NICE Guidelines JMS Flashcards
(130 cards)
1
Q
fibroadenoma indication for surgery
A
> 3cm
2
Q
breast cyst treatment
A
Aspirate
If blood-stained, do a biopsy or excise
3
Q
sclerosis adenosis
A
biopsy + excision
4
Q
fat necrosis investigation
A
biopsy
5
Q
duct papilloma treatment
A
Microdochectomy
6
Q
Beast cancer screening programme
A
anyone aged 47-73 is invited for 3 yearly mammogram
given to younger patients if they have a first degree relative with:
- breast cancer <40
- bilateral breast cancer <50
- male breast cancer
7
Q
4 indications for wide local excision
A
small cancer large breast
DCIS <4cm
peripheral tumour
solitary lesion
8
Q
4 indications for mastectomy
A
Large cancer small breast
DCIS >4cm
central tumour
multifocal tumour
9
Q
indications for adjuvant radiotherapy in breast cancer
A
- mastectomy with >4 lymph nodes involved
- after any wide local excision
10
Q
treatment for ER+ tumours pre-menopausal & post-menopausal
A
tamoxifen for 5 years
anastrozole
11
Q
contraindication for herceptin
A
History of heart disorders
12
Q
management of angina
A
- aspirin, nitrate, statin for everyone
- CCB (no verapamil with heart failure) or beta blocker
- max dose
- CCB and BB (not verapamil and BB so use modified release nifedipine)
- PCI + other things like long acting nitrate, nicorandil (K activator)
13
Q
monitoring statins
A
LFTs at baseline, 3 month, 12 month
14
Q
investigating heart failure
A
- previous MI –> echo in 2 weeks
- no previous MI –> BNP. if normal, monitor. If elevated, echo in 6 weeks. If high, echo in 3 week.
15
Q
treating systolic heart failure
A
ACE or BB (pro or carv)
spironolactone, ARB, hydralazine/nitrate if black
cardiac resynchronisation/digoxin
others (furosemide + vaccines)
16
Q
hypertension management
A
ACEi or CCB
add other
add thiazide like (indapamine/chlorthalidone)
add spironolactone (if K >4.5 then add more thiazide)
alpha or BB
Centrally acting antihypertensives (methyldopa, monoxidine, clonidine)
17
Q
primary prevention statins
A
20mg use if: - >10% 10 yr risk - most type 1 diabetics - CKD with eGFR <60
18
Q
secondary prevention statins
A
80mg
use if:
- underlying IHD, PVD, Cerebrovascular disease
19
Q
Non ST-elevation ACS
A
M O N A (aspirin 300, clop 300) heparin 5 days GRACE (>3% 6 month mortality then use tirofiban and PCI in 96 hours)
20
Q
STEMI
A
M O N A aspirin 300, ticag 180 B A S H PCI
21
Q
acute LV failure
A
oxygen diuretics opiates vasodilators inotropic agents CPAP ultrafiltration mechanical circulatory assistance (VAD, IAC)
22
Q
CHADSVASC
A
CHF HTN A >75=2, >65=1 Diabetes Stroke/TIA = 2 V = PVD, MI, IHD Sc = female
0 = no treatment
1 in man = consider
1 in women = no treatment
=>2 = warfarin target INR 2.5 or NOAC
23
Q
INR target first VTE
recurrent VTE
A
- 5
3. 5
24
Q
foods to avoid on warfarin
A
sprouts, spinach, kale, brocolli
25
SVT
acute
prophylaxis
unstable --> DC cardio version
Stable
vagal manoeuvres
adenosine 6 12 12
DC cardio version
BB and ablation
26
HbA1c in diabetics
monitored every 6 months
| target of 48mmol/mol (6.5%)
27
blood glucose targets
4-7
| 5-7 first thing in morning
28
insulin
Basal-bolus is first line (levemir and actrapid)
| metformin can be used if BMI>25
29
driving and diabetes
inform if >=2 hypos in 12 months. no need to say if not on something that can induce hypos
30
T2DM first line treatment and target
metformin + lifestyle
| 48mmol/mol (6.5%)
31
when to add and what is T2DM second line treatment and target
if HbA1c >58mmol/mol (7.5%)
add one of any of the others apart from GLP-1 mimetic
53mmol/mol (7%)
32
third line treatment T2DM
a triple therapy
or insulin medium acting OD or BD (isophane)
or exanatide (GLP1 agonist)
33
thyrotoxicosis tremor control
propranolol
34
thyrotoxicosis first line drug
carbimazole
35
main SE of carbimazole
agranulocytosis
36
2nd line treatment for thyrotoxicosis
radioiodine treatment
37
treatment of hypothyroidism
thyroxine
38
starting dose of thyroxine
50-100micrograms (25 if elderly or IHD)
39
how often do you measure TFTs after starting or changing dose of thyroxine
8-12 weeks
40
therapeutic goal of thyroxine
normalisation of TSH
41
diagnostic criteria of DKA
glucose >11 or known DM
ketones >3 or ++ on urine
pH <7.3
bicarb <15
42
treatment of DKA
1000ml of saline in first hour (will need 5-8L over 24hrs)
| IV insulin and when glucose gets <15 add dextrose
43
treatment of gastroparesis in diabetes
metoclopromide
44
BPPV diagnosis
clinical picture + positive Dix hallpike
45
BPPV treatment
epley
home Brandt-Daroff exercises
betahistine?
46
menieres acute attack
buccal or IM prochlorperazine
47
prevention of menieres
betahistine
| vestibular rehab
48
driving and menieres
don't until controlled
49
PUD treatment
1st line = PPI + amox + clarithromycin (7day course)
retest for H.pylori 4 weeks later using C13 breath test
2nd line = PPI + BC + met + tetracycline
retest
repeat 2nd line
retest
refer
50
criteria for emergency upper GI endoscopy
```
Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Malaena/haematemesis
Swallowing difficulty
```
51
management of diverticular disease - general
fibre
52
management of diverticular disease - mild attacks
conservative with antibiotics
53
Severity classification of diverticulitis and management based on that
```
Hinchey
1 = paraboloni abscess --> drain
2 = pelvic abscess --> drain
3 = purulent perforation --> Hartmanns or lap washout
4 = faeculent perforation --> Hartmanns
```
54
CRC monitoring
carcinoembryonic antigen
55
screening programme for CRC
60-74 (50-74 in scotland) is invited for faecal occult blood
if positive, get colonoscopy
of these, 5/10 are normal, 4/10 have polyps, 1/10 has cancer
56
asymptomatic gallstone disease
in gallbladder
in CBD
no treatment
| remove as will cause problems
57
acute cholecystitis
Antibiotics + supportive therapy
| resect 1 week later
58
Upper GI bleeding
```
Blatchford = bleeding risk stratification
Rockall = rebleed
```
59
fissure in ano
GTN ointment or diltiazem cream
botulinum toxin
internal spinchterotomy
60
haemorrhoids
lifestyle fibre and fluids
| injection sclerotherapy/band ligation/HALO
61
rectal cancer
high up
near dentate line
preop radiotherapy + surgery:
anterior resection
abdominoperineal resection of rectum
62
acute pancreatitis grading
```
Glasgow
PAO2 <8
Aage >55
Neutrophils WBC >15
Calcium
Renal function urea
Enzymes LDH >600; AST >200
Albumin
Sugar >10
```
3 or more of the above means it is severe
63
imaging of choice for chronic pancreatitis
CT pancreas with contrast
64
Intestinal obstruction
Drip and suck
cyclizine or ondansetron can be used
NOT metoclopromide as it is prokinetic
65
when to start antiepileptics
2 seizures >24 hours apart
1 seizure + >60% risk of another one
epilepsy syndrome in a child
risk of another seizure is unacceptable
66
generalised tonic clonic
sodium valproate
67
myoclonic
sodium valproate
68
focal seizure
carbamazepine
69
absence seizure
ethosuximide
70
pregnancy
lamotrigine
71
parkinsons
```
motor? levodopa
No motor?
- non-ergot derived dopamine agonists (bromocriptine, cabergiline, pergolide)
- MAO-B (seleginine)
- levodopa
```
2nd line
- COMT inhibitor (entacapone)
72
drug induced parkinson's
procyclidine (antimuscarinic)
73
diagnosing MS
2 episodes in space and time
OR
1 episode that fulfils McDonald criteria
74
acute MS
methypred
75
chronic management of MS
1st line = beta interferon
2nd line = choose from:
- glatiramer = immune decoy/suppressant
- natalizumab = a4b1 preventing BBB crossing of WBC
- alemtuzumab = glycoprotein CD52
- fingolimod = sphingosine 1 phosphate stops leaving lymph nodes
76
MS symptoms relief: residual volume bladder dysfunction
self catheterisation
77
MS symptoms relief: bladder dysfunction with no residual
anticholinergics oxybutinin
78
MS symptoms relief: oscilloscopia
gabapentin
79
spasticity
baclofen or gabapentin
80
fatigue
CBT or amantadine
81
stroke diagnosis
ROSIER score >0
- syncope = -1
- seizure = -1
- asymmetrical face/arm/leg = +1 each
- speech/visual field disturbance = +1 each
82
stroke investigation
CT head
| swallowing assessment
83
ischaemic stroke acute treatment
within 4.5 hours --> alteplase
| 300mg aspirin stat
84
CI of thrombolysis
```
>4.5 hours
brain cancer
recent stroke
seizure with stroke
active bleeding
pregnancy
varices
hypertension >200
```
85
secondary prevention of stroke
in hospital
at home
intermittent pneumatic calf pump
statin if >3.5
clopidogrel 75mg for life (After 2 weeks) - if CI use aspirin and dipyridamole
BP control
86
haemoragic stroke treatment
control BP to 100-120
reverse anticoagulation
call neurosurgeons
87
alzheimers management
triple therapy of anticholinesterases (donepezil, galantamine, rivastigmine)
2nd line = memantine (NMDA antagonist)
88
TIA (in past week)
300mg aspirin stat
| send in to hospital
89
delerium
haloperidol is first line sedative
90
status epilepticus
rectal diazepam/IV loraz/buccal midaz
IV loraz
phenytoin
anaesthesia
91
subarachnoid haemorage
ABCDE + neurosurgery review
After:
- nimodipine CCB (reduces deficits)
- stools softness, antitussives (reduces rebreeds)
92
acute migraine
triptan
93
migraine prophylaxis
2 or more over 1 month (60% effective)
```
1st = propranolol + topiromate
2nd = gabapentin + acupuncture (10 sesh/5-8wks)
```
menstrual = triptans
94
renal stones imaging
```
Initial = USS
Best = CTKUB no contrast
```
95
medical management of urinary stones
IM/rectal diclofenac
| tamsulosin + nifedipine
96
indication for medical management of stones
<5mm and no obstruction
97
indication for ECSL
5mm-2cm
98
indication for percutaneous nephrolithotomy
>2cm or complex shape (e.g. staghorn)
99
indication for decompression with stent or percutanoues nephrostomy
hydronephrosis or pyrexia
100
prevention of stones:
calcium
oxalate
urate
thiazides
cholestyramine
allopurinol/urinary alkalisation (bicarb(
101
BPH
1st line = tamsulosin
| 2nd line = finasteride (takes 6 months)
102
prostate cancer
T1/T2
T3/T4
Metastatic
- brachy, radio, surgery
- + hormonal therapy
- only hormonal therapy:
cyproterone acetate (prevents DHT/antiandrogen)
goserelin (GnRH analogue)
degarelix (gnRH antagonist)
103
CKD management of anaemia
replenish iron stores
| give EPO
104
CKD and HTN
ACEi
| when GFR <45, furosemide
105
AKI diagnostic guidelines
<0.5ml/kg/hr for more than 6 hours
GFR 50% rise in 7 days
rise in creatinine >26 in 48 hours
106
hyperkalaemia management
1st thing = calcium gluconate
others = insulin+dextrose, salbutamol
to get rid of K = resonium, dialysis
107
diagnosing asthma
FeNO >40ppb
spirometer FEV1/FVC <70%
reversibility of FEV1 >12%
108
chronic management of asthma
```
SABA
+ ICS
+ LTRA
+ LABA
+ increase ICS in a MART
+ increase ICS and add theophylline
refer onwards
```
Move up if using SABA 3x or more a week
109
COPD diagnosis
FEV1/FVC <70% and symptoms
110
Management of COPD
```
SABA or SAMA
Add LAMA or LABA (if FEV1 <50%, add ICS to LABA)
Add all three
theophylline
mucolytics
```
111
indications for home use oxygen
```
ankle oedema
two ABGs with pO2 <7.3
FEV1 <30%
cyanosis
polycythaemia
raised JVP
Sats of less than 92% on room air
```
112
investigating legionella
| psittacosis
urinary antigen
| sputum PCR
113
Assessment of pneumonia
```
Confusion <8/10 AMTS
Urea >7
RR >30
BP <90/60
<65
```
```
0-1 = home with 5 days of amox (3%)
2-3 = hospital with amox/clari 7 days (3-15%)
4-5 = ITU with tazocin (15%)
```
114
recovery timeline for pneumonia
1 week = fever
4 weeks = chest pain + sputum
6 weeks = cough + breathlessness
6 months = fatigue
115
acute asthma management
```
Oxygen
Salbutamol back to back through oxygen neb
Hydrocortisone/ pred for at least 5 days
Ipratropium bromide just once
Magnesium
IV salbutamol
Escalate
```
116
acute asthma severity
moderate = 50-75% peak flow
acute severe = 33-50% Peak flow, can't complete sentences. RR>25, pulse >110.
life-threatening = <33% peak flow, <92% sats, cyanosis, silent chest, normal CO2
117
COPD exacerbation when to give Abx
Anthsonian criteria. give Abx when 2 of:
- increased sptutum
- increased purulence
- increased breathlessness
118
target sats for COPD
88-92
| if proven to not be CO2 retainer, 94-98
119
indications for BIPAP with COPD
acidosis <7.35
type 2 respiratory failure
unresponsive to CPAP with cardiogenic pulmonary oedema
weaning from tracheal intubation
120
pneumothorax management
primary
<2cm --> review in clinic
>2cm or breathless --> aspirate, wait, clinic or drain
secondary
1-2cm aspirate and then maybe drain
>2cm drain and admit
121
Wells score
diagnosing PE
```
DVT = 3 points
PE most likely = 3 points
HR>100 = 1.5 points
surgery <3wks, immobilisation>3days = 1.5 points
previous DVT/PE = 1.5 points
haemolytic = 1 point
malignancy = 1 point
```
For PE
If <4 --> D-dimer and PERC
if >4 --> CTPA
For DVT
>=1 you doppler the leg
0 then you do D-dimer
If pregnant, allergic or CKD, V/Q scan instead of CTPA
122
treating PE
massive with shock --> thombolysis
```
no shock:
5 days of LMWH
start warfarin within 24 hours
3 months if provoked, 6 months if unprovoked
INR 2.5 if first, 3.5 if recurrent
```
pregnant or cancer --> LMWH for 6 months
123
post thrombotic syndrome treatment
compression stocking and elevation
| no prophylaxis anymore
124
treatment for peripheral artery disease
exercise training
80mg statin
clopidogreal (better than aspirin)
other: vasodilator, angioplasty, stent, bypass
125
AAA surgery indications
>5.5cm
>1cm/year growth
pain
EVAR is surgery of choice
126
venous ulcers treatment
4 layer compression banding
| if fail to heal after 12 weeks, skin graft
127
screening for osteoporosis
women >65, men >75 use FRAX
if low risk --> nothing
if high risk --> treat (alendronate and vita/Ca
if medium --> DEXA and recalculate
128
rate control
atenolol
verapamil/diltiazem
digoxin (unless HF then first line)
129
rhythm control
DC cardio version if there isn't a reason they're in AF
sotalol
amiodarone
flecanaide (is paroxysmal and normal heart)
130
complete heart block
temporary pacing until surgery puts pacemaker in
atropine can be used until then.
0.5mg up to 6 times up to 3mg
