Treatment Pathways

Question 1

Management of ascites:

Answer 1

Restrict sodium intake.
Spironolactone 1st line. (Furosemide can be added if not working).

If refractory to medical therapy above, or causing respiratory compromise, consider large volume paracentesis.
Give human albumin solution alongside (100ml for every 2.5L drained).

Question 2

Management of SBP:

Answer 2

Establish whether on cotrimoxazole prophylaxis:
If yes, treat with coamoxiclav (IV).
If no, treat with cotrimoxazole (Oral / IV).
If allergy, levoflox

+ human albumin solution IV infusion on day 1 and day 3

Question 3

SBP prophylaxis is given when:

Answer 3

One episode of proven SBP, either previously or currently.

Patients with ascitic protein <10g/L

CO-TRIMOXAZOLE 1st line
(Cipro 2nd line)
*cotrimox should be monitored, can reduce renal function and increase potassium

Question 4

Diet management in decompensated liver disease:

Answer 4

Restrict salt
High protein, high calorie diet (but reduce protein slowly if encephalopathic).
Vitamin K (phytomenadione) slow infusion over 3-5 minutes. Day 1,2,3.
If history of alcohol abuse give Pabrinex.

Question 5

Mild skin / soft tissue infection Abx:

Answer 5

Oral fluclox 5 days

Allergic to penicillin = doxy or cotrimox

Question 6

Moderate / Severe cellulitis Abx:

Answer 6

IV Fluclox 7-10days

If penicillin allergic = IV Vanc
If rapidly progressive = add IV clindamycin

Question 7

Suspected nec fasc:

Answer 7

Benzylpenicillin
Metronidazole
Gentamicin
Clindamycin
Flucloxacillin
10 days

If allergic to penicillin = benpen + vanc

Question 8

Immediate management of acute severe asthma (+ if life threatening features are present):

Answer 8

Salbutamol nebs (oxygen driven)
Ipratropium bromide nebs (oxygen driven)
Oral prednisolone or IV hydrocortisone if can’t be taken PO
+ maintain sats 94-98%

If life-threatening features:
Senior referral
Consider IV magnesium sulfate
More frequent salbutamol nebs
ABG

Question 9

When to discharge someone following an acute asthma attack, and discharge plan:

Answer 9

Been on discharge meds for 12-24 hours and have had their inhaler technique checked.
PEF >75% best or predicted.
Treat with oral prednisolone + ICS (start ICS if new diagnosis or increase dose if already on).
GP follow up within 2 working days, and respiratory clinic follow up in 4 weeks.

Question 10

Exacerbation of COPD management (8 steps):

Answer 10

1. Oxygen 28% venturi mask if sats <88%, then titrate when ABG available
2. Steroids: oral pred (if PO not available, then IV hydrocortisone)
3. Salbutamol nebs (air) –> if not enough, add ipratropium air nebs –> consider IV aminophylline with input from a senior
4. NIV if worsening respiratory acidosis or hypercapnia despite adequate inital therapy and oxygen sats control.
5. Abx - if purulent sputum OR raised inflammatory markers OR CXR changes
6. DVT prophylaxis
7. Physio for chest, if lots of sputum or dense consolidation on CXR
8. Mucolytic therapy for mucous clearance e.g. acetylcysteine

Question 11

Immediate management of SVCO:

Answer 11

Aim to alleviate symptoms +/- direct cause management.

If clinical suspicion high, start oral dexamethasone (IV if swallow problems) + PPI cover whilst awaiting CT.
If CT positive, continue dex and seek urgent advice.

If CT negative, stop dex.

If symptoms not improving after 7 days of dex consider stopping.