PACES Exams Management

Question 1

Management of Cystic Fibrosis

Answer 1

Managed under the CF MDT…

Conservative:
 Chest physiotherapy & education
 Vaccinations
 Enzyme replacement
 Family planning counselling (in males)
Medical:
 ABx prophylaxis: Flucloxacillin
 Mucolytic: rhDNase or Mannitol dry powder
Surgical:
 Lung transplantation

Question 2

Complications of Cystic Fibrosis

Answer 2

 Recurrent & chronic pulmonary infections:
P.aeruginosa, Burkholderia, Haemophilus, Aspergillus.
 Nutritional deficiency (failure to thrive)
 Endocrine: Diabetes Mellitus (insulin dependent), Osteoporosis, Infertility

Question 3

Chronic Management of COPD

Answer 3

Conservative
 Smoking cessation
 Vaccinations
 Pulmonary Rehabilitation (MRC dyspnoea 3+)

Medical
Nebulisers:
 1st: a short acting inhaler (SABA or SAMA)
 2nd: a) switch to long acting (LABA + LAMA)
b) if asthma/reversible features (LABA + ICS)
 3rd: trial of all three (LABA + LAMA + ICS)

If still regular exacerbations/impaired mucus clearance – prophylactic azithromycin

Consider LTOT

Surgical
 Lung volume reduction surgery

Question 4

Indications for LTOT in COPD

Answer 4

Assessed via multiple ABGs
 PaO2 <7.3
OR
 PaO2 <8.0 + any of the following:
 Polycythaemia
 Pulmonary HTN
 Peripheral oedema

Note: No LTOT if still smoking

Question 5

Acute COPD management

Answer 5

Conservative
 Titrate oxygen between 88-92% using venturi
 Regular ABG monitoring

Medical
 Infection: qSOFA and Sepsis 6. Abx therapy
 Inflammation:
o SABA – 5mg Salbutamol nebulised
o SAMA – 0.5 micrograms Ipratropium bromide nebulised
o 30mg prednisolone for 5 days + nebulisers
 Ventilation: BiPAP -> intubation

Note: common bacterial cause is Haemophilus influenzae.

Question 6

What classification system is used for COPD?

Answer 6

GOLD classification: Based on FEV1 as a % of predicted value for individual…

20, 30, 20 30 (interval sizes)

Stage 1: >80%
Stage 2: 79-50%
Stage 3: 49-30%
Stage 4: <30%

Question 7

What are the levels of the MRC dyspnoea scale and what does it describe?

Answer 7

Symptomatic severity of dyspnoea (chronically)
1: Sports
2: Steep hill
3: slower
4: stop after 100m
5: stays at home (breathless on undressing etc.)

Question 8

What classifcation is used to determine severity in heart failure?

Answer 8

NYHA:
I. No symptoms
II. Ordinary activity causes dyspnoea
III. Sub-ordinary causes dyspnoea
IV. Dyspnoea at rest

Note: this is a functional assessment

Question 9

What is the difference between a Pacemaker and an ICD?

Answer 9

An ICD is an Implanatable cardioverter defibrillator.

ICDs are installed to recognise tachyarrhthymias and shock the patient (without warning).

Pacemakers act as surrogate SANs. They maintain a heartbeat they do not stop it.

Question 10

What are the types of Pacemaker?

Answer 10

Temporary
 Percutaneous (by defibrillator)
 Transvenous (by cardio)
 Epicardial (by cardiothoracics)

Permanent
 Single Chamber (RA or RV)
 Dual Chamber (RA + RV)
 Biventricular (RA + RV + LV)

Question 11

What are some indications for Pacing?

Answer 11

Temporary:
 Bradycardia unresponsive to Atropine
 Post-MI (anterior) complications

Permanent:
 Sick Sinus syndrome*
 AF
 Heart Block (including trifascicular block)

*SAN dysfunction leading to tachy and brady spells

Question 12

What are some potential complications of Pacemaker insertion?

Answer 12

Immediate
 Bleeding
 Pneumothorax/haemothorax

Early
 Infection: endocarditis & sepsis
 Insertion site infection
 VTE

Late
 Wire displacement (pacing failure)
 Device malfunction & Twiddler’s syndrome (fiddling with it)

Question 13

Management of Pulmonary oedema

Answer 13

Conservative:
 Sit them upright
 15L non rebreathe and titrate <94%
 Fluid balance review
 Monitor Weight & renal function

Medical:
 Diuretics: Furosemide 40mg IV infusion

Question 14

Management of Chronic Heart failure

Answer 14

Heart failure treatment is carried out by the MDT including specialist cardiac failure nurses.

Conservative
 Monitor exercise tolerance.
 Smoking & alcohol cessation
 Cardiac rehabilitation: Exercise and weight loss
 Vaccination: Annual influenza + one off pneumococcal

Medical
 Prognostic benefit: 1st: ACEi + Beta Blocker, 2nd: Spironolactone
 Symptom relief: Diuretics

Surgical
 Heart transplant

Note: 3rd line is specialist: Entresto is used if <35% Ejection Fraction

Question 15

Management of Acute Asthma

Answer 15

Conservative
 Peak flow + ABG
 15L Oxygen via Non-rebreathe mask to maintain >94%

Medical:
 1st: 5mg nebulised Salbutamol + 40mg Prednisolone PO for 5 days
 2nd: 0.5mg nebulised Ipratropium (4 hourly)
 3rd: 2g Mg Sulphate IV (SENIOR)

Question 16

Diagnostic criteria of asthma in adults

Answer 16

 PEF variability >20%
 FEV1 >12% / 200ml
 FeNO > 40 ppb

Question 17

Grading of acute asthma severity

Answer 17

Moderate >50%
Severe >33% Tachyp, Tachyc + cannot complete sentence
Life threatening <33% SpO2 <92%, Silent chest, Hypotensive
Near fatal Raised PaCO2

Question 18

Chronic Asthma management in Adults

Answer 18

Conservative
 Personalised Asthma action plan (check inhaler technique)
 Trigger avoidance (vacuum cleaning, mattress covers)
 Breathing exercise programmes
 Weight loss

Medical
 1st: SABA + low ICS
 2nd: LABA + low ICS
 3rd: LABA + low ICS + LTRA
 4th: Conversion to MART (+/- LTRA)
 5th: MART with Medium ICS dose (+/- LTRA)
 6th: MART with High ICS dose or add LAMA or REFER
Note: from 5th step – can continue with MART as shown or revert back to separate drugs i.e. LABA and ICS inhalers.

Question 19

Management of pulmonary fibrosis

Answer 19

Conservative:
 Smoking cessation
 LTOT
 Pulmonary rehabilitation
Medical
 None
Surgical
 Lung transplantation

Question 20

Antibiotic therapy of HAP

Answer 20

 <5 days of admission = cefuroxime
 >5 days of admission = Piperacillin with Tazobactam

Question 21

Causes of AF

Answer 21

Reversible
 Intrinsic Cardiac: pericarditis, myocarditis, MI, WPW, cardiac surgery
 Intrinsic Respiratory: PE, pneumonia.
 Extrinsic: Hyperthyroidism, alcohol, caffeine, iatrogenic

Irreversible
 Structural: heart failure, HOCM.
 Valvular: Mitral valve disease
 Ischaemic: IHD

Question 22

Acute management of AF

Answer 22

<2 days since onset:
 Rhythm control: DC cardioversion -> Flecainide (not in IHD) -> Amiodarone
>2 days since onset:
 Rate control: Beta blockers (if contra- diltiazem), Amiodarone can be used in paroxysmal AF

Note: catheter ablation +/- pacemaker can also be considered in Slow AF

Question 23

Long term management of AF

Answer 23

If reversible, treat cause.
Conservative
 Optimise stroke/IHD risk factors. D&E

Medical
 Anticoagulation: DOAC, Warfarin
 Bisoprolol for rate control
 Flecainide* (if paroxysmal AF, no other co-morbidities)

Surgical (invasive)
 Catheter Ablation
 Pacemaker insertion

Question 24

Management of Parkinson’s

Answer 24

PD treatment is principally governed by a consultant neurologist but executed by the MDT.

Conservative
 Patient education
 Care plan discussed early for progression
 Vaccinations
 Physiotherapy: improve walking ability (posture & muscle strength)
 OT: home modification including coloured floor and lasers (to stop freezing)
 SALT referral (swallowing, talking, drooling)
 Diet advice: less protein near medication times, VITAMIN D & CALCIUM
 Mental health monitoring
Medical
 MAO-B inhibitors (selegiline) = Mild
 Dopamine agonists (ropinirole) = Moderate
 Levodopa & carbidopa (madopar) = severe
Surgical
 Deep brain stimulation (severe disease)

Question 25

Complications of Parkinson's

Answer 25

 GI: eating, swallowing, constipation + urinary incontinence  MSK: Mobility, postural hypotension, falls risk  Psych: Depression, Dementia, sleep difficulty, sexual dysfunction,

Question 26

How can ischaemic stroke be classified?

Answer 26

Oxford-Bamford: TACS (all 3) or PACS (2 of 3)  Unilateral weakness/sensory deficit of face, arm and leg  Homonymous hemianopia  Higher cerebral dysfunction POCS (just posterior circulation syndrome – no partial. One of below:)  CN palsy + contralateral S/M deficit  Conjugate eye movement disorder (both eyes in same direction)  Cerebellar dysfunction  Isolated homonymous hemianopia LACS (one of:)  Pure Sensory  Pure Motor  Sensory/motor stroke (no other features)  Ataxic Hemiparesis

Question 27

Acute management of a confirmed Ischaemic stroke

Answer 27

Conservative  Senior clinician involvement  Urgent Referral to hyper acute stroke unit Medical  300mg Aspirin  If <4.5 hours: Thrombolysis – Alteplase or Streptokinase (BP <185/110) Surgical  If <6 hours: Mechanical Thrombectomy* (additionally)  If <24 hours: Mechanical Thrombectomy* There is a 1/25 chance of haemorrhagic transformation after thrombolysis. *Mechanical thrombectomy is used for proximal anterior/posterior circulation strokes. Generally reserved for severe strokes (NIHSS 5+) in patients with a good baseline.

Question 28

Chronic management of an Ischaemic Stroke

Answer 28

Conservative  Transfer to stroke rehabilitation unit  Physiotherapy  SALT assessment  Occupational therapy (to review any needed home changes etc.)  Consider package of care  Secondary prevention via risk factor modification… Medical: secondary prevention  Aspirin 300mg for 2 weeks  Clopidogrel monotherapy 75mg for life  High dose Statin Surgical  Carotid endarterectomy

Question 29

What can be used to grade the severity of an acute stroke?

Answer 29

NIH Stroke Score. It correlates to prognosis.

Question 30

Risk factors for Ischaemic stroke

Answer 30

Non-modifiable:  FH  Ethnic origin (south east Asian & afro-Caribbean) Modifiable:  Atrial fibrillation  Diabetes (& obesity)  Hypercholesterolaemia  Smoking  Alcohol

Question 31

Risk factors for haemorrhagic stroke

Answer 31

VASC'D:  Vascular anomaly (Aneurysmal disease, AVM or cavernous angioma)  Amyloid angiopathy  Small vessel disease – HYPERTENSION.  Coagulopathy + Drugs: cocaine, alcohol, smoking. Note: Haemorrhagic transformation can also occur in ischaemic strokes

Question 32

Acute management of haemorrhagic stroke

Answer 32

Conservative  Sit upright as possible (reduce ICP)  Regular neuro-observations  Senior clinician involvement  Immediate referral to Neurosurgery  Consider anticoagulation reversal if on anticoagulant. Medical  Blood pressure: aim for 130 to 140 SBP. Surgical  Burr Hole  Craniotomy  Specific cause: aneurysm coiling, AVM removal.

Question 33

Acute management of UC flare

Answer 33

Conservative  If Severe, admit. Medical: Mild  1st: Topical Aminosalicylate (proctitis) e.g. sulfasalazine  2nd: + High dose PO aminosalicylate (if extensive) Severe  1st: IV steroids  2nd: IV ciclosporin  3rd: Infliximab Note: Toxic Megacolon can develop – which might need a life-saving Colectomy.

Question 34

Chronic UC management

Answer 34

Conservative  Diet: smaller meals, fluids, supplements + food diary  Osteoporosis monitoring  Bowel cancer screening (10 years after diagnosis) Medical  Aminosalicylates (topical or PO)  Azathioprine PO  Biologics: infliximab Surgical  Total colectomy with permanent Ileostomy  Total colectomy with Ileoanal pouch anastomosis

Question 35

Management of an Acute Crohn's flare

Answer 35

Conservative  Admit Medical  1st: Corticosteroids +/- Azathioprine / methotrexate  2nd: Budesonide +/- Azathioprine / methotrexate  3rd: Aminosalyclates +/- Azathioprine / methotrexate Note: if in bowel obstruction, manage accordingly.

Question 36

Long term management of Crohn's

Answer 36

Conservative  Smoking cessation  Referral to an IBD nurse specialist  Surveillance colonoscopy for bowel cancer (after 10 years)  Monitoring for osteoporosis medical  1st: azathioprine  2nd: Methotrexate  3rd: Biologic drugs Surgical  Ileo-caecal resection  Colectomy (various forms)  Strictuloplasty

Question 37

Complications of IBD

Answer 37

Systemic  Eyes: Episcleritis, anterior uveitis  Skin: Erythema nodosum, Pyoderma gangranosum, Apthous ulcers  Joints: enteropathy associated arthritis, osteoporosis  Constitutional: weight loss, faltering (in paediatric patients) Gastro-intestinal  Nutritional deficiency: B12, folate, iron, vitamin D  Colorectal Cancer, (PSC)  Bowel obstruction  Fistulae  Strictures  Anal fissures

Question 38

Management of acute pancreatitis

Answer 38

Conservative  Fluids (monitor urine output)  Anti-emetics: consider NBM  Electrolyte monitoring (hypoglycaemia, hypocalcaemia)  Critical care outreach Medical  Analgesia (opiod)  Enteral nutrition (NG feeding)  Chlordiazepoxide & Pabrinex Invasive  Cholecystectomy (if due to gallstones)  ECRP (if due to biliary obstruction)  Pancreatic necrosectomy* (for infected necrosis)

Question 39

Complications of acute pancreatitis

Answer 39

 Local: Pseudocyst*, Abscess, Haemorrhagic pancreatitis  Systemic: hypovolaemic shock, hypoglycaemia, hypocalcaemia

Question 40

Complications of Chronic pancreatitis

Answer 40

 Endocrine failure: T1DM  Exocrine failure: malabsorption, mineral deficiencies (osteoporosis) + Pancreatic pseudocyst (again)

Question 41

How is an ectopic pregnancy managed and what are the indications for each option?

Answer 41

Expectant  Stable + pain free + tubal ectopic <35mm + no FHB + Serum hCG <1000 + will follow up.  Consider if <1500 hCG Treatment…  Repeat serum hCGs on Day, 2, 4, 7 (think: 24/7) after first test  Education Medical  No significant pain + tubal ectopic unruptured >35mm + no FHB + <1500 + will return to follow up  Consider if 5000 > x < 1500  Note: must have no confirmed intrauterine pregnancy Treatment…  IM Methotrexate  Repeat serum hCGs (4, 7 + weekly until negative) + FBC & LFTs on day 7.  Education (no pregnancies for next 3 months) Surgical (any)  Significant pain  >35 mm  FHB visible  >5000 serum hCG Treatment…  Laparoscopic > open  1st: Salpingectomy  2nd: Salpingotomy IF infertility risk factors  IF RHESUS NEGATIVE: 250IU (no kleihauer)  Education  Advise to take urine pregnancy test after 3 weeks

Question 42

Management of Multiple Sclerosis

Answer 42

MS treatment is guided by a consultant neurologist and carried out by the MDT. Conservative  Smoking cessation  Patient Education: referral to MS specialist Nurse  Symptom control: Sleep hygiene, CBT, Intermittent self catheterisation  PT/OT  SALT referral Medical  Symptom control: Baclofen (anti-spasmodic), amitriptyline, Oxybutynin  Disease modifying drugs: Beta-interferon (specific criteria)

Question 43

Complications of Multiple Sclerosis

Answer 43

 Immobility & fatigue  Swallowing & Speech difficulties  Incontinence  Driving: need to inform DVLA

Question 44

Describe the general management of Osteoarthritis

Answer 44

Conservative  Weight loss: diet & exercise  Physiotherapy  Occupational therapy  Walking aids & orthotics  Adjunctive alternative medicine – if all else fails Medical  Analgesia… I. Paracetamol + topical NSAIDs II. Oral NSAIDs or opioids (codeine)  Intra-articular steroid injections  Intra-articular hyaluronic acid injections Surgical  Joint washout & debridement  Corrective Osteotomy  Arthroplasty  Arthrodesis  Amputation (small joints)

Question 45

Complications of Hip/Knee athroplasty

Answer 45

Local… Immediate  Intra-operative fracture  If cement: Cement reaction  Nerve injury* Early  Wound infection  Joint infection Late  Aseptic loosening  Prosthetic infection & loosening  Stress fractures  Dislocation Systemic…. Immediate  Anaesthetic complications: tooth damage, malignant hyperthermia, allergic reaction  Fat embolism syndrome  Bleeding/anaemia Early  PE/DVT  Sepsis  Ileus  Deconditioning Late  Leg length discrepancy

Question 46

How is Rheumatoid Arthritis diagnosed?

Answer 46

Using the EULAR criteria: EULAR criteria >6 points  Joint involvement number  Antibodies  Acute Markers  Symptoms >6 weeks

Question 47

Describe the management of RhA

Answer 47

Conservative  Monitoring via DAS 28 (<2.6 is remission) + Osteoporosis risk assessment  FBC & LFTs monitoring  PT/OT assessment  Analgesia: NSAIDs (in early disease) Medical  DMARD monotherapy: methotrexate, sulfasalazine, hydroxychloroquine + Steroids: intra-articular depots  DMARD dual therapy  Biologic agents (if DAS >5.1 despite 2 DMARDs) Note: Methotrexate should not be taken during illness. Steroids can be used to ‘bridge’ the latent effect of DMARDs when starting therapy.

Question 48

How is Ankylosing Spondylitis diagnosed?

Answer 48

New York: 1 feature + Radiographic Sacroilitis  >3 months back pain  Limited limber spine movement  Reduced chest expansion

Question 49

How is Ankylosing spondylitis managed

Answer 49

Conservative  BASDAI & Spinal pain VAS (>4/10 = high disease activity)  1st: Analgesia (NSAIDs)  Physiotherapy Medical  Axial: TNF alpha antagonists e.g. Infliximab  Peripheral: DMARDs

Question 50

What are some complications of ankylosing spondylitis?

Answer 50

 Atlanto-axial subluxation  Apical fibrosis  Aortic regurgitation  Achilles Tendonitis  AV node block  IgA Nephropathy  Amyloidosis  CaudA EquinA