This is according to the 2016 guidlines of the BTS 1SABA plus low dose ICS 2 SABA plus low dose ICS and LABA 3 SABA plus medium dose ICS and LABA 4 SABA plus medium dose ICS and LABA and additional agents (leukotrine R antagonist (monteluklast) or theophylline 5 SABA plus above plus orla steroids ```

Question 52

Management of pneumonia

Answer 52

Management of this patient would involve calculating his CURB 65 score and pharmaceutical and non pharmaceutical interventions. Non- pharm: fluids, chest PT, address any other co-morbilidad, and follow up chest x ray at 6 weeks. Pharm- according to the GAP app CAP (score 1) amoxicillin (2) amox plus clarithromyocin. (3) co-amox plus clarithromyocin aspiration: co amox COPD exacerbation: amoxicillin 7 days HAP - 8 days (2) pip taz (3) pip taz plus clarithromyocin plus gent (if unstable) plus vanc

Question 53

Management of polycystic kidney disease

Answer 53

non-pharmacological increase water intake to 3-4 litres *supress ADH and urine osmolalaity reduce cyst size low sodium diet cyst decompression MDT approach with primary care

Question 54

Management of PKD pharm

Answer 54

treat the HTN target 130/80 first line ACEI or ARB then thiazide diuretic statin- increased risk of CVD tolvaptan- vasopressin receptor analogue octeotide (somatostatin) does not alter disease progression. RRT

Question 55

Management of testicular torsion

Answer 55

emergency surgery fixation of the testes NPO analgesia and fluids etc

Question 56

Management of Bell’s palsy

Answer 56

Bell’s palsy can be managed conservatively with physiotherapy, massage, electrical stimulation, lubricating eye drops early treatment with corticosteroids acyclovir

Question 57

What is the treatment for Parkinson’s

Answer 57

``` Parkinson is amovement disorder due to dopamine depletion of the substantia niagra treatment can be divided into pharmacological and non-pharmacological if life limiting symptoms: dopamine L dopa and carbidopa (sinemet) if non life limiting can start on dopamine agonist (non-ergot derived Pramipraxole MAO-B inhibitor selegine (inhibiting breakdown of dopamine) COMT inh (entacapone) ```

Question 58

What is the treatment for Huntington’s disease?

Answer 58

``` There is no cure but there is symptomatic relief psychiatric symptoms- atypical antipsychotics decreased risk of extrapyramidal SE chorea: reserpine depression SSRIs dystonia: botulinum toxin ```

Question 59

What is the treatment for Motor Neuron Disease

Answer 59

The treatment can be divided into conservative and non conservative and disease modifying medications patient educationa dn counselling of family MDT neurologist, GP palliative nurse, physio, OT, Dietician symtomatic relief: drooling: amitriptyline (anticholingeric) dysphagia: blend food, NGTm PEG feeds dysarthria SLP respiratory failure: NIV muscle weakness physio, walking aids spasticity: botulinum toxin, baclofen pain- analgesia ladder disease modifying Riluzole (3 months longer)

Question 60

What is the treatment Amyotrophic Lateral Sclerosis

Answer 60

supportative there is no cure for ALS | drooling anticholinergic like amitriptyline

Question 61

What is the treatment for foot drop?

Answer 61

``` conservative orthotics and splits physiotherapy non conservative surgical decompression ```

Question 62

What is the treatment for Guillian Barre syndrome?

Answer 62

``` Supportive and disease modifying monitor inspiratory force and vital capacity PFTs and need for ICU autonomías dysfunction- monitoring CVS manage BP and arrhythmias (sinus tachycardia) bowel and bladder care catherter pain control- analgesia rehabilitation disease modifying IVIG (0.4g/kg daily for 5 days) plasma exchange peres is ```

Question 63

What is the treatment for Myasthenia Gravis?

Answer 63

Pharmacological anticholinesterase agents (pyridostigamine 30mg TDS) chronic immunosupression (steriods, azathioprine, cyclosporine) Plasmapharesis plus or minus IVIG for crisis surgical: thymectomy

Question 64

What is the treatment for Lambert Eaton Mysathenic syndrome?

Answer 64

treatment: underlying condition- small cell lung cancer with resection need for acetylcholine so increase release: diaminopyridine. guanidine decrease the breakdown with pyridostigmine immunosuppresion

Question 65

What is the treatment for MS

Answer 65

Involvement of a Multidisciplinary team acute: methyprednisone 1000 my IV daily for 3-7 days symptom treatment patient education spasticity- baclofen bladder dysfunction- oxybutin pain- TCAs depression TCAS disease modifying treatment: 1st ABCs (Avonex, Betaseron, Copolymer) all interferon Betas Monoclonal antibodies- Natalizumab acts as alpha 4 intergrin antagonist used in severe relapsing remitting MA that is unresponsive to interferon.

Question 66

What is the treatment for spinal cord compression?

Answer 66

Emergency: treat with high dose steriods IV ultimately need to do surgical decompression symptomatic relief: mobilization of patient: avoid bed sores cathertisation- urinary retention manual evacuation of faeces passive physio- avoid formation of contratares Baclofen, botulinum toxin spasticity LMWH- thromboprophylaxis

Question 67

What is the treatment for Cauda Equina?

Answer 67

surgical decompression in less than 48 hours | consult with radio oncology for symtomatomatic relief in malignancy

Question 68

What is the treatment for subacute degeneration of the spinal cord?

Answer 68

B12 injection with variable response

Question 69

How do you treat an acute relapse in MS

Answer 69

oral methylprednisolone 0.5 g daily for 5 days | if severe consider IV

Question 70

What is the treatment for transverse myelitis?

Answer 70

High dose steriod in acute | plasmapheresis

Question 71

What is the treatment of Myasthenia gravis?

Answer 71

cholinesterase inhibitors pyridostigmine steiods- prednisolone azathioprine- steriod sparing agents other immunosuppression MTX plasma exchange and IV immunoglobulin used in crisis and severe MG with sevre bulbar and respitory compromise surgical thymectomy

Question 72

Charcot Mary Tooth disease treatment?

Answer 72

evaluate all pd for weakness booth distal and proximal, psyical conditioning, ambulatory, balance coordination, and manual dexterity. daily exercises may improvise function with ADLs orthotics to stabilise the ankles ortho surgery

Question 73

What drugs should you avoid in CMT

Answer 73

``` vincristine amiodarone cisplatin metronidazole nitrofurantoin ```

Question 74

What is the treatment for myotonic dystrophy?

Answer 74

``` genetic counselling pre natal dx if family history muscle pain- NSAIDS, TCAs, Mexiletine myotonia mexiletine- check ECG for QT prolongation alveolar hypoventilation regular use of incentive spirometers nutrition screen for depression MDT ```

Question 75

What drugs should not be offered as first line treatment for PD?

Answer 75

ergot derived dopamine agonists because of the monitoring considered in patients who have developed dyskinesia or motor fluctuations second line if not sx controlled enough