Management of conditions Flashcards
(96 cards)
1
Q
Management
Varicose veins
A
- Conservative = exercise, elevation of legs at rest and support stockings, lose weight,
- venous telangectasia and reticular veins = laser/radiofrequency ablation, microinjection sclerotherapy (foam sclerotherapy);
- surgical = saphenofemoral ligation, stripping of the long saphenous vein, avulsion of varicosities
2
Q
Management
DVT
A
- likely to have it based on Well’s score:
- Take D-dimer, 24hr dose parenteral anticoagulant, USS of proximal leg vein
- Anticoagulation: Heparin/rivaroxaban whilst waiting for warfarin to increase INR to target range, DVT’s not above knee can be observed and anticoag for 3 months, DVT beyond knee need anticoag for 6 months; recurrent DVT need long term warfarin
- IVC filter: if anicoag contraindicated and risk of embolisation
- Prevention: graduated compression stockings, mobilisation prophylactic heparin
3
Q
Management
Heart Block
A
- Chronic block: permanent pacemaker in complete, Advance mobitz II and symptomatic Mobitz I;
- Acute: associated with clinical deterioration = IV atropine, with temp external pacemaker
4
Q
Management
HF
A
ALVF:
- Tx of cardiogenic shock (severe CF with low BP) = inotropes (dobutamine)
- Tx of pulm oedema = sit up, 60-100% O2 (?CPAP), diamorphine (venodilator and anxiolytic), GTN infusion (venod), IV furosemide (venod and diuretic) -> monitor BP, RR, O2 sats, urine output and ECG
Chronic LVF:
- Treat cause and exacerbating factors
- ACEi, beta blockers, loop diuretics, aldosterone antagonists, Ang receptor blockers, (hydralazine and nitrate), digoxin, N-3 polyunsat Fatty acids, cardiac resynch therapy (biventricular pacing and elegible for cardiac defib implanted) - antiplatelet drug for atherosclerotic disease
5
Q
management
HTN
A
- Conservative: stop smoking, lose weight, reduce alcohol intake, reduce dietary Na, stress management
- Investigate 2ry causes
- Medical if >160/100, multiple drug therapy needed:
- <55 - start with ACEi OR ARB
- >55 or black - CCB or thiazide
- Then: ACEi/ARB AND CCB/Thiazide
- Then ACEi/ARB AND CCB AND Thiazide
- Then: low dose spironolactone, high dose thiazide or alpha/beta blocker
- Target BP: <140/90 in non-diabetic, diabetic = <130/80, diabetes with proteinuria = <125/75)
- Severe HTN management (dias >140) = atenolol and nifedipine
- Acute malignant HTN: IV BB (emolol), labetalol, hydralazine Na nitroprusside. NB: lower BP slowly to prevent cerebral infarction
6
Q
Management
IHD
A
- Stable angina:
- Stop smoking, cardioprotective dietand exercise
- Minimise cardiac risk factors -> aspirin 75mg a day (unless PAD/stroke, then should already be on clopidrogel)
- Immediate Syx relief = GTN spray
- Long term = beta blockers (not in acute HF, cardiogenic shock, bradycardia, heart block, asthma), CCB or if neither tolerated: long acting nitrates
- Percutaneous coronary intervention
- Coronary artery bypass graft
- Unstable angina/NSTEMI (MONABASH)
- Coronary care unit -> O2, IV access, monitor vital signs and serial ECG
- GTN, morphine, metoclopramide (nausea), aspirin (300mg initially then 75mg indefinitely), clopidogrel (300mg initially then 75mg for at least 1 yr), LMWH (enoxaparin), beta blocker, insulin infusion if >11mmol/L, GlpIIb/IIIa inhibitors considered if undergoing PCI
- STEMI: same as above except clopidogrel = 600mg if PCI, 300mg if thrombolysis and <75, 75mg if thrombolysis and >75 annd 75mg daily for 1yr+;
- PCI: IV heparin and GlpIIb/IIIa inhibitor, Bivalirudin. 1ry PCI <90 min, thrombolysis within 12h of chest pain, rescue PCI if continued chest pain/STE after thrombolysis;
- 2ry prevention: aspirin and clopidogrel, beta blockers, ACEi, statins and control risk factors;
- no driving for 1 month after MI, CABG in pts with left main stem/3 vessel disease
7
Q
management
Infective endocarditis
A
- ABx for 4-6wks.
- On clinical suspicion: benzylpenicillin, gentamicin;
- strep continue with benzylpenicillin and gentamicin;
- staph: flucloxacillin/vancomycin and gentamicin;
- enterococci: Ampicillin, gentamicin;
- Culture -ve: vancomycin and gentamicin.
- Surgery for urgent valve replacement needed if poor response to ABx
8
Q
Management
Pericarditis
A
- Acute: cardiac tamponade = pericardiocentesis;
- Medical = underlying cause and NSAIDs for pain and fever relief;
- Recurrent = low dose steroids, immunosuppressants, colchicine;
- surgical = pericardiectomy (constrictive)
9
Q
management
SVT
A
- If haemodynamically unstable -> DC cardioversion;
- if stable -> vagal maneouvres (Valsalva/carotid massage) and chemical cardioversion (adenosine 6mg bolus, verapmil 2.5-5mg (atenolol/amiodarone as alternatives)).
- If unresponsive to above or >250bpm or low BP/HF/low consciousness then sedate and sync DC cardioversion and amiodarone.
- Ongoing Mx:
- AVNRT = radiofrequency ablation of slow pathway, beta blockers (alternative: fleicanide, propafenone, verapmil);
- AVRT = radiofrequency ablation;
- Sinus tachy = exclude 2ry cause and beta blocker/ rate limiting CCB
10
Q
Management
Venous ulcers
A
- Graduated compression (exclude diabetes, neuropathy and PVD before attempt),
- debridement and cleaning,
- ABx if infected, topical steroids (surrounding dermatitis)
11
Q
Management
Ventricular tachycardia
A
- ABC approach;
- Pulse? NO = ALS;
- unstable VT = reduced cardiac output so defib, correct lectrolyte abnormalities and amiodarone;
- stable VT = no haemodynamic compromise, correct electrolyte abnormalities, Amiodarone, synchronised DC shock;
- implantable cardioverter defib if sustained VT causiing syncope, sustained VT with EF <35%, previous cardiac arrest due to VT/VF, MI complicated by non-sustaned VT
12
Q
Treatment
Cardiac arrest
A
- BLS,
- ALS - cardiac monitor and defib,
- assess rhythm = if pulseless V-tachy/V-fib then defib once, resume CPR and then shock again
- if still in pulseless V-T/V-F, admin adrenaline 1mg IV (after 2nd and every 3-5min)
- if shockable rhythm persists after 3rd shock then amiodarone IV bolus 300mg;
- if puseless electrical activity/asystole then CPR for 2, reassess and admin adrenaline (1mg IV every 3-5min), atropine (3mg IV once) if asystole/PEA with 60bpm),
- Tx of reversible causes;
- warm hypothermia slowly,
- correction of electrolyte levels for hypo/erK,
- hypovol use IV colloids/crystalloids and blood products,
- tamponade = pericardiocentesis,
- tenion pneumothorax = aspiration/chest drain,
- TE = treat as PE/MI,
- toxins = antidote
13
Q
Treatment
AF
A
- Treat any reversible causes, then rhythm control and rate control:
- Rhythm: >48h onset = anticoagulate for 3-4wks before cardioversion; if <48h = cardioversion, chemical cardioversion (flecainide/amiodarone), contraindicated if IHD Hx; prophylaxis against AF = sotalol, amiodarone and flecainide
- Rate: Chronic = digoxin, verapamil, beta-blockers aiming for ventricular rate of 90
- Stroke risk stratification: Low risk can use aspirin; high risk require warfarin => based on CHADS-Vasc score, RF = previous thromboembolic event, >75yrs, HTN, DM, Vascular/Valvular disease, HF, impaired LV function
14
Q
Management
asthma
A
- Acute:
- ABCDE, resuscitate, monitor O2 stats, ABG, PEFR,
- high flow O2, salbutamol nebulizer (5mg, initially continuously then 2-4hrly), ipatropium bromide (0.5mg QDS), steroid therapy (100-200mg IV hydrocortisone;
- followed by 40mg oral prednisolone for 5-7d and if not improved IV MgSO4),
- consider IV aminophylline infusion/salbultamol;
- treat underlying cause (Abx),
- monitor electrolytes (drop in K),
- invasive ventilation in severe attacks
- Discharge when: PEF >75% predicted, diurnal variaton <25%, inhaler technique checked, stable on discharge meds for 24h, pt owns PEF meter and has steroid and bronchodilator therapy -> arrange follow up
- Chronic =>
- Step match severity to pick start =
- inhaled SABA, if needed >1/d then onto step 2
- inhaled SABA and reg inhaled low dose steroids (400mcg/d)
- 2+inhaled LABA; if inadequate control with LABA then increase steroid to 800mcg/day (no control with LABA = stop LABA and up steroid)
- increased inhaled steroid (2000 mcg/d), 4th drug (leukotriene antagonist, slow release theophylline or b2 agonist)
- Regular oral steroids, maintain high-dose oral steroids, refer to specialist
- Advice = teach proper inhaler technique, explain importance of PEFR monitoring and avoid provoking factors
15
Q
Management
Bronchiectasis
A
- Acute exacerbations with 2 Abx IV, covering P. aeruginosa;
- prophhylactic Abx if frequent exacerbations;
- inhaled corticosteroids; bronchodilators;
- maintain hydration;
- flu vaccine;
- physio for mucus and sputum clearance;
- bronchial artery embolisation;
- surgical
16
Q
Management
COPD
A
- Stop smoking;
- bronchodilators = SABA, LABA, anticholinergics;
- steroids = inhaled beclamethasone (FEV1 <50% or > 2 exacerbations per yr;
- pulm rehab;
- O2 therapy (stopped smoking and pO2 <7.3kpa);
- tx of acute exacerbations = 24% O2 with venturi mask, corticosteroids, abx therapy, resp physio for sputum
17
Q
Management
Pneumonia
A
- Assess severity with british thoracic society guidelines (markers).
- Start empirical Abx = oral amoxicillin (0), oral/IV amoxicillin and rythromycin (1), IV cefuroxime/cefotaxime/co-amoxiclav + erythromycin (>1), add metronidazole if aspiration, lung abcess or empyema, and switch based on sensitivity.
- Supportive treatment = O2, IV fluids, CPAP/BiPAP/ITU care for resp failure, surgical drainage for lung abcessess and empyema
- Discharge planning = 2 or more = high temp, tachycardia/pnoea, hypotension, low O2 sats, means high risk of readmission
- Prevention = pneumococcal vaccine, H. influenzae B vaccine
18
Q
Management
Pneumothorax
A
- Tension = EMERGENCY so max O2, insert large bore needle into 2nd ICS at MCL, aspirate up to 2.5L of air, stop if cough/resistance is felt; follow up CXR 2hr and 2wks later;
- Chest drain with underwater seal = performed if aspiration fails, fluid in pleural cavity or after decompression of tension, inserted in 4-6th ICS at mid axillary line;
- Recurrent = clhemical pleurodesis (fusing visceral+parietal pleura with tetracycline), surgical pleurectomy.
- Advice = avoid air travel until follow up CXR confirms it resolved, avoid diving
19
Q
Management
Pulm Embolism
A
- 1ry prevention: compression stocking, heparin prophylaxis and good mobilisation and adequate hydration
- If haemodynamically stable = O2, anticoag with heparin/LMWH, switch to oral warfarin for at least 3months (INR at 2-3), analgesia
- If haemodynamically unstable = Resuscitate, O2, IV fluids, thrombolysis with tPA if cardiac arrest imminent
- Surgical/Radiological = embolectomy, IVC filters (sometimes for recurrent PEs despite adequate anticoag/anticoag contraindicated
20
Q
Management
Acute cholangitis
A
- Resus if in septic shock
- Broad spec Abx: give after culture and those effective against anaerobes and GNB: cefuroxime and metronidazole
- Endoscopic biliary drainage usually required to treat underlying obstruciton
- Depends on severity:
- Stage 1: anti-microbial therapy, percutaneous, endoscopic, operative intervention for non-responders
- Stage 2: early percutaneous or endoscopic drainage (biliary is recommended)
- Stage 3: Severe includes shock, conscious disturbance, acute lung injury, AKI, hepatic injury or DIC;
- tx of organ failure with ventilatory support, VP;
- urgent percutaneous or endoscopic drainage
21
Q
Management
Alcoholic hepatitis
A
- Acute: thiamine, vit C and multivits (pabrinex), monitor and correct K/Mg/glucose;
- adequate urine output;
- encephalopathy tx with oral lactulose or phosphate enemas;
- ascites with diuretics (spirono and frusemide);
- therapeutic paracentesis;
- glypressing and N-acetylcysteine for hepatorenal syndrome
- nutrition: via oral/NG feeding;
- protein restriction avoided unless ecephalopathic;
- nutritional supplementation and vit (B group, thiamine and folic acid) should be started parenterally initially and continued orally
- Steroid therapy: reduce short term mortality for severe alcoholic hepatitis
- NB:hepatorenal syndrome (dev of renal failure in pts with advanced chronic liver disease - RAS activated and vasoconstriction of vessels in kidney leads to kidney failure
22
Q
Management
Anal fissure
A
- Conservative: high fibre diet, softening the stools (laxative), good hydration
- Medical: lidocaine ointment, GTN ointment and diltiazem (relaxing anal sphincter and promoting healing), botulinum toxin injection
- Surgical: lateral sphincterotomy, relax anal sphincter and promotes healing but has complication, so reserved for non-tolerant pts to non-surgical tx
23
Q
Management
Appendicitis
A
Prompt appendicectomy; ABx: cefuroxime, metronidazole; laparoscopy - dx and therapuetic advantages
24
Q
Investigations
Barrett’s oesophagus
A
OGD and biopsy: show replacement of squamous epithelium with columnar epithelium
25
Management
Biliary colic
1. Analgesia, IV fluids, NBM;
2. surgical: laproscopic cholecystectomy;
3. ERCP can also be used to help remove stones or stent a blocked bile duct
26
Management
Cholecystitis
1. Conservative - mild biliary colic, follow low-fat diet
2. Medical: NBM, IV fluids, analgesia, anti-emetics,
3. Abx; if obstruction: urgent biliary drainage by ERCP or via percutaenous route is necessary
4. Surgical: laproscopic cholecytectomy
27
Management
Cirrhosis
1. Tx the cause; avoid alcohol, sedative, opiates, NSAIDs and drugs that affect the liver, nutrition is important, enteral supplements should be given, NG feeding may be indicated;
2. Tx complications:
1. Encephalopathy: tx infections, exclude GI bleed, use lactulose and phosphate enemas, avoid sedation
2. Ascites: Diuretics, dietary Na restriction, therapeutic paracentesis, monitor weight, fluid restrict if plasma Na \<120 mmol/L, avoid alcohol and NSAIDs
3. Spontaneous bacterial peritonitis: Abx, prophylaxis against recurrent SBP with ciprofloxacin
4. Surgical: consider Transjugular intrahepatic portosystemic shunt, helps reduce portal HTN;
5. liver transplant is only curable method
28
Management
Coeliac disease
1. Advice: avoid gluten
2. Medical: vit and mineral supplements, oral corticosteroids if disease doesn't subside with avoidance of gluten
29
Management
Crohn's disease
1. Acute exacerbation: fluid restriction, IV/oral corticosteroids, 5-ASA analogues, analgesia, parenteral nutrition may be necessary, monitor markers of disease activity
2. Long term:
1. Steroids for acute exacerbation
2. 5-ASA analogues - decreases freq of relapses
3. Immunosuppression: using steroid sparing agents reduces freq of relapses
4. Anti-TNF agents: very effective at inducing/maintaining remission
3. General advice: stop smoking, dietician referral
4. Surgery indicated if: medical tx fails, failure to thrive in children with complications;
5. involves resection of affected bowel and stoma formation
30
Management
Diverticular disease
1. Asyx: soluble high fibre diet, some drugs for preventing recurrent flares of diverticulitis
2. GI bleed: PR bleeeding usually managed conservatively with IV rehydration, Abx, blood transfusion if necessary;
3. angiography and embolism or surgery if severe
4. Diverticulitis: IV Abx, fluid rehydration, bowel rest, abscesses may be drained by radiologically sited drains
5. Surgery: pt with recurrent attacks or complications; open: hartmann's procedure leaving stoma, one-stage resection and anastamosis;
6. laproscopic drainage, peritoneal lavage and drain placement can be effective
31
Management
Gastroenteritis
1. Bed rest, fluid and electrolyte replacement with oral rehydration solution;
2. IV rehydration may be necessary with severe vomiting;
3. most are self-limiting;
4. Abx tx only if severe or if infective agent identified
32
Management
Gastrointestinal perforation
1. Resus: correct fluid and electrolytes, IV abx
2. Surgical:
3. large bowel: Id site of perf with peritoneal lavage, resection of perforated section;
4. gastroduodenal: laparotomy, peritoneal lavage, perf closed with omental patch, gastric ulcers biopsied, H pylori eradication if positive
5. oesophageal: pleural lavage, repair of ruptured oesophagus
33
Management
GORD
1. Advice: wt loss, elevating head of bed, avoid provoking factors, stop smoking, lower fat meals, avoid large meals in the evening
2. Medical: antacids, alginates, H2 antagonists, PPI
3. Endoscopy: annual endoscopic surveillance looking for barrett's, neessary for stricture dilation or stenting
4. Surgery: antireflux surgery if refractory to medical tx
5. Nissen fundoplication: fundus of stomach is wrapped around lower oesophagus - helps reduce risk of hiatus hernia and reduce reflux
34
Management
Haemorrhoids
1. Conservative: high fibre diet, increase fluid intake, bulk laxatives, topical creams (local anaesthetics)
2. Injection sclerotherapy: induces fibrosis of the dilated veins
3. Banding: barron's bands applied proximal to the haemorrhoids, haemorrhoid will fall off after a few days, BUT may be more painful than injection sclerotherapy
4. Surgery: reserved for syx 3rd and 4th degree;
5. milligan-morgan haemorrhoidectomy: excision of 3 haemorrhoidal cushions;
6. stapled haemorrhoidectomy is an alternative method;
7. post-op the pt should be given laxatives to avoid constipation
35
Management
Inguinal hernias
1. Surgical: usually elective, mesh repair to reinforce defect in transversalis fascia;
2. laproscopic mesh repair;
3. emergency: obstructed or strangulated, laparotomy with bowel restriction may be indicated if bowel is gangrenous
36
Management
Hiatus hernia
1. Medical: modify lifestyle factors, inhibit acid production, enhance upper GI motility
2. Surgical: necessary in pt minority, usually performed in pts with complications of reflux disease, despite aggressive med tx or pulm complications;
3. Nissen fundoplication - stomach pulled down through oesophageal hiatus and part of stomach wrapped 360 degrees around oesophagus to make a new sphincter
4. Belsey Mark IV fundoplication: 270 degree wrap
5. Hill repair: gastric cardia is anchored to the posterior abdo wall
37
Management
Intestinal obstruction
1. General: gastric aspiration via NGT if pt is vomiting, IV fluids, electrolyte replacement, monitor vital sx, fluid balance and urine output;
2. Surgical: emergency laparotomy in acute obstruction
38
Management
IBS
1. Advice: dietary modification;
2. Medical: depends on main syx affecting the pt: antispasmodics, prokinetic agents, anti-diarrhoeals, laxatives, low-dose TCA
3. Psych therapy: CBT, relaxation and psychotherapy
39
Management
Liver failure
1. Resus ABC, tx cause if possible - N-acetylcysteine: tx of paracetamol ODs
2. tx/prevention of complications: monitor - vital sx, PT, pH, creatinine, urine output, encephalopathy
3. Manage encephalopathy: lactulose and phosphate enemas
4. Abx and antifungal prophylaxis
5. hypoglycaemia tx
6. coagulopathy tx - IV vitamin K, FFP, platelet infusions
7. gastric mucosa protection PPIs, sucralfate
8. Avoid sedatives or drugs met by the liver,
9. cerebral oedema - decrease ICP with mannitol
10. Renal failure: haemodialysis, nutritional support
11. Surgical liver transplant
40
Management
Mallory Weiss tear
1. 80-90% of the time, bleeding will stop on its own;
2. surgery: only if bleeding doesn't stop - injection sclerotherapy, coagulation therapy, arteriography;
3. anti-reflux meds may be prescribed
41
Management
Non-alcoholic steatohepatitis
1. Conservative - control
2. RF: BP, DM, cholesterol, weight, smoking, exercise, alcohol (makes it worse)
42
Management
Acute pancreatitis
1. 2 main scales: modified glasgow score (with CRP) and Apache-II score
2. Medical: fluid and electrolytes resus, urinary catheter and NGT if vomiting, analgesia, blood sugar control, HDU and ITU care, prophylactic ABx
3. ERCP and sphincterotomy: used for gallstone pancreatitis, cholangitis, jaundice or dilated common bile duct - within 72hrs
4. Early detection and tx of complications: e.g. persistent syx or \>30% pancreatic necrosis or sx of sepsis
5. Surgical: necrotising pancreatitis mx by specialists
43
Management
Chronic pancreatitis
1. General: mainly syx and supportive - dietary advice, stop smoking/drinking, tx DM, oral pancreatic enzyme replacement, analgesia; chronic pain may need specialist input
2. Endoscopy: sphincterotomy, stone extraction, dilatation and stenting of strictures, ESWL
3. Surgical: Lat pancreaticojejunal drainage, panc resection (whipple's procedure), limited resection of panc head (beger procedure), open panc duct and excavate head of pancreas (Frey)
44
Management
Peptic ulcer disease and gastritis
1. Acute: fluid resus if ulcer perf/bleeding (IV colloids), close monitoring of vital sx, endoscopy, surgical tx; pts with upper GI bleeds treated with IV PPIs at presentation until bleeding ID
2. Endoscopy: haemostasis for bleeding ulcer with injection sclerotherapy, laser coag, electrocoag
3. Surgery: indicated if ulcer perf/bleeding can't be controlled
4. H pylori eradication: 3x therapy for 1-2wks, 2Abx and PPI
5. If not HP: tx with PPIs/H2 antags, stop NSAIDS, use misoprostol if NSAID use necessary
45
Management
Perineal abscess and fistula
1. Surgical tx;
2. open drainage of abscess;
3. ABx;
4. laying open of fistula - dye inserted to find internal opening
5. Low fistula = fistulotomy and care with anal sphincter
6. High fistula = fistulotomy cause incontinence so NOT performed; seton - suture threaded through fistula to allow drainage
46
Management
Peritonitis
1. Localised peritonitis: depends on cause, some causes may require surgery, some causes can be treated with Abx
2. Generalised: may look at risk of death from sepsis or shock, IV fluids/Abx, urinary catheter, NGT, central venous line;
3. laparotomy: to remove infected or necrotic tissue, treat cause, peritoneal lavage;
4. 1ry tx with Abx
5. Spontaneous bacterial peritonitis: quinolone Abx OR cefuroxime and metronidazole
47
Management
Pilonidal sinus
1. Acute pilonidal abscess: incision and drainage;
2. chronic pilonidal sinus: excision under GA with exploration;
3. prevention: good hygiene, shaving
48
Management
Portal HTN
1. difficult to tx specifically;
2. tx mainly focused on tx underlying cause where possible;
3. conservative = salt restriction, diuretics
4. Tx oesophageal varices
5. non-selective b-blocker to reduce portal pressure and reduce risk of variceal bleed
6. Terlipressin to reduce portal venous pressure
7. TIPS - surgical shunt between hepatic portal vein and hepatic vein to ease congestion in portal vein
8. Liver transplant
49
Management
Ulcerative colitis
1. Markers of diseae activity: decreased Hb/albumin, increased ESR/CRP, diarrhoea freq: \<4 is mild, 4-6 mod, 6+ severe; bleeding, fever
2. Mx of acute exacerbation: IV rehydration/corticosteroids, ABx, bowel rest, parenteral feeding may be necessary, DVT prophylaxis: toxic megacolon - proctolectomy because it has high mortality
3. Mx of mild disease: oral/rectal 5-ASA derivatices and/or rectal steroids
4. Mx of moderate/severe disease: oral steroids, oral 5-ASA, immunosuppression (azathioprine, cyclosporine, 6-MPU)
5. Advice: pt education/support, treat complications, regular colonoscopic surveillance
6. Surgical: Proctolectomy with ileostomy, ileoanal pouch formation
50
Management
Viral Hep A and E
1. No specific mx, bed rest, syx tx (antipyretics/antiemetics/cholestyramine)
2. Prevention and control:
1. public health - safe water,
2. sanitation, food hygeine;
3. notifiable disease,
4. immunisation available for HAV - passive immunisation with IM human Ig (effective for short time),
5. active immunisation with attenuated HAV vaccine offers safe and effective immunity for those travelling to endemic areas and high risk individuals
51
Management
Viral Hep B and D
1. Prevention: blood screening, safe sex, instrument sterilisation;
2. passive immunisation: hep B Ig following acute exposure and to neonates born to HBeAg+ mothers
3. Active immunisation: recombinant HBsAg vaccine for individuals at risk and neonates born to HB
4. Acute HBV hepatitis: syx tx (antipyretics, antiemetics and cholestyramine) and bed rest, notifiable disease
5. Chronic HBV: Interferon alpha causing side effects: flu-like syx such as fevers, chills, myalgia, headaches, bone marrow suppression and depression;
6. nucleoside/sucleotide analogues (adefovir, entecavir, telbivudine, tenofovir
52
Management
Viral Hep C
1. Prevention: screen blood, blood products and organ donors, needle exchange scheme for IV drug users, instrument sterilisation,
2. NO VACCINE AVAILABLE
3. Medical: Acute - mainly supportive (antipyretics, antiemetics, cholestyramine;
4. chronic: pegylated interferon Alpha, Ribavirin for genotype 1/4: 24-48wks, for genotype 2/3: 12-24wks;
5. regular USS of liver needed if cirrhosis
53
Management
Spontaneous bacterial peritonitis
1. ABx: cefotaxime IV,
2. IV albumin
54
Management
Acromegaly
1. Surgical: transphenoidal hypophysectomy
2. RT: adjunctive to surgery
3. Medical if surgery refused:
4. subcut Somatostatin analogues (e.g. octreotide/lanreotide) with side effects of abdo pain,steatorrhoea, glucose intolerance and gallstones;
5. Oral DA agonists (bromocriptine and cabergoline), side effects: N/V, constipation, postural hypotension, psychosis (rare);
6. GH antagonist = pegvisomant
7. Monitor: GH and IGF1 levels can be used to monitor
55
Management
Adrenal insufficiency
1. Addisonian crisis =
1. rapid IV fluid rehydration;
2. 50mL of 50% dextrose to correct hypoglycaemia;
3. IV 200mg hydrocortisone bolus, followed by 100mg 6hrly hydrocortisone until BP is stable, treat precipitating cause (Abx for infection), monitor
2. Chronic:
1. replacement of glucocorticoids with hydrocortisone (3/d), mineralocorticoids with fludrocortisone;
2. hydrocortisone dosage increased during times of acute illness or stress.
3. NB: hydrocortisone before thyroxine if hypothyroidism
3. Advice: have a steroid warning card, wear a medic alert bracelet, emergency hydrocortisone on hand
56
Management
Cushing's syndrome
1. Iatrogenic = discontinue steroids, use lower dose or steroid-sparing agents
2. Medical = used pre-op or if unfit for surgery, inhibit cortisol synth with metyrapone or ketoconazole, treat osteoporosis, physio for muscle weakness
3. Surgical = pit adenomas (trans-sphenoidal resection), adrenal adenoma/carcinoma (surgical removal), ectopic ACTH (tx directed at the tumour)
4. RT = performed in those not cured and have persistent high cortisol after resection of tumour; bilat adrenalectomy may be performed in refractory cushing's disease
57
Management
Diabetes insipidus
1. Treat the cause;
2. cranial DI: give DP and if mild chlorpropamide/carbamazepine to potentiate the residual effects of any residual VP
3. nephrogenic DI: Na and/or protein restriction helps with polyuria, thiazide diuretic
58
Management
T2DM
1. Glycaemic control:
2. at dx: lifestyle and metformin
3. HBA1c \>7% after 3m:
1. lifestyle + metformin + sulphonylurea (can be monotherapy if metformin not tolerated)
2. lifestyle +metformin + basal insulin
3. And fasting blod glucose \>7: add premeal rapid actign insulin
4. NB: pioglitaqzone can be given alongside metformin and sulphonylurea
4. Screening for complications: retinopathy, nephropathy, vascular disease, diabetic foot, cardiovascular risk factors
5. Pregnancy: requiring strict glycaemic control and planning of conception
6. Hyperosmolar hyperglycaemic state: mx similar to DKA, except 0.45% saline if serum Na \>170mmol/L
59
Management
Hyperparathyroidism
1. Acute hypercalcaemia = IV fluids, avoid factors that exacerbate hyperCa, maintain adequate hydration, moderate ca and vit D intake;
2. surgical mx: subtotal/total parathyroidectomy
3. 2ry herPTH: treat underlying cause and ca/vit D supplements may be needed
60
Management
Hypopituitarism
1. Hormone replacement:
1. hydrocortisone,
2. levothyroxine,
3. sex hormones: testosterone in males, oestrogen with/out progesterone in females,
4. growth hormone,
5. desmopressin
61
Management
Hypothyroidism
1. Chronic:
1. levothyroxine (25-200mcg/d), important to rule out underlying adrenal insufficiency before starting THR,
2. thyroid hormone replacement in the context of adrenal insufficiency can precipitate an addisonian crisis,
3. adjust dose based on clinical picture and TFTs
2. Myxoedema coma: oxygen, rewarming, rehydration, IV T4/3, IV hydrocortisone, treat underlying disease
62
Management
1ry hyperaldosteronism
1. BAH = spironolactone, eplerenone if spironolactone side effects intolerable, amiloride -\> monitor serum K and creatinine and BO, can also add ACEi and CCBs;
2. Aldosterone producing adenomas = adrenalectomy;
3. adrenal carcinoma = surgery,
4. post op mitotane (anti-neoplastic)
63
Management
Prolactinoma
1. Goals: treat cause, relieve syx, prevent complications, restore fertility;
2. DA agonists (cabergoline and bromocriptine) effective in most pts, long-term basis and
3. if ineffective: surgery and RT
64
Management
SIADH
1. Treat underlying cause,
2. fluid restriction,
3. VP, receptor antagonists (tolvaptan);
4. severe cases = slow IV hypertonic saline and furosemide with close monitoring
65
Management
Thyroiditis
1. Pharm: thyroide hormone replacement - oral levothyroxine sodium, titrate dose based on pts needs
2. Surgical: considered if there is a large goitre that is causing syx due to compression of surrounding structures or if there is a malignant nodule
66
Management
Vit d Deficiency and osteomalacia
1. Vit D and Ca replacement,
2. monitor 24hr urinary calcium;
3. also monitor: serum Ca, PO4, ALP, PTH, Vit D;
4. treat underlying Cause
67
Management
Acute Kidney Injury
1. Treat cause and monitor serum creatinine, Na, K, Ca, PO4, glucose, ID and treat infection;urgent relief of urinary tract obstruction;
2. refer to nephrology if intrinsic renal disease suspected;
3. Renal replacement therapy considered if hyperk refractory to medical management, pulm oedema refractory to medical mx, severe met acidaemia, uraemic complications.
4. Mx 4 main components:
1. Protect pt from hyperkalaemia
2. Optomise fluid balance
3. Stop nephrotoxic drugs
4. Consider for dialysis
68
Management
BPH
1. Emergency = catheterisation;
2. conservative = watchful waiting;
3. medical = selective alpha blocker (tamsulosin, relax internal sphincter and prostate capsule) and 5-alpha-reductase inhibitors (finasteride, reduce prostate size);
4. surgery (TURP and open prostatectomy)
69
Management
Testicular Torsion
1. Exploration of scrotum within 6hrs of onset of syx;
2. after testicle twisted back into place, a bilat orchidopexy performed, involving suturing the testicle to scrotal tissue to prevent recurrence, if testicle is necrotic orchidectomy may be performed
70
Management
Urinary tract calculi
1. Acute presentation = analgesia, bed rest, fluid rep-placement, urine collection to try and retrieve stone that passed (obstructed and infected kidney is an emergency and treated asap to relieve obstruction;
2. removal of calculi = urethoscopy (to remove stone or place a JJ stent), extracorporeal shock wave lithotripsy (break down stone for spontaneous passage, non-invasive), percutaneous nephrolithotomy (large stones, nephroscope inserted allowing disintegration and removal of stones);
3. Treat cause;
4. advice = increase oral fluid intake
71
Management
UTI
1. For uncomplicated UTI = trimethoprim OR nitrofurantoin, treat for 3-6d (men may need longer course),
2. alternatives = co-amoxiclav or cefalexin
72
Management
Bell's palsy
1. Protection of cornea with protective glasses/patches or artificial tears;
2. high dose corticosteroids useful within 72hrs (only if ramsey-hunt syndrome is excluded;
3. surgery - lateral tarsorrhaphy
73
Management
Epilepsy
1. Status epilepticus tx = initiated early, ABC approach, glucose check, IV lorazepam or IV/PR diazepam (repeat again after 10 min if seizure doesn't terminate) - IV phenytoin considered if seizures recurr after next dose, consider also GA, or treat the cause, check plasma levels of anticonvulsants;
2. Newly dx epilepsy tx = Start anti-convulsants after \>2 unprovoked seizures,
1. focal = lamotrigine/carbamazepine,
2. generalised = Na valproate, only ONE drug (others inc. phenytoin, levetiracetam, clobazam, topiramate, gabapentin, vigabatrin);
3. Pt education = avoid triggers, use seizure diaries, women of child-bearing age (!), drug interactions
74
Management
Meningitis
1. Immediate IV ABx before LP (3rd gen cephalosporins, and benzylpenicillin may be used for initial blind therapy),
2. Dexamethasone IV (shortly before/with 1st dose of ABx, reduced risk of complications),
3. resus (manage in ITU, notify public heallth services)
75
Management
Migraine
1. Analgesia overuse can cause headaches;
2. Acute = NSAIDs, paracetamol, codeine, antiemetis, triptans (5-HT agonists) like sumatriptan
3. Prophylaxis = b-blockers, amitriptyline, topiramate, Na valproate, menstrual migraines can be controlled with COCP
4. Advice = avoid triggers, rest in a quiet dark room during episodes
76
Management
Stroke
1. Hyperacute = \<4.5hrs onset, exclude haemorrhage using head CT, thrombolysis may then be considered
2. Acute ischaemic = Aspirin+clopidogrel for further thrombosis, heparin if high risk of emboli recurrence/stroke progression; swallow assessment (NGT for feeding?), GCS monitoring, thromboprophylaxis
3. 2ry prevention = aspirin and dipyridamole, warfarin anticoagulation (AF), control RF = HTN, hyperlipidaemia, CAD
4. Surgical treatment = carotid endarterectomy
77
Management
Subdural haemorrhage
1. Acute = ALS protocol, cervical spine injury awareness, if ICP raised consider osmotic diuresis
2. Conservative tx if small
3. Surgical - prompt Burr hole/craniotomy
4. Chronic - syx = Burr hole/craniotomy and drainage
5. Children = percutaneous aspiration via open fontanelle
78
Management
Tension headache
1. Episodic: reassurance, address triggers, advice on avoinding meds that can cause medication-induced headaches;
2. simple analgesia (ibuprofen, paracetamol, aspirin);
3. Tricyclic antidepressants may be considered in frequently recurrent episodic tension headaches or chronic tension headaches
79
Management
Transient Ischaemic Attack
1. Acute neuro syx that resolve completely within 24hrs should be given 300 mg aspirin immediately and assessed urgently within 24hrs;
2. pts confirmed TIA: clopidogrel - 300mg loading dose and 75mg thereafter, high-intensity statin therapy (atorvastatin 20-80mg);
3. 2ry prevention: anti-platelets, anti-HTN, lipid-modifying tx, management of AF
4. Assessment of future stroke risk in TIA pts: ABCD2 score
80
Management
Giant cell arteritis
1. High dose oral prednisilone immediately to prevent visual loss;
2. reduce dose of prednisolone gradually;
3. many pts need to keep on maintenance dose of prednisolone for 1-2yrs;
4. low dose aspirin with PPIs and gastroprotection and reduces risk of visual loss, TIAs and stroke;
5. annual CXR for up to 10yrs to look for thoracic aortic aneurysms
81
Management
Polymyalgia Rheumatica
1. Corticosteroids;
2. steroid sparing agents sometimes;
3. assistance from PT/OT;
4. monitor for adverse effects of steroids
82
Management
Giant cell arteritis
1. High dose oral prednisilone immediately to prevent visual loss;
2. reduce dose of prednisolone gradually;
3. many pts need to keep on maintenance dose of prednisolone for 1-2yrs;
4. low dose aspirin with PPIs and gastroprotection and reduces risk of visual loss, TIAs and stroke;
5. annual CXR for up to 10yrs to look for thoracic aortic aneurysms
83
Management
Polymyalgia Rheumatica
1. Corticosteroids;
2. steroid sparing agents sometimes;
3. assistance from PT/OT;
4. monitor for adverse effects of steroids
84
Management
Macrocytic anaemia
1. Pernicious anaemia: IM hydroxycobalamin for life;
2. folate: oral folic acid, and if b12 def present, treated before folic acid def
85
Management
Microcytic anaemia
1. IDA: oral iron supplements;
2. sideroblastic anaemia: treat cause, pyridoxine in inherited forms, blood transfusion and iron chelation considered if no response
3. Lead poisoning: remove source, dimercaprol, D-penicillinamine
86
Management
Sickle cell disease
1. Acute (painful crises) -\> O2, IV fluids, strong analgesia (IV opiates), Abx;
2. Infection prophylaxis: penicillin V, regular vaccinations
3. Folic acid: severe haemolysis or in pregnancy
4. Hydroxyurea/carbamide: increases HbF levels, reduces the frequency and duration of sickle cell crisis
5. Red cell transfusion: for severe anaemia, repeated transfusions (with iron chelators), may be required in pts suffering from repeated crises
6. Advice: avoid precipitating factors, good hygeine and nutrition, genetic counselling, prenatal screening
7. Surgical: bone marrow transplantation; joint replacement in cases with avascular necrosis
87
Management
Alcohol withdrawal
1. **_Chlordiazepoxide_** - reduces syx of alcohol withdrawal
2. Barbiturates may be used if refractory to BZD
3. Thiamine prevents progression to wernicke-korsakoff syndrome
88
Management
Anaphylaxis
1. ABCDE;
2. high flow oxygen,
3. IM adrenaline,
4. chlorpheniramine (antihistamine),
5. hydrocortisone,
6. if continued resp deterioration,
7. may require bronchodilator therapy,
8. monitor pulse oximetry,
9. ECG,
10. BP
89
Managment
Benign breast disease
1. Conservative: symptomatic tx (analgesia for mastalgia), fibroadenoma may be treated conservatively
2. Surgery: removal or excision biopsy of a breast lump, wide local incision if any suspicion of the lump not being benign;
3. microdochectomy (surgical removal of a lactiferous duct - for Intraductal papilloma)
4. Hadfield's procedure (surgical removal of all lactiferous ducts under the nipple - used for duct ectasia
90
Management
Breast abscess
1. Medical: ABx - lactational: flucloxacillin;
2. non-lactational: flucloxacillin + metronidazole
3. Surgical: lactational: incision and drainage;
4. non-lactational: open drainage should be avoided, involved duct system should be excised once the infection has settled
91
Management
Abscess
1. Some small skin abscesses may disappear by themselves;
2. Incision and drainage: first check whether foreign object is causing the abscess;
3. abscess cut open and drained
4. ABx: alongside incision and drainage
92
Management
Cellulitis
1. Medical: oral penicillins or tetracyclines effective;
2. if hospital acquired -\> treat empirically based on local guidelines and change depending on the sensitivity of cultured organisms
3. Surgical: orbital decompression may be needed in orbital cellulitis (emergency)
4. Abscess: aspirate, incision and drainage, excised completely
93
Management
Infectious mononucleosis
1. Bed rest; paracetamol and NSAIDs for fever and malaise
2. Corticosteroids in severe cases
3. DON'T give amoxicillin/ampicillin if suspected as develop maculopapular rash
4. Advice: avoid contact sports for 2wks (rupture spleen)
94
Management
Varicella zoster
1. Chickenpox: children - tx syx;
2. adult: consider acyclovir
3. Shingles: aciclovir, valaciclovir, famciclovir
4. Prevention: VZIg - in immunosuppressed/pregnant
95
Management
dyslipidaemia
1. Lipid modification treatment for people with a 10-year CVD risk of 10% or greater (QRISK)
2. Inv: Lipid measurement, creatine kinase (if general muscle pain), LFTs, Renal function inc. eGFR, HbA1c, TSH
3. High intensity statin - atorvastatin and combined with lifestyle measures: increased exercise, reduced alcohol, cardioprotective diet
4. if contraindiated and 1ry hypercholesterolaemia then can consider ezetimibe
96
Managment
smoking cessation
1. NHS stop smoking services
2. Behavioural therapy, advice and support - pharm or non-pharm treatment
3. drugs: NRT, buproprion or varenicline; prescribe for 2wks, then review
4. High dependence: better to use 2 forms of NRT, like a patch and gum/inhaler/lozenge/nasal spray
