TO DO Flashcards
(167 cards)
1
Q
ASTHMA
What is the long-term guideline mediation regime for asthma?
A
- low dose ICS/formoterol combination inhaler (AIR therapy) or if very symptomatic start low dose MART
- low dose MART
- moderate dose MART
- check FeNO + eosinophil level (if either is raised, refer to specialist).
- If neither are raised = LTRA or LAMA in addition to moderate dose MART
- if still not controlled, stop LTRA or LAMA and try other drug option (LTRA/LAMA) - refer to specialist
2
Q
COPD
What are the treatments for COPD?
A
- SABA or SAMA as required
if NO asthmatic features:
2. SABA as required, LABA + LAMA regularly
if asthmatic features:
2. SABA or SAMA as required, LABA + ICS regularly
- SABA as required, LABA + LAMA + ICS regularly
3
Q
PHARMACOLOGY
give 2 examples of LABAs
A
- salmeterol
- formoterol (full agonist)
4
Q
PHARMACOLOGY
give an example of a SAMA
A
ipratropium
5
Q
PHARMACOLOGY
give an example of a LAMA
A
tiotropium
6
Q
PNEUMOTHORAX
what is the management for a secondary spontaneous pneumothorax?
A
SMALL (1-2cm)
- aspirate with 16-18G needle
- admit with high flow oxygen
LARGE (>2cm) or breathless
- insert chest drain
- admit with high flow oxygen
7
Q
RESPIRATORY FAILURE
what are the causes of type 1 respiratory failure?
A
- pneumonia
- heart failure
- asthma
- PE
- high altitude pulmonary oedema
8
Q
RESPIRATORY FAILURE
what are the causes of type 2 respiratory failure?
A
- opiate toxicity
- iatrogenic
- neuromuscular disease (MND, GBS)
- reduced chest wall compliance (Obesity)
- increased airway resistance (COPD)
9
Q
PLEURAL EFFUSION
what is the light’s criteria?
A
exudate is likely if:
- pleural fluid to serum protein ratio >0.5
- pleural fluid LDH to serum LDH ratio >0.6
- pleural fluid LDH >2/3 upper limits of normal serum LDH
10
Q
PLEURAL EFFUSION
what does low glucose in pleural fluid indicate?
A
- rheumatoid arthritis
- tuberculosis
11
Q
PLEURAL EFFUSION
what does heavy blood staining in pleural fluid indicate?
A
- mesothelioma
- PE
- tuberculosis
12
Q
PLEURAL EFFUSION
what are the indications of a pleural infection?
A
- purulent or turbid/cloudy fluid
- clear fluid but pH <7.2 (chest drain must be inserted)
13
Q
PULMONARY FIBROSIS
what are the causes of upper lobe pulmonary fibrosis?
A
SCART
- sarcoidosis
- coal miners pneumoconiosis
- ankylosing spondylitis
- radiation
- TB
14
Q
PULMONARY FIBROSIS
what are the causes of lower lobe pulmonary fibrosis?
A
RASIO
- Rheumatoid
- Asbestosis
- Scleroderma
- Idiopathic pulmonary fibrosis (most common)
- other
15
Q
ASTHMA
what are the investigations for asthma in adults?
A
1st line = FeNO or eosinophil levels
2nd line = bronchodilator reversibility with spirometry
3rd line = peak expiratory flow variability
4th line = skin prick or total IgE
16
Q
ASTHMA
what are the investigations for asthma in children aged 5-16?
A
1st line = FeNO (asthma = >35)
2nd line = bronchodilator reversibility with spirometry
3rd line = peak expiratory flow variability
4th line = skin prick or total IgE
if still in doubt = bronchial challenge test
17
Q
ASTHMA
what are the 3 drugs and their doses that should be immediately administered in an acute asthma exacerbation?
A
- oxygen - 15L via non-rebreather
- salbutamol nebuliser 2.5-5mg
- IV hydrocortisone 20mg or 40-50mg oral prednisolone
18
Q
LUNG CANCER
what paraneoplastic features are associated with small cell lung cancer?
A
- ADH
- ACTH (cushing’s)
- Lambert Eaton syndrome
19
Q
LUNG CANCER
what are the paraneoplastic features of squamous cell lung cancer?
A
- parathyroid hormone-related protein (PTH-rp)
- clubbing
- hypertrophic pulmonary osteoarthropathy (HPOA)
- hyperthyroidism
20
Q
LUNG CANCER
what are the paraneoplastic features of adenocarcinoma lung cancer?
A
- gynaecomastia
- hypertrophic pulmonary osteoarthropathy (HPOA)
21
Q
COPD
how is a mild exacerbation of COPD managed?
A
- increase bronchodilator use + consider nebuliser
- 30mg oral prednisolone for 5 days
- only give antibiotics if sputum is purulent or signs of infection
- 1st line abx = amoxicillin, clarithromycin or doxycycline
22
Q
ACS
Describe the initial management of ACS
A
- Analgesia - morphine + sublingual GTN
- Oxygen (if SpO2 > 94%)
- dual antiplatelets
- ALL patients = aspirin 300mg
- if PCI = prasugrel or clopidogrel
- if fibrinolysis = ticagrelor or clopidogrel
MONA
23
Q
ACS
Describe the secondary prevention therapy for people after having a STEMI
A
- lifestyle changes
- manage CVD risks
- thrombolysis = 12 months aspirin 75mg + ticagrelor
- PCI = lifelong aspirin + 12 months ticagrelor/prasugrel
- ACEi
24
Q
DVT
What investigations might be done in order to diagnose a DVT?
A
- WELLS score
if WELLS >2 DVT likely
- duplex ultrasound of leg within 4 hours (if not within 4 hrs, offer anticoagulation)
- d-dimer
if WELLS <1 DVT unlikely
- D-dimer with results within 4 hrs (if not within 4hrs offer anticoagulation)
- if D-dimer is raised = duplex USS
- if D-dimer normal = no further Ix
bloods - FBC, U&Es, LFTs, PT + APTT
25
HEART FAILURE
what is the management for chronic HF?
1st line = BB + ACEi (started one at a time)
If ACEi not tolerated, try ARB or hydralazine with nitrate
2nd line = aldosterone antagonist (SPIRONOLACTONE)
3rd line = cardiac resynchronisation therapy (CRT) or ICD insertion, digoxin (particularly in AF) or ivabradine
other options:
- fluid restriction
- loop diuretics (for symptom management)
- annual flu + pneumococcal vaccine
26
ABNORMAL ECGS
Give 3 effects hyperkalaemia on an ECG
GO - absent P wave
GO TALL - tall T wave
GO long - prolonged PR
GO wide - wide QRS
27
ABNORMAL ECGS
Give 2 effects of hypokalaemia on an ECG
1. Flat T waves
2. QT prolongation
3. ST depression
4. Prominent U waves
U have no Pot and no T, but a long PR and a long QT
28
ABNORMAL ECGS
Give an effect go hypocalcaemia on an ECG
1. QT prolongation
2. T wave flattening
3. Narrowed QRS
4. Prominent U waves
29
ABNORMAL ECGS
Give an effect of hypercalcaemia on an ECG
1. QT shortening
2. Tall T wave
3. No P waves
30
ATRIAL FIBRILLATION
Describe the treatment for atrial fibrillation
HAEMODYNAMICALLY UNSTABLE
- 1st line = synchronised DV cardioversion
STABLE
onset <48hrs
- 1st line = rate control (BB or CCB)*
- 2nd line = rhythm control (flecanide or amiodarone)
onset >48hrs
- 1st line = rate control (BB or CCB)* + anticoagulation for at least 3 weeks, then offer rhythm control if appropriate
*consider digoxin 1st line in patients with AF + HF, those who do no exercise or other drugs excluded
avoid CCB in HF
avoid non-selective BB (e.g. propranolol) in asthma
31
ATRIAL FLUTTER
what is the management for atrial flutter?
- Cardioversion
- Give a LMWH
- Shock with defibrillator
- Catheter ablation = definitive treatment – creates a conduction block
- IV Amiodarone – restore sinus rhythm
32
DVT
what are the components of the WELLS score?
- active cancer
- bedridden or recent major surgery
- calf swelling >3cm compared to other leg
- superficial veins present (non-varicose)
- entire leg swollen
- tenderness along veins
- pitting oedema of affected leg
- immobility of affected leg
- previous DVT
- alternative diagnosis likely (-2)
all score +1
33
PE
what are the components of the WELLs two level score?
- clinical signs + symptoms of DVT (+3)
- PE is no.1 diagnosis (+3)
- tachycardia <100 (+1.5)
- immobilisation for >3 days
- previous PE/DVT (+1.5)
- haemoptysis (+1)
- malignancy with treatment in last 6 months (+1)
34
ATRIAL FIBRILLATION
which medications are used for rate control?
1st line = beta-blocker (bisoprolol) or CCB (diltiazem/verapamil)
consider digoxin 1st line when AF + HF
2nd line = combination therapy with any two
- beta-blocker (bisoprolol)
- diltiazem
- digoxin
35
ATRIAL FIBRILLATION
what medications are used for rhythm control?
if no structural/ischaemic heart disease = flecainide or amiodarone
if structural/ischaemic heart disease = amiodarone
36
SVT
what is the management?
UNSTABLE
- synchronised DC shock (up to 3 attempts)
- if unsuccessful, 300mg amiodarone IV + repeat shock
STABLE
- 1st line = vagal manoeuvres (Valsalva, carotid sinus massage)
- 2nd line = adenosine 6mg, if unsuccessful give 12mg then 18mg
- 3rd line = verapamil or BB
- long term = catheter ablation
37
VENTRICULAR TACHYCARDIA
what is the management of pulsed VT?
IF ADVERSE FEATURES PRESENT (HF, MI, shock syncope)
- 1st line = synchronised DC cardioversion (up to 3 attempts)
- 2nd line = amiodarone 300mg IV over 10-20 mins
IF NO ADVERSE FEATURES PRESENT
- 1st line = amiodarone 300mg IV
- 2nd line = synchronised DC cardioversion
if drug therapy fails
- ICD implanted
38
ANGINA
what is the long term management?
- 1st line = beta blocker or CCB
- 2nd line = combination of BB + CCB (nifedipine, or amlodipine)
- 3rd line = long acting nitrate, ivabradine, nicorandil or ranolazine
all patients should be given aspirin + statin unless contraindicated
39
SAH
What is the management of SAH?
1st line
- nimodipine 60mg 4hrly
- endovascular coiling (2nd line = surgical clipping)
- if raised ICP = IV mannitol, hyperventilation + head elevation
- conservative = bed rest, stool softeners
40
SDH
What is the management of SDH?
IV mannitol
ACUTE
- monitor intracranial pressure
- decompressive craniectomy
CHRONIC
- can be monitored + managed conservatively
- burr hole decompression if pt is confused, has neuro deficit or severe image findings
41
STATUS EPILEPTICUS
What is the step-wise management of status epilepticus?
PRE-HOSPITAL/EARLY STATUS (<10 MINS)
- in community 1st line = buccal midazolam (2nd line = rectal diazepam)
- in hospital 1st line = 4mg IV lorazepam (2nd line = IV diazepam)
two doses of benzodiazepine given 10 mins apart
ESTABLISHED STATUS (>10 MINS)
- alert on-call anaesthetist
- one of following: phenytoin, levetiracetam, sodium valproate
if one fails, try another agent on list
REFRACTORY STATUS (>30 MINS)
- phenobarbitone
- general anaesthesia with propofol, midazolam or thiopental
42
BRAIN ABSCESS
What is the management of brain abscess?
1ST LINE
- empirical antibiotics (IV ceftriaxone + metronidazole)
- treat underlying cause
2ND LINE
- abscess drainage/excision
43
BRAIN DEATH + COMA
What are the components of 'eyes' in GCS?
E4 = opens spontaneously
E3 = opens to verbal command
E2 = opens to pain
E1 = no response
44
BRAIN DEATH + COMA
What are the components of 'verbal' in GCS?
V5 = orientated in TPP, answers appropriately
V4 = confused conversation, odd answers
V3 = inappropriate words (random, abusive)
V2 = incomprehensible sounds (groans)
V1 = no response
45
BRAIN DEATH + COMA
What are the components of 'motor' in GCS?
M6 = obeys commands
M5 = localises pain
M4 = withdraws away from painful stimulus
M3 = flexion to pain
M2 = extension to pain
M1 = no response
46
MULTIPLE SCLEROSIS
In terms of the symptoms of MS, what is Lhermitte's sign?
Neck flexion causes electric shock sensation down spine
47
MULTIPLE SCLEROSIS
In terms of the symptoms of MS, what is Uhthoff's phenomenon?
symptoms worsening in heat e.g. in the shower/exercise
48
EPILEPSY
what is the treatment for generalised myoclonic epilepsy?
male = sodium valproate
female = levetiracetam
49
EPILEPSY
what is the management for different types of seizures?
GENERALISED TONIC-CLONIC
- male = sodium valproate
- female = lamotrigine or levetiracetam
FOCAL SEIZURES
- 1st line = lamotrigine or levetiracetam
- 2nd line = carbamazepine, oxcarbazepine or zonisamide
ABSENCE SEIZURES
- 1st line = ethosuximide
- 2nd line (male) = sodium valproate
- 2nd line (female) = lamotrigine or levetiracetam
MYOCLONIC SEIZURES
- male = sodium valproate
- female = levetiracetam
TONIC OR ATONIC SEIZURES
- male = sodium valproate
- female = lamotrigine
50
TIA
What is the secondary prevention following a stroke/TIA?
- 1st line = clopidogrel 75mg
- 2nd line = aspirin 75mg + MR dipyridamole
- 3rd line = MR dipyridamole
- 4th line = aspirin 75mg
all patients = high dose statin (atorvastatin 20-80mg)
manage HTN, DM, smoking and CVD risk factors
51
ENCEPHALITIS
what is the management?
IV acyclovir
52
STROKE
How would a Total Anterior Circulation Infarct (TACI) present?
(involves middle and anterior cerebral arteries)
- unilateral hemiparesis +/- hemisensory loss of face, arm and leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphagia
53
STROKE
how would a Partial Anterior Circulation Infarct present?
2 of the criteria are present:
- unilateral hemiparesis +/- hemisensory loss of face, arm and leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphagia
54
STROKE
how does a lacunar infarct (LACI) present?
presents with one of the following:
- unilateral weakness (+/- sensory deficit) of face, arm and leg or all 3
- pure sensory stroke
- ataxic hemiparesis
55
STROKE
what vessels are affected in a lacunar infarct?
perforating arteries around the internal capsule, thalamus and basal ganglia
56
STROKE
how would a posterior circulation infarct (POCI) present?
presents with one of the following:
- cerebellar or brainstem syndromes
- loss of consciousness
- isolated homonymous hemianopia
57
STROKE
what is the presentation of lateral medullary syndrome?
IPSILATERAL
- ataxia
- nystagmus
- dysphagia
- facial numbness
- cranial nerve palsy
CONTRALATERAL
- limb sensory loss
58
STROKE
what vessels are affected in lateral medullary syndrome?
posterior inferior cerebellar artery
(also known as Wallenberg's syndrome)
59
STROKE
what is the presentation of Weber's syndrome?
- ipsilateral CN III palsy
- contralateral weakness
60
MENINGITIS
what are the most common causes of viral meningitis?
enteroviruses e.g. coxsackie B, echovirus
61
APHASIA
what is the presentation of Wernicke's aphasia?
speech is normal but sentences do not make sense (comprehension is impaired)
62
APHASIA
what is Wernicke's aphasia
receptive aphasia (can speak but do not make sense, comprehension is impaired)
63
APHASIA
what is the presentation of Broca's aphasia?
comprehension is normal
speech is non-fluent
repetition is impaired
64
APHASIA
what is Broca's aphasia?
expressive aphasia (can comprehend but cannot speak fluently)
65
APHASIA
what is the presentation of conduction aphasia?
comprehension is normal
speech is fluent
repetition is poor
66
APHASIA
what is the presentation of global aphasia?
- expressive + receptive aphasia
- can communicate using gestures
67
APHASIA
where is the lesion for Broca's (expressive) aphasia?
inferior frontal gyrus
68
APHASIA
where is the lesion for Wernicke's (receptive) aphasia?
lesion in superior temporal gyrus
69
APHASIA
where is the lesion for conductive aphasia?
arcuate fasciculus
70
CEREBELLAR LESIONS
what is the cause of finger-nose ataxia?
cerebellar hemisphere lesion
71
CEREBELLAR LESIONS
what is the cause of gait ataxia?
cerebellar vermis lesions
72
STROKE
what is the definition of a stroke?
rapidly developing neurological deficit of vascular origin lasting over 24 hours or resulting in death
73
CROHNS DISEASE
What is the treatment for induction of remission for Crohn's disease?
INDUCTION OF REMISSION
MILD (1st presentation/1 exacerbation in 1yr)
- 1st line = IV/PO steroid
- 2nd line = oral ASA (MESALAZINE)
- distal/ileocaecal disease = budesonide
MODERATE (>2 exacerbations in 1yr)
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate
SEVERE (unresponsive to conventional therapy)
- 1st line = infliximab or adalimumab (anti-TNF)
- 2nd line = other biological agents
REFRACTORY
- surgery
74
ULCERATIVE COLITIS
What is the treatment for induction of remission for Ulcerative colitis?
INDUCTION OF REMISSION
PROCTITIS
- 1st line = topical ASA (RECTAL MESALAZINE)
- 2nd line = topical ASA + oral ASA (oral MESALAZINE)
- 3rd line = oral ASA + oral corticosteroid
PROCTOSIGMOIDITIS/LEFT-SIDED UC
- 1st line = topical ASA
- 2nd line = topical ASA + high-dose oral ASA / high-dose oral ASA + topical corticosteroid
- 3rd line = oral ASA + oral corticosteroid
EXTENSIVE DISEASE
- 1st line = topical ASA + high-dose oral ASA
- 2nd line = oral ASA + oral corticosteroid
SEVERE DISEASE
- should be treated in hospital
- 1st line = IV steroids (IV ciclosporin if contraindicated)
- 2nd line = IV steroids + IV ciclosporin or consider surgery
75
VARICES
what is the treatment for gastroesophageal varices?
- ABCDE
- Rockfall Score (Prediction of Rebleeding and Mortality)
- Bleeding Varices - Terlipressin + Prophylactic Antibiotics (Ciprofloaxcin), Balloon tamponade (Sengstaken-Blakemore tube), Endoscopic Banding, TIPS
- Bleed Prevention - BB + Endoscopic Banding. Cirrhosis = screening endoscopy
76
DIVERTICULAR DISEASE
what is the management for diverticulitis?
ANTIBIOTICS
- 1st line = co-amoxiclav (if penicillin allergic = ciprofloxacin/metronidazole)
ANALGESIA
- paracetamol
SUPPORTIVE
- high fibre diet
SURGERY
77
C.DIFF
what is the treatment for c.diff?
1st line = vancomycin orally for 10 days
2nd line = oral fidaxomicin
3rd line = oral vancomycin +/- IV metronidazole
78
ACHALASIA
what are the investigations?
- oesophageal manometry (diagnostic) = excessive LOS tone
- barium swallow = expanded oesophagus, fluid level (birds beak appearance)
- CXR = wide mediastinum, fluid level
79
ACHALASIA
what is the management?
- 1st line = pneumatic (balloon) dilation
- heller cardiomyotomy (if recurrent or severe symptoms)
- intra-sphincteric botox injection
- drug therapy (nitrates, CCBs)
80
CONSTIPATION
what is the management for faecal impaction?
1st line = osmotic laxative (macrogol) +/- stimulant laxative (senna)
2nd line = suppository (bisacodyl/glycerol)
3rd line = enema (sodium phosphate)
81
ABDOMINAL WALL HERNIAS
where are inguinal hernias found?
above + medial to pubic tubercle
82
ABDOMINAL WALL HERNIAS
where are femoral hernias found?
why are they dangerous?
below + lateral to pubic tubercle (more common in women)
are at high risk of strangulation
83
CROHN'S DISEASE
what is the management for maintenance of remission in crohn's disease?
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate
- post surgery = consider azathioprine +/- methotrexate
STOP SMOKING
84
ULCERATIVE COLITIS
what is the management for the maintenance of remission in UC?
MILD-MODERATE
- proctitis + rectosigmoid = topical ASA / topical ASA + oral ASA / oral ASA
- left-sided + extensive = low dose oral ASA
SEVERE (severe exacerbation or >2 exacerbations
- oral azathioprine or oral mercaptopurine
85
UPPER GI BLEED
when is Glasgow-Blatchford scoring system used?
risk assessment before endoscopy to help decide if a patient can be managed as an outpatient
86
UPPER GI BLEED
what is the management of a variceal bleed?
terlipressin
prophylactic antibiotics (ciprofloxacin)
endoscopy
band ligation
TIPS
87
UPPER GI BLEED
what is the management of non-variceal bleed?
PPI after endoscopy
88
RECTAL CANCER
what blood marker can be used to monitor response to treatment?
carcinoembryonic antigen (CEA)
89
PEPTIC ULCER
what is the management of h.pylori?
7 day course of:
- PPI + amoxicillin + (clarithromycin or metronidazole)
if penicillin allergic
- PPI + metronidazole + clarithromycin
90
BLOOD TRANSFUSION REACTIONS
what is the mechanism of action for acute haemolytic transfusion reactions?
ABO incompatibility
RBC destruction by IgM antibodies
91
BLOOD TRANSFUSION REACTIONS
what is the management for acute haemolytic transfusion reaction?
- immediate transfusion termination
- send blood for direct Coombs test, repeat typing + cross match
- fluid resuscitation with IV saline
92
BLOOD TRANSFUSION REACTIONS
what is the mechanism of action for non-haemolytic febrile reactions?
due to white blood cell HLA antibodies
93
BLOOD TRANSFUSION REACTIONS
what is the management for non-haemolytic febrile reactions?
- slow or stop transfusion
- paracetamol
- monitor
94
BLOOD TRANSFUSION REACTIONS
what is the mechanism of action for mild allergic reaction?
thought to be caused by foreign plasma proteins
95
BLOOD TRANSFUSION REACTIONS
what is the management for a minor allergic reaction?
- temporarily stop transfusion
- antihistamine (cetirizine)
- once symptoms resolve, transfusion may be continued with no need for further work up
96
BLOOD TRANSFUSION REACTIONS
what can cause anaphylaxis?
patients with IgA deficiency who have anti-IgA antibodies
97
BLOOD TRANSFUSION REACTIONS
what are the clinical features for transfusion-related acute lung injury (TRALI)?
- hypoxia
- fever
- HYPOTENSION
- pulmonary infiltrates on CXR
98
BLOOD TRANSFUSION REACTIONS
what is the mechanism of action for transfusion-related acute lung injury (TRALI)?
non-cardiogenic pulmonary oedema
thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood
99
BLOOD TRANSFUSION REACTIONS
what is the management for transfusion-related acute lung injury (TRALI)?
- stop transfusion
- supportive care
- oxygen
100
BLOOD TRANSFUSION REACTIONS
what are the clinical features of transfusion-associated circulatory overload (TACO)?
- pulmonary oedema
- HYPERTENSION
101
BLOOD TRANSFUSION REACTIONS
what is the management for transfusion associated circulatory overload (TACO)?
- slow or stop transfusion
- consider loop diuretic (furosemide)
- consider oxygen
102
DOACs
what is the mechanism of action?
Rivaroxaban, apixaban and edoxaban= direct factor Xa inhibitor
Dabigatran = direct thrombin inhibitor
103
DOACs
how can they be reversed?
Rivaroxaban + apixaban = andexanet alpha
Dabigatran = idarucizumab
Edoxaban = no reversal agent
104
LMWH
what is the mechanism of action?
activates antithrombin III
forms a complex that inhibits factor Xa
105
LMWH
how can it be reversed?
- protamine sulfate
106
WARFARIN
how would you manage INR > 8?
MAJOR BLEED OR REQUIRE SURGERY
- stop warfarin
- give IV vitamin K
- give dried prothrombin complex concentrate (PCC) or Fresh frozen plasma (FFP) if PCC is unavailable
MINOR BLEED
- stop warfarin
- IV vitamin K
- repeat vitamin K dose after 24hrs if INR still too high
- restart warfarin when INR<5
NO BLEED
- stop warfarin
- oral vitamin K
- repeat vitamin K dose after 24hrs if INR still too high
- restart warfarin when INR <5
107
WARFARIN
how would you manage INR 5-8?
MINOR BLEED
- stop warfarin
- give IV vitamin K
- restart warfarin when INR<5
NO BLEED
- withhold 1-2 doses of warfarin
- reduce subsequent maintenance dose
108
ACNE VULGARIS
Describe the treatment for mild to moderate acne
12 week fixed course of one of the following:
- topical adapalene + topical benzoyl peroxide
- topical tretinoin + topical clindamycin
- topical benzoyl peroxide + topical clindamycin
109
PSORIASIS
what is the management?
1st line
- patient education
- regular emollients
- topical corticosteroids + vit D for 4 weeks
- if poor response, continue for 4 more weeks
- if poor response after 8 weeks, stop corticosteroid + take vit D BD
- if poor response after 12 weeks, potent topical steroid BD for 4 weeks
2nd line
- short-acting dithranol
- phototherapy
3rd line
- DMARDS (methotrexate, apremilast, ciclosporin)
- biologics (adalimumab, infliximab)
110
ROSACEA
what is the management?
CONSERVATIVE
- high factor sun cream
- camouflage cream to conceal redness
SYMPTOM CONTROL
- flushing = topical brimonidine gel or oral propranolol
- telangiectasia = laser therapy
- papules/pustules
- mild-moderate = 1st line - ivermectin (other options = topical metronidazole, topical azelaic acid)
- mod-severe = topical ivermectin + oral doxycycline
111
ACNE
what is the management of moderate to severe acne?
1st line = 12 week fixed course of one of the following:
- topical adapalene + topical benzoyl peroxide
- topical tretinoin + topical clindamycin
- topical adapalene + topical benzyl peroxide + oral lymecycline/doxycycline
- topical azelaic acid + oral lymecycline/doxycycline
2nd line = isotretinoin (acutane)
112
CHLAMYDIA
How would you manage chlamydia?
- Test for other STIs, contraceptive advice, ?safeguarding if child.
- Doxycycline 100mg BD for 7d (C/I pregnancy or breastfeeding).
- 1g azithromycin stat dose in pregnancy (erythromycin or amoxicillin safe too)
- Referral to GUM for partner notification + contact tracing.
113
GONORRHOEA
What is the management of gonorrhoea?
- 1g single dose IM ceftriaxone
- if needle phobic = oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose)
- Follow-up test of cure with NAAT testing or cultures
114
SYPHILIS
What is the clinical presentation of primary syphilis?
SYMPTOMS
- single painless ulcer (chancre) on genitals
- occasionally chancre on throat, anus or intravaginally
115
SYPHILIS
How would you manage syphilis?
- Specialist GUM (full STI screening, contact tracing, contraceptive information).
- early syphilis = Single dose IM benzathine benzylpenicillin or PO doxycycline if allergic
- late latent/gummatous = 3 doses IM benzathine benzylpenicillin once weekly for 3 weeks
- cardiovascular syphilis = 3 days of PO prednisolone + 3 once weekly doses IM benzathine benzylpenicillin
- neurosyphilis = 14 days IM procaine penicillin + oral probenecid
116
GENITAL HERPES
What is the clinical presentation of genital herpes?
- Multiple painful ulcers
- Neuropathic type pain (tingling, burning, shooting)
- Flu Sx (fatigue, headaches, fever, myalgia)
- Dysuria
117
GENITAL HERPES
What is the management or primary genital herpes contracted before 28w gestation?
- Aciclovir during infection
- Prophylactic aciclovir from 36w gestation onwards to reduce risk of genital lesions during labour + delivery
- Asymptomatic at delivery can have vaginal if >6w from initial infection, if Sx then c-section
118
GENITAL HERPES
What is the management of primary genital herpes after 28w gestation?
- Aciclovir during infection + immediate prophylactic aciclovir
- C-section in all cases
119
CANDIDIASIS
What is the management of candidiasis?
1st line = oral fluconazole 150mg single dose
2nd line = clotrimazole 500mg intravaginal pessary single dose
- if there are vulval symptoms, consider topical imidazole in addition to oral/intravaginal antifungal
- if pregnant, only local treatments (creams/pessaries) may be used - oral is contraindicated
120
LYMPHOGRANULOMA VENEREUM
what are the clinical features?
Painless genital ulcer
Painful Inguinal lymph nodes
Proctitis, rectal pain, rectal discharge (in rectal infections)
Systemic symptoms such as fever and malaise
121
LYMPHOGRANULOMA VENEREUM
what is the management?
Treatment is with antibiotics. Common regimes include:
Oral doxycycline 100 mg twice daily for 21 days
Oral tetracycline 2 g daily for 21 days
Oral erythromycin 500 mg four times daily for 21 days
122
CHANCROID
what are the clinical features?
- painful genital ulcer
- tender unilateral inguinal lymphadenopathy
123
CHANCROID
what is the management?
- single dose AZITHROMYCIN
- alternatives = ceftriaxone, erythromycin or ciprofloxacin
- partner notification + treatment
- abscess drainage
124
ERECTILE DYSFUNCTION
what is the management?
1st line
- lifestyle modification (weight loss, physical activity, reduced alcohol, smoking cessation, BP control)
- psychosexual counselling
- phosphodiesterase-5 (PDE-5) inhibitors = SILDENAFIL (viagra)
- vacuum erection device
2nd line
- intracavernous injection therapy
- surgical intervention (penile prosthesis implant)
125
ACID-BASE ABNORMALITY
what are the different causes of metabolic acidosis?
NORMAL ANION GAP
- GI bicarbonate loss (diarrhoea, ureterosigmoidstomy, fistula
- renal tubular acidosis
- drugs (acetazolamide)
- ammonium chloride injection
- addisons disease
RAISED ANION GAP
- lactate (shock, hypoxia)
- ketones (DKA, alcohol)
- urate (renal failure)
- acid poisoning (salicylates, methanol)
126
ACID-BASE ABNORMALITY
what are the causes of metabolic alkalosis?
usually GI/renal
- vomiting/aspiration
- diuretics
- liquorice, carbenoxolone
- hypokalaemia
- primary hyperaldosteronism
- cushings syndrome
- Bartter's syndrome
- congenital adrenal hyperplasia
127
ACID-BASE ABNORMALITY
what are the causes of respiratory acidosis?
Caused by inadequate alveolar ventilation, leading to CO2 retention
- COPD
- decompensation in other respiratory conditions (life-threatening asthma/pulmonary oedema)
- sedative drugs (benzodiazepines, opiate overdose)
- GBS
128
ACID-BASE ABNORMALITY
what are the causes of respiratory alkalosis?
caused by excessive alveolar ventilation, resulting in more CO2 than normal being exhaled.
- anxiety leading to hyperventilation
- PE
- salicylate poisoning
- CNS disorders (stroke, SAH, encephalitis)
- altitude
- pregnancy
129
OVERDOSE
what is the criteria for liver transplant following paracetamol overdose?
KINGS COLLEGE HOSPITAL CRITERIA FOR LIVER TRANSPLANT
- pH < 7.3 24 hours after ingestion
or all of the following
- prothrombin time >100 seconds
- creatinine >300umol/L
- grade III or IV encephalopathy
130
ANAPHYLAXIS
what is the management for children?
IM adrenaline
- <6m = 100-150 micrograms
- 6m - 6yrs = 150 micrograms
- 6-12yrs = 300 micrograms
131
RHEUMATIC FEVER
What are the major criteria in rheumatic fever?
JONES –
- Joint arthritis (migratory as affects different joints at different times)
- Organ inflammation (pancarditis > pericardial friction rub)
- Nodules (subcut over extensor surfaces)
- Erythema marginatum rash (pink rings of varying sizes on torso + proximal limbs)
- Sydenham chorea
132
RHEUMATIC FEVER
What are the minor criteria in rheumatic fever?
FEAR –
- Fever
- ECG changes (prolonged PR interval) without carditis
- Arthralgia without arthritis
- Raised CRP/ESR
133
ASTHMA
What is the stepwise management of chronic asthma in <5y?
1. SABA + low dose ICS (trial for 8-12 weeks)
IF SYMPTOMS RESOLVE
2. stop SABA + low dose ICS for 3 months
3. if symptoms recur restart SABA + low-dose ICS and titrate up to moderate dose ICS as needed
4. consider further trial without treatment
5. SABA + moderate dose ICS + LTRA
6 stop LTRA + refer to specialist
IF SYMPTOMS DO NOT RESOLVE
2. check inhaler adherence, review if alternative diagnosis is likely
3. refer to specialist
134
ASTHMA
What is the stepwise management of chronic asthma 5-12yrs?
1. SABA + ICS
2. decide whether MART pathway or conventional pathway is more suitable
MART PATHWAY
3. SABA + low dose MART
4. SABA + moderate dose MART
5. refer to specialist
CONVENTIONAL PATHWAY
3. SABA + ICS + LTRA (trial for 8-12 weeks)
4. SABA + low dose ICS/LABA (+/- LTRA)
5. SABA + moderate dose ICS/LABA (+/- LTRA)
135
CONSTIPATION
What is the medical management of constipation?
- 1st = MACROGOL (osmotic) laxative like polyethylene glycol + electrolytes (Movicol)
- 2nd = stimulant laxative if no effect like Senna, bisocodyl ± osmotic laxative (lactulose) or stool softener (docusate) if hard stools
- 3rd = consider enema ± sedation or specialist manual evacuation
- Continue for several weeks after regular bowel habit then gradual dose reduction
136
BILIARY ATRESIA
What is the management of biliary atresia?
1st line
- Kasai portoenterostomy
- ursodeoxycholic acid
2nd line
- liver transplant
137
EPILEPSY
What is the management of generalised seizures?
- 1st line = sodium valproate
- 2nd line = lamotrigine, carbamazepine (TC), clonazepam (myoclonic)
138
EPILEPSY
What is the management of focal seizures?
- 1st line = carbamazepine or lamotrigine
- 2nd line = levetiracetam or sodium valproate
139
EPILEPSY
What is the management of absence seizures?
- Ethosuximide or sodium valproate
140
EPILEPSY
What is the management of myoclonic seizures?
- 1st line = sodium valproate
- 2nd line = clonazepam
141
DEVELOPMENTAL DELAY
what are the referral points?
- doesn't smile at 10 weeks
- cannot sit unsupported at 12 months
- cannot walk at 18 months
142
KAWASAKI DISEASE
What is the diagnostic criteria for Kawasaki disease?
Fever + 4 (MyHEART) –
- Mucosal involvement (red/dry cracked lips, strawberry tongue)
- Hands + feet (erythema then desquamation)
- Eyes (bilateral conjunctival injection, non-purulent)
- lymphAdenopathy (unilateral cervical >1.5cm)
- Rash (polymorphic involving extremities, trunk + perineal regions
- Temp >39 for >5d
143
VACCINATIONS
What vaccines are attenuated?
- MMR, BCG, nasal flu, rotavirus + Men B
144
VACCINATIONS
What vaccines are given at...
i) 2m?
ii) 3m?
iii) 4m?
i) 6-in-one, rotavirus + men B
ii) 6-in-one, rotavirus + PCV
iii) 6-in-one, men B
145
VACCINATIONS
What vaccines are given at...
i) 1y?
ii) 3y + 4m?
iii) 12-13y?
iv) 14y?
i) Men B, PCV, Hib/Men C + MMR
ii) MMR, 4-in-one preschool booster = DTaP + IPV
iii) HPV
iv) 3-in-1 teenage booster = tetanus, diphtheria + IPV, men ACWY
146
VACCINATIONS
Which vaccines are included in the 6-in-1 injection?
- diphtheria
- tetanus
- pertussis DTaP (whooping cough)
- polio IPV
- Haemophilus influenza B (HiB)
- Hepatitis B
147
TETANUS
when is tetanus vaccine given?
- 2 months
- 3 months
- 4 months
- 3-5 years
- 13-18 years
5 doses are now considered adequate long term protection
148
TETANUS
how can you classify a wound?
- clean wound
- tetanus prone wound
- high-risk tetanus prone wound
149
TETANUS
what is classed as a clean wound?
- less than 6 hours old
- non-penetrating injury
- negligible tissue damage
150
TETANUS
what is classed as a tetanus prone wound?
- puncture type wounds in contaminated environment
- wounds containing foreign bodies
- compound fractures
- wounds/burns with systemic sepsis
- certain animal bites and scratches
151
TETANUS
what is classed as high risk tetanus prone wound?
- heavy contamination with material likely to contain tetanus spores e.g. soil, manure
- wounds or burns that show extensive devitalised tissue
- wounds or burns that require surgical intervention
152
TETANUS
how would you manage a patient who has had a full course of tetanus vaccines, with the last dose < 10 years ago?
Regardless of wound severity:
- no vaccine required
- no tetanus immunoglobulin
153
TETANUS
what is the management for a patient that has had a full course of tetanus vaccine with the last dose >10 years ago?
if tetanus prone wound:
- vaccine dose
if high risk wound:
- vaccine dose
- tetanus immunoglobulin
154
TETANUS
how would you treat a patient with unknown or incomplete vaccination history?
- vaccine regardless of wound severity
- if tetanus prone or high risk = vaccine + immunoglobulin
155
LOCAL ANAESTHETIC
what is the management of local anaesthetic toxicity?
20% lipid emulsion
156
HEPATIC ENCEPHALOPATHY
what is the 1st line management?
lactulose
157
HEPATIC ENCEPHALOPATHY
what is the secondary prophylaxis?
lactulose + rifaximin
158
CXR
how can you tell the difference between lung collapse and pleural effusion on CXR?
- lung collapse = trachea deviates towards affected side
- pleural effusion = trachea deviates away from affected side
159
ACUTE LIMB ISCHAEMIA
what is the management for acute limb threatening ischaemia?
IV heparin (usually unfractionated)
160
HYPERKALAEMIA
how can excess potassium be removed from the body?
- calcium resonium
- furosemide
- dialysis
161
PROSTATE CANCER
what is a complication of GnRH agonists?
can cause a tumour flare when first started, causing bone pain, bladder obstruction + other symptoms
162
HYPERTHYROIDISM IN PREGNANCY
what is the management?
- 1st trimester = propylthiouracil
- 2nd and 3rd trimester = carbimazole
163
CUSHINGS SYNDROME
what VBG results would be seen?
hypokalaemic metabolic alkalosis
164
CUSHINGS
what does the following indicate?
cortisol = not suppressed
ACTH = suppressed
cushing's syndrome (adrenal adenoma)
165
CUSHINGS
what does the following indicate?
cortisol = suppressed
ACTH = suppressed
cushing's disease (pituitary adenoma)
166
CUSHINGS
what does the following indicate?
cortisol = not suppressed
ACTH = not suppressed
ectopic ACTH syndrome
167
