Disease Treatment

Question 1

Acute Myocardial infarction

Answer 1

Aspiring 300mg to chew and swallow. (in ambulance). In hospital patients given tissue plasminogen activator to bust the clot. but big danger of cerebral and GI haemorrage when given IV. Mechanical reperfusion done in heart attack centers. Catheters introduced into heart through radial artery. Post MI treatement include statin, aspirin, ramipril, bisoprolol ticagrelor

Question 2

Stable Angina

Answer 2

To treat symptoms: reduce cardiac O2 demand (vasodilator) and increase supply to the ischaemic zone. To prevent acute coronary disease (NICE): 1. B-blocker/ calcium channel blocker CCB). 2. selective CCB + b blocker. 3. add ivabradine/nicorandil/ ranolazine/ long acting nitrate

Question 3

Complete 3rd degree heart block

Answer 3

Implantation of a permanent pacemaker (may need an immediate one in urgent cases).

Question 4

Atrial Fibrillation

Answer 4

1. Rate control. reduce proportion of impulses cinducted through AV node (class 2 & 4 anti-arrhythmic) 2. Rythym control.Target source of arrythmia or the conduction of the impusle away from the source by blocking reentry (class 3 & 1). radiocatheter ablation, maze procedure. Always anticoagulant given. Radiofrequency catheter ablation (used for supraventricular re-entry)

Question 5

Ventricular tachycardia

Answer 5

Implanted cardioverter, class 1-3 anti-arrhythmic drugs, radiocatheter ablation.

Question 6

Ventricular fibrillation

Answer 6

Defibrillation via paddles placed at sternum and RV apex. CPR. A thump of the chest in absence of equipement.

Question 7

Plural effusion

Answer 7

Use ultrasound to guide site of plural effusion. Thoracocentesis (plural tap). Ask patient to sit leaning forward and collect fluid. If heavy pus, use chest drain. can also inject tack substance to cause fusion of lung and chest wall, causing pleuridisis. Tunnel drain.

Question 8

Lung cancer

Answer 8

Chemo, cancer therapy, drain fluid.

Question 9

Pleural effusion dur to heart failure.

Answer 9

treat the heart failure/

Question 10

Pneumothorax

Answer 10

fluid removal

Question 11

Tension pneumothorax

Answer 11

canula into second intercostal space. Then put normal canula in to drain.

Question 12

Pulmunary fibrosis

Answer 12

Pirfenidone (antifibrotic) and nintedanib (triple tyrosine kinase inhibitor), O2, pulmunary rehabilitation, palliative care, lung transplant

Question 13

Sarcoidosis

Answer 13

NSAIDS, bedrest, steroid, prednisolone. In severe cases immunisuprresans and methyprednisolone

Question 14

Asthma

Answer 14

First line: inhaled corticosteroid (reduce inflammation). Second line: add Long Acting Beta Agonist. Third line: add Leukotriene receptor antagonist (LTRA), increase dosage. If still doesn’t work (3% of patients), add antinflammatory drugs short courses (prednisolone, oral). If more than 4 courses needed,

Question 15

Acute asthma attack

Answer 15

If mild or moderate, start SABA every 20 min + predinisolone + O2. If severe, nebulized salbutamol, ipratropium + oral or IV steroids (IV if possible), O2, IV Magnésium single dose

Question 16

Pneumonia

Answer 16

Perform BURB65 score (see slides). ABCDE approach. Give oxygen if appropriate, IV fluids of required, assess mental state, treat symptoms and most importantly give antibiotics. Start with oral broad spectrum (penicillin good) then narrow when culture results are obtained. Can change to IV blactamase resistant plus a macrolide. If viral infection, can give antivirals but not much evidence it helps. Mostly supportive treatment. See slides for bacteria specific treatements.

Question 17

Type I resp failure

Answer 17

Treat the underlying condition. Also give supportive treatement: O2 if appropriate, ventilation is appropriate. Preferably with venturi masks.

Question 18

Type II resp failure

Answer 18

Treat the underlying condition. non-Invasive ventilation (via mask) good evidence for COPD and immunosuppression, invasive ventilation in more acute situations, gold standard gives more control. ECMO if ventilation is not possible (e.g. fluid in lung)

Question 19

Chronic Obstructive Pulmunary disease

Answer 19

To prevent symptoms: bro chodilatora (SM tone) SABA, LABA, antimuscarinic long acting. Can also give combination LAMA/LABA. Other thpe is inhaled corticosteroids in later stage to reduced inflammation but beware of side effects. to prevent exacerbations of symptoms: flu vaccination, stop smoking support, pulmonary rehabilitationt (education, muscle strenghtening), iotropium, LABA. Surgical treatement: lung volume reduction removes the emphysema part of the lung. Can also give oxygen at home to improve life expectancy but must be prescribed appropriately.

Question 20

Acute COPD exacerbation

Answer 20

If purulent sputum, probs bacterial so give antibiotics. Controlled oxygen therapy (beware of hypercapnics). Short acting bronchodilators, systemic glucocorticoids (e.g. prednisolone). If respiratory acidosis, non invasive ventilation, or invasive. If patient is smoker, treat with nicotine replacement. Check fluid balance.

Question 21

Delirium tremens

Answer 21

Benzodiazepines (almost replacement, lasts very long in system to progressive resensitization). Lorazepam or diazepam high dose until symptoms controlled. Symptom-triggered approach. use scale reguralry to asses progression of withdrawal and adapt doses accordingly. If it is not well done then not worth, just do fixed dose schedule. keep in side room, family presence,

Question 22

Wernicke’s Encephalopathy

Answer 22

Parenteral thiamine or pabrinex (thiamine and other B vitamines). ensure the cannula stays in the patient and nutrition is maintained

Question 23

G overdose

Answer 23

Supportive: G has very small half life. So will clear quickly. Don’t intubate unless vomiting, siezing. Be alert to mixed intoxication (other drugs?). Give them advice on how to safely use it. Use pre measured dose, take minimum of 90-120 min interval.

Question 24

G withdrawal

Answer 24

Use CIWA to evaluate withdrawal severity. If planned, can give baclofen (higher than recommended doses) before and after stopping.

Question 25

Heroin overdose

Answer 25

Naloxone. Titrate dose against response. Talk to patient, be positive and reassuring as much as you can.

Question 26

Delirium

Answer 26

Address acute medical issue, reorientate involving family counseling, correct sensory imparement, avoid moving patient too much, ask family to bring photographs. Limit medical interventions and moving patients as much as possible. promote normal sleep cycle, monitor symptoms and record progress. This is a curable condition. Only give medication if you have no other solutions. Do ECG (QTc interval). Use lorazepam.

Question 27

Delayed sleep phase

Answer 27

Do they want treatement or not? If they do, opt for combination of phototherapy, melatonin, CBT-I, examin for psychiatric co-morbidity.

Question 28

Shift work disorder

Answer 28

Power naps, max 2-3 consecutive shifts. Proper distribution of rest days.

Question 29

parasomnia

Answer 29

Education, CBT, keep room safe, not automatically wake up patient. Melatonin, clonazepam, antidepressants

Question 30

REM Parasomnias

Answer 30

Patient education, safety (seperate bed needed?), simple home oximetry, need for medication? Clonazepam, melatonin

Question 31

Chronic fatigue syndrome

Answer 31

Graded exercise therapy and CBT good evidence.

Question 32

Acute Kidney Injury (pre renal)

Answer 32

Exclude life threatening complication. Identify aetiology and treat (fluids, drugs, stop drugs). Supportive treatment (nutrition, ulcer prophylaxis). COntinue checking ABGs and bloods. Dextrose + insulin for hyperkalaemia. Determine cause of AKI.

Question 33

Hyponatraemia

Answer 33

If they are hypovolumic, replace with saline fluids. If euvolumic, treat underlying cause, fluid restriction. If they are hypervolumic, fluid restriction and vasopressin receptor antagonists (to allow water excretion). Can also give hypertonic saline in extreme cases but seek expert help

Question 34

Hypernatraemia

Answer 34

Treat underlying cause, use hypotonic fluids (5% dextrose). Lower Na levels but very slowly (no more than 10mmol/L per day).

Question 35

Hypokalaemia

Answer 35

Correct Mg Levels, k replacement slowly with cardiac monitoring. Address the cause.

Question 36

Hyperkalaemia

Answer 36

IV calcium gluconate or IV insulin with glucose, remove K from body (haemodialysis), treat underlying causes.

Question 37

1st degree block

Answer 37

Stop AV blocking medication (beta blockers, calcium channel blockers and digitalis). Pacemaker if severe.

Question 38

2nd degree type I block

Answer 38

Stop AV blocking medication (beta blockers, calcium channel blockers and digitalis). Pacemaker if severe.

Question 39

2nd degree type 2 block

Answer 39

Stop AV blocking medication (beta blockers, calcium channel blockers and digitalis). Pacemaker if severe.

Question 40

Pericarditis

Answer 40

If purulent, pericardiocentesis, systemic antibiotics +NSAIDS. If viral or idiopathic: NSAIDS, antiviral therapy, corticosteroids.

Question 41

Transient Ischaemic attack

Answer 41

300mg Aspirin, statin, blood pressure lowering, warfarin. Carotid endarectomy if carotid stenosis present.

Question 42

Ischaemic Stroke

Answer 42

Intravenous thrombolysis (Tissue plasminogen activator Altepase) if less than 4.5h after stroke. Aspirin 300mg.

Question 43

Haemorragic stroke

Answer 43

Neurosurgical care evaluation, BP control, supportive care, stop anticoagulants.

Question 44

Diabetic ketoacidosis

Answer 44

Aims include clearing ketonaemia and acidosis and preventing complications from treatement. So start with fluid replacement (IV norm saline). Fixed insulin infusion. As soon as potassium is normal give potassium replacement. Treat the cause. VTE prophylaxis.

Question 45

Hyperosmolar hyperglycaemic state

Answer 45

Graduallly normalise osmolality, fluid status and glucose. Slow fluid replacement (normal saline). When plateaus, insluin replacement fixed rate and close monitoring.