ETG Flashcards
Pneumonia
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
STD
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
Schisto and Tapeworms
Prazitenqual
Hytatid cyst
PAIR approach: puncture aspirate cystinject hypertonic saline re-aspirate after 25min; continue albendazole for 30d to prevent recurrence.
Nematodes
Abendazole or Mebendazole
Trypanosomiasis
nifurtimox
Giardia
Tinidazole
Entomoeba
metronidazole then diloxainide furoate
Migraine
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.
Tardive dyskinesia
tetrabenazine 12.5–50mg/8h PO.79 Quetiapine, olanzapine and clozapine are examples of atypical antipsychotics that are less likely to cause tardive syndromes.
Stroke
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.
Stroke
Once excluding ICH by imaging –> aspirin orally or NG tube 300mg, continue indefinitely
Prevention - aspirin, clopidogrel, dipyramidole.
No driving for at least a month
SAH
• 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.
Dementia
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
Epilepsy
• 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.
Parkinson’s
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).
MS
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.
