Scoring systems

Question 1

Manage an acute MI and post MI

Answer 1

Slow IV morphine 5mg (PLUS 10mg slow IV metochlopramide for anti-emetic)
Oxygen if sats <94
Aspirin 300mg chewable
Clopidogrel 300mg PO
PCI if available, must be within 120mins of when thrombolyis (alteplase + LMWH) could have been given

Post-MI: 
Dual anti platelet therapy (e.g. aspirin 75mg OD + ticagrelor 90mg BD 12/12) 
Statins 
ACEi
Beta blocker 
Lifestyle- smoking cessation, exercise,

Question 2

Manage AF (acute and chronic)

Answer 2

Acute:
1. treat underlying condition (e.g. pneumonia, sepsis, MI, hypertension, hyperthyroidism, IHD, valvular heart disease)
2. Normally rate control:
Rate control- beta blocker or CCB
If haemodynamically unstable may need DC cardioversion in ITU, or if AF >48hrs
3. Assess stroke risk (CHA2DS2VASC) and risk of bleeding with anticoagulation (HAS-BLED inc. HTN, stroke, abnormal liver/renal function, alcohol)
4. Prophylactic heparin

Chronic:
Beta blockers/CCBs PLUS warfarin/apixaban to reduce VTE risk

Question 3

Manage heart failure (acute and chronic)

Answer 3

Fluid restriction and IV furosemide

Longer term ACEi and beta blockers reduce mortality
Give pneumococcal and influenza vaccinations
Smoking cessation

Question 4

Manage infective endocarditis

Answer 4

Normally gentamicin + amoxicillin IV for 4-6wks if native valves
Prosthetic valves for 6wks
(often viridans streptococci, or staph aureus if IVDU)

Needs ECG, TTE (trans thoracic echocardiography)
Blood cultures x3 from 3 separate sites
If decompensated HF and severe sepsis then needs surgery

Question 5

Anti-hypertensive drugs and their side effects

Answer 5

ACEi- dry cough
Beta blockers- bronchospasm, coldness of extremities
CCBs- vasodilation –> flushing, headache

Question 6

Manage hypoglycemia

Answer 6

ABCDE approach
Insert 2 wide bore cannulas
CBG every 10 mins until >4mmol/L
ECG
Stat glucose 10g PO (orange juice/glucose gel)
If unconscious give 1mg glucagon IM once only
If not effective in 10 mins give 100ml IV glucose 20%
Follow with long acting carbohydrate 20g (e.g. two biscuits) or 40g if glucagon was given

DVLA: if >1 episode of severe hypoglycaemia in 12 months no driving
Must check BM <2hrs pre driving and every 2 hours whilst driving if insulin treated

Question 7

Manage DKA

Answer 7

Hyperglycemic, acidotic, ketotic
Average fluid deficit of 6L

IV fluids 0.9% NaCl, 1st litre over 1 hr
Include KCl with fluids unless anuric
IV insulin at fixed rate 0.1units/kg/hour at 1unit/1ml
VTE

ICU if haemodynamic instability

Once stable (ketones <0.6 and pH >7.3) can either change to normal SC insulin regimen or VRIII and dextrose-saline infusion if unable to eat

Question 8

Manage HHS

Answer 8

Hyperosmolar hyperglycaemic state.

Give IV 0.9% NaCl, 1L in first hour
Add KCl 40mmol/L if K is normal (insulin drives K into cells)
Glucose will fall with hydration, but insulin if it doesn’t (fixed rate of 0.05 unit/kg/hr)
DVT prophylaxis (stroke, MI, PE, DIC risk from hypovolemia with increased viscosity)
Stop fixed rate insulin when blood ketones <0.3 and cap glucose <15mmol/L

Then if eating and drinking return to normal SC regimen
If not, start VRIII

Do urinalysis, CRP, WCC because 30-60% of HHS is due to infection. Note also cortisol inhibits insulin.

Question 9

Meds for diabetes

Answer 9

Bigunide e.g. Metformin. Inhibits hepatic gluconeogenesis to overcome insulin resistance

DDP4 inhibitors e.g. linagliptin- destroy the hormone incretin, which increases insulin

Sulfonylureas e.g. gliclazide which squeezes all the insulin out of the pancreas

Question 10

Meds for diabetes

Answer 10

Biguanide e.g. Metformin. Inhibits hepatic gluconeogenesis to overcome insulin resistance

DDP4 inhibitors e.g. linagliptin- inhibits DDP4, which normally inhibits incretin, which increases insulin

GLP1 analogues e.g. exenatide which increase incretins
(increasing tide)

Sulfonylureas e.g. gliclazide which squeezes all the insulin out of the pancreas
(zide, zesty, squeezing)

SGLT2 inhibitors e.g. dapagliflozin which reduces glucose absorbed in kidneys so more is excreted
(flo out)

Question 11

Education programmes for T1DM and T2DM

Answer 11

DAFNE for T1

DESMOND for T2

Question 12

Manage a diabetic foot ulcer

Answer 12

ABPI, Doppler, foot XR for osteomyelitis
Clean ulcer with saline then dry and dress (low-adherent)
High compression multi-layer bandaging but not if infected
Offloading footwear to minimise repetitive trauma

Features suggestive of osteomyelitis: depth >3mm, probe to bone test (probe ulcer with sterile blunt probe and see if reaches bone)

Neuropathic arthropathy = Charcot joint. Bone and joint changes secondary to loss of sensation from DM, syphilis, leprosy. Includes destruction of articular surfaces, opaque subchondral bones, joint debris, deformity, and dislocation

Question 13

Which diabetes meds should be used with caution for CKD 3-5?

Answer 13

Metformin (risk of lactic acidosis) avoid if eGFR <30
DDP-4 (renally excreted) e.g. saxagliptin decrease dose if <60
SGLT-2 inhibitors e.g. dapaglifozin <60 avoid use

Question 14

Manage a patient who has suddenly stopped long term prednisolone for RA

Answer 14

IV fluids 0.9% NaCl 1L rapidly

IV hydrocortisone

Question 15

Manage acute hyponatremia (has just run a triathlon)

Answer 15

IV 3% NaCl (if less than 48hrs onset) 2-4ml/kg

(beware central pontine myelinolysis if corrected too quickly. Sudden water moving out of cells destroys myelin)

If has developed <48hrs has risk of cerebral oedema

Question 16

Name 4 complications of hypernatremia and proposed management of hypernatremia

Answer 16

1. ECG changes- prolonged QT
2. Muscle weakness/cramps/rhabdomyolysis –> renal failure
3. Brain cell shrinkage –> vascular rupture/intracerebral haemorrhage
4. Myelinolysis also possible (but more common in rapid correction of hyponatremia)

Correct with IV Hartmann’s
Risk of too rapid correction is cerebral oedema (the opposite to hypo)

Question 17

Patient following recent thyroidectomy presents with numbness/tingling around mouth and in hands, wrists are is spasm, and difficulty breathing with laryngeal spasm. What will you do?

Answer 17

So parathyroid glands have been damaged in thyroidectomy, meaning they do not release PTH to increase Ca absorption/levels. She is hypocalcemic.

Do ECG (cardiac hyperexcitability)
Check Mg (can't fix Ca if Mg low) 
Give IV calcium gluconate 10ml slow IV 10% in 50ml 5% glucose

PT glands often recover in 6-8wks. If not, can give levothyroxine, Ca +/- vit D for life

Other common causes of hypocalcemia: vit D deficiency, IBD, PPIs/phenytoin (also lead to vit D def), renal disease so can’t make calcitriol, hypomagnesaemia

Question 18

Patient presents polyuric, thirsty, nauseous, constipated, confused, with muscle weakness. What will you do?

Answer 18

Indicates hypercalcemia.
?spine mets
Skeletal survey/CXR/CT abdominal/PTH (should be normal/low)
Do an ECG (shortened QT)

High calcium and high PTH = primary or tertiary hyperparathyroidism
High calcium and low PTH = malignancy or other rarer causes

Treat with IV 0.9% NaCl 4-6L in 24hrs
When rehydrated give IV bisphosphanates (zoledronic acid) which blocks osteoclastic bone resorption, takes 2-4days.
Can give IV calcitonin if no response

80% hyper cal from tumour secretion of PTHrP (most common lung, multiple myeloma, RCC, breast, colorectal)
20% is local osteolytic hypercalcemia caused by bony mets

Question 19

Manage alcohol withdrawal

Answer 19

Chlordiazepoxide (anxiolytic, anticonvulsant) 25-50mg. This is better than diazepam because has less potential for abuse. May need dose reduction in liver failure. Reduced does by 20% per day.
Pabrinex (to avoid Wernicke’s encephalopathy)

Obs every 2 hours:

• use alcohol withdrawal scale CIWA-Ar
• BP, PR, RR

Question 20

Manage Wernicke’s encephalopathy (and describe presentation)

Answer 20

Classic triad of acute confusion, ataxia and ophthalmoplegia. However only occurs in 10% of patients. Treat if no more likely explanation with any one+ of confusion, ataxia, opthalmoplegia, memory disturbance, unexplained hypotension with hypothermia, nystagmus.

Give pabrinex IV

After can give thiamine 100mg TDS and vitamin B OD, continue for 2-6wks

Question 21

Difference between delirium tremens and WE?

Answer 21

Delirium tremens has no neurological signs (only symptoms).

WE has neurological signs (ophthalmoplegia, confusion, ataxia).

Question 22

What monitoring should liver cirrhosis patients undergo?

Answer 22

Every 6mo USS +/- serum AFP for hepatocellular carcinoma

At diagnosis offer OGD for oesophageal varies then again every 3 years

Question 23

Name two types of NAFLD

Answer 23

NASH- steatohepatitis. Involves inflam of the liver which can cause fibrosis, can lead to cirrhosis or liver cancer

Simple fatty liver (also called NAFL). No inflammation, normally no complications.

Question 24

Why is alcohol protective with paracetamol OD?

Answer 24

Changes cytochrome enzymes so less NAPQI is oxidised

Question 25

Patient presents (feeling fine) 6hrs post paracetamol ingestion. What will you do?

Answer 25

Most have no symptoms in first 24hrs and then 2-3days later ALT, AST and PT rise, encephalopathy/coma, hepatorenal syndrome. May have N&V, headache, change in conscious level, anorexia, abdominal pain.

Ix: LFTs, serum paracetamol, electrolytes, U&Es, PT & INR, ABG

Mx: Consult TOXBASE. Use Rumack-Matthew nomogram-check paracetamol level 4hrs post ingestion and plot. If it falls on or above line, treat with acetylcysteine.

150 mg/kg over 1 hour, dose to be administered in 200 mL Glucose Intravenous Infusion 5%

Question 26

What is the time limit for treating paracetamol OD with acetylcysteine and activated charcoal?

Answer 26

Acetylcysteine- most effective <8hrs but up to 24hrs

Activated charcoal up to 2hrs

Question 27

What criteria should be met before discharging a paracetamol OD patient?

Answer 27

Paracetamol level below treatment line
Normal INR (liver function)
Normal ALT (liver hurt)
Normal creatinine (kidneys)