ETG

Question 1

Pneumonia

Answer 1

MILD - Amoxy or doxy
Moderate - Benzyl IV plus doxy oral
Severe - Ceftriaxone or cefotaxime PLUS azithro

Tropical - Meropenem, Piptaz PLUS azithro
Burkholderia - ceftriaxone + gent
Atypical - Doxyclyline
Moxifloxacin - if immediate hypersensitivity to penicillin

RED FLAGS
>30 RR
Systolic <90
O2 <92
Acute confusion
HR >100
Multilobar involvement

Question 2

STD

Answer 2

Ceftriaxone + Azithro - Chlamydia and Gonorrhoea
ADD on probenecid if resistant gonorrhoea

Herpes - Valaciclovir 500mg BD 5 days, (3 days of episodic treatment), OD as suppressive

Chancroid - Azithro 1g single dose / Cef or Cipro

Donovanosis - Azithro 1g / once a week for 4 weeks

Genital warts - Imiquiomoid topical 3/week alternate days at bed time

PID - Cef + metro (BD 14 days) + azithromycin + (doxy for 14 days BD or azithro as a single dose a week later)

Severe PID - IV antibiotics - Cef, plus Azithro plus metro daily (gent, clind and azithro if penicillin hypersensitivity)

Proctitis - Cef, doxy + antiviral

LGV - Doxy 12 hourly 3 weeks

Syphilis - Benzathine penicillin or doxy 12 hourly 14 days
(IV FOR TERTIARY SYPHILIS +/- prednisolone if CV or neurosyphilis)

BV and tricho - metronidazole

Question 3

Schisto and Tapeworms

Answer 3

Prazitenqual

Question 4

Hytatid cyst

Answer 4

PAIR approach: puncture aspirate cystinject hypertonic saline  re-aspirate after 25min; continue albendazole for 30d to prevent recurrence.

Question 5

Nematodes

Answer 5

Abendazole or Mebendazole

Question 6

Trypanosomiasis

Answer 6

nifurtimox

Question 7

Giardia

Answer 7

Tinidazole

Question 8

Entomoeba

Answer 8

metronidazole then diloxainide furoate

Question 9

Migraine

Answer 9

Diagnostic criteria >/= 5 headaches lasting 4-72 hours with either nausea/vomiting or photo/phonophobia and >2/= Pulsating, O, Unilateral, N, Disabiling (functional)

CHOCOLATE
Cheese
Oral contraceptives
Caffeine
Alcohol
Anxiety
Travel
Exercise

Not allowed to use triptans with IHD, coronary spasm, unrolled BP, recent lithium, SSRI’s or ergot use.

Prophylaxis Propranol, topiramate, amitriptyline
Anti epileptics 2nd line

Warm or cold packs, rebreathing.

Question 10

Tardive dyskinesia

Answer 10

tetrabenazine 12.5–50mg/8h PO.79 Quetiapine, olanzapine and clozapine are examples of atypical antipsychotics that are less likely to cause tardive syndromes.

Question 11

Stroke

Answer 11

tPA infusion:

CI to thrombolysis:
Major infarct or haemorrhage on CT 
Mild/non-disabling deficit 
Recent birth, surgery, trauma, or artery or vein puncture at uncompressible site
Past CNS bleed 
AVM or aneurysm 
Severe liver disease, varices or portal hypertension • 
Seizures at presentation 
Anticoagulants or INR >1.7 
Platelets <100≈109/L 
BP >220/130.

Question 12

Stroke

Answer 12

Once excluding ICH by imaging –> aspirin orally or NG tube 300mg, continue indefinitely

Prevention - aspirin, clopidogrel, dipyramidole.

No driving for at least a month

Question 13

SAH

Answer 13

• Re-examine CNS often; chart BP, pupils and GCS (p802). Repeat CT if deteriorating. • Maintain cerebral perfusion by keeping well hydrated, and aim for SBP 160mmHg.
Treat BP only if very severe.
• Nimodipine (60mg/4h PO for 3wks, or 1mg/h IVI) is a Ca2+ antagonist that reduces
vasospasm and consequent morbidity from cerebral ischaemia.
• Endovascular coiling is preferred to surgical clipping where possible (7%  in independent survival over 7yrs follow-up, but  risk of rebleeding).140 Do catheter or CT angiography to identify single vs multiple aneurysms before intervening. Intracranial stents and balloon remodelling enable treating wide-necked an- eurysms. Microcatheters can now traverse tortuous vessels to treat previously
unreachable lesions.141 AV malformations and fistulae may also benefit from this.

Question 14

Dementia

Answer 14

BC, ESR, U&E, Ca2+, LFT, TSH, autoantibodies, B12/folate (treat low- normals, p328); syphilis serology.176 CT/MRI (for vascular damage, haemorrhage or structural pathology). Consider also: EEG, CSF, functional imaging (FDG, PET, SPECT).177 Metabolic, genetic, and HIV tests if indicated.

Ameliorable causes
• T4; B12/folate
• Thiamine (eg alcohol) • Syphilis
• Tumours (meningioma) • Subdural haematoma
• Parkinson’s (p498)
• CNS cysticercosis (p444) • HIV (± cryptococcosis)
• Normal pressure hydro-
cephalus (dilated vent- ricles without enlarged cerebral sulci. Signs: gait apraxia, incontinence, de- mentia; CSF shunts help)
• Whipple’s disease (p730) • Pellagra (p278)

DOnezepil, Rivigistamine, Galantamine,

Memantine - SSE, hallucinations, hyper sexuality, hypertonia, confusion

Folic acid, b vitamins, gingko blob

Question 15

Epilepsy

Answer 15

• Generalized tonic-clonic seizures: Sodium valproate or lamotrigine (often better tolerated,227 and less teratogenic) are 1st-line, then carbamazepine or topiramate. Others: levetiracetam, oxcarbazepine, clobazam.
• Absence seizures: Sodium valproate, lamotrigine or ethosuximide.228
• Tonic, atonic and myoclonic seizures: As for generalized tonic-clonic seizures, but
avoiding carbamazepine and oxcarbazepine, which may worsen seizures. •Partial seizures ± secondary generalization: Carbamazepine is 1st-line, then sodium valproate, lamotrigine, oxcarbazepine or topiramate. Others: levetiracet-
am, gabapentin, tiagabine, phenytoin, clobazam.

Question 16

Parkinson’s

Answer 16

Levodopa+bensaride/carbidopa TDS 1-2 weeks for early
OR pramipexole

Domperidone for nausea

Fludrocortisone for hypotension

Donepezil/Rivastigmine for Dementia

VIVID - 
Vertical gaze palsy
Impotence/Incontinence
Visual hallucinations
Interfering activity by affected limb
Diabetic/hypertensive patient

a key decision is when to start levodopa. Personalize your care plan. Discuss pros & cons with your patient, eg end-of-dose wearing off and dopa- mine-induced dyskinesias (develops over 5–10yrs). In view of these, starting late may be wise, eg when >70yrs or when PD seriously interferes with life. NICE recommends referring to a neurologist before drugs are used. Dopamine agonists and MAO-B in- hibitors may allow delay in starting levodopa, or allow lower doses of levodopa.
• Neuropsychiatric complications, such as depression, dementia and psychosis, are common and may reflect disease progression or drug SES. Try SSRIS for depression. Distinguish drug-induced psychosis (consider reducing DA-agonist doses) from dis- ease progression (try atypical antipsychotics, eg quetiapine, olanzapine).
• Respite care is much valued by carers in advanced disease.
• Deep brain stimulation (DBS) may help those who are partly dopamine-responsive. 240
• Surgical ablation of overactive basal ganglia circuits (eg subthalamic nuclei).

Question 17

MS

Answer 17

Reduce inflammatory disease activity

Monoclonal antibodies, interferons,

Methylprednisolone sodium succinate

Spasticitiy - clonazepam, diazepam

Diminished mobility - Fampridine

Paroxysmal - Carbamazepine

Bladder - Oxybutynin

Steroids: Methylprednisolone, eg 1⁄2–1g/24h IV/PO for 3d shortens acute relapses; use sparingly ( twice/yr; steroid SE, p371). It doesn’t alter overall prognosis.
Interferons (IFN-1 & IFN-1):  relapses by 30% in active relapsing-remitting MS;257 and lesion accumulation on MRI.258, 259 Their power to delay disability is modest at best, as is their role in progressive MS. SE: flu symptoms, depression, abortion. NB: new gadolinium-enhancing lesions on IFN correlate with severe disability 15yrs later.259
Monoclonal antibodies: Alemtuzumab acts against T cells in relapsing-remitting MS. 2 trials show it’s better than INF.260 SE: infections, while the immune system recon- stitutes itself; autoimmune disease (thyroid, skin, kidney). Natalizumab acts against VLA-4 receptors that allow immune cells to cross the blood–brain barrier. It  relapses in relapsing-remitting MS by 68% and MRI lesions by 92%. SE: progressive leucoen- cephalopathy; antibody-mediated resistance.
Non-immunosuppressives: Glatiramer; mitoxantrone (doxorubicin analogue; helps in secondary progressive MS; safety is an issue).
Other drugs: Azathioprine may be as good as interferons for relapsing-remitting MS and is 20≈ cheaper.261 NB: there are no good drugs for primary progressive MS.262
Palliation: Spasticity: Baclofen 5–25mg/8h PO; diazepam 5mg/8–24h PO (addictive); dantrolene 25mg/24h (max 100mg/6h); tizanidine 2mg/24h PO,  every 4d in steps of 1mg/12h (max 9mg/6h). Endocannabinoid system modulation (Sativex®) has a role.263 Tremor: Botulinum toxin type A injections improve arm tremor and functioning.264 Urgency/frequency: If post-micturition residual urine >100mL, teach intermittent self-catheterization; if <100mL, try tolterodine.